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How calorie-focused thinking about obesity and related diseases may mislead and harm public health. An alternative



Prevailing thinking about obesity and related diseases holds that quantifying calories should be a principal concern and target for intervention. Part of this thinking is that consumed calories – regardless of their sources – are equivalent; i.e. ‘a calorie is a calorie’. The present commentary discusses various problems with the idea that ‘a calorie is a calorie’ and with a primarily quantitative focus on food calories. Instead, the authors argue for a greater qualitative focus on the sources of calories consumed (i.e. a greater focus on types of foods) and on the metabolic changes that result from consuming foods of different types. In particular, the authors consider how calorie-focused thinking is inherently biased against high-fat foods, many of which may be protective against obesity and related diseases, and supportive of starchy and sugary replacements, which are likely detrimental. Shifting the focus to qualitative food distinctions, a central argument of the paper is that obesity and related diseases are problems due largely to food-induced physiology (e.g. neurohormonal pathways) not addres- sable through arithmetic dieting (i.e. calorie counting). The paper considers potential harms of public health initiatives framed around calorie balance sheets – targeting ‘calories in’ and/or ‘calories out’ – that reinforce messages of overeating and inactivity as underlying causes, rather than intermediate effects, of obesity. Finally, the paper concludes that public health should work primarily to support the consumption of whole foods that help protect against obesity-promoting energy imbalance and metabolic dysfunction and not continue to promote calorie-directed messages that may create and blame victims and possibly exacerbate epidemics of obesity and related diseases.
How calorie-focused thinking about obesity and related diseases
may mislead and harm public health. An alternative
Sean C Lucan
* and James J DiNicolantonio
Department of Family and Social Medicine, Albert Einstein College of Medicine/Monteore Medical Center,
1300 Morris Park Avenue, Block Building, Room 410, Bronx, NY 10461, USA:
Department of Preventive
Cardiology, Mid America Heart Institute at Saint Lukes Hospital, Kansas City, MO, USA
Submitted 29 May 2014: Final revision received 2 October 2014: Accepted 3 October 2014
Prevailing thinking about obesity and related diseases holds that quantifying
calories should be a principal concern and target for intervention. Part of this
thinking is that consumed calories regardless of their sources are equivalent;
i.e. a calorie is a calorie. The present commentary discusses various problems
with the idea that a calorie is a calorieand with a primarily quantitative focus on
food calories. Instead, the authors argue for a greater qualitative focus on the
sources of calories consumed (i.e. a greater focus on types of foods) and on the
metabolic changes that result from consuming foods of different types. In
particular, the authors consider how calorie-focused thinking is inherently biased
against high-fat foods, many of which may be protective against obesity and
related diseases, and supportive of starchy and sugary replacements, which are
likely detrimental. Shifting the focus to qualitative food distinctions, a central
argument of the paper is that obesity and related diseases are problems due
largely to food-induced physiology (e.g. neurohormonal pathways) not addres-
sable through arithmetic dieting (i.e. calorie counting). The paper considers
potential harms of public health initiatives framed around calorie balance sheets
targeting calories inand/or calories out’–that reinforce messages of overeating
and inactivity as underlying causes, rather than intermediate effects, of obesity.
Finally, the paper concludes that public health should work primarily to support
the consumption of whole foods that help protect against obesity-promoting
energy imbalance and metabolic dysfunction and not continue to promote calorie-
directed messages that may create and blame victims and possibly exacerbate
epidemics of obesity and related diseases.
Public health
Chronic disease
With worldwide concerns about obesity and diseases rela-
ted to it (e.g. diabetes and CVD), there is substantial interest
in shifting populations to healthier weights and better health.
More precisely, there is interest in reducing body fat since
fat particularly visceral or abdominal fat may matter
more than weight when it comes to health
much of the evidence regarding obesity and related diseases
focuses on body weight, rather than body fat. In reviewing
such evidence, therefore, the present paper will therefore
also often use the imprecise term weightas opposed to
fat, pointing out when such imprecision might mislead
One way such imprecision might mislead thinking is in
supporting the notions that (i) a calorie is a calorie’† and
(ii) intervening on calories is the best way to address obe-
sity (i.e. the quantitative problem of excess pounds or
kilograms on a scale as opposed to the qualitative problem
Public Health Nutrition
†‘Calorie’–or more correctly kilocalorie (kcal), for which the word often
imprecisely substitutes is the main unit of energy used to discuss food
and obesity-related issues in the USA. It is also the word used in common
expressions like a calorie is a calorie. The word appears throughout this
commentary as the energy unit of choice, but readers should feel free to
substitute all instances with their own preferred energy unit; e.g. the joule
(or the kilojoule or megajoule). No mathematical conversions are required
as arguments are abstract and do not rely on specic quantities.
Public Health Nutrition: page 1 of 11 doi:10.1017/S1368980014002559
*Corresponding author: Email © The Authors 2014
of altered body metabolism). The two calorie notions are
largely about balance sheets, essentially considering cal-
ories like units of body weight and units of body weight like
inverse units of health; according to the logic, obese indi-
viduals need only try to consume fewer calories than they
burn and they will achieve healthier weights and better
Although such logic is intuitive and enticing, reality is
not quite so simple and existing evidence challenges
calorie-focused notions. A view focused more on food
quality, rather than caloric quantity, may help better
explain and better address the growing problems of
excess weight or more precisely excess fat and related
conditions. Conversely, messages and initiatives based on
the idea of calorie equivalency (that a calorie is a calorie)
and interventions directed at calorie balance sheets may
make these problems worse. The present paper reviews
various problems with calorie-focused thinking, considers
several advantages of more-nuanced thinking(that
considers calories principally as subordinate concerns to
qualitative differences in food) and proposes an alternative
path for public health to move forward.
The problem with the idea of calorie equivalency
A calorie is a unit of energy. As related to food energy,
calories measure the potential energy a food could
release. One calorie of potential energy equals one calorie
of potential energy, just as one unit of anything equals
another unit of that same anything. To say a calorie is a
caloriethen is tantamount to the identity property in
mathematics (A =A). As such, it is irrefutable.
In practice, however, the statement that a calorie is a
calorieoften implies something different from mathema-
tical identity. It implies that any two different foods, which
have equivalent amounts of potential energy, will produce
identical biological effects with regard to body weight/
body fatness when consumed. By this thinking, a calories
worth of salmon, olive oil, white rice or vodka would each
be equivalent and each expected to have the same
implications for body weight and body fatness. Indeed,
stating a calorie is a caloriesuggests that potential energy
is the essential concern and that qualitative differences in
the substances providing that energy are irrelevant.
But a caloriesworthofsalmon(largelyprotein)anda
biological effects from a caloriesworthofwhiterice(rened
carbohydrate) or a caloriesworthofvodka(mostlyalcohol)
particularly with regard to body weight/body fatness.
Indeed, scientists have recognized differences in the weight-
related physiological effects of different calorie sources for
more than half a century
was based on animal studies, subsequent studies in human
subjects have shown that calorie-providing proteins, fats,
carbohydrates and alcohol each have substantially different
effects on a variety of physiological pathways and hormones
relevant to satiety, food consumption, weight maintenance
and body composition: for example, different effects
on ghrelin (an appetite-stimulating hormone), leptin (an
appetite-suppressing hormone), glucagon (a hormone that
raises blood sugar) and insulin (a hormone that lowers
blood sugar)
The aforementioned descriptions of hormone activities
are greatly oversimplied and the list of hormones far from
exhaustive, but the examples serve to suggest that a given
calories worth of salmon, olive oil, white rice or vodka
might each behave quite differently in the body and pro-
duce different ultimate effects. Indeed, whereas some
calories(i.e. some amounts of different foods, quantied
by their potential energy) induce metabolic pathways and
hormones that squelch appetite and promote energy
utilization, others stimulate pathways that promote hunger
and energy storage. Even controlling for total calorie
intake and energy expenditure from physical activity,
qualitative differences in calories have different implica-
tions for obesity
; a calories worth of one food is not the
same a calories worth of another
Trying to intervene on calories is implausible
and ineffective
It follows from the problematic notion of calorie equivalency
that any calorie consumed might be offset by a single calorie
expended. Thus individuals wishing to lose weight should
simply consume fewer calories than they expend. In other
words, individuals should intervene on caloric quantity by
consciously trying to eat lessand move morethan they
otherwise would to establish caloric decitor negative
energy balance
The problem with trying to eat lessand move moreto
achieve and more importantly, maintain caloric decit or
negative energy balance is that it is practically and biologi-
cally implausible. Practically, even the most motivated,
informed and knowledgeable individuals are unlikely to be
able to estimate their actual calorie intake (not just ingested,
informed by misleading food labels
) or their actual calorie expenditure (not just in
physical activity
but in variably efcient, silent and
constantly uctuating digestive and metabolic pro-
) and do so with sufcient accuracy and
precision to maintain any kind of useful real-time calorie
balance sheets. Biologically, calorie intake and calorie
expenditure are coupled
pling occurs, reducing calories consumed will necessarily
result in a compensatory drive to reduce calories expended
and vice versa
. For this reason, people who try
underconsuming calories become tired (an expenditure
compensation) and hungry (an intake compensation), and
one reason they often fail to lose weight (or have unim-
pressive results)
may be that resultant hunger,
Public Health Nutrition
2 SC Lucan and JJ DiNicolantonio
particularly an increased desire for high-calorie foods
drives compensatory overconsumption
Of course, some individuals do succeed at sufciently
uncoupling energy balance (i.e. do expend more calories
than they consume) and do lose weight. But saying that
these individuals lose weight because they expend more
calories than they consume is like saying that students are
late for class because they arrive after the bell rings. Both
statements are true, but neither is causal. The associations
do not explain the why(i.e. in the case of expending more
calories than consumed, why the uncoupling occurred).
Calorie equivalency and calorie balance sheets cannot
explain the why; why some people succeed in eating less
and/or moving more and lose weight while others fail and
gain weight. Calorie-focused thinking does not tell us why
some people achieve net burning or net storage of calories,
or how it is entirely possible to lose weight (as lean mass)
and still gain fat (i.e. become more obese). Calorie thinking
also cannot account for the dynamic non-linear response of
body weight to stable energy imbalances over time
Likewise, calorie thinking does not address why obesity-
related metabolic abnormalities
and adverse events of
obesity-related diseases
may both occur before there is
any gain in weight
, why metabolic improvements may
occur at stable weight
or why obesity-related adverse
events may not decline with weight loss
for obesity should provide insights into these observations.
More-nuanced thinking about obesity and related
To understand another kind of thinking about obesity and
related diseases and why individuals may show meta-
bolic changes associated with being overweight before
any detectable weight gain occurs it is useful to consider
body fat. Body fat particularly visceral or abdominal
fat is a complex tissue that plays critical roles in appetite
stimulation, energy expenditure and weight regulation.
Normally, when a bodys fat cells are replete (i.e. full with
stored fat), they release a hormone called leptin. Leptin
stimulates parts of the brain to send additional hormone
and nerve signals to the thyroid gland, skeletal muscles,
heart, intestines and other fat cells
. These signals are
to decrease energy intake (i.e. to eat less) and increase
energy expenditure (e.g. to move more)
As individuals start to become obese, however (meta-
bolically speaking, if not yet by weight on a scale),
something goes awry with the signalling. Fat-cell repletion
is no longer recognized and rather than there being signals
to suppress appetite and increase activity as fat stores
increase, there are signals to increase energy intake and
reduce energy expenditure
. In other words,
eating moreand moving less, thought to be causes of
body fattening by calorie-focused thinking, may actually
be a result of body fattening
So if eating more and moving less could be a result of body
fattening, what causes bodies to fatten (i.e. to undergo
metabolic dysfunction followed by fat gain, and then weight
gain) in the rst place; that is, what prevents leptin from
doing its job of satiating appetite and promoting energy
expenditure? The answer is not entirely clear, but one
hypothesis implicates concentrated sources of rapidly
absorbable carbohydrates in the diet and the hormone
Insulin is a pancreatic hormone that helps drive inges-
ted nutrients into cells; its release is most brisk and pro-
nounced following the ingestion of rapidly absorbable
carbohydrates (as compared with fats, proteins, alcohol
and more slowly absorbed carbohydrates
). Rapidly
absorbable carbohydrates sugars and rened starches
like white rice and foods consisting substantively of white
our cause blood sugar to rise briskly and insulin levels
to respond in kind
. The rapid insulin elevations
produced by these foods cause correspondingly rapid
drops in blood sugar. Food cravings result (to restore
fallen fuel levels), particularly appetites for something
. Thus, in the short term, intake of rapidly
absorbable carbohydrates may promote eating morein
general and create a reinforcing loop for overconsumption
of additional rapidly absorbable (sweet) carbohydrates in
particular (Fig. 1)
Over the long term, overconsumption of rapidly
absorbable carbohydrates may promote leptin resistance.
Such resistance may occur through microbiota-mediated
inammatory pathways
or through other metabolic
changes (e.g. chronic insulin elevations)
. Regardless,
with leptins actions largely disabled, the result of high
sugar and starch intake is a neurohormonal drive to eat
moreand move less(Fig. 1)
By more-nuanced thinking, then, what counts for obe-
sity and related diseases is not the number of calories in
specic foods but rather the concentration and type of
carbohydrates these foods contain
. Total calorie
balance is important in both ways of thinking, but whereas
calorie-focused thinking directs dietary recommendations
towards calorie counts (being primarily quantitative),
more-nuanced thinking directs dietary recommendations
towards calorie sources (being primarily qualitative); the
number of calories consumed and expended are only
secondary/intermediate considerations.
Different dietary recommendations by calorie-
focused thinking and more-nuanced thinking
A comparison of selected foods that might be encouraged
or discouraged by calorie-focused thinking and a more-
nuanced thinking appears in Fig. 2. Concordant cells
reveal there is some common ground. For example, both
ways of thinking discourage sodas, but whereas more-
nuanced thinking discourages sodas based on
Public Health Nutrition
Calorie-focused thinking and an alternative 3
Public Health Nutrition
Encouraged Discouraged
Nuts and nut butters;
avocados, olives and olive oil;
whole dairy; oily fish
Most vegetables, legumes,
whole fresh fruits and
unprocessed or sprouted
grains; lean meats, poultry,
and fish; water and
unsweetened tea and coffee
Sodas and other sugar-
sweetened beverages;
candies; baked sweets; French
fries and batter-fried foods,
snack chips and other
processed items
100 % fruit juices; enriched
breads and pastas; fortified
breakfast cereals (e.g. corn
flakes, crisp rice); low-fat dairy
(including sugary flavoured fat-free
Fig. 2 Comparison of selected foods that might be encouraged or discouraged by calorie-focused thinking and more-nuanced
thinking. This figure is not comprehensive, is not a description of any specific diet plan, and does not represent the
recommendations or guidelines of any particular individual or organization. It does not explicitly address issues relevant to public
health nutrition beyond calorie- and carbohydrate-related concerns (e.g. food production, climate change, One Health, etc.).
Additionally, categorizations are based on somewhat relative concepts such as how emptycalories are and how rapidly
absorbablecarbohydrate content is; placement of listed and unlisted items within the construct may be debatable.
Encouraged=okay to eat or even desirable as a focus of ones diet, particularly as an alternative to foods that are
discouraged;discouraged=to be avoided or limited in quantity
Expending fewer calories
(e.g. ‘moving less’)*
Consuming more calories
(i.e. ‘eating more’)*
Increasing intake of
rapidly absorbable
Short-term reinforcing loop (by more-nuanced thinking)
Long-term reinforcing loop (by more-nuanced thinking)
Explanatory path (by calorie-focused thinking); path from intermediates (by more-nuanced thinking)
Independent factors (by calorie-focused thinking); physiologically coupled factors (by more-nuanced thinking)
with uncoupling and imbalance from neurohormonal changes that may be driven by sugar and/or starch intake
Calorie-focused thinking
Consuming food calories in excess of
calories expended causes obesity
More-nuanced thinking
Rapidly absorbable carbohydrates
stimulate neurohromonal signals that
cause increased calorie intake over the
short term and fat storage, increased
calorie intake and decreased calorie
expenditure over the long term
Fig. 1 Calorie-focused thinking versus more-nuanced thinking about obesity. Single-headed arrows represent direct associations in
presumed causal directions. *Expending fewer caloriesincludes all energy expenditure, but moving lessspecifically refers to a
relatively lower degree of physical inactivity from baseline. Eating morerefers to relative overeating from baseline. Over the short
term, the intake of rapidly absorbable carbohydrates through spikes in blood sugar and insulin, and through sweet cravings
promotes a reinforcing loop with eating morein general and eating more rapidly absorbable carbohydrates in particular (dotted
arrows). Over the long term, neurohormonal alterations, perhaps chiefly through insulin and leptin resistance leading to and
contributed by growing abdominal fat perpetuate an indirect reinforcing loop with eating more(dashed arrows) and also promote
moving less. Decreasing the intake of rapidly absorbed sugars and starches (as found abundantly in processed foods) and
increasing the consumption of whole/minimally processed foods may disrupt these loops, overall calorie imbalance, and both the
hormonal dysfunction and excess body mass characterizing obesity
4 SC Lucan and JJ DiNicolantonio
carbohydrate content and character (i.e. high concentra-
tions of rapidly absorbable sugar), calorie-focused think-
ing discourages sodas based on the idea of empty
calories.Empty caloriesare foods that contribute energy
but few substances thought to be benecial like vitamins,
minerals and bre. By calorie-focused thinking, empty
calorieswaste precious space on the intake side of calorie
balance sheets.
Figure 2 also demonstrates important discordance
between calorie-focused thinking and more-nuanced
thinking. For instance, 100 % fruit juices full of vita-
mins, minerals and sometimes bre are not emptyand
may even be considered healthy and desirable by calorie-
focused thinking
. By more-nuanced thinking, however,
100 % fruit juices are just as undesirable as sodas given
both are mostly sugar in concentrated liquid form
Other discordances in dietary recommendations
between calorie-focused thinking and more-nuanced
thinking, and perhaps the most important differences,
relate to dietary fat. Dietary fat has by far the most calories
of any of the energy-providing compounds in food: about
9 kcal/g as compared with roughly 7 kcal/g for alcohol,
4 kcal/g for protein and 4 kcal/g for carbohydrate
Thus, calorie-focused thinking has an inherent bias against
dietary fat. This bias leads to public health messages and
interventions to decrease the intake of fatty foods or
reduce or remove the fat from high-fat foods (often
replacing fat with less-calorie-dense often rapidly
absorbable carbohydrates).
Calorie-focused thinking generally endorses foods that
are low in fat and calories, as long as those calories are
not empty. In contrast, more-nuanced thinking has no
problems with fat or calories, per se, and places the blame
squarely on foods with the most rapidly absorbable
carbohydrates (Fig. 2). Clearly these two ways of thinking
are very different. A question for public health moving
forward is: would food choices that could result from a
continued primary focus on calories (calorie-focused
thinking Fig. 2) be best for population weight and health?
Pertinent clinical and population evidence for two
different ways of thinking
Consider an experiment in children
. Sixth graders with
comparable baseline satiety were allowed to eat as much
as they wanted of two highly palatable child-friendly
snacks: cheese wedges/rounds or potato chips. A quantity
of cheese (mostly fat with some protein and negligible
carbohydrate) might offer about 50 % more calories than
an identical quantity of chips (mostly carbohydrate and fat
with negligible protein). By calorie-focused thinking,
comparably hungry children should eat more calories of
cheese because cheese has more calories. By more-
nuanced thinking, comparably hungry children should eat
more calories of chips because chips, being rich in rapidly
absorbable starch, should tend to promote continued
eating (short-term reinforcing loop, Fig. 1)
What actually happened in the experiment was that
children in the potato chip group consumed over three
times more calories than children in the cheese group
While a protein difference between the snacks might cer-
tainly have been a factor (with experimental trials suggesting
, albeit not always statistically signicant
satiating power of protein), all foods are inevitable mixes of
different components and the point here is that the food
with the higher starch content prompted greater consump-
tion. This result is consistent with a meta-analysis showing
children have greater energy intake following consumption
of the most rapidly absorbable carbohydrates
Notably in the experiment described above, the effect of
eating more calories in the high-carbohydrate (chips)
condition was even more pronounced among overweight
and obese children
. This result is consistent with
another trial showing greater hunger in obese children
after a high-carbohydrate meal
and consistent with the
long-term reinforcing loop in Fig. 1.
Although the chips-and-cheese experiment did not
assess childrens total caloric intake for the day outside of
the single snack episode, it is likely that children con-
suming cheese ate fewer calories overall for the day,
whereas children consuming chips ate more. Such an
outcome would be suggested by fteen of sixteen single-
day studies in adults that showed increased hunger, lower
satiety or greater calorie intake after consuming rapidly
absorbable carbohydrates v. not
. The outcome might
also be suggested by two other studies in children in
which restaurant fast-food consumption was associated
with a net increase in total energy intake for the day
although only for overweight individuals in one study
consistent with the long-term reinforcing loop in Fig. 1.
Granted, for a given fast-food meal, the studies referenced
above cannot distinguish if greater total caloric intake was
the result of a greasy burger (per calorie-focused think-
ing), a rened bun (per more-nuanced thinking) or
accompanying French fries (per both ways of thinking).
However, substantial evidence now implicates foods that
are low in fat (and, thus, relatively low in calories), like
, white rice
and sugary beverages
in the development and persistence of obesity and risk for
related diseases. Conversely, evidence is mounting to
exonerate higher-calorie foods that are rich in fat like
, oily sh
and olive oil
, and even
foods high in saturated fat
like dairy products
Indeed, higher-calorie fattier foods and higher-fat diets may
produce and sustain as much or more weight loss than
calorie-restricted or higher-carbohydrate diets
particularly among those already having metabolic
. Moreover, certain fattier/lower-car-
bohydrate diets may also be associated with favourable
metabolic indicators
, reduced adverse
health events
and delayed mortality
Public Health Nutrition
Calorie-focused thinking and an alternative 5
The situation for public health moving forward
Fuelled not exclusively but in no small part by calorie-
focused thinking, fats in foods and fattier diets became the
enemies of public health campaigns of the 1980s and
1990s. Lower-calorie sugars replaced higher-calorie oils in
many foods and people shifted their consumption from
fats to carbohydrates (most often, the rapidly absorbable
kinds). As in the chips-and-cheese experiment described
above, greater rened carbohydrate intake was associated
with greater total calorie intake, but now on a population
. In other words, people did not eat less
when lower-calorie foods and diets were advised, they ate
more. Obesity rates increased right along with greater
. Diabetes rates increased too
and although these ndings do not prove causation, they
certainly do not support continuing forward under the
current logic of calorie-focused thinking, with the food
choices it could encourage (Fig. 2) or the tenuous notions
that follow from it (Table 1).
Calorie-focused public health initiatives might continue to
produce unintended, even ironic, consequences. Initiatives
like calorie labelling for example rst for food packages
and more recently for restaurant menus and menu boards
are meant to steer both consumer choices and food-industry
offerings towards lower-calorie options
. Despite national
enthusiasm for the idea
, whether calorie labelling will
have the desired effect seems doubtful
is whether labelling will actually improve population health.
There is already suggestion that some labelling may produce
effects opposite to those intended
. And there is the
distinct possibility that calorie labelling could further move
food production and consumption away from healthful
high-fat foods (like nuts) and towards sugary and starchy
items (like low-fat baked potato chips), promoting further
increases in diseases characterized by abdominal fat and
metabolic dysfunction.
There are, admittedly, other existing public health
initiatives that, at least on the surface, seem more consistent
with the logic of more-nuanced thinking; for instance,
proposals to tax and limit sugary beverages
Nevertheless, these initiatives are usually framed around
the idea of empty calories, which totally misses the point.
Even the Food and Drug Administrations proposed
changes to packaged-food labels which would newly
report the amount of added sugarsin a product place
even more emphasis on calories than current labels by
visually subordinating all other label information and
highlighting calories in an enormous bold typeface
What existing and planned initiatives seem not to
acknowledge is that calories from added sugars and starches
are worse than just empty(detriment through omission);
evidence suggests they are actively harmful (detriment
through commission)
dual consumers may vary (e.g. due to their personal genetic
or that of their resident gut microbes
there is good reason to believe that rapidly absorbable car-
bohydrates tend to promote obesity, and diseases commonly
associated with it, in general
The problem for public health is that continuing to focus
on quantifying calories may misdirect thinking on obesity
and related diseases and promote destructive messages.
For instance, in a 2013 editorial, the president of the
Institute of Medicine listed gluttony and sloth as obvious
deadly sinsfor public health to address
. His argument
(which had been made before
) suggested obesity and
related diseases are matters only of personal resolve
and self-control; if people just had more motivation and
will-power, they could consciously control their calorie
balance sheets, eat less, move more and lose weight. It
stands to reason that those subscribing to the Institute of
Medicine logic might blame an overconsuming, inactive
adolescent for growing fat. But would they blame the
same overconsuming, inactive adolescent for growing tall?
Public Health Nutrition
Table 1 Notions derived from calorie-focused thinking and challenges to those notions
Notion Challenge
1. A calorie is a calorie
2. Eating lessand moving moreto achieve
calorie deficit will produce weight loss
3. Consuming more calories than expended
causes obesity
4. High-calorie foods/diets (i.e. high-fat
foods/diets) are undesirable
5. Low-calorie foods/diets (i.e. low-fat foods/
diets) are desirable
6. Low-fat foods without empty calories
are best
1. Calories from protein, fat, carbohydrate and alcohol each stimulate different
physiological pathways and have different metabolic effects
2. Trying to underconsume calories (without paying attention to qualitative differences in
calorie sources) will result in compensatory hunger and fatigue, generally with little
weight/fat loss in the short term and rebound weight gain in the long term
3. Energy consumption and expenditure are dependently linked; consuming more calories
than needed results in compensatory energy expenditure (e.g. reduced metabolic efficiency)
and/or reduced appetite and subsequent intake. If calories are consumed in excess of
calories expended in some kind of sustained way, then such imbalance is the result not the
cause of developing obesity (and of the neurohormonal changes that underlie it)
4. Many foods that are higher in fat may protect against obesity, lead to favourable
metabolic indicators and help protect against chronic diseases and early mortality
5. Low-fat foods and diets are often high in the most rapidly absorbable sugars and
starches), which may be distinctly detrimental for obesity and related diseases
6. Even for foods that have vitamins, minerals, fibre, and various other constituents
believed to be healthy, if they are concentrated sources of rapidly absorbable sugars
and starches, they are likely to cause metabolic dysfunction and harm
6 SC Lucan and JJ DiNicolantonio
Just as children do not enter puberty and grow tall
because they overeat and sleep more, neither do indivi-
duals start to fatten and become obese because they eat too
much and move too little. In both cases overconsumption
and inactivity are intermediate effects; neurohormonal
changes are the cause. The case of pubertal growth
represents normal development, but the case of fattening
represents decided pathology; pathology that may be
modiable through dietary change. Perhaps if we shifted
food production and peoples consumption away from
added sugars and rened starches, we could avoid the
resultant metabolic dysfunction and corpulence that have
come to plague our populations. Instead of futilely pro-
moting messages to eat lessand move more
perhaps we should do more to promote the consumption
of whole/minimally processed foods
like more of
those in the upper row of Fig. 2 foods that might make
eating lessand moving moremore possible.
Concluding thoughts
Calorie-focused thinking may have already exacerbated
the epidemics of obesity and related diseases. And while
there has been much progress in redirecting dietary focus
towards actual foods
, there is still too much focus on
eating too much
. Focusing quantitatively, particularly
on the calories available from specic foods, fails to
recognize the broader metabolic effects of foods them-
selves. Foods that are highly processed and comprised
mostly of rapidly absorbable sugars and starches may be
of greatest concern. Such carbohydrates may induce
neurohormonal changes that might, in turn, help produce
the overeating and inactivity often interpreted as causative
for obesity. In other words, unhealthy foods
may make double victims of their consumers, who might
not only become obese by eating them but also receive
harsh criticism for their substantial appetites and apparent
laziness that result.
As the saying often attributed to the Albert Einstein
goes, not everything that can be counted counts, and
advice to count calories, or to try to change calorie balance
sheets by intervening on quantities of undifferentiated
foods, seems misdirected. Imagine comparably mis-
directed advice: for instance, to count uid ounces, drink
less and urinate more advice that might likewise result
in temporary weight loss (but no fat loss) and be
uncomfortable, unsustainable, unreasonable and unhelp-
ful; and likewise oppose coupled neurohormonally driven
physiology in futility. Yes, calories count, and calorie
balance sheets matter, but net intake or expenditure
probably results more from qualitative distinctions in
the foods we eat than conscious attempts at quantitative
. New public health initiatives and messages
focused on encouraging consumption of whole/minimally
processed foods would be ideal
, especially to counteract
industrys near-exclusive marketing of foods that are highly
processed/rened and concentrated sources of the most
rapidly absorbable starches and sugars.
Promoting the consumption of whole foods will require
careful attention to food systems, cultural traditions, peer
inuences, food environments, assistance programmes
and a host of other issues beyond the scope of the present
commentary. But as a guiding principle, the public health
community should not be trying to cut calories from
available foods
, we should be improving the quality
of the foods available that provide our calories. We should
be promoting foods that do not prompt, or indeed
programme, us to overeat.
Although focusing on rened starch and sugar content
might seem like a logical path forward, such narrow focus
could lead to unintended consequences, as when public
health campaigns demonized fat. For this reason, the
recent WHO draft guideline to more strictly limit the intake
of all sugars
, the recent proposition in England for a
sugar tax
, and the recent proposal in California to
place health warning labels on sugary drinks
, while all
appropriately focused, should be evaluated carefully
before wider implementation. Coordination with the food
industry will be challenging, but while working towards
improving the quality of foods that are produced and
working to support the consumption of whole/minimally
processed products, at the very least, public health should
not continue to promote messages that create and blame
victims or that, in all likelihood, continue to exacerbate
epidemics of obesity and related diseases.
Acknowledgements: S.C.L. would like to thank Sanjay
Basu, MD, PhD, Jennifer L Pomeranz, JD, MPH, Paul R
Marantz, MD, MPH and Manisha Sharma, MD for reviewing
very early drafts of this manuscript and providing critical
comments. Financial support: This research received no
specic grant from any funding agency in the public,
commercial or not-for-prot sectors. Conict of interest:
None. Authorship: S.C.L. conducted the primary literature
review, conceived the paper, drafted the main arguments,
and created Figs 1 and 2. J.J.D. helped revise the text,
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Public Health Nutrition
Calorie-focused thinking and an alternative 11
... Calorie labels may oversimplify the nutritional and social values of food [17,18] (though generally, the caloric content of foods is correlated with its overall healthfulness [19]) and reinforce behaviours associated with disordered eating, such as calorie counting [20]. Individuals trying to modify their weight actively seek out nutrition information [21,22] and those engaged in disordered eating appear more likely to use labels than those who are not [23,24]. ...
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Background Menu labelling, and more specifically calorie labelling, has been posited as an intervention to improve nutrition literacy and the healthfulness of consumers’ food purchases. However, there is some concern calorie labelling may unintentionally trigger or exacerbate disordered eating among vulnerable persons. The purpose of this research was to explore young adults’ experiences with labelling, with a focus on its implications for their relationships with food. Methods Individual semi-structured interviews were conducted with participants from a campus-based menu labelling study. Interview data were inductively coded using thematic analysis and supported by survey data assessing disordered eating, body esteem, and related constructs. Results The sample consisted of 13 participants (10 women, 3 men), most of whom perceived themselves as “about the right weight” (62%). Four key themes included: (1) participants’ support of and skepticism about labelling interventions, (2) the identification of knowledge and autonomy as mechanisms of labelling interventions, (3) the role of the individual’s and others’ relationships with food in experiences with labelling, and (4) disordered eating and dieting as lenses that shape experiences with interventions. Participants’ perceptions of and experiences with calorie labels were shaped by gender, body esteem, and disordered eating risk. Conclusions The results provide insight into the complexity of young adults’ interactions with labelling interventions and context for future research exploring the unintended consequences of public health nutrition interventions.
... We determined no threshold of harm for free sugars from solids; intakes above 2.5TE%, 5TE% and 10TE% thresholds were associated with lower overweight risk while intakes above 5TE% were associated with lower GDM risk, relative to intake below each of these thresholds, consistent with other studies discussed that considered different but related outcomes. Thus, a growing body of literature [47,49] suggests that with respect to free sugars, we should focus guidelines on SSB rather than specify restrictions on sugars from food sources, given the current absence of evidence for harm. Our study has some limitations. ...
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Background Sugar-sweetened beverages have obesogenic and diabetogenic effects ascribed to free sugars. These include added sugars and naturally occurring sugars in juices. A meta-analysis indicates that some foods with added sugars are associated with lower type 2 diabetes rates. To expand the evidence relevant to free sugars from solid sources, we examined a young to middle-aged population with respect to overweight and gestational diabetes (GDM) outcomes. Methods We studied female participants (12–50 years old) from the 2004–2005 Canadian Community Health Survey 2.2 (CCHS) with data linked to the hospital Discharge Abstract Database (DAD) until 2017, providing 13 years of follow-up. We estimated free sugars by solid and liquid sources from 24-h dietary recalls as percent total energy intake (TE%), and computed body mass index (BMI). We applied ICD-10 diagnostic codes for deliveries and GDM to DAD. We conducted multivariable logistic regression analyses to evaluate associations between free sugars with overweight at baseline (cross-sectional component) and, in those who delivered, with GDM during follow-up (nested case control component). We compared those with consumption above versus below various thresholds of intake for free sugars, considering solid and liquid sources separately (2.TE%, 5TE%, 10TE% and 15TE% thresholds). Results Among 6305 participants, 2505 (40%) were overweight, defined as BMI ≥ 85th percentile below 18 years and BMI ≥ 25 kg/m² for adults. Free sugars from solid sources were associated with lower odds of overweight above versus below the 2.5TE% (adjusted odds ratio [adjOR] 0.80, 95%CI 0.70–0.92), 5TE% (adjOR 0.89, 95%CI 0.79–0.99), and 10TE% (adjOR 0.86, 95%CI 0.75–0.97) thresholds. Free sugars from liquid sources were associated with greater odds of overweight across the 2.5TE% (adjOR 1.20, 95%CI 1.07–1.36), 10TE% (adjOR 1.17, 95%CI 1.02–1.34), and 15TE% (adjOR 1.43, 95%CI 1.23–1.67) thresholds. There were 113 cases of GDM among the 1842 women who delivered (6.1%). Free sugars from solid sources were associated with lower odds of GDM above versus below the 5TE% threshold (adjOR 0.56, 95%CI 0.36–0.85). Conclusions Our findings support limiting free sugars from liquid sources, given associations with overweight. We did not identify adverse associations of free sugars from solid sources across any of the thresholds examined.
... 30 From a food quality perspective, rather than just calorie-focused thinking, intake of rapidly absorbable carbohydrates-sugars and refined starches-may induce neurohormonal changes that might result in metabolic dysfunction and corpulence. 38 Thus, while shifting consumption away from added sugars, the removal of sugar subsidies could potentially reinforce the direct effect of the intervention by fostering the consumption of healthier foods, such as fruit and vegetable intake, that are inversely associated with weight gain and risk of obesity. 39,40 These results are relatively small compared to an observational study that modeled the effect of a 20% tax on high-sugar snacks and sugar-sweetened beverages, which showed reductions on the average BMI by -0.53 (95% CI -1.01 to -0.06) and a decrease of 2.68 percentage points in the obesity prevalence a year after the introduction of the tax. ...
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Objectives To model the potential impact on obesity of removing butter, cheese, and sugar subsidies in the Canary Islands. Methods A simulation model was applied based on a local data set of subsidies and retail prices (2007-2016), data on own-price elasticity estimates, and representative nutritional and health surveys. We estimated marginal obesity prevalence and population attributable fraction to assess the potential impact of the butter, cheese, and sugar subsidies intervention. Results The intervention was predicted to avoid 10 363 obese adults over the study period, because of the reduction of the obesity prevalence by -0.7 percentage points. Overall, the predicted effect was largest in elderly and male groups, although females with a low socioeconomic status experienced the greatest decrease in the prevalence. The population attributable fraction predicted that 4.0% of population with obesity were attributable to the existence of these subsidies. Conclusions This analysis provides policy makers with the predicted impact on obesity of the butter, cheese, and sugar subsidies disposal, enabling them to incorporate this health impact into decision making across policy areas in the economic and health field. This study aims to model the potential impact on obesity of removing industrial subsidies for butter, cheese and sugar in the Canary Islands.
... Omega-6 PUFAs may stimulate fat mass build-up containing prevention of rising in fatty acid oxidation, basal metabolic rate increase, the elevation of protein and muscle synthesis, and progression of fat-storing prostaglandins, endocannabinoids, and augmented hunger [47]. The thermic effect of the MUFA-rich meal was also high compared to the SFArich meal in subjects with a high WC [48]. Substituting a high MUFA diet for a diet rich in SFA significantly reduced body weight and fat mass in overweight and obese men [49]. ...
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In the present research, we have evaluated the association between patterns of nutrient intake and obesity. The present cross-sectional study recruited 850 adults aged between 20-59 years old. Dietary intakes were assessed with three 24-hour recalls. As well, data on anthropometric measures were collected. General obesity was specified as body mass index ≥ 30 kg/m 2. Factor analysis was conducted, and followed by a varimax rotation, was performed to extract major nutrient patterns. Our analysis identified three major nutrient patterns: The first nutrient pattern was characterized by the high consumption of saturated fatty acids (SFAs), protein, vitamins B 1 , B 2 , B 6 , B 5 , B 3 , B 12 , Zinc, and iron. The second nutrient pattern was rich in total fat, polyunsaturated fatty acids, monounsaturated fatty acids, SFAs, oleic acid, linolenic acid, zinc, vitamin E, α-tocopherol, and β-carotene. The third one was greatly loaded with protein, carbohydrate, potassium, magnesium, phosphorus, calcium, vitamin C, and folate. Women in the third quintile of the first pattern were less likely to be generally obese in the fully adjusted model (odds ratio, 0.44; 95% confidence interval, 0.25-0.75). None of the other nutrient patterns had a significant association with obesity, even after adjusting for confounders. Adherence to a nutrient pattern rich in water-soluble vitamins was significantly associated with a greater chance of general obesity among women. Further studies in other populations, along with future prospective studies, are required to confirm these findings.
... There is always a tendency of paying excessive attention on the "energy" and neglecting the food composition. However, food composition may disturb energy homeostasis, thereby inducing obesity or lean (Lucan and DiNicolantonio 2015). Consequently, this may explain why somebody could succeed in getting rid of obesity via eating less/moving more and others fail. ...
The purpose of this study was to investigate the association between refined grains intake and obesity in China. Refined grain intake was considered in relation to energy intake and at varied levels of macronutrient distribution. A cross-sectional study of 6913 participants was conducted using internet-based dietary questionnaire for Chinese (IDQC). The associations and dose-response relationships between refined grains intake and obesity were investigated using multivariable logistic regression analyses and restricted cubic spline (RCS) models. There was a positive association between refined grains intake and abdominal obesity for all participants (forth quartile OR, 1.313; 95% CI, 1.103-1.760; p < .05) and this association persisted in low energy, low carbohydrate, high fat and high protein level subgroups. A range of favourable refined grains intake was 88-116 g/d (3-4 servings/d), which might decrease the likelihood of obesity for Chinese residents. Further prospective studies are needed to confirm these findings.
The purpose of this study was to investigate the association between refined grains intake and obesity in China. Refined grain intake was considered in relation to energy intake and at varied levels of macronutrient distribution. A cross-sectional study of 6913 participants was conducted using internet-based dietary questionnaire for Chinese (IDQC). The associations and dose–response relationships between refined grains intake and obesity were investigated using multivariable logistic regression analyses and restricted cubic spline (RCS) models. There was a positive association between refined grains intake and abdominal obesity for all participants (forth quartile OR, 1.313; 95% CI, 1.103–1.760; p <.05) and this association persisted in low energy, low carbohydrate, high fat and high protein level subgroups. A range of favourable refined grains intake was 88–116 g/d (3–4 servings/d), which might decrease the likelihood of obesity for Chinese residents. Further prospective studies are needed to confirm these findings.
Background: Many dietary indexes exist to evaluate nutrition quality, but few specifically assess the quality of a single meal. Objective: Our aim was to compare 4 different diet quality indexes in their ability to assess the nutrition quality of single meals. Design: This was a secondary analysis of data from the PACE (Effects of Physical Activity Calorie Expenditure) food labeling study (2015-2017). Data were collected in business cafeterias in North Carolina and included photos of lunch trays before consumption from an adult population and serving sizes of each food item. Additional nutrient analysis was conducted to compile macro- and micronutrient data for each food item, in addition to servings provided from each food group. Main outcome measures: The main outcome was individual meal nutrition quality. Data from the PACE study were used to calculate the scores of the following diet quality indexes: Healthy Eating Index 2015, Dietary Approaches to Stop Hypertension accordance score, Main Meal Quality Index, and Nutrient Rich Foods Index. Statistical analysis performed: To score the meals, algorithms were created in SAS software, version 9.4, to combine individual foods and beverages into meals and calculate scores according to the individual index components. The total scores for each of the indexes were compared using Spearman correlation coefficients. Results: A total of 8,070 observations or "meals" from 379 participants were scored for this study. The scores for each observation varied by index. The Spearman correlation coefficients between the indexes for the total score for all observations ranged from 0.26 to 0.68. The correlation coefficients did not change equally among the indexes when observations were excluded based on predefined criteria for what constitutes a meal. Conclusions: There is wide variability in scores of the 4 diet quality indexes analyzed in this study. In addition, the indexes show weak to moderate correlation, indicating that the appropriateness of the index will depend greatly on the study questions and objectives.
Oil palm (Elaeis guineensis Jacq.) is a heterogeneous, perennial crop having long breeding cycle with a genome size of 1.8 Gb. The demand for vegetable oil is steadily increasing, and expected that nearly 240–250 million tons of vegetable oil may be required by 2050. Genomics and next generation technologies plays crucial role in achieving the sustainable availability of oil palm with good yield and high quality. A successful breeding programme in oil palm depends on the availability of diverse gene pool, ex-situ conservation and their proper utilization for generating elite planting material. The major breeding methods adopted in oil palm are either modified recurrent selection or the modified reciprocal recurrent selection method. The QTLs of yield and related traits are chiefly located on chromosome 4, 10, 12 and 15 which is discussed in the current review. The probable chromosomal regions influencing the less height increment is observed to be on chromosomes 4, 10, 14 and 15. Advanced genomic approaches together with bioinformatics tools were discussed thoroughly for achieving sustainable oil palm where more efforts are needed. Major emphasis is given on oil palm crop improvement using holistic approaches of various genomic tools. Also a road map given on the milestones in the genomics and way forward for making oil palm to high yielding quality oil palm.
Within conventional scientific and policy analyses of malnutrition in all its forms, three forms of malnutrition are commonly distinguished: under-nutrition, micronutrient deficiencies and over-weight/obesity. This paper will identify and critically analyse the key features, limitations and consequences of this tripartite classification and the tripartite paradigm of malnutrition. Within this paradigm, the three forms of malnutrition are defined as being nutritionally and biologically specific; as essentially separate and distinct; as internally uniform and singular; and as decontextualized and de-socialised conditions. It is argued that this classification and framing legitimizes and promotes narrowly-focused policies, technological and commodified solutions and political and commercial interests. The paper concludes with notes towards an alternative framing of malnutrition.
Factors contributing to therapeutic inertia related to patients' medication experiences include concerns about side effects and out-of-pocket costs, stigmatization for having diabetes, confusion about frequent changes in evidence-based guidelines, low health literacy, and social determinants of health. A variety of solutions to this multifactorial problem may be necessary, including integrating pharmacists into interprofessional care teams, using medication refill synchronization programs, maximizing time with patients to discuss fears and concerns, being cognizant of language used to discuss diabetes-related topics, and avoiding stigmatizing patients. Managing diabetes successfully is a team effort, and the full commitment of all team members (including patients) is required to achieve desired outcomes through an individualized approach.
Introduction: The effectiveness of low-fat diets for weight loss has been debated for decades. Dozens of randomized control trials (RCTs) have assessed whether decreasing the intake of total fat leads to weight loss, giving mixed results. Hypothesis: We hypothesized that low-fat dietary interventions do not lead to greater weight loss when comparator diet intervention intensity is considered. Methods: We conducted a systematic review and meta-analysis. RCTs were included if they compared a low-fat dietary intervention to any control diet with at least 1 year of follow-up. We estimated the combined fixed effect inverse variance weighted mean difference of low-fat vs. comparison diets. Several a priori stratified analyses were considered to explore heterogeneity. Results: Fifty studies met inclusion criteria, reporting 1-10 years of follow-up on 70,054 participants. Overall, low-fat dietary interventions resulted in 0.51kg greater weight loss compared to other diets (95% CI = -0.62, -0.40, p<0.001; I2 = 83%). However, when trials where greater attention was given to the low-fat group were excluded, comparator diets led to greater weight loss than low-fat diets (n=30; WMD=0.87, 95% CI=0.56, 1.17, p<0.001). Similarly, when the type of comparator diet was considered, low-fat diets were only beneficial compared to control groups who were simply asked to maintain their usual diet (n=18; WMD = -1.03, 95% CI = -1.18, -0.88, p<0.001). When equal attention was given to intervention groups, low-carbohydrate diets (n=15; WMD = 1.13kg, 95% CI = 0.53, 1.73, p<0.001) and other “healthy” diets without a low-fat component (n=20; WMD = 0.77kg, 95% CI = 0.42, 1.13, p<0.001) led to greater weight loss than low-fat diets. Comparison diets, irrespective of type, were associated with 1.30kg greater weight loss than low-fat diets when the interventions were intended to be isocaloric (n=19; 95% CI = 0.92, 1.69, p<0.001). Conclusions: Low-fat dietary interventions are not more effective than other diets for weight loss when differences in intervention intensity between treatment groups are considered. Rather, evidence from long-term (>=1 year) randomized trials indicates low-carbohydrate or other healthful dietary pattern interventions without a low-fat focus may be more effective for weight loss than low-fat dietary interventions. Further evidence is needed to establish the role of these interventions in longer-term weight loss and weight maintenance.
Consumption of sugar-sweetened beverages (SSBs), particularly carbonated soft drinks, may be a key contributor to the epidemic of overweight and obesity, by virtue of these beverages’ high added sugar content, low satiety, and incomplete compensation for total energy. Whether an association exists between SSB intake and weight gain is unclear. We searched English-language MEDLINE publications from 1966 through May 2005 for cross-sectional, prospective cohort, and experimental studies of the relation between SSBs and the risk of weight gain (ie, overweight, obesity, or both). Thirty publications (15 cross-sectional, 10 prospective, and 5 experimental) were selected on the basis of relevance and quality of design and methods. Findings from large cross-sectional studies, in conjunction with those from well-powered prospective cohort studies with long periods of follow-up, show a positive association between greater intakes of SSBs and weight gain and obesity in both children and adults. Findings from short-term feeding trials in adults also support an induction of positive energy balance and weight gain by intake of sugar-sweetened sodas, but these trials are few. A school-based intervention found significantly less soft-drink consumption and prevalence of obese and overweight children in the intervention group than in control subjects after 12 mo, and a recent 25-week randomized controlled trial in adolescents found further evidence linking SSB intake to body weight. The weight of epidemiologic and experimental evidence indicates that a greater consumption of SSBs is associated with weight gain and obesity. Although more research is needed, sufficient evidence exists for public health strategies to discourage consumption of sugary drinks as part of a healthy lifestyle.
Background: Observational studies have found that dietary glycemic load is positively associated with C-reactive protein (CRP) concentrations in healthy humans, which suggests that the type of carbohydrate ingested influences inflammatory activity. Objective: We investigated the effect of a diet with a high content of sucrose or artificial sweeteners on the inflammatory markers CRP, haptoglobin, and transferrin in overweight subjects. Design: Overweight men and women consumed daily food and drink supplements containing either sucrose [n = 21; body mass index (BMI, in kg/m²): 28.0] or artificial sweeteners (n = 20; BMI: 27.6), predominantly from soft drinks (70%; average ≈1.3 L/d) for 10 wk. Results: During the intervention, sucrose intake increased by 151% in the sucrose group and decreased by 42% in the sweetener group, resulting in a 1.6-kg weight gain in the sucrose group and a 1.2-kg weight loss in the sweetener group over 10 wk (P < 0.001). Concentrations of haptoglobin, transferrin, and CRP increased by 13%, 5%, and 6%, respectively, in the sucrose group and decreased by 16%, 2%, and 26%, respectively, in the sweetener group (between-group differences: P = 0.006, P = 0.01, and P = 0.1, respectively). Adjustment for changes in body weight and energy intake did not substantially influence this outcome. Conclusions: The study shows that in the present group of overweight subjects a high consumption of sugar-sweetened foods and drinks increased haptoglobin and transferrin but had, at best, only a limited influence on CRP.
The glycemic index was proposed in 1981 as an alternative system for classifying carbohydrate-containing food. Since then, several hundred scientific articles and numerous popular diet books have been published on the topic. However, the clinical significance of the glycemic index remains the subject of debate. The purpose of this review is to examine the physiological effects of the glycemic index and the relevance of these effects in preventing and treating obesity, diabetes, and cardiovascular disease.