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Efficacy and safety of low and very low carbohydrate diets for type 2 diabetes remission: systematic review and meta-analysis of published and unpublished randomized trial data.
Goldenberg, JZ, Day, A, Brinkworth, GD, Sato, J, Yamada, S, Jönsson, T, Beardsley, J, Johnson, JA, Thabane, L, Johnston, BC
BMJ (Clinical research ed.). 2021;372:m4743
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Diet modification has long been recognised as a component for the treatment of diabetes. Diets low in carbohydrates have been extensively researched, as a diet for those with Type 2 Diabetes (T2D). This systematic review and meta-analysis aimed to determine the effect of low carbohydrate diets on T2D. The systematic review found 23 studies, including 1357 individuals, investigating the role of low carbohydrate diets on T2D outcomes. Low carbohydrate diet was defined as less than 130g of carbohydrate (less than 26% of calories from carbohydrate) for at least 12 weeks. Results reported at 6 months, found low carbohydrate diets were more effective than a normal diet at achieving diabetes remission. However, this effect diminished at 12 months, although longer term improvements were seen in blood lipids, weight loss and measures of prediabetes. It was concluded that individuals with T2D, eating a low carbohydrate diet for 6 months may reverse the disease. This study could be used by healthcare professionals to recommend a short-term low carbohydrate diet to individuals with T2D, to improve their chance of going into remission.
Expert Review
Conflicts of interest:
None
Take Home Message:
- Type 2 diabetes remains a significant and worsening problem worldwide, despite many pharmaceutical developments and a global emphasis on glycemic control.
- This review highlights structured LCDs as a worthwhile option for the management and treatment of diabetes, providing an opportunity for Nutritional Therapy Practitioners to support clients in adopting evidence-informed, modifiable dietary and lifestyle changes for Type Two Diabetes.
Evidence Category:
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A: Meta-analyses, position-stands, randomized-controlled trials (RCTs)
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B: Systematic reviews including RCTs of limited number
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C: Non-randomized trials, observational studies, narrative reviews
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D: Case-reports, evidence-based clinical findings
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E: Opinion piece, other
Summary Review:
- Type 2 diabetes is the most common form of diabetes, accounting for 90-95% of cases.
- Previous randomised trials assessed low carbohydrate diets (LCDs) (<26-45% of daily calories from carbohydrate) as encouraging to improve blood glucose control and outcomes of type 2 diabetes but did not systematically assessed remission of diabetes using low carbohydrate diets (LCDs) and very low carbohydrate diets (VLCDs) for people with type 2 diabetes.
- Systematic reviews (SR) and meta-analyses represent the most valuable, reliable, and objective tool to summarise evidence from primary studies.
- This SR assessed 23 randomised controlled trials comparing LCDs with mostly low fat control diets in individuals / subjects / participants with type 2 diabetes. LCDs were defined as diets with less than 130 g/day or less than 26% of calories from carbohydrates, based on 2000 kcal/day. The authors used the Cochrane Risk of Bias tool 2.0 (RoB 2) to assess methodological quality of evidence, GRADE to assess the certainty of evidence
- On the basis of assessment of moderate to low certainty evidence, individuals / subjects / participants adhering to a LCD for six months may experience remission of type 2 diabetes without adverse consequences.
- Primary outcomes of interest were remission of type 2 diabetes (dichotomously defined as HbA1c <6.5% or fasting glucose <7.0 mmol/L), with or without the use of diabetes medication.
- Eight studies reported on remission of diabetes at six months. Pooled analysis showed that when remission was defined by an HbA1c level below 6.5% independent of medication use, LCDs increased remissions by an additional 32 per 100 patients followed (risk difference 0.32, 95% confidence interval 0.17 to 0.47; 8 studies, n=264; GRADE=moderate)
- When remission was defined by an HbA1c level below 6.5% and the absence of diabetes medication, LCDs increased remissions at a lower rate (risk difference 0.05, –0.05 to 0.14; 5 studies, n=199; GRADE=low)
- Additional primary outcomes were weight loss, HbA1c:
- 18 studies reported on Weight loss results (mean difference –3.46, 95% confidence interval –5.25 to –1.67; n=882 (note that positive results not sustained at 12 mo)
- Seventeen studies reported on HbA1c levels at six months, LCDs achieved greater reductions in HbA1c than did control diets (mean difference –0.47%, –0.60 to –0.34; n=747
- Limitations of study: 1) the definition of remission of diabetes, 2) Self-reported dietary intake data are prone to measurement error, particularly in dietary trials in which participants are not blinded
- This SR was funded in part by Texas A&M University.
- The authors declared no conflicts of interest.
Clinical practice applications:
The Authors highlight LCD diets incorporating carbohydrate of less than 130 g/day or less than 26% of calories (based on 2000 kcal/day) may be a safe strategy to help individuals with type 2 diabetes achieve weight loss and better blood glucose control over a six-month period. Results may not be sustained at 12 months.
Considerations for future research:
- The definition of diabetes remission needs clarification, especially with regard to threshold concentrations of Hb1Ac or fasting glucose and the use of diabetes medication.
- Safety concerns have been raised with LCDs. Although no significant or clinically important increase in total or serious adverse events was identified in this SR, these outcomes should be reported in future trials to confirm the certainty of evidence for safety.
- The Authors suggest long term, well designed, calorie controlled randomised trials are needed to determine the effects of LCD on sustained weight loss and remission of diabetes.
- Larger treatment effects for LCDs in shorter term trials (3 to <6 months), may be trialed as an effect modifier
Abstract
OBJECTIVE To determine the efficacy and safety of low carbohydrate diets (LCDs) and very low carbohydrate diets (VLCDs) for people with type 2 diabetes. DESIGN Systematic review and meta-analysis. DATA SOURCES Searches of CENTRAL, Medline, Embase, CINAHL, CAB, and grey literature sources from inception to 25 August 2020. STUDY SELECTION Randomized clinical trials evaluating LCDs (<130 g/day or <26% of a 2000 kcal/day diet) and VLCDs (<10% calories from carbohydrates) for at least 12 weeks in adults with type 2 diabetes were eligible. DATA EXTRACTION Primary outcomes were remission of diabetes (HbA1c <6.5% or fasting glucose <7.0 mmol/L, with or without the use of diabetes medication), weight loss, HbA1c, fasting glucose, and adverse events. Secondary outcomes included health related quality of life and biochemical laboratory data. All articles and outcomes were independently screened, extracted, and assessed for risk of bias and GRADE certainty of evidence at six and 12 month follow-up. Risk estimates and 95% confidence intervals were calculated using random effects meta-analysis. Outcomes were assessed according to a priori determined minimal important differences to determine clinical importance, and heterogeneity was investigated on the basis of risk of bias and seven a priori subgroups. Any subgroup effects with a statistically significant test of interaction were subjected to a five point credibility checklist. RESULTS Searches identified 14 759 citations yielding 23 trials (1357 participants), and 40.6% of outcomes were judged to be at low risk of bias. At six months, compared with control diets, LCDs achieved higher rates of diabetes remission (defined as HbA1c <6.5%) (76/133 (57%) v 41/131 (31%); risk difference 0.32, 95% confidence interval 0.17 to 0.47; 8 studies, n=264, I2=58%). Conversely, smaller, non-significant effect sizes occurred when a remission definition of HbA1c <6.5% without medication was used. Subgroup assessments determined as meeting credibility criteria indicated that remission with LCDs markedly decreased in studies that included patients using insulin. At 12 months, data on remission were sparse, ranging from a small effect to a trivial increased risk of diabetes. Large clinically important improvements were seen in weight loss, triglycerides, and insulin sensitivity at six months, which diminished at 12 months. On the basis of subgroup assessments deemed credible, VLCDs were less effective than less restrictive LCDs for weight loss at six months. However, this effect was explained by diet adherence. That is, among highly adherent patients on VLCDs, a clinically important reduction in weight was seen compared with studies with less adherent patients on VLCDs. Participants experienced no significant difference in quality of life at six months but did experience clinically important, but not statistically significant, worsening of quality of life and low density lipoprotein cholesterol at 12 months. Otherwise, no significant or clinically important between group differences were found in terms of adverse events or blood lipids at six and 12 months. CONCLUSIONS On the basis of moderate to low certainty evidence, patients adhering to an LCD for six months may experience remission of diabetes without adverse consequences. Limitations include continued debate around what constitutes remission of diabetes, as well as the efficacy, safety, and dietary satisfaction of longer term LCDs. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020161795.
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Comparison of dietary macronutrient patterns of 14 popular named dietary programmes for weight and cardiovascular risk factor reduction in adults: systematic review and network meta-analysis of randomised trials.
Ge, L, Sadeghirad, B, Ball, GDC, da Costa, BR, Hitchcock, CL, Svendrovski, A, Kiflen, R, Quadri, K, Kwon, HY, Karamouzian, M, et al
BMJ (Clinical research ed.). 2020;369:m696
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Dietary recommendations to combat obesity and its associated risk for heart disease are extensive. Many different diets and patterns of eating are being tried by millions of people, however no systematic review comparing their effectiveness has been performed. This systematic review and meta-analysis aimed to determine the effectiveness of 14 popular diets and diets which restrict certain nutrients on weight loss and heart disease risk. The results identified 121 studies with 21942 patients for inclusion. The Atkins diet, the Zone diet and the Dietary Approaches to Stop Hypertension (DASH) diet were the most effective for weight loss and for reducing blood pressure. Low carbohydrate and low-fat diets achieved similar weight loss when compared to a normal diet. Low carbohydrate diets had less effect on heart disease risk factors than low fat and moderate macronutrient diets. There were no improvements in good cholesterol with any of the diets. Interestingly any benefits on weight loss for any of the diets disappeared after 12 months and this was also observed for heart disease risk, except in those on the Mediterranean diet. It was concluded that most diets show improvements to weight loss and heart disease risk factors over 6 months, however these are largely unsustainable after 12 months. Differences between diets are small and healthcare practitioners could use this study to recommend any number of diets to achieve weight loss and the Mediterranean diet in particular to decrease heart disease risk. However, it is important to understand that this may be a short-term fix and at 12 months patients need to be assessed to ensure that weight loss is sustained.
Abstract
OBJECTIVE To determine the relative effectiveness of dietary macronutrient patterns and popular named diet programmes for weight loss and cardiovascular risk factor improvement among adults who are overweight or obese. DESIGN Systematic review and network meta-analysis of randomised trials. DATA SOURCES Medline, Embase, CINAHL, AMED, and CENTRAL from database inception until September 2018, reference lists of eligible trials, and related reviews. STUDY SELECTION Randomised trials that enrolled adults (≥18 years) who were overweight (body mass index 25-29) or obese (≥30) to a popular named diet or an alternative diet. OUTCOMES AND MEASURES Change in body weight, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, systolic blood pressure, diastolic blood pressure, and C reactive protein at the six and 12 month follow-up. REVIEW METHODS Two reviewers independently extracted data on study participants, interventions, and outcomes and assessed risk of bias, and the certainty of evidence using the GRADE (grading of recommendations, assessment, development, and evaluation) approach. A bayesian framework informed a series of random effects network meta-analyses to estimate the relative effectiveness of the diets. RESULTS 121 eligible trials with 21 942 patients were included and reported on 14 named diets and three control diets. Compared with usual diet, low carbohydrate and low fat diets had a similar effect at six months on weight loss (4.63 v 4.37 kg, both moderate certainty) and reduction in systolic blood pressure (5.14 mm Hg, moderate certainty v 5.05 mm Hg, low certainty) and diastolic blood pressure (3.21 v 2.85 mm Hg, both low certainty). Moderate macronutrient diets resulted in slightly less weight loss and blood pressure reductions. Low carbohydrate diets had less effect than low fat diets and moderate macronutrient diets on reduction in LDL cholesterol (1.01 mg/dL, low certainty v 7.08 mg/dL, moderate certainty v 5.22 mg/dL, moderate certainty, respectively) but an increase in HDL cholesterol (2.31 mg/dL, low certainty), whereas low fat (-1.88 mg/dL, moderate certainty) and moderate macronutrient (-0.89 mg/dL, moderate certainty) did not. Among popular named diets, those with the largest effect on weight reduction and blood pressure in comparison with usual diet were Atkins (weight 5.5 kg, systolic blood pressure 5.1 mm Hg, diastolic blood pressure 3.3 mm Hg), DASH (3.6 kg, 4.7 mm Hg, 2.9 mm Hg, respectively), and Zone (4.1 kg, 3.5 mm Hg, 2.3 mm Hg, respectively) at six months (all moderate certainty). No diets significantly improved levels of HDL cholesterol or C reactive protein at six months. Overall, weight loss diminished at 12 months among all macronutrient patterns and popular named diets, while the benefits for cardiovascular risk factors of all interventions, except the Mediterranean diet, essentially disappeared. CONCLUSIONS Moderate certainty evidence shows that most macronutrient diets, over six months, result in modest weight loss and substantial improvements in cardiovascular risk factors, particularly blood pressure. At 12 months the effects on weight reduction and improvements in cardiovascular risk factors largely disappear. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015027929.
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Non-Systematic Review of Diet and Nutritional Risk Factors of Cardiovascular Disease in Obesity.
Rychter, AM, Ratajczak, AE, Zawada, A, Dobrowolska, A, Krela-Kaźmierczak, I
Nutrients. 2020;12(3)
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Nutrition is a major factor influencing obesity associated heart disease risk, however many people with this disease do not follow nutritional recommendations. This review of 155 studies aimed to summarise dietary aspects of heart disease prevention. The paper began by outlining the role of obesity through the development of other disorders that contribute to heart disease, such as type 2 diabetes, high blood pressure and blood sugar imbalance. The quantity and distribution of fat tissue also can contribute to heart disease risk, especially if it is located within the heart or around the major organs of the body. Dietary factors which can increase heart disease risk were described as an increased intake of processed foods, sugar, salt and certain fats and low intakes of fruit, vegetables, fibre, whole grains, beans and nuts. The Mediterranean diet, the dietary approaches to stop hypertension (DASH) diet, plant-based diets, the portfolio dietary pattern and low carbohydrate diets were all reviewed and although mixed results were stated for low carbohydrate diets, most of the diets reviewed reported improved heart disease outcomes. The role of intestinal microbiota in heart disease were also reviewed and the influence of a poor diet was implicated in imbalanced gut microbiota and the development of heart disease. It was concluded that an unhealthy diet can contribute to heart disease and that dietary patterns such as the Mediterranean diet and plant-based diets may be favourable for its management. This study could be used by healthcare professionals to individualise dietary recommendations for patients with heart disease or who are at risk of it.
Abstract
Although cardiovascular disease and its risk factors have been widely studied and new methods of diagnosis and treatment have been developed and implemented, the morbidity and mortality levels are still rising-cardiovascular disease is responsible for more than four million deaths each year in Europe alone. Even though nutrition is classified as one of the main and changeable risk factors, the quality of the diet in the majority of people does not follow the recommendations essential for prevention of obesity and cardiovascular disease. It demonstrates the need for better nutritional education in cardiovascular disease prevention and treatment, and the need to emphasize dietary components most relevant in cardiovascular disease. In our non-systematic review, we summarize the most recent knowledge about nutritional risk and prevention in cardiovascular disease and obesity.
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Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis.
Seidelmann, SB, Claggett, B, Cheng, S, Henglin, M, Shah, A, Steffen, LM, Folsom, AR, Rimm, EB, Willett, WC, Solomon, SD
The Lancet. Public health. 2018;3(9):e419-e428
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Previous trials have shown that low carbohydrate diets are beneficial for short-term weight loss. However, the long-term impact of carbohydrate restriction on mortality is less clear, with research producing conflicting results. Additionally, previous studies have not addressed the source or quality of proteins and fats consumed in low-carbohydrate diets. This study aimed to find out whether there is an association between carbohydrate consumption and mortality. It also looked at whether animal-based or plant-based foods had any impact on the association. The researchers began by studying over 15,000 adults in the US, enrolled between 1987 and 1989. At the start of the study and again six years later, participants completed food frequency questionnaires. These were used to estimate the percentage of calories they derived from carbohydrate, fat and protein. The results showed a U-shape association between overall carbohydrate intake and life expectancy, with low (less than 40% of calories from carbohydrates) and high (more than 70%) intake of carbohydrates associated with a higher risk of mortality compared with moderate intake (50-55% of calories). The researchers estimated that the average life expectancy was 4 years shorter for those with low carbohydrate consumption, and 1 year shorter for those with high carbohydrate consumption, compared to those with a moderate carbohydrate intake. However, the authors point out that since diets were only recorded at the start of the trial and six years later, participants’ diets could have changed during the 25-year follow-up period. Next, the authors performed a meta-analysis of data from eight previous studies. This revealed similar trends, with participants whose overall diets were high and low in carbohydrates having a shorter life expectancy than those with moderate consumption. In further analyses examining the source of proteins and fats, animal-derived protein and fat sources, such as lamb, beef, pork and chicken, were associated with higher mortality, whereas plant-derived protein and fat intake, from sources such as vegetables, nuts, peanut butter and whole-grains, were associated with lower mortality. The authors suggest that, when restricting carbohydrate intake, replacement of carbohydrates with predominantly plant-based fats and proteins could be considered as a long-term approach to promote healthy ageing.
Abstract
BACKGROUND Low carbohydrate diets, which restrict carbohydrate in favour of increased protein or fat intake, or both, are a popular weight-loss strategy. However, the long-term effect of carbohydrate restriction on mortality is controversial and could depend on whether dietary carbohydrate is replaced by plant-based or animal-based fat and protein. We aimed to investigate the association between carbohydrate intake and mortality. METHODS We studied 15 428 adults aged 45-64 years, in four US communities, who completed a dietary questionnaire at enrolment in the Atherosclerosis Risk in Communities (ARIC) study (between 1987 and 1989), and who did not report extreme caloric intake (<600 kcal or >4200 kcal per day for men and <500 kcal or >3600 kcal per day for women). The primary outcome was all-cause mortality. We investigated the association between the percentage of energy from carbohydrate intake and all-cause mortality, accounting for possible non-linear relationships in this cohort. We further examined this association, combining ARIC data with data for carbohydrate intake reported from seven multinational prospective studies in a meta-analysis. Finally, we assessed whether the substitution of animal or plant sources of fat and protein for carbohydrate affected mortality. FINDINGS During a median follow-up of 25 years there were 6283 deaths in the ARIC cohort, and there were 40 181 deaths across all cohort studies. In the ARIC cohort, after multivariable adjustment, there was a U-shaped association between the percentage of energy consumed from carbohydrate (mean 48·9%, SD 9·4) and mortality: a percentage of 50-55% energy from carbohydrate was associated with the lowest risk of mortality. In the meta-analysis of all cohorts (432 179 participants), both low carbohydrate consumption (<40%) and high carbohydrate consumption (>70%) conferred greater mortality risk than did moderate intake, which was consistent with a U-shaped association (pooled hazard ratio 1·20, 95% CI 1·09-1·32 for low carbohydrate consumption; 1·23, 1·11-1·36 for high carbohydrate consumption). However, results varied by the source of macronutrients: mortality increased when carbohydrates were exchanged for animal-derived fat or protein (1·18, 1·08-1·29) and mortality decreased when the substitutions were plant-based (0·82, 0·78-0·87). INTERPRETATION Both high and low percentages of carbohydrate diets were associated with increased mortality, with minimal risk observed at 50-55% carbohydrate intake. Low carbohydrate dietary patterns favouring animal-derived protein and fat sources, from sources such as lamb, beef, pork, and chicken, were associated with higher mortality, whereas those that favoured plant-derived protein and fat intake, from sources such as vegetables, nuts, peanut butter, and whole-grain breads, were associated with lower mortality, suggesting that the source of food notably modifies the association between carbohydrate intake and mortality. FUNDING National Institutes of Health.
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Dietary Patterns in Secondary Prevention of Heart Failure: A Systematic Review.
Dos Reis Padilha, G, Sanches Machado d'Almeida, K, Ronchi Spillere, S, Corrêa Souza, G
Nutrients. 2018;10(7)
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Diet is recognised as an important factor in the prevention of heart failure, however there is no consensus about which dietary protocol is the most effective. This systematic review aims to clarify links between different dietary measures and markers of heart failure. The review included 12 studies of different types (randomised controlled trials, cross-sectional studies and cohort studies), which examined the DASH diet, Mediterranean diet, high protein diet and low carbohydrate diet. The studies examining the DASH diet demonstrated improvements in various measures of cardiac function and may have benefits for secondary prevention of heart failure. The Mediterranean diet was associated with lower levels of inflammation and improved cardiac function in cross-sectional studies only. High protein and low carbohydrate diets also demonstrated positive effects on markers of heart function however, only one study for each was included. The authors conclude that the current science suggests a positive role for diet in relation to prevention of heart failure and call for further RCTs to be conducted to identify which elements of these different diets are impacting on markers of heart failure.
Abstract
BACKGROUND Diet is an important factor in secondary prevention of heart failure (HF) but there is still no consensus as to which dietary model should be adopted by this population. This systematic review aims to clarify the relationship between dietary patterns and secondary prevention in HF. METHODS We searched the Medline, Embase and Cochrane databases for studies with different dietary patterns and outcomes of secondary prevention in HF. No limitation was used in the search. RESULTS 1119 articles were identified, 12 met the inclusion criteria. Studies with Dietary Approaches to Stop Hypertension (DASH), Mediterranean, Hyperproteic and Low-carb diets were found. The DASH pattern showed improvement in cardiac function, functional capacity, blood pressure, oxidative stress and mortality. The Mediterranean diet had a correlation with inflammation, quality of life and cardiac function but just on cross-sectional studies. Regarding the Hyperproteic and Low-carb diets only one study was found with each pattern and both were able to improve functional capacity in patients with HF. CONCLUSIONS DASH pattern may have benefits in the secondary prevention of HF. The Mediterranean diet demonstrated positive correlation with factors of secondary prevention of HF but need more RCTs and cohort studies to confirm these effects. In addition, the Hyperproteic and Low-carb diets, despite the lack of studies, also demonstrated positive effects on the functional capacity in patients with HF.
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Micronutrient Gaps in Three Commercial Weight-Loss Diet Plans.
G Engel, M, J Kern, H, Brenna, JT, H Mitmesser, S
Nutrients. 2018;10(1)
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Globally, around 39% of adults are overweight and 13% obese, and more than one third of American adults are obese. Being overweight or obese is associated with many chronic conditions, such as heart disease, high blood pressure and type 2 diabetes. Weight loss, even at moderate level, can reduce the risk of these obesity-related chronic conditions. Commercial weight-loss diet plans can vary greatly, not only in energy content but also in macronutrient and micronutrient composition. Most plans restrict calories or certain macronutrients, particularly carbohydrate or fat, and in doing so, often overlook micronutrient, i.e. vitamin and mineral, content. Previous studies have shown that many weight-loss plans do not provide adequate amounts of all micronutrients, and in order to reach the reference daily intakes for various vitamins and minerals, dieters would need to increase their calorie intake significantly and often unrealistically. The authors of this paper analysed seven single-day menus of three select commercial diet plans to determine their micronutrient sufficiency. The diet plans included were Eat to Live-Vegan, Aggressive Weight Loss (ETL-VAWL), Fast Metabolism Diet (FMD), and Eat, Drink and Be Healthy (EDH). ETL-VAWL diet provided less than 90% of recommended amounts for B12, B3, D, E, calcium, selenium and zinc. The FMD diet was low in B1, D, E, calcium, magnesium and potassium, while EDH diet didn’t meet the recommended amounts for vitamin D, calcium and potassium. Even after adjusting all the plans to an intake of 2000 kcal/day, several micronutrients were found to remain inadequate (vitamin B12 in ETL-VAWL, calcium in FMD and EDH and vitamin D in all diets). The authors conclude that, in order to reduce the risk of micronutrient deficiencies, more attention needs to be paid to micronutrient rich foods when designing commercial diet plans. Alternatively, these nutrient gaps should be filled in other ways, e.g. using appropriate dietary supplements.
Abstract
Weight-loss diets restrict intakes of energy and macronutrients but overlook micronutrient profiles. Commercial diet plans may provide insufficient micronutrients. We analyzed nutrient profiles of three plans and compared their micronutrient sufficiency to Dietary Reference Intakes (DRIs) for male U.S. adults. Hypocaloric vegan (Eat to Live-Vegan, Aggressive Weight Loss; ETL-VAWL), high-animal-protein low-carbohydrate (Fast Metabolism Diet; FMD) and weight maintenance (Eat, Drink and Be Healthy; EDH) diets were evaluated. Seven single-day menus were sampled per diet (n = 21 menus, 7 menus/diet) and analyzed for 20 micronutrients with the online nutrient tracker CRON-O-Meter. Without adjustment for energy intake, the ETL-VAWL diet failed to provide 90% of recommended amounts for B12, B₃, D, E, calcium, selenium and zinc. The FMD diet was low (<90% DRI) in B₁, D, E, calcium, magnesium and potassium. The EDH diet met >90% DRIs for all but vitamin D, calcium and potassium. Several micronutrients remained inadequate after adjustment to 2000 kcal/day: vitamin B12 in ETL-VAWL, calcium in FMD and EDH and vitamin D in all diets. Consistent with previous work, micronutrient deficits are prevalent in weight-loss diet plans. Special attention to micronutrient rich foods is required to reduce risk of micronutrient deficiency in design of commercial diets.