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Regular eating, not intermittent fasting, is the best strategy for a healthy eating control

February 2020
IJEDO 2:5-7

DOI:10.32044/ijedo.2020.02

Authors:

Riccardo Dalle Grave

Villa Garda Hospital, Italy

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IJEDO

Italian Journal of Eating Disorders and Obesity

ORIGINAL ARTICLE

IJEDO 2020;2:5-7

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Riccardo Dalle Grave, MD ( ) rdalleg@gmail.com

Received: 11 January 2020; Accepted: 20 January 2020; Published online: 17 February 2020. doi:10.32044/ijedo.2020.02

Abstract

Intermitting fasting has been proposed as a dietary strategy to improve general

health indicators, slow or reverse disease processes and aging. However, data

supporting the beneﬁcial health effects of intermittent fasting mainly derive from

preclinical studies in animals and short-term clinical studies on weight loss

and non-communicable disease risk factors, with no signiﬁcant differences on

these outcomes when intermittent fasting has been compared with moderate

continuous energy restriction in humans. No data are available on the effect of

intermitting fasting on clinically important outcomes in humans, such as the onset

of cardiovascular diseases, cancer, and life expectancy. Instead, several studies

found an association between delayed eating (i.e., spending many hours during the

day without eating) and increased risk of developing episodes of overeating and

binge eating. Moreover, the procedure of regular eating, adopted by the “enhanced”

cognitive behavior therapy for eating disorders (CBT-E), results in a rapid decease

in the frequency of binge-episodes in patients with bulimia nervosa and binge-

eating disorders. These data indicate that regular eating, not intermitting fast, is the

best choice for adopting a healthy eating control and avoiding the development of

unregulated and, in some cases, disturbed eating behavior.

Key words

Intermittent fasting

Regular eating

Starvation

Life expectancy

Health disease

Aging

Eating disorders

Bulimia nervosa

Binge-eating disorder

Regular eating, not intermittent fasting,

is the best strategy for a healthy eating control

Riccardo Dalle Grave

Depar tment of Eating and Weight Disorders, Villa Garda Hospital, Garda ( VR), Italy

Intermittent fasting has been recently proposed as an eating

pattern strategy to elicit, through the metabolic switch from

the use of glucose as fuel source to the use of fatty acids and

ketone bodies, the improvement of insulin resistance, obe-

sity, dyslipidemia, high blood pressure and cognitive fun-

ctions, the increased resistance to stress, the suppression of

inﬂammation and the increase of life expectancy (de Cabo

& Mattson, 2019). These dietary practices in its more com-

mon forms (e.g., alternate fasting days; 5:2 intermittent

fasting, i.e., fasting 2 days each week; daily time-restricted

feeding) (Anton et al., 2018) has been proposed to treat

obesity, diabetes, cardiovascular diseases, cancer, neurode-

generative diseases, asthma, multiple sclerosis, osteoarthri-

tis, surgical tissue lesions and ischemic and to prolong life

expectancy (de Cabo & Mattson, 2019).

Data supporting the beneﬁcial effects of intermittent

fasting derives from preclinical studies on animals (e.g.

rats) (Anton et al., 2018; Swindell, 2012). The few clini-

cal published studies assessed only the short-term (weeks

or months) effect of this intervention on weight loss and

some non-communicable diseases risk factors. To date no

data are available on the effect of intermitting fasting on

clinically important outcomes, such as the onset of cardio-

vascular diseases, cancer, and lifer expectancy in humans.

Furthermore, most studies did not compare the long-term

effects of intermittent fasting with continuous energy re-

Riccardo Dalle Grave

doi:10.32044/ijedo.2020.02

IJEDO

Italian Journal of Eating Disorders and Obesity

onlineijedo.positivepress.net IJEDO 2020;2:5-7

striction. Therefore, it is not known whether the observed

positive effects on risk factors are the result of intermittent

fasting or calorie restriction per se.

The only published clinical study with long-term outco-

me data (i.e., 24 months) on weight loss and cardiovascular

risk factors is a one-year randomized parallel trial which

randomized 332 adults with overweight or obesity to one of

three groups: (1) continuous energy restriction (1000 kcal/

day for women and 1200 kcal/day for men); (2) week-on-

week-off energy restriction (alternating between the same

energy restriction as the continuous group for one week and

one week of habitual diet); or (3) 5:2 (500 kcal/day on mo-

diﬁed fast days each week for women and 600 kcal/day for

men, the 2 days of energy restriction could be consecutive

or non-consecutive). The study did not ﬁnd signiﬁcant dif-

ferences in weight loss and in the modiﬁcation of the cardio-

vascular risk factors among the three groups at both 12 and

24 months (Headland, Clifton, & Keogh, 2019, 2020).

Other tr ials with shor ter duration achieved t he same con-

clusion as the Headland et al. study (2020). For example, a

short-term randomized study, comparing alternate-day fa-

sting with moderate daily caloric restriction in adults with

obesity, found no signiﬁcant between-group differences in

change in weight body composition, lipids and insulin sen-

sitivity index after 8-weeks of treatment, and no signiﬁcant

differences in weight regain after 24 weeks of unsupervised

follow-up (Catenacci et al., 2016). The same conclusion was

reached by a 12-month trial that found no signiﬁcant diffe-

rences in adherence, weight loss and maintenance, and car-

diovascular protection between intermittent fasting (25%

of energy needs on fast days; 125% of energy needs on al-

ternating “feast days”) compared to a moderate continuous

energy restriction (75% of energy needs every day) (Tre-

panowski et al., 2017). The results of these studies conﬁrm

the conclusions of a systematic metanalytical review of 9

studies of a minimum duration of 6 months, in which no

difference in weight loss was observed between continuous

calorie restriction and intermittent fasting (Headland, Cli-

fton, Carter, & Keogh, 2016).

Although there are no signiﬁcant differences in terms

of weight loss and improvement of cardiovascular risk fac-

tors between intermittent fasting and continuous energy

restriction, several studies found an association between

delayed eating (i.e., spending many hours during the day

without eating) and increased risk of developing episodes

of overeating and binge eating. A laboratory experiment

found that participants deprived of food for 6-hour con-

sumed signiﬁcantly more calories at the buffet compared

to subjects in the 1-hour food deprivation condition (Tel-

ch & Agras, 1996). Studies on binge-eating disorder (BED)

have observed that patients with overweight and BED who

ate three meals per day weighed signiﬁcantly less, and had

signiﬁcantly fewer binge eating episodes, than those who

did not regularly eat three meals per day (Masheb & Grilo,

2006). Moreover, regular consumption of breakfast, lunch

and dinner was signiﬁcantly correlated with a lower body

mass index in people with obesity and BED (Masheb, Grilo,

& White, 2011). Research has also shown that dieting signi-

ﬁcantly predicted future weight gain in normal weight in-

dividuals (Lowe, Doshi, Katterman, & Feig, 2013), and was

a risk factor for the development of eating disorders of cli-

nical severity (Schaumberg & Anderson, 2016; St ice, 2016).

The most important evidence in favor of regular eating

pattern (3 + 2 + 0), however, derives from the results of stu-

dies that assessed the efﬁcacy and effectiveness of “enhan-

ced” cognitive behavioral therapy (CBT-E) for eating disor-

ders (Dalle Grave & Calugi, 2020; Fairburn, 2008). CBT-E

is based on a theory postulating that delayed eating and the

adoption of extreme and rigid dietary rules are the most

potent mechanisms maintaining binge-eating episodes

(Fairburn, Cooper, & Shafran, 2003). For this reason, a key

procedure adopted by CBT-E is “regular eating” that sug-

gest patients to plan in advance 3 main meals (breakfast,

lunch and dinner) and 2 snacks (mid-morning snack and

mid-afternoon snack) and not eating between these inter-

vals: a procedure also called 3 + 2 + 0. Randomized and

cohort studies have shown that regular eating procedures

result in a rapid decrease in the frequency of binge-episo-

des in patients with bulimia nervosa (Dalle Grave, Calugi,

Sartirana, & Fairburn, 2015; Fairburn et al., 2009) and BED

(Grilo & Masheb, 2005). A study assessing the efﬁcacy of

CBT for bulimia nervosa has also found that participants

who ate 80 meals and at least 21 afternoon snacks in the

previous month reported the highest abstinence rate (70%)

from binge-eating episodes (Shah, Passi, Bryson, & Agras,

2005). This ﬁnding was also observed in a study using CBT

guided self-help in patients with binge-eating episodes

(Zendegui, West, & Zandberg, 2014). These results led to

afﬁrm that regular eating is probably the single most im-

portant procedure in the treatment of eating disorders with

binge-eating episodes (Fairbu r n, 2013).

In conclusion, there are no evidences, supported by

long-term randomized controlled trials, that intermittent

fasting produces additional clinical beneﬁts, compared to

healthy and regular eating patterns, and greater weight

loss, compared to a moderate continuous energy restri-

ction. Instead, there are some evidences that delayed ea-

ting increases the risk of developing episodes of overeating

Riccardo Dalle Grave

doi:10.32044/ijedo.2020.02

IJEDO

Italian Journal of Eating Disorders and Obesity

onlineijedo.positivepress.net IJEDO 2020;2:5-7

and binge eating. For these reasons, it is inappropriate to

recommend intermitting fasting as a healthy eating practi-

ce. Regular eating, preferably based on the Mediterranean

diet model (Estruch et al., 2018), is the best choice to re-

duce the risk of disease and to avoid the development of

unregulated and, in some cases, disturbed eating behavior.

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Cognitive behavior therapy for adolescents with eating disorders

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Aug 2020

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Article

May 2017

Importance: Alternate-day fasting has become increasingly popular, yet, to date, no long-term randomized clinical trials have evaluated its efficacy. Objective: To compare the effects of alternate-day fasting vs daily calorie restriction on weight loss, weight maintenance, and risk indicators for cardiovascular disease. Design, setting, and participants: A single-center randomized clinical trial of obese adults (18 to 64 years of age; mean body mass index, 34) was conducted between October 1, 2011, and January 15, 2015, at an academic institution in Chicago, Illinois. Interventions: Participants were randomized to 1 of 3 groups for 1 year: alternate-day fasting (25% of energy needs on fast days; 125% of energy needs on alternating "feast days"), calorie restriction (75% of energy needs every day), or a no-intervention control. The trial involved a 6-month weight-loss phase followed by a 6-month weight-maintenance phase. Main outcomes and measures: The primary outcome was change in body weight. Secondary outcomes were adherence to the dietary intervention and risk indicators for cardiovascular disease. Results: Among the 100 participants (86 women and 14 men; mean [SD] age, 44 [11] years), the dropout rate was highest in the alternate-day fasting group (13 of 34 [38%]), vs the daily calorie restriction group (10 of 35 [29%]) and control group (8 of 31 [26%]). Mean weight loss was similar for participants in the alternate-day fasting group and those in the daily calorie restriction group at month 6 (-6.8% [95% CI, -9.1% to -4.5%] vs -6.8% [95% CI, -9.1% to -4.6%]) and month 12 (-6.0% [95% CI, -8.5% to -3.6%] vs -5.3% [95% CI, -7.6% to -3.0%]) relative to those in the control group. Participants in the alternate-day fasting group ate more than prescribed on fast days, and less than prescribed on feast days, while those in the daily calorie restriction group generally met their prescribed energy goals. There were no significant differences between the intervention groups in blood pressure, heart rate, triglycerides, fasting glucose, fasting insulin, insulin resistance, C-reactive protein, or homocysteine concentrations at month 6 or 12. Mean high-density lipoprotein cholesterol levels at month 6 significantly increased among the participants in the alternate-day fasting group (6.2 mg/dL [95% CI, 0.1-12.4 mg/dL]), but not at month 12 (1.0 mg/dL [95% CI, -5.9 to 7.8 mg/dL]), relative to those in the daily calorie restriction group. Mean low-density lipoprotein cholesterol levels were significantly elevated by month 12 among the participants in the alternate-day fasting group (11.5 mg/dL [95% CI, 1.9-21.1 mg/dL]) compared with those in the daily calorie restriction group. Conclusions and relevance: Alternate-day fasting did not produce superior adherence, weight loss, weight maintenance, or cardioprotection vs daily calorie restriction. Trial registration: clinicaltrials.gov Identifier: NCT00960505.

A Randomized Pilot Study Comparing Zero-Calorie Alternate-Day Fasting to Daily Caloric Restriction in Adults with Obesity

Article

Sep 2016
OBESITY

Objective: To evaluate the safety and tolerability of alternate-day fasting (ADF) and to compare changes in weight, body composition, lipids, and insulin sensitivity index (Si) with those produced by a standard weight loss diet, moderate daily caloric restriction (CR). Methods: Adults with obesity (BMI ≥30 kg/m(2) , age 18-55) were randomized to either zero-calorie ADF (n = 14) or CR (-400 kcal/day, n = 12) for 8 weeks. Outcomes were measured at the end of the 8-week intervention and after 24 weeks of unsupervised follow-up. Results: No adverse effects were attributed to ADF, and 93% completed the 8-week ADF protocol. At 8 weeks, ADF achieved a 376 kcal/day greater energy deficit; however, there were no significant between-group differences in change in weight (mean ± SE; ADF -8.2 ± 0.9 kg, CR -7.1 ± 1.0 kg), body composition, lipids, or Si. After 24 weeks of unsupervised follow-up, there were no significant differences in weight regain; however, changes from baseline in % fat mass and lean mass were more favorable in ADF. Conclusions: ADF is a safe and tolerable approach to weight loss. ADF produced similar changes in weight, body composition, lipids, and Si at 8 weeks and did not appear to increase risk for weight regain 24 weeks after completing the intervention.

Interactive and Mediational Etiologic Models of Eating Disorder Onset: Evidence from Prospective Studies

Article

Apr 2016

Eric Stice

It is vital to elucidate how risk factors work together to predict eating disorder onset because it should improve the yield of prevention efforts. Risk factors that have predicted eating disorder onset in multiple studies include low body mass index (BMI) for anorexia nervosa; thin-ideal internalization, perceived pressure to be thin, body dissatisfaction, dieting, and negative affect for bulimia nervosa; and body dissatisfaction and dieting for purging disorder. No risk factors have been identified for binge eating disorder. Classification tree analyses have identified several amplifying interactions, mitigating interactions, and alternative pathway interactions between risk factors, such as evidence that elevated BMI amplifies the risk between appearance overvaluation and the future onset of recurrent binge eating. However, there have been no tests of mediational risk factor models in the prediction of eating disorder onset. Gaps in the literature are identified and procedures for providing rigorous tests of interactive and mediational etiologic models are outlined. Expected final online publication date for the Annual Review of Clinical Psychology Volume 12 is March 28, 2016. Please see http://www.annualreviews.org/catalog/pubdates.aspx for revised estimates.

Regular eating, not intermittent fasting, is the best strategy for a healthy eating control

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