Obesity and the metabolic syndrome: role of different dietary
macronutrient distribution patterns and specific nutritional
components on weight loss and maintenance
Itziar Abete, Arne Astrup, J Alfredo Martínez, Inga Thorsdottir, and Maria A Zulet
Weight loss and subsequent body weight maintenance are difficult for obese
individuals despite the wide variety of dietary regimens and approaches. A
substantial body of scientific evidence has shown that by simply varying the
macronutrient distribution and composition of dietary factors, weight losses of
varying amounts, longer-term body weight maintenance periods, better appetite
diets, simultaneously restrict fat consumption to no more than 30%, favor
polyunsaturated fat, have carbohydrates account for between 40 and 50% of total
energy intake, and promote the consumption of low-glycemic foods. The present
and sustainable strategies for weight loss and body weight stability as well as for
treating specific features of the metabolic syndrome.
© 2010 International Life Sciences Institute
An excess amount of body fat not only leads to reduced
quality of life and large healthcare-associated costs,it also
increases the risk of death.1Indeed, obesity has been
related to a number of cardiovascular and metabolic dis-
orders such as hypertension, type 2 diabetes, hyperin-
sulinemia,dyslipidemia,atherosclerosis,and even certain
types of cancers.2,3In addition to genetic predisposition,
an inactive lifestyle and high caloric intake are the over-
riding causes of excessive weight gain.4,5Thus, lifestyle
changes affecting dietary habits and physical activity are
essential to promote weight loss.6–8For decades, nutri-
tional intervention studies have been focused on reduc-
ing dietary fat with no positive results over long-term
periods.9,10The carbohydrate content of diets was also
tinued to increase.11
In diets designed to prevent and treat obesity by
manipulating energy content,macronutrient distribution
was commonly set at 15% protein, <30% lipids, and
50–55% carbohydrates,with reductions in dietary fat and
seemed to be effective for decreasing energy density and
promoting weight loss in the short term, the low level of
observed satiety it achieved decreased dietary adherence
over longer periods.5,11Monitoring of low-energy diets
with these macronutrient proportions revealed that they
were often not sustainable for long periods of time.12
Likewise, low-carbohydrate diets (low-CHO) have
over short-term periods, but their long-term effects have
not been fully established.13Moreover, the higher satu-
rated fat intake of these diets may increase LDL-
cholesterol levels14and have other adverse effects.15Other
clinical intervention programs have studied different
Affiliations: I Abete, J Alfredo Martínez, and MA Zulet are with the Department of Nutrition, Food Science, Physiology andToxicology,
University of Navarra, Pamplona, Navarra, Spain. A Astrup is with the Faculty of Life Sciences, Department of Human Nutrition, Centre for
Advanced Food, Studies, University of Copenhagen, Frederiksberg, Denmark. I Thorsdottir is with the Unit for Nutrition Research Faculty of
Food Science and Nutrition School of Health Sciences, University of Iceland and University Hospital IS-101, Reykjavik, Iceland.
Correspondence: J Alfredo Martínez, Department of Nutrition, Food Science, Physiology andToxicology, University of Navarra, C/Irunlarrea
1, 31008 Pamplona, Spain. E-mail: firstname.lastname@example.org, Phone: +34 948425600 ext. 6424, Fax: +34 948425649.
Key words: dietary compliance, metabolic syndrome, protein content, weight loss diets, weight management
Nutrition Reviews® Vol. 68(4):214–231
nutritional treatments in order to improve both weight
loss and weight maintenance or associated metabolic
ing: varying macronutrient composition,13,16–18incorpo-
rating bioactive ingredients such as fiber19or flavonoids,20
manipulating the glycemic index (GI)21,22on the omega-3
fatty acid profile,23and manipulating the composition of
minerals such as calcium24and selenium.25Studies with
low-GI diets have shown a number of favorable effects
such as rapid weight loss, better management of glucose
and insulin levels, and reductions in triglyceride levels
and blood pressure.5,26,27
On the other hand, current evidence indicates that
diets moderately high in protein and modestly restricted
in carbohydrate and fat may have more beneficial effects
on body weight homeostasis and associated metabolic
parameters.28–32Likewise,the increase of dietary omega-3
fatty acids (FAs) may be an important factor in weight
loss and weight maintenance approaches affecting satiety
focused on decreasing hunger and promoting satiety in
an effort to improve adherence and make weight loss and
weight maintenance easier.32–34Thus, diets designed to
low-GI carbohydrates, and specific omega-3 FAs may
have beneficial effects on satiety and compliance contrib-
uting to weight loss and weight control,which may be an
alternative to conventional diets.35,36
The current article reviews the effects of different
weight-loss diets on body weight,metabolic markers,and
body weight maintenance with a particular emphasis on
moderate-protein diets (30–35% energy at the expense of
carbohydrates), those with low-GI carbohydrates (within
the 40% energy),and diets in which omega-3 FA intake is
high at the expense of saturated FAs (within 30% of total
studies are presently
Ad libitum versus energy-restricted diets
The role of specific foods and nutrients in the prevention
and treatment of obesity,as well as in associated compli-
cations, has become a major focus of concern in nutri-
tional research.37,38Dietary strategies to reduce fat mass
have changed over time with variations seen in macronu-
trient composition, fiber content, and bioactive food
ingredients; however, there is still an intense debate over
which,if any,dietary regime might be the most beneficial
for weight loss and long-term weight maintenance.39
Control of food intake is one of the most important
factors putatively involved in the success of dietary treat-
ment of obesity due to its relation with energy balance.33
The regulation of appetite as well as feelings of hunger
and satiety is a determinant factor affecting adherence to
a weight-loss program. Thus, nutritional programs have
modified the type of energy restriction to improve com-
pliance over long-term periods.Several decades ago most
dietary strategies were energy restricted,but a number of
currently available weight-loss diets are designed to be ad
libitum. Energy restriction has consistently been proven
to produce weight loss and to have beneficial health
effects. However, most individuals are unable to sustain
weight losses induced by reducing energy intake, poten-
tially because of increased hunger levels9and energy
monotony and lack of variability make compliance diffi-
cult during extended periods.
Conversely, ad libitum programs with variety in the
being restricted to a diet, which could improve their
adherence and weight loss. Ad libitum low-fat diets, low-
as tools for facilitating weight lowering and stability
thereafter.22,41Indeed,a few long-term trials have demon-
strated better results in weight loss and weight mainte-
nance with ad libitum programs. Some studies based on
low-CHO intake strategies, lasting up to 12 months and
performed in obese subjects with no energy restriction,
resulted in more weight loss than a conventional energy-
restricted diet.42,43The CARMEN trial also investigated
the long-term effect of ad libitum, low-fat, high-CHO
diets containing simple or complex carbohydrates on
normal macronutrient intake.After 6 months,they found
it was favorable to replace dietary fat with carbohydrates
(simple or complex) for the purpose of body weight regu-
lation, since those patients following the low-fat high-
CHO (simple or complex) diets registered greater losses
of weight and fat mass than patients in the control
Thus, adherence to slimming programs and mainte-
nance of achieved body weight reduction are challenging
aspects of weight-loss strategies.46Different nutritional
intervention studies considering both energy-restricted
and ad libitum approaches have been reported to differ-
entially affect thermogenesis,energy expenditure,satiety,
hormonal balance, and other factors that would not only
reduce energy intake, but improve compliance, weight
loss, and weight maintenance.11
The adoption of healthy dietary patterns to facilitate
weight loss, cardiovascular disease risk reduction, and
weight management is often really difficult in an obe-
Nutrition Reviews® Vol. 68(4):214–231
sogenic environment in which palatable,inexpensive,and
high-fat foods are easily available. Thus, alternative
dietary strategies are being studied to facilitate adherence
to healthy dietary habits. To this end, a number of inves-
tigations have suggested that meal-replacement products
may represent an important strategy for combating the
convenience.11,47–49Meal replacements may simplify the
weight-loss regimens by replacing one or two meals a day
with a product of defined nutrient and calorie content.
Compared with the simple provision of food plans, a
weight-loss program based on meal replacements for one
or two meals per day has been shown to improve com-
pliance with a calorie-restricted diet as well as weight
management in overweight and obese individuals.47,48,50
The composition of the meal replacement is also of inter-
ments may increase feelings of satiety and may favor the
reduction of energy intake in subsequent meals.51
Accordingly, one nutritional intervention study showed
that a relatively high-protein meal (25% proteins; 45%
carbohydrates; 30% fats) was more satiating and had a
proteins; 60% carbohydrates; 30% fats).52Several health
professionals currently recommend the use of meal-
replacement products, and these products are used
increasingly in weight-loss studies Meal-replacement
products may prove very useful for facilitating compli-
ance with weight-reduction programs and weight man-
agement, at least in the short term.
Low-calorie diets can achieve acute weight loss,but often
the slimming result is not maintained long term.53A
rently being investigated. There is intense controversy
about the types of diets and macronutrient distributions
that are most effective for treating overweight or obesity.
Many trials investigating the macronutrient composition
weight loss and the weight maintenance process. One
recent nutritional intervention study compared the effect
protein, and carbohydrates.54The investigators assessed
the change in body weight after 2 years, comparing diets
with low fat versus high fat, average protein versus high
protein,and the highest and lowest carbohydrate content.
At 6 months,participants had lost 7% of their initial body
weight with no group differences; however, all groups
began to regain weight after 12 months. After 2 years,
differences in weight loss were not apparent among the
dietary groups. The authors also concluded there was no
major macronutrient influence on weight loss.Neverthe-
less,compliance with dietary goals (whether high protein
or low fat) was associated with improved weight loss.54,55
Low-fat diets. An alternative to calorie restriction is to
decrease the fat content of the diet. In this context, a
multicenter intervention trial investigated whether a
hypoenergetic low-fat diet was superior to a hypoener-
getic moderate high-fat diet for the treatment of obesity.
After a 10-week weight-loss period, the low-fat diet pro-
duced similar mean weight loss to the high-fat diet,but it
weight and fewer dropouts.56However, the long-term
effects of fat-restricted diets on weight loss have not been
established. In a literature review by Summerbell et al.12
the authors investigated low-fat diets for obesity and con-
cluded that fat-restricted diets are no better than calorie-
restricted diets for achieving stable weight loss in
overweight or obese people.
Another recent nutritional intervention trial com-
tenance after an initial weight loss of ?8%.The diets had
different dietary contents, including carbohydrates and
35–45% fat and >20% MUFA content; low-fat diet with
20–30% fat; or control diet with 35% fat),but the protein
content was similar (10–20%). After 6 months, dietary
composition had no major effect on preventing weight
regain;however,both the MUFA diet and the low-fat diet
resulted in less body fat regain than the control diet.57
Overall, the evidence supports that low-fat diets are
an optimal choice for the prevention of weight gain and
obesity. A reduction in the percentage of energy con-
sumed as fat is positively associated with weight loss.
Indeed, a 10% reduction in dietary fat is predicted to
produce a 4–5 kg weight loss in an individual with a BMI
of 30 kg/m2.58However,future research needs to focus on
improving and maintaining adherence to the treatments
used to promote weight loss and maintenance.
Low-carbohydrate diets. Low-CHO/high-fat diets have
been compared with low-fat energy-restricted diets. This
nutritional strategy becomes an alternative to a low-fat
diet for producing weight loss in short periods of time.
their proven effectiveness in producing rapid weight
losses and beneficial metabolic changes.13,59However,the
lackof long-termstudiesandreportsof someundesirable
effects, such as increased levels of ketone bodies, high
losses of body water, headache, constipation, and, espe-
cially, difficulties maintaining weight loss after the diet,
make it difficult to recommend these diets as a healthy
option for weight loss.Nevertheless,a recent intervention
study evaluated the effect of a low-CHO high-fat diet for
Nutrition Reviews® Vol. 68(4):214–231
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