1. Nutrition 26 (2010) 141–145
www.nutritionjrnl.com
Review article
Carbohydrate for weight and metabolic control: Where do we stand?
Kevin J. Acheson, Ph.D.*
Department of Nutrition and Health, Nestle Research Centre, Lausanne, Switzerland
´
Manuscript received June 30, 2009; accepted July 7, 2009.
Abstract Changes in lifestyle are considered to play an important role in the etiology of obesity and type
2 diabetes, and improvements in diet and physical activity are the first-choice treatment for these met-
abolic diseases. Since the dietary recommendations of almost 40 y ago that fat should be decreased and
that carbohydrate should be increased, recommendations for a healthy diet, except for minor amend-
ments, have not changed that much. It is generally considered that caloric restriction is more important
than changes in the macronutrient composition of the diet for weight loss and body weight control.
Although this is true, there is increasing evidence that changes in the macronutrient composition of
the diet (decreasing carbohydrate and increasing unsaturated fats and/or protein) play a role that facil-
itates weight loss, increases insulin sensitivity and glucose tolerance, and improves cardiovascular risk
factors, such as blood pressure, blood lipid profile, and inflammatory markers, often independent of
weight loss. Low-carbohydrate diets, whether they be high in unsaturated fats and/or protein, are
not recommended by the American Diabetes Association; however, despite this the Joslin Diabetes
Center currently advocates a diet composition of w40% carbohydrate, 30% fat, and 30% protein
energy for overweight and obese adults with type 2 diabetes or prediabetes or those at high risk of
developing type 2 diabetes. Hopefully, future studies will indicate whether diets with a more equili-
brated macronutrient composition than presently recommended are more appropriate for body weight
and metabolic control. Ó 2010 Elsevier Inc. All rights reserved.
Keywords: Obesity; Diet; Macronutrient composition; Weight reduction
Introduction be in the 10–20% range of energy intake. However, despite
these recommendations, the prevalence of obesity and type
Lifestyle change in diet and physical activity is the best 2 diabetes has continued to increase. Although this has led
first-choice treatment for weight management [1] and, some to question the recommendations, it is also very possi-
although the success rate over the long term is considered ble that many individuals do not comply with the recommen-
poor, it is still regarded as the primary strategy for weight dations that have been made [15]. Nevertheless, one might
loss in obesity and for improving metabolic control in type expect that type 2 diabetics and others who have the meta-
2 diabetics [2–6]. bolic consequences of an inappropriate diet would be more
Thirty years ago the Lausanne group provided evidence compliant, unless they were willing to resort to pharmaco-
that fat synthesis from dietary carbohydrate (de novo lipo- logic therapy. Although the use of oral hypoglycemics and
genesis) was a minor contributor to fat accumulation in obe- insulin reduce hyperglycemia in the short and medium
sity [7–10] and this was later confirmed by a series of isotope term, the fact that in some individuals it is possible to reduce,
studies measuring fractional hepatic de novo lipogenesis or completely discontinue, these medications by dietary
[11–14]. Such results were in line with, and supportive of, changes alone [16] should be sufficient evidence for greater
dietary guidelines at that time, which have remained rela- efforts to be made to convince them to follow the most appro-
tively unchanged to the present day, namely that the propor- priate diet to correct their metabolic symptoms. Unfortu-
tion of carbohydrates in the diet should be relatively high, nately, where diet and weight control are concerned, there
dietary fat should be restricted to 30%, and protein should is a mass of controversial literature available and the
individual who wishes to lose weight and/or correct meta-
* Corresponding author. Tel.: þ41-21-785-8919; fax: þ41-21-785-8544. bolic symptoms often has to try several diets before finding,
E-mail address: kevin.acheson@rdls.nestle.com (K. J. Acheson). if at all, the one that works best for him or her.
0899-9007/10/$ – see front matter Ó 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.nut.2009.07.002

2. 142 K. J. Acheson / Nutrition 26 (2010) 141–145
Low-carbohydrate diets concentrations, and further reduced estimated cardiovascular
risk. The researchers discussed the potential of hypocaloric
Since the publication of a number of intervention trials in diets rich in protein or monounsaturated fats to facilitate
2003 that demonstrated certain advantages of consuming weight loss and the possibility that the DASH diet could be
a low-carbohydrate diet [17–19], evidence is accumulating improved by partial substitution of carbohydrate with pro-
that will help define the most favorable macronutrient com- tein, from plant and animal sources, or with monounsaturated
position of the diet for body weight and metabolic control. fats. Indeed, under controlled hypocaloric conditions, the
Although this evidence is not clearcut, it does appear to be low-fat, high-protein and high-monounsaturated fat, stan-
having some influence on the nutritional guidelines recom- dard-protein diets induced similar weight loss, w10 kg, in
mended by a number of medical associations and institutions, overweight and obese individuals over a 12-wk period,
which rely more and more on results from randomized, with concomitant improvements in insulin sensitivity and
controlled clinical trials. cardiovascular disease risk factors [25].
In a meta-analysis of randomized control trials comparing Reaven [26] proposed substituting unsaturated for satu-
low-carbohydrate diets, without energy restriction against rated fats to reduce LDL cholesterol concentrations and pro-
low-fat, energy-restricted diets, Nordmann et al. [20] con- vided evidence to support this by assigning insulin-resistant
cluded that low-carbohydrate diets were at least as effective obese individuals to a 16-wk energy-restricted diet similar
as low-fat diets for weight loss, with the caveat that favorable to that recommended by the American Diabetes Association
changes in triacylglycerols and high-density lipoprotein (ADA) composed of 15% protein, 60% carbohydrate, and
(HDL) cholesterol should be weighed against potentially un- 25% fat or another diet in which 20% of carbohydrate energy
favorable increases in low-density lipoprotein (LDL) choles- was substituted for by mono- and polyunsaturated fats such
terol. However, the atherogenic potential of LDL cholesterol that the final composition was 15% protein, 40% carbohy-
appears to depend more on particle size than its concentration drate, and 45% fat [27]. Weight loss was slightly, but not sig-
[21]. Although two studies that investigated the effect of nificantly, greater on the 40% carbohydrate diet, which one
three popular diets, the Atkins, Ornish, and Zone diets, on might expect if the subjects adhered to their energy-restricted
weight loss and metabolic risk factors over 1 y observed dis- diet, and improved insulin sensitivity correlated with weight
parate results [22,23], with respect to weight loss on the loss. Throughout the day insulin and triacylglycerol concen-
Atkins diet the authors of both studies commented in favor trations were significantly lower, fasting triacylglycerol and
of low-carbohydrate diets for weight loss [23] and improve- E-selectin concentrations were lower, and greater increases
ment of cardiovascular risk factors [22,23]. Dansinger et al. in HDL cholesterol concentrations and LDL particle size
[22] commented that their study was designed to investigate were observed after the lower-carbohydrate diet, indicating
dietary adherence under uncontrolled conditions rather than that, although weight loss was similar on the two diets, reduc-
identify the most appropriate diet for weight loss and reduc- ing the carbohydrate content of the diet and replacing it with
tion of cardiovascular risk. Because the attrition rates were unsaturated fats improved cardiovascular disease risk factors.
high (35% to 50%) and adherence to the diets decreased Other short-term studies have observed that an isocaloric
over time, they concluded that sustained adherence to high-protein diet increases satiety [28]. In the same study,
a diet, rather than diet type, predicted weight loss and reduc- increasing the protein content of an ad libitum diet from
tion of cardiac risk factors. 15% to 30%, by replacing fat and keeping carbohydrate at
Further support for low-carbohydrate diets was provided 50% energy for 12 wk, decreased spontaneous energy intake
by the results of the OmniHeart trial [24], which demon- with concomitant reductions in body weight and body fat
strated that the macronutrient composition of the diet, even [28]. Increasing the protein content of a weight-maintenance
under weight-maintenance conditions, could have significant diet, after a period of weight loss, was also found to improve
effects on improving blood pressure and cardiovascular risk weight maintenance when compared with a diet rich in carbo-
factors. They observed that consuming a carbohydrate diet, hydrates over a 12-wk period [29]. More extreme diets, such as
similar to the Dietary Approaches to Stop Hypertension the very low carbohydrate ketogenic diet, evaluated over a sim-
(DASH) diet, providing 15% protein, 58% carbohydrate, ilar time frame, have also demonstrated better body weight and
and 27% fat energy for 6 wk, resulted in decreased blood fat losses, improved insulin sensitivity and glucose control,
pressure and lower total cholesterol, LDL cholesterol, and and decreased leptin concentrations in overweight and obese
HDL cholesterol concentrations. Although HDL cholesterol subjects with atherogenic dyslipidemia when compared with
decreased, the decrease was much less than that of LDL a low-fat diet [30]. Although anti-inflammatory effects were
cholesterol. However, two other weight-maintenance diets observed on both diets, they were greater on the very low car-
consumed over the same period and designed to replace bohydrate ketogenic diet [31]. When such a diet was extended
10% of carbohydrate energy with protein (i.e., 25% protein, to 6 mo and compared with a low glycemic index diet, it was
48% carbohydrate, and 27% fat) or unsaturated fat (15% associated with greater weight loss, better improvements in
protein, 48% carbohydrate, and 37% fat) lowered systolic metabolic control, and more frequent reduction or discontinu-
and diastolic blood pressures further, improved blood lipid ation of diabetes medication [16].

3. K. J. Acheson / Nutrition 26 (2010) 141–145 143
Although these short-term studies have provided evidence only deleterious if there is sufficient carbohydrate in the diet
that dietary carbohydrate restriction has a number of health to provide an hormonal state in which fat will be stored rather
benefits, longer trials have shown mixed results [32,33]. than oxidized [30,38]. Furthermore, the ‘‘high-fat diet’’ was
A comparison of three diets, low-carbohydrate unrestricted the subject of a number of short-term studies (8 to 24 d) in the
energy, Mediterranean restricted energy, and low-fat 1950s, reported in the Lancet [39], before it was popularized
restricted energy, on weight loss in moderately obese subjects by the publication of Dr. Atkins Diet Revolution [40] in 1972.
over 2 y demonstrated significant decreases in body weight, It was clearly demonstrated that subjects consumed less fat
blood pressure, and waist circumference with all diets; how- on a ‘‘high-fat diet’’ than when they followed their habitual
ever, these were greater on the low-carbohydrate and Medi- diet, because it is virtually impossible to consume large
terranean diets than on the low-fat diet [33]. Concomitant amounts of fat in the absence of carbohydrate, and it was pro-
improvements in lipid profiles and other markers were also posed that the high-fat diet was a misnomer and that it should
more favorable on the low-carbohydrate and Mediterranean be referred to as the low-carbohydrate diet [39].
diets [33]. In contrast, Sacks et al. [32], found that weight If carbohydrate is replaced by increasing protein, one
loss of overweight subjects consuming reduced-calorie diets might expect that the satiating and thermogenic effects of
with different fat, protein, and carbohydrate contents over 2 y protein [28,36,37,41] would encourage a negative energy
occurred regardless of the macronutrient composition of the balance and weight loss. However, potential deleterious ef-
diet. Unfortunately, despite intensive participant instruction fects of long-term high-protein intakes on liver and kidney
throughout this trial, adherence to the diets was poor and functions have often been used as an argument against the
the requisite differences between groups for energy intake use of low-carbohydrate, high-protein diets.
and macronutrient composition were not attained. Although The 2005 Dietary Guidelines for Americans consider that
the shortcomings of this study were highlighted in an accom- proteins are consumed in sufficient amounts not to be a focus
panying editorial [34], it is probable that many readers will of the guidelines and because calorie restriction is believed to
accept the researchers’ conclusions without criticism. be more important for weight control than the macronutrient
composition of the diet, these topics are not discussed [1].
Dietary guidelines The ADA recognizes the increasing number of studies pro-
viding evidence in support of low-carbohydrate diets for
In the latest edition of Dietary Guidelines for Americans, weight control [42] and that diets with protein contents
2005, [1] it is emphasized that for body weight control, it is greater than 20% reduce glucose and insulin concentrations,
the amount of calories consumed rather than the proportions reduce appetite, and increase satiety. Although the acceptable
of protein, carbohydrate, and fat in the diet that is important, macronutrient distribution range for protein recommended by
provided that the macronutrients are within the acceptable the IOM is 10–35% [35], the ADA maintains that there is in-
macronutrient distribution range, recommended by the Insti- sufficient evidence to suggest that the usual protein intake of
tute of Medicine (IOM) [35]. Although reference is made to 15–20% should be modified because long-term effects on
the DASH eating plan (21% protein, 57% carbohydrate, and kidney function in diabetes are unknown and that the ADA
22% fat energy) and the US Department of Agriculture food requires more information on the long-term efficacy and
guide (18% protein, 55% carbohydrate, and 29% fat energy, safety of low-carbohydrate, high-protein diets.
which includes a slight percentage discrepancy), the accept- Despite these recommendations by the ADA, it is interesting
able macronutrient distribution range for each macronutrient to note that the Joslin Clinical Nutrition Guidelines for over-
is considerable, 10–35% for protein, 45–65% for carbohy- weight and obese adults with type 2 diabetes or prediabetes
drate, and 20–35% for fat [35], and can cover a wide variety or those at high risk for developing type 2 diabetes recommends
of different dietary paradigms. Although it is true that calorie a diet with a macronutrient composition of w40% energy from
restriction per se is important for weight loss [1], if calorie carbohydrate, 30–35% fat, and 20–30% protein [43] and that
restriction can be achieved more easily by changing the mac- their Why Wait program, albeit over 12 wk, provides a diet
ronutrient composition of the diet and help an individual with an energy composition of 40% carbohydrate, 30% fat,
maintain the required energy deficit by possible effects on and 30% protein [44]. Not only has the carbohydrate content
metabolism and/or reducing appetite [28,36,37], then the of the diet been reduced, but it has been replaced by increasing
macronutrient composition of the diet is certainly an option the protein component of the diet. Interestingly this type of diet
worth consideration. One important benefit of low-carbohy- composition is similar to that of the Paleolithic diet, considered
drate diets is that only carbohydrate, not energy, intake is to be the most appropriate diet for our genome [45].
consciously restricted. In reality energy intake decreases
spontaneously, due to the increasing proportion(s) of protein Paleolithic diet
and/or fat in the diet, which results in body weight loss as
good, if not better, than on conventional energy-restricted Over the years Eaton and Eaton [46] have made slight
weight-loss diets. Replacing carbohydrate by unlimited fat adjustments to the macronutrient composition of the Paleolithic
has been criticized for increasing saturated fat and cholesterol diet, but in general it covers a range that provides 19–35% pro-
intake; however, it has been proposed that high dietary fat is tein, 22–40% carbohydrate, and 28–58% fat [47]. Even though

4. 144 K. J. Acheson / Nutrition 26 (2010) 141–145
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