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Food as Medicine for Obesity Treatment and Management

      ABSTRACT

      Purpose

      Nutrition is an important lifestyle modification used in the treatment of obesity. The purpose of this review is to highlight different dietary interventions used to promote weight loss in both adults and children.

      Methods

      A search using PubMed was performed for articles on topics related to nutrition and management and/or treatment of obesity in adults adolescents and children. The literature was reviewed and pertinent sources were used for this narrative review.

      Discussion

      There are many effective nutrition interventions used to treat obesity, including altering macronutrient composition, implementing different dietary patterns, and changing meal timing. Although these interventions can induce weight loss in adults, management of obesity in children is more difficult given their varied nutrition needs in growth and development. The use of food as medicine in obesity treatment is individualized based on patient's age, food preference, and concurrent medical conditions.

      Implications

      Given the multifactorial etiology of obesity, treatment requires multidisciplinary care beyond nutrition intervention.

      Key words

      Introduction

      Obesity, defined as excess body fat or commonly recognized by body mass index (BMI) ≥30 kg/m2, is one of the most prevalent chronic diseases worldwide.

      Centers for Disease Control and Prevention. Adult Obesity Facts 2021.

      Affecting >40% of US adults and ∼20% of US children aged 2 to 19 years, obesity is a risk factor for >200 medical conditions, including type 2 diabetes mellitus, hypertension, osteoarthritis, depression, and, more recently, COVID-19.

      Centers for Disease Control and Prevention. Adult Obesity Facts 2021.

      • Jastreboff AM
      • Kotz CM
      • Kahan S
      • Kelly AS
      • Heymsfield SB.
      Obesity as a disease: The Obesity Society 2018 Position Statement.
      • Kwok S
      • Adam S
      • Ho JH
      • et al.
      Obesity: a critical risk factor in the COVID-19 pandemic.

      Centers for Disease Control and Prevention. Childhood Obesity Facts 2021.

      Nutrition is an important lifestyle modification that is critical in the treatment of obesity. Although many patients are aware of various dietary recommendations to promote weight loss, prior research has not reported the best diet or dietary pattern to manage obesity. Therefore, in clinical practice, a patient's nutrition plan must be individualized based on age, food preference, cultural preference, lifestyle, and concurrent medical diseases. In this discussion of “Food as Medicine,” the most popular nutrition interventions to manage obesity in adults, adolescents , and children are reviewed.

      Materials and Methods

      Following the recommendations of the Center for Reviews and Dissemination for performing reviews in health care, we determined inclusion criteria based off of the PICOS (Population, Intervention, Comparators, Outcomes, Study Design) format. We systemically searched the PubMed database for relevant human studies. Search terms included “nutrition AND obesity AND adults,” “nutrition AND obesity AND pediatrics OR children OR pediatrics,” “diet AND obesity AND adults,” and “diet AND obesity and pediatrics OR children OR pediatrics.” Although the majority of this review includes systematic reviews and meta-analyses, special attention was given to randomized controlled trials that evaluated specific dietary interventions, including macronutrient composition, dietary patterns, and meal timing (i.e. intermittent fasting) in particular subpopulations of children, adolescents, and adults with obesity.

      Nutrition in Adults

      Weight Loss

      The goal of nutritional intervention in the treatment and management of obesity is to induce weight loss by creating a negative energy balance using one of the following strategies:
      • Raynor HA
      • Champagne CM.
      Position of the Academy of Nutrition and Dietetics: interventions for the treatment of overweight and obesity in adults.
      (1) reduce calorie consumption by 500 to 750 kcal/d; and (2) limit total caloric intake to 1200 to 1500 kcal/d for women and 1500 to 1800 kcal/d for men. The diet should be adjusted to reduce excessive energy intake and enhance dietary quality to increase the likelihood of achieving recommendations in the 2020 to 2025 Dietary Guidelines for American.
      • Raynor HA
      • Champagne CM.
      Position of the Academy of Nutrition and Dietetics: interventions for the treatment of overweight and obesity in adults.
      ,

      Dietary Guidelines for Americans, 2020-2025. 9th Edition ed.

      This is achieved via numerous dietary changes that include alterations to macronutrient composition, specific dietary patterns, and changes to meal timing.

      Macronutrient Composition

      Macronutrient composition refers to the relative contribution of macronutrients, namely protein, carbohydrates, and fat. Altered macronutrient composition and the quality of dietary macronutrients often shift mediators of caloric intake and diet sustainability, such as satiety and fullness, with the goal to improve adherence to an energy-restricted diet. The 2013 American Heart Association/American College of Cardiology/The Obesity Society guidelines for management of overweight and obesity in adults showed that alteration in macronutrient composition produced a weight loss of –4 and –12 kg at the 6-month follow-up.
      • Jensen MD
      • Ryan DH
      • Apovian CM
      • et al.
      2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.

      Higher Protein

      Higher protein diets have long been considered advantageous for weight loss, often in conjunction with low-fat or low-carbohydrate diets.
      • Freire R.
      Scientific evidence of diets for weight loss: different macronutrient composition, intermittent fasting, and popular diets.
      These diets generally consist of 20% to 30% of energy intake supplied by protein, whereas “normal protein” diets derive 10% to 15% of energy from protein.
      • Westerterp-Plantenga MS
      • Lemmens SG
      • Westerterp KR.
      Dietary protein—its role in satiety, energetics, weight loss and health.
      ,
      • Magkos F.
      The role of dietary protein in obesity.
      Protein has a high thermogenic advantage over carbohydrates and fat in that a substantial 20% to 30% of protein-derived calories are used by the body in digestion, transport, and storage processes rather than being metabolized, thus presumably creating a larger energy deficit.
      • Magkos F.
      The role of dietary protein in obesity.
      ,
      • Hall KD
      • Guo J.
      Obesity energetics: body weight regulation and the effects of diet composition.
      In addition, studies have shown that satiety associated with protein intake is greater than with other macronutrients, and fullness ratings increase with protein intake.
      • Westerterp-Plantenga MS
      • Lemmens SG
      • Westerterp KR.
      Dietary protein—its role in satiety, energetics, weight loss and health.
      ,
      • Magkos F.
      The role of dietary protein in obesity.
      ,
      • Li J
      • Armstrong CLH
      • Campbell WW.
      Effects of dietary protein source and quantity during weight loss on appetite, energy expenditure, and cardio-metabolic responses.
      This is due to multiple factors, which include circulating amino acid levels and secretion of anorexigenic gut hormones. Higher protein diets also preserve lean body mass during weight loss better than normal protein diets.
      • Westerterp-Plantenga MS
      • Lemmens SG
      • Westerterp KR.
      Dietary protein—its role in satiety, energetics, weight loss and health.
      ,
      • Leidy HJ
      • Carnell NS
      • Mattes RD
      • Campbell WW.
      Higher protein intake preserves lean mass and satiety with weight loss in pre-obese and obese women.
      Studies have suggested that higher protein diets are effective in producing modest weight loss among adults under ad libitum feeding and energy-restricted conditions, with satiety playing an important role in decreasing volitional energy intake.
      • Westerterp-Plantenga MS
      • Lemmens SG
      • Westerterp KR.
      Dietary protein—its role in satiety, energetics, weight loss and health.
      ,
      • Magkos F.
      The role of dietary protein in obesity.
      Similar weight loss efficacy has been observed using plant and animal sources of protein.
      • Westerterp-Plantenga MS
      • Lemmens SG
      • Westerterp KR.
      Dietary protein—its role in satiety, energetics, weight loss and health.
      ,
      • Yannakoulia M
      • Poulimeneas D
      • Mamalaki E
      • Anastasiou CA.
      Dietary modifications for weight loss and weight loss maintenance.
      Although one study showed that an energy-restricted higher protein diet achieved a 3.6 kg loss on average at 24 months, a meta-analysis actually showed that differences in weight loss between higher and normal protein isocaloric diets are not significant.
      • Sacks FM
      • Bray GA
      • Carey VJ
      • et al.
      Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates.
      • Schwingshackl L
      • Hoffmann G.
      Long-term effects of low-fat diets either low or high in protein on cardiovascular and metabolic risk factors: a systematic review and meta-analysis.
      • Wycherley TP
      • Moran LJ
      • Clifton PM
      • Noakes M
      • Brinkworth GD.
      Effects of energy-restricted high-protein, low-fat compared with standard-protein, low-fat diets: a meta-analysis of randomized controlled trials.
      Furthermore, although higher protein diets may induce greater weight loss compared with low-fat or low-carbohydrate diets during the first 3 to 6 months of the intervention, the differences attenuate and are no longer significant when compared over 12 to 24 months.
      • Westerterp-Plantenga MS
      • Lemmens SG
      • Westerterp KR.
      Dietary protein—its role in satiety, energetics, weight loss and health.
      ,
      • Magkos F.
      The role of dietary protein in obesity.
      Therefore, dietary adherence and energy restriction are primary drivers of long-term weight loss, rather than an inherent association with higher protein intake.

      Carbohydrate Quality

      The quantity and quality of carbohydrates are of great interest in the treatment and management of obesity. According to the carbohydrate-insulin model of obesity, carbohydrates elevate insulin secretion, thereby directing fat toward storage in adipose tissue.
      • Freire R.
      Scientific evidence of diets for weight loss: different macronutrient composition, intermittent fasting, and popular diets.
      Carbohydrate quality is a function of several variables, including glycemic index and load, fiber quantity, and the presence of added sugars during processing.
      • Raynor HA
      • Champagne CM.
      Position of the Academy of Nutrition and Dietetics: interventions for the treatment of overweight and obesity in adults.
      We examine the evidence underlying interventions concerning both the quality and quantity of dietary carbohydrates.
      Glycemic Index and Load. Glycemic index refers to a quantification of how responsive blood glucose is to consumption of a particular carbohydrate product, relative to a reference. A product's glycemic load is defined as the product of its glycemic index and the quantity of carbohydrates, thereby reflecting the total blood glucose–raising potential of that dietary intake.
      • van Dam RM
      • Seidell JC.
      Carbohydrate intake and obesity.
      It has been hypothesized that the rapid rises and declines in blood glucose and subsequent hormones associated with high glycemic index foods may increase food intake and self-reported hunger, as well as preferentially lead to carbohydrate over fat oxidation postprandially.
      • van Dam RM
      • Seidell JC.
      Carbohydrate intake and obesity.
      ,
      • Brand-Miller JC
      • Holt SH
      • Pawlak DB
      • McMillan J.
      Glycemic index and obesity.
      Currently, there is no standard definition of a low glycemic index or low glycemic load diet,
      • Raynor HA
      • Champagne CM.
      Position of the Academy of Nutrition and Dietetics: interventions for the treatment of overweight and obesity in adults.
      but it is theorized that lower glycemic index/load foods promote satiety to minimize postprandial insulin secretion and maintain insulin sensitivity.
      • Brand-Miller JC
      • Holt SH
      • Pawlak DB
      • McMillan J.
      Glycemic index and obesity.
      Although lower glycemic index diets are associated with benefit for other chronic diseases, including type 2 diabetes mellitus and coronary artery disease, evidence from both observational and intervention trials comparing low and high glycemic index foods for weight loss among adults with obesity have been mixed and limited.
      • Thomas D
      • Elliott EJ
      • Baur L.
      Low glycaemic index or low glycaemic load diets for overweight and obesity.
      Studies using isocaloric control diets have generally shown similar weight loss produced by low and high glycemic index diets at 6 months and beyond, which precludes practical guidance on the efficacy of glycemic index–based interventions for weight loss.
      • van Dam RM
      • Seidell JC.
      Carbohydrate intake and obesity.
      ,
      • Juanola-Falgarona M
      • Salas-Salvadó J
      • Ibarrola-Jurado N
      • et al.
      Effect of the glycemic index of the diet on weight loss, modulation of satiety, inflammation, and other metabolic risk factors: a randomized controlled trial.
      ,
      • Chao AM
      • Quigley KM
      • Wadden TA.
      Dietary interventions for obesity: clinical and mechanistic findings.
      Added Sugars and Sugar-Sweetened Beverages. Added sugars are defined by the US Food and Drug Administration as sugars added during the processing of foods, foods packaged as sweeteners, sugars from syrups and honey, and those from concentrated fruit or vegetable sources, with a recommended daily value of <10% of total calories or 50 g/d for adults.
      • Buddemeyer S
      • Kauwell GP.
      The new nutrition facts label.
      However, US adults consume well over 15% of total energy, with sugar-sweetened beverages accounting for nearly 50% of added sugars.
      • Malik VS
      • Schulze MB
      • Hu FB.
      Intake of sugar-sweetened beverages and weight gain: a systematic review.
      Studies have suggested that calories consumed in liquid form are associated with less postprandial satiety compared with calories from solid food sources, likely due to a lack of dietary fiber and rapid transit through the digestive tract.
      • van Dam RM
      • Seidell JC.
      Carbohydrate intake and obesity.
      ,
      • Chen L
      • Appel LJ
      • Loria C
      • et al.
      Reduction in consumption of sugar-sweetened beverages is associated with weight loss: the PREMIER trial.
      This reduced satiety along with high-energy density, higher palatability due to sweetness, and reduced perception of energy consumption may drive the association of sugar-sweetened beverages with weight gain and obesity.
      • van Dam RM
      • Seidell JC.
      Carbohydrate intake and obesity.
      ,
      • Malik VS
      • Schulze MB
      • Hu FB.
      Intake of sugar-sweetened beverages and weight gain: a systematic review.
      There is ample scientific evidence to support the understanding that reduced consumption of added sugars and sugar-sweetened beverages is associated with weight loss.
      • Chen L
      • Appel LJ
      • Loria C
      • et al.
      Reduction in consumption of sugar-sweetened beverages is associated with weight loss: the PREMIER trial.
      ,
      • Hu FB.
      Resolved: there is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases.
      Most recently, a large randomized trial in adults aged 18 to 40 years with a BMI from 18.5 to 40 kg/m2 showed that consumption of sugar-sweetened beverages was associated with weight gain (4.4 [1.0] kg) compared with artificially sweetened beverages (0.5 [0.9] kg) or unsweetened beverages (–0.2 [0.9] kg).
      • Ebbeling CB
      • Feldman HA
      • Steltz SK
      • Quinn NL
      • Robinson LM
      • Ludwig DS.
      Effects of sugar-sweetened, artificially sweetened, and unsweetened beverages on cardiometabolic risk factors, body composition, and sweet taste preference: a randomized controlled trial.
      However, population-based modeling studies predict that reductions in sugar-sweetened beverage consumption would reduce the prevalence of obesity nationally by an estimated range of 0.3% to 1.7%.
      • Ebbeling CB
      • Feldman HA
      • Steltz SK
      • Quinn NL
      • Robinson LM
      • Ludwig DS.
      Effects of sugar-sweetened, artificially sweetened, and unsweetened beverages on cardiometabolic risk factors, body composition, and sweet taste preference: a randomized controlled trial.
      ,
      • Duffey KJ
      • Poti J.
      Modeling the effect of replacing sugar-sweetened beverage consumption with water on energy intake, HBI score, and obesity prevalence.
      Therefore, reduction in added sugar and sugar-sweetened beverage intake is strongly recommended in the treatment and management of obesity in adults.
      Dietary Fiber. Dietary fiber is classified into insoluble and viscous soluble fiber. Insoluble fiber is important for stool bulking and colonic health, whereas viscous soluble fiber has numerous cardiometabolic benefits, especially with intake of 14 g of total fiber per 1000 kcal daily.
      • Dahl WJ
      • Stewart ML.
      Position of the Academy of Nutrition and Dietetics: health implications of dietary fiber.
      ,
      • Melanson KJ
      • Angelopoulos TJ
      • Nguyen VT
      • et al.
      Consumption of whole-grain cereals during weight loss: effects on dietary quality, dietary fiber, magnesium, vitamin B-6, and obesity.
      Common dietary sources of fiber include whole grains, fruits, vegetables, legumes, nuts, and dietary supplements. Viscous fiber is important in appetite regulation, by increasing viscosity and decreasing energy density of food, delaying gastric emptying, blunting energy metabolism from absorbed macronutrients, and modulating appetite-suppressing hormones.
      • Jovanovski E
      • Mazhar N
      • Komishon A
      • et al.
      Can dietary viscous fiber affect body weight independently of an energy-restrictive diet? A systematic review and meta-analysis of randomized controlled trials.
      ,
      • Miketinas DC
      • Bray GA
      • Beyl RA
      • Ryan DH
      • Sacks FM
      • Champagne CM.
      Fiber intake predicts weight loss and dietary adherence in adults consuming calorie-restricted diets: the POUNDS Lost (Preventing Overweight Using Novel Dietary Strategies) Study.
      Therefore, dietary fiber is believed to be a key tool in increasing satiety and satiation, and thus in maintaining a caloric deficit.
      • Jovanovski E
      • Mazhar N
      • Komishon A
      • et al.
      Can dietary viscous fiber affect body weight independently of an energy-restrictive diet? A systematic review and meta-analysis of randomized controlled trials.
      ,
      • Miketinas DC
      • Bray GA
      • Beyl RA
      • Ryan DH
      • Sacks FM
      • Champagne CM.
      Fiber intake predicts weight loss and dietary adherence in adults consuming calorie-restricted diets: the POUNDS Lost (Preventing Overweight Using Novel Dietary Strategies) Study.
      The randomized trial POUNDS Lost (Preventing Overweight Using Novel Dietary Strategies) trial studied 345 participants (53.9% female) with a mean age of 52.5 (8.7) years and a mean BMI of 32.6 (3.9) kg/m2 and assessed the role of dietary fiber as a predictor for weight loss.
      • Miketinas DC
      • Bray GA
      • Beyl RA
      • Ryan DH
      • Sacks FM
      • Champagne CM.
      Fiber intake predicts weight loss and dietary adherence in adults consuming calorie-restricted diets: the POUNDS Lost (Preventing Overweight Using Novel Dietary Strategies) Study.
      The mean weight loss at 6 months was –7.27 (5.6) kg, with fiber intake being the most influential predictor for weight loss compared with caloric density and fat, carbohydrate, and protein content. This finding was further supported by a recent meta-analysis which showed that dietary viscous fiber improved body weight and parameters of adiposity, independent of caloric restriction.
      • Jovanovski E
      • Mazhar N
      • Komishon A
      • et al.
      Can dietary viscous fiber affect body weight independently of an energy-restrictive diet? A systematic review and meta-analysis of randomized controlled trials.
      In sum, dietary fiber is a potent tool for the management of obesity and common cardiometabolic comorbidities.
      Low Carbohydrate. Reduction in the quantity of carbohydrate intake is one of the most well-known dietary interventions for obesity. The Academy of Nutrition and Dietetics defines low-carbohydrate diets as those restricted to no more than 20 g/d of carbohydrates, without restriction on other macronutrients or total energy.
      • Raynor HA
      • Champagne CM.
      Position of the Academy of Nutrition and Dietetics: interventions for the treatment of overweight and obesity in adults.
      However, others consider a 20 g/d restriction to be a very low carbohydrate ketogenic diet, with a general low-carbohydrate diet defined as ≤ 20% to 45% of daily energy intake from carbohydrates.
      • Chao AM
      • Quigley KM
      • Wadden TA.
      Dietary interventions for obesity: clinical and mechanistic findings.
      It has been hypothesized that low-carbohydrate diets may be associated with increased satiety and decreased hunger. The carbohydrate-insulin model has become increasingly popular in scientific literature surrounding nutrition and obesity. As mentioned previously, the carbohydrate-insulin model proposes that high-carbohydrate diets may lead to greater weight gain because of their tendency to increase insulin secretion, which favors adipose storage and decreases fat oxidation by metabolically active tissues.
      • Hall KD
      • Guo J.
      Obesity energetics: body weight regulation and the effects of diet composition.
      ,
      • Sievenpiper JL.
      Low-carbohydrate diets and cardiometabolic health: the importance of carbohydrate quality over quantity.
      This leads to an adaptive decrease in metabolic rate, thereby leading to weight gain.
      A large meta-analysis of adults with obesity concluded that low-carbohydrate diets (<40% of total energy) promote a 6.8 kg decrease in body weight on average after 6 months.
      • Willems AEM
      • Sura-de Jong M
      • van Beek AP
      • Nederhof E
      • van Dijk G.
      Effects of macronutrient intake in obesity: a meta-analysis of low-carbohydrate and low-fat diets on markers of the metabolic syndrome.
      However, weight loss with low-carbohydrate diets is not significantly superior in efficacy to isocaloric diets, with higher carbohydrate content, or to isocaloric low-fat diets by 12 months of dietary change.
      • Raynor HA
      • Champagne CM.
      Position of the Academy of Nutrition and Dietetics: interventions for the treatment of overweight and obesity in adults.
      ,
      • Jensen MD
      • Ryan DH
      • Apovian CM
      • et al.
      2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.
      ,
      • Yannakoulia M
      • Poulimeneas D
      • Mamalaki E
      • Anastasiou CA.
      Dietary modifications for weight loss and weight loss maintenance.
      ,
      • van Dam RM
      • Seidell JC.
      Carbohydrate intake and obesity.
      ,
      • Sievenpiper JL.
      Low-carbohydrate diets and cardiometabolic health: the importance of carbohydrate quality over quantity.
      ,
      • Willems AEM
      • Sura-de Jong M
      • van Beek AP
      • Nederhof E
      • van Dijk G.
      Effects of macronutrient intake in obesity: a meta-analysis of low-carbohydrate and low-fat diets on markers of the metabolic syndrome.
      Low-carbohydrate diets may be associated with lower triglyceride levels than low-fat diets, with unclear effects on other cardiometabolic markers.
      • Seid H
      • Rosenbaum M.
      Low carbohydrate and low-fat diets: what we don't know and why we should know it.
      In addition, adherence patterns are similar between low-carbohydrate and low-fat diets, although more adverse effects, including constipation, headache, muscle cramps, and diarrhea, are observed with low-carbohydrate diets compared with low-fat diets.
      • Yannakoulia M
      • Poulimeneas D
      • Mamalaki E
      • Anastasiou CA.
      Dietary modifications for weight loss and weight loss maintenance.
      ,
      • Ge L
      • Sadeghirad B
      • Ball GDC
      • et al.
      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.
      Therefore, it is increasingly understood that higher quality carbohydrate sources, such as those with other important nutrients and substances, including fiber, vitamins, minerals, low glycemic index, and no added sugars, may confer more substantial benefit in the treatment of obesity, given the lack of clear benefit of strictly low-carbohydrate diets compared with other effective energy restriction methods.
      • Sievenpiper JL.
      Low-carbohydrate diets and cardiometabolic health: the importance of carbohydrate quality over quantity.

      Low-Fat

      Low-fat diets are those that contain < 30% of total daily calories from fat and are typically energy restricted.
      • Jensen MD
      • Ryan DH
      • Apovian CM
      • et al.
      2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.
      Mechanisms that contribute to weight loss through low-fat diets are multifactorial, including reducing consumption of dietary fat. Therefore, following an isocaloric energy-restricted low-fat diet allows for increased volume consumption of carbohydrates and protein, thereby improving satiation while maintaining a total caloric deficit.
      • Chao AM
      • Quigley KM
      • Wadden TA.
      Dietary interventions for obesity: clinical and mechanistic findings.
      In addition, high dietary fat consumption is hypothesized to potentially lead to weight gain through multiple molecular mechanisms, including alterations to intestinal microbiota, decreased fatty acid oxidation, and decreased gut hormone secretion of glucagon like peptide-1 and peptide YY, leading to low satiety and insulin resistance.
      • Seid H
      • Rosenbaum M.
      Low carbohydrate and low-fat diets: what we don't know and why we should know it.
      Low-fat diets have been similarly well studied and shown to be effective in producing weight loss among adults with obesity. The Diabetes Prevention Program (DPP) reported 12-month weight loss to be ∼7.1 kg, with meta-analyzed data suggesting that ad libitum low-fat diets may also produce weight loss, although likely less efficaciously.
      • Chao AM
      • Quigley KM
      • Wadden TA.
      Dietary interventions for obesity: clinical and mechanistic findings.
      However, the reductions in weight seen using a low-fat diet among adults with obesity are similar to those of a low-carbohydrate diet, with no clearly demonstrated large-scale advantage in efficacy, sustainability, adherence, or cardiometabolic protection.
      • Jensen MD
      • Ryan DH
      • Apovian CM
      • et al.
      2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.
      ,
      • Yannakoulia M
      • Poulimeneas D
      • Mamalaki E
      • Anastasiou CA.
      Dietary modifications for weight loss and weight loss maintenance.
      ,
      • Chao AM
      • Quigley KM
      • Wadden TA.
      Dietary interventions for obesity: clinical and mechanistic findings.
      ,
      • Seid H
      • Rosenbaum M.
      Low carbohydrate and low-fat diets: what we don't know and why we should know it.
      ,
      • Ge L
      • Sadeghirad B
      • Ball GDC
      • et al.
      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.
      Notably, although satiety and fullness may be modulated by gastric distention and ingested volume, perceived diet satisfaction overall is generally higher in high-fat diets.
      • Seid H
      • Rosenbaum M.
      Low carbohydrate and low-fat diets: what we don't know and why we should know it.

      Dietary Patterns

      There is a large variety of dietary patterns that can be used as interventions for chronic disease and obesity management. Each type focuses on different dietary components to accomplish patient goals.
      • Vajdi M
      • Farhangi MA.
      A systematic review of the association between dietary patterns and health-related quality of life.
      The three patterns reviewed are the Mediterranean diet, Dietary Approaches to Stop Hypertension (DASH), and select exclusionary diets, including the vegan, vegetarian, and pescatarian diets.
      Mediterranean Diet. The Mediterranean diet is a dietary pattern that is based on the eating habits of those who live in the Mediterranean Basin whose diets primarily comprise native plants and seafood found in the surrounding sea.
      • Urquiaga I
      • Echeverría G
      • Dussaillant C
      • Rigotti A.
      [Origin, components and mechanisms of action of the Mediterranean diet].
      ,
      • Altomare R
      • Cacciabaudo F
      • Damiano G
      • et al.
      The Mediterranean diet: a history of health.
      The Mediterranean diet is defined by its lowered intake of saturated fats and increased intake of vegetable oils; those adhering to this diet prioritize olive oils, vegetable and plant products (eg, leafy green vegetables, fruits, nuts, legumes), whole grain cereals, and fish and other seafoods.
      • Davis C
      • Bryan J
      • Hodgson J
      • Murphy K.
      Definition of the Mediterranean diet; a literature review.
      The Mediterranean diet also includes moderating intake of meat and dairy products and decreasing consumption of sugar and processed foods.
      • Davis C
      • Bryan J
      • Hodgson J
      • Murphy K.
      Definition of the Mediterranean diet; a literature review.
      • Schwingshackl L
      • Morze J
      • Hoffmann G.
      Mediterranean diet and health status: Active ingredients and pharmacological mechanisms.
      • Romagnolo DF
      • Selmin OI.
      Mediterranean diet and prevention of chronic diseases.
      The nutritional profile tends to have higher fat and lower carbohydrate levels compared with a traditional western diet. In addition, the Mediterranean diet promotes increased consumption of dietary fiber, antioxidants, and omega fatty acids.
      • Castro-Quezada I
      • Román-Viñas B
      • Serra-Majem L.
      The Mediterranean diet and nutritional adequacy: a review.
      Currently, the Mediterranean diet has been shown to be an effective preventative measure and supplementary treatment for cardiovascular disease, stroke, hypertension, and cancer.
      • Romagnolo DF
      • Selmin OI.
      Mediterranean diet and prevention of chronic diseases.
      ,
      • Abbate M
      • Gallardo-Alfaro L
      • Bibiloni MDM
      • Tur JA.
      Efficacy of dietary intervention or in combination with exercise on primary prevention of cardiovascular disease: a systematic review.
      • Lakkur S
      • Judd SE.
      Diet and stroke: recent evidence supporting a Mediterranean-style diet and food in the primary prevention of stroke.
      • Mentella MC
      • Scaldaferri F
      • Ricci C
      • Gasbarrini A
      • Miggiano GAD.
      Cancer and Mediterranean diet: a review.
      • De Pergola G
      • D'Alessandro A
      Influence of Mediterranean diet on blood pressure.
      • Jennings A
      • Berendsen AM
      • de Groot L
      • et al.
      Mediterranean-style diet improves systolic blood pressure and arterial stiffness in older adults.
      The Mediterranean diet promotes weight loss and improves metabolic abnormalities in combination with caloric restriction or when combined with increased physical activity.
      • Chao AM
      • Quigley KM
      • Wadden TA.
      Dietary interventions for obesity: clinical and mechanistic findings.
      A meta-analysis of 16 randomized controlled trials showed weight reduction by a mean of 1.8 kg compared with control diets over course of 1 to 60 months.
      • Chao AM
      • Quigley KM
      • Wadden TA.
      Dietary interventions for obesity: clinical and mechanistic findings.
      The ongoing PREDIMED (Prevenciόn con Dieta Mediterránea)-Plus trial has enrolled 7000 participants who were randomized to either an energy-restricted Mediterranean diet (in combination with physical activity and lifestyle counseling) or a usual-care control group. The mean weight loss after 1 year was 3.2 kg in the intervention group vs 0.7 kg in control participants.
      • Chao AM
      • Quigley KM
      • Wadden TA.
      Dietary interventions for obesity: clinical and mechanistic findings.
      DASH Diet. The DASH diet refers to a diet proposed after the 1997 DASH Study.
      • Steinberg D
      • Bennett GG
      • Svetkey L.
      The DASH diet, 20 years later.
      DASH focuses on high-protein, high-fiber, and low-fat intakes to lower blood pressure in patients experiencing or beginning to experience hypertension. DASH diet guidelines include increasing consumption of fruits, vegetables, legumes, lean meats, whole grains, and low-fat dairy products as well as moderating sodium intake.
      • Guo R
      • Li N
      • Yang R
      • et al.
      Effects of the modified DASH diet on adults with elevated blood pressure or hypertension: a systematic review and meta-analysis.
      • Challa HJ
      • Ameer MA
      • Uppaluri KR.
      DASH Diet To Stop Hypertension.
      • Filippou CD
      • Tsioufis CP
      • Thomopoulos CG
      • et al.
      Dietary Approaches to Stop Hypertension (DASH) diet and blood pressure reduction in adults with and without hypertension: a systematic review and meta-analysis of randomized controlled trials.
      Although intended for treating and preventing hypertension, the DASH diet has been shown to lower cardiovascular disease, stroke, and type 2 diabetes. In a meta-analysis completed by Ge et al,
      • Ge L
      • Sadeghirad B
      • Ball GDC
      • et al.
      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.
      the DASH diet promoted a mean 3.63 kg weight loss compared with a usual diet.
      • Ge L
      • Sadeghirad B
      • Ball GDC
      • et al.
      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.
      Exclusionary Diets. Exclusionary diets include diets that restrict entire food groups. The vegan diet restricts consumption of animals and all animal products, including any meat, seafood, dairy, and eggs.
      • Key TJ
      • Appleby PN
      • Rosell MS.
      Health effects of vegetarian and vegan diets.
      A common vegetarian diet, similar to the vegan diet, restricts intake of animal flesh but permits consumption of other animal products, including dairy or eggs.
      • Craig WJ.
      Nutrition concerns and health effects of vegetarian diets.
      The pescatarian diet integrates fish and seafood into a common vegetarian diet. Both vegan and vegetarian diets are plant based and have the potential to be nutritious, sustainable diets.
      • Medawar E
      • Huhn S
      • Villringer A
      • Veronica Witte A
      The effects of plant-based diets on the body and the brain: a systematic review.
      Plant-based diets that consciously focus on unprocessed foods, decreased consumption of sugar and saturated fats, and maintaining proper intake of protein and various vitamins have some benefits in health measures, including decreased BMI and inflammation.
      • Medawar E
      • Huhn S
      • Villringer A
      • Veronica Witte A
      The effects of plant-based diets on the body and the brain: a systematic review.
      • Jafari S
      • Hezaveh E
      • Jalilpiran Y
      • et al.
      Plant-based diets and risk of disease mortality: a systematic review and meta-analysis of cohort studies.
      • Szabó Z
      • Erdélyi A
      • Gubicskóné Kisbenedek A
      • et al.
      [Plant-based diets: a review].
      • Dinu M
      • Abbate R
      • Gensini GF
      • Casini A
      • Sofi F.
      Vegetarian, vegan diets and multiple health outcomes: a systematic review with meta-analysis of observational studies.
      However, the range of nutritional quality of plant-based diets is considerably large. Education and economic status play a significant role in how nutritionally wholesome a plant-based diet may be, and access to that education and fresh produce can dramatically change the nutritional profile of a plant-based diet.
      • Key TJ
      • Appleby PN
      • Rosell MS.
      Health effects of vegetarian and vegan diets.
      Without proper supplementation, plant-based diets can lack nutrients such as iron, vitamin B12, and calcium.
      • Sanders TA.
      The nutritional adequacy of plant-based diets.
      • Pawlak R
      • Lester SE
      • Babatunde T.
      The prevalence of cobalamin deficiency among vegetarians assessed by serum vitamin B12: a review of literature.
      • Larpin C
      • Wozniak H
      • Genton L
      • Serratrice J
      [Vegetarian and vegan diets and their impact on health].
      In addition, unplanned or ill-informed vegan and vegetarian diets can be made of heavily processed foods, leading to weight gain.
      • Gehring J
      • Touvier M
      • Baudry J
      • et al.
      Consumption of ultra-processed foods by pesco-vegetarians, vegetarians, and vegans: associations with duration and age at diet initiation.
      ,
      • Bakaloudi DR
      • Halloran A
      • Rippin HL
      • et al.
      Intake and adequacy of the vegan diet. A systematic review of the evidence.
      Therefore, careful consideration and planning are important in considering these diets as a means for obesity treatment and management. However, vegetarian-based diets in combination with energy restriction have shown significant weight loss compared with nonvegetarian-based diets.
      • Huang RY
      • Huang CC
      • Hu FB
      • Chavarro JE.
      Vegetarian diets and weight reduction: a meta-analysis of randomized controlled trials.
      • Crosby L
      • Rembert E
      • Levin S
      • et al.
      Changes in food and nutrient intake and diet quality on a low-fat vegan diet are associated with changes in body weight, body composition, and insulin sensitivity in overweight adults: a randomized clinical trial.
      • Turner-McGrievy GM
      • Barnard ND
      • Scialli AR.
      A two-year randomized weight loss trial comparing a vegan diet to a more moderate low-fat diet.

      Meal Timing

      Meal Timing (ie, intermittent fasting) is another approach to promote weight loss and metabolic benefits that is comparable to a standard daily energy restriction. Various types of intermittent fasting have been described in the literature that include alternate-day fasting, 5:2 intermittent fasting, and time-restricted feeding.
      • Templeman I
      • Gonzalez JT
      • Thompson D
      • Betts JA.
      The role of intermittent fasting and meal timing in weight management and metabolic health.
      Alternate-Day Fasting. The alternate-day fasting consists of severe dietary restriction during alternating days and as much food as necessary in the eating days, ad libitum. Any permitted energy during fasting days is provided in a single meal. Trepanowski and colleagues
      • Trepanowski JF
      • Kroeger CM
      • Barnosky A
      • et al.
      Effect of alternate-day fasting on weight loss, weight maintenance, and cardioprotection among metabolically healthy obese adults: a randomized clinical trial.
      compared the alternate-day fasting diet with a daily energy restriction of 25% among 69 adults with obesity in a 6-month period. The fasting day consisted of a single meal containing 25% of energy requirements consumed between the time of noon and 2:00 pm and 125% of energy requirements on feeding days. A similar body mass loss (fat and lean mass) of 6.8% between the 2 groups was observed. Metabolic health markers such as triglycerides, adipokines, fasting glucose, and insulin resistance were unaffected by either intervention.
      • Templeman I
      • Gonzalez JT
      • Thompson D
      • Betts JA.
      The role of intermittent fasting and meal timing in weight management and metabolic health.
      • Trepanowski JF
      • Kroeger CM
      • Barnosky A
      • et al.
      Effect of alternate-day fasting on weight loss, weight maintenance, and cardioprotection among metabolically healthy obese adults: a randomized clinical trial.
      • Trepanowski JF
      • Kroeger CM
      • Barnosky A
      • et al.
      Effects of alternate-day fasting or daily calorie restriction on body composition, fat distribution, and circulating adipokines: secondary analysis of a randomized controlled trial.
      Thus, alternate-day fasting does not seem to be superior to daily energy restriction.
      5:2 Intermittent Fasting. The 5:2 diet consists of 2 days of severe (up to 75%) energy restriction per week with ad libitum food consumption on the remaining 5 days.
      • Templeman I
      • Gonzalez JT
      • Thompson D
      • Betts JA.
      The role of intermittent fasting and meal timing in weight management and metabolic health.
      When diet restriction for 2 nonconsecutive days was compared with a daily energy restriction of 25% in young women with overweight, Harvie and colleagues reported similar body mass and fat mass reductions, along with modest reductions in fasting insulin and insulin resistance in both groups.
      • Templeman I
      • Gonzalez JT
      • Thompson D
      • Betts JA.
      The role of intermittent fasting and meal timing in weight management and metabolic health.
      ,
      • Harvie MN
      • Pegington M
      • Mattson MP
      • et al.
      The effects of intermittent or continuous energy restriction on weight loss and metabolic disease risk markers: a randomized trial in young overweight women.
      Another study by Antoni and colleagues reported that the 5:2 approach, with 2 restrictive consecutive days, showed similar body composition and fasting biochemical outcomes compared with daily energy restriction.
      • Templeman I
      • Gonzalez JT
      • Thompson D
      • Betts JA.
      The role of intermittent fasting and meal timing in weight management and metabolic health.
      ,
      • Antoni R
      • Johnston KL
      • Collins AL
      • Robertson MD.
      Intermittent v. continuous energy restriction: differential effects on postprandial glucose and lipid metabolism following matched weight loss in overweight/obese participants.
      Daily Time-Restricted Feeding. Daily time-restricted feeding requires only awareness of the time at which eating occasions occur. It aims to keep food intake within an 8- to 10-hour window and a 14- to 16-hour overnight fast. This approach results in decreased fat mass and leptin but no significant difference in the resting energy expenditure. Evidence suggests that extended fasting intervals influence fat mass, particularly when the fasting has been extended to at least 16 hours. However, the long-term impact of this approach in metabolic health and weight loss remains to be elucidated.
      • Templeman I
      • Gonzalez JT
      • Thompson D
      • Betts JA.
      The role of intermittent fasting and meal timing in weight management and metabolic health.

      Weight Maintenance

      Although weight maintenance is not clearly defined, the duration of 1 year is often used. Long-term weight maintenance is particularly difficult for the majority of patients who lose weight due to biologic compensatory mechanisms (including hormonal changes) that promote weight regain and an obesogenic environment found in many developed countries that is saturated with inexpensive, calorie-dense and highly processed foods that lead to increase appetite and overconsumption. Many studies estimate that more than one half of weight lost is regained within 2 years, and nearly 80% is regained within 5 years.
      • Anderson JW
      • Konz EC
      • Frederich RC
      • Wood CL.
      Long-term weight-loss maintenance: a meta-analysis of US studies.
      Food and the practice of healthy eating are essential to weight maintenance. By choosing foods that are nutrient dense, improved satiety and weight stability can be achieved. In general, adherence to a low-calorie diet that incorporates fruit, vegetables, healthy fat, protein, and whole-grain carbohydrates is effective for weight maintenance.
      • Paixão C
      • Dias CM
      • Jorge R
      • et al.
      Successful weight loss maintenance: a systematic review of weight control registries.
      This principle can be achieved by consuming more home-cooked meals using unprocessed whole foods and/or eating smaller, more frequent meals.
      • Tran E
      • Dale HF
      • Jensen C
      • Lied GA.
      Effects of plant-based diets on weight status: a systematic review.
      ,
      • Hall KD
      • Kahan S.
      Maintenance of lost weight and long-term management of obesity.
      The National Weight Control Registry(NWCR) is a cross-sectional study of 2959 subjects who maintained weight loss of at least 30 pounds for 1 year.
      • Wing RR
      • Phelan S.
      Long-term weight loss maintenance.
      Consistent nutrition strategies used to aid in weight maintenance include consuming a low-calorie, low-fat diet and eating breakfast regularly. On average, subjects consumed 1381 kcal/d with 24% of calories from fat. Registry members also report eating ∼2.5 meals weekly in restaurants and <1 meal weekly in a fast food establishment. In addition, 78% of subjects in the NWCR ate breakfast daily. Other behaviors important to weight maintenance are frequent monitoring of food intake, weighing oneself at least once a week, and engaging in a high level of physical activity.
      • Wing RR
      • Phelan S.
      Long-term weight loss maintenance.

      Nutrition in Pediatrics and Adolescents

      The effects of obesity are important to consider across the life span as obesity affects the physical and psychological health in children and adolescents.
      • Kelly AS
      • Barlow SE
      • Rao G
      • et al.
      Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association.
      Starting in the womb, expectant mothers with obesity carry an increased risk for their offspring to develop obesity and other weight-related conditions.
      • Schwarzenberg SJ
      • Georgieff MK
      • Comm N.
      Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health.
      The most rapid period of weight gain has been shown to occur during the early years between ages 2 and 6 years.
      • Geserick M
      • Vogel M
      • Gausche R
      • et al.
      Acceleration of BMI in early childhood and risk of sustained obesity.
      Excessive weight gain that occurs over childhood is generally due to an imbalance of calories-in vs calories-out. Many clinical trials in the pediatric population have targeted behavioral interventions, including diet and physical activity, to address this imbalance of more calories-in than calories-out.
      • Mead E
      • Brown T
      • Rees K
      • et al.
      Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years.
      Systematic reviews of these behavioral interventions alone reliably show small reductions in BMI and BMI z scores compared with control groups.
      • Lakkur S
      • Judd SE.
      Diet and stroke: recent evidence supporting a Mediterranean-style diet and food in the primary prevention of stroke.
      ,
      • Mead E
      • Brown T
      • Rees K
      • et al.
      Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years.
      • Cardel MI
      • Atkinson MA
      • Taveras EM
      • Holm J-C
      • Kelly AS.
      Obesity treatment among adolescents: a review of current evidence and future directions.
      • Cuda SE
      • Censani M.
      Pediatric obesity algorithm: a practical approach to obesity diagnosis and management.
      Therefore, obesity in childhood is best treated with a multifaceted approach that includes behavior change, as well as consideration of pharmacologic and surgical therapies.
      • Cardel MI
      • Atkinson MA
      • Taveras EM
      • Holm J-C
      • Kelly AS.
      Obesity treatment among adolescents: a review of current evidence and future directions.
      Dietary changes in children and adolescents, although first-line, are often difficult to achieve and sustain. Nutritional goals beyond the newborn period vary by age as growing children need differing amounts of protein, carbohydrates, and fat. Therefore, specific nutrition recommendations for weight management also vary according to age of development.
      • Cuda SE
      • Censani M.
      Pediatric obesity algorithm: a practical approach to obesity diagnosis and management.
      Dieting in children should also be handled with caution and overseen by a clinician as part of a supervised medical program given the association of fad diets and other restrictive food intake behaviors with significant risks, including disordered eating.
      • Jebeile H
      • Gow ML
      • Baur LA
      • Garnett SP
      • Paxton SJ
      • Lister NB.
      Treatment of obesity, with a dietary component, and eating disorder risk in children and adolescents: a systematic review with meta-analysis.
      In addition, many children with obesity benefit from slowed weight gain rather than frank weight loss during times of vertical growth and pubertal change.
      • Stratbucker W.
      Fad dieting and weight loss in children.
      The data on optimal diet prescriptions for the treatment of childhood obesity are limited.
      • Spear BA
      • Barlow SE
      • Ervin C
      • et al.
      Recommendations for treatment of child and adolescent overweight and obesity.
      ,
      • Sadeghirad B
      • Duhaney T
      • Motaghipisheh S
      • Campbell NRC
      • Johnston BC.
      Influence of unhealthy food and beverage marketing on children's dietary intake and preference: a systematic review and meta-analysis of randomized trials.
      Longitudinal data sets tracking food consumption and weight over time have shown that excess weight gain is associated with consumption of fat spreads (eg, butter and margarine), coated poultry and fish (ie, battered), potatoes prepared in oil (including French fries and potato chips), desserts, and sugar-sweetened beverages.
      • Dong D
      • Bilger M
      • van Dam RM
      • Finkelstein EA.
      Consumption of specific foods and beverages and excess weight gain among children and adolescents.
      Conversely, weight loss over time is associated with the intake of whole grains and high-fiber cereals.
      Clinical trials have shown that the likelihood of achieving clinically significant weight loss (defined as a decrease in BMI z score of ≥ 0.2 unit/1 year) is associated with younger age, mild to moderate forms of obesity at the time of intervention, and reduced consumption of sugar-sweetened beverages.
      • Fiechtner L
      • Castro I
      • Cheng ER
      • et al.
      Characteristics of achieving clinically important weight loss in two paediatric weight management interventions.
      These findings highlight the importance of implementing prevention and treatment measures early when habits are still being formed and lifestyle modification may be most effective.
      • Apovian CM.
      The obesity epidemic—understanding the disease and the treatment.
      School-based interventions have positively affected the quality of foods consumed. The Healthy, Hunger-Free Kids Act, which was implemented in 2012, requires that at least 51% of grains be whole grains and that each student takes at least one-half cup serving of fruits or vegetables per meal.
      • Dietz WH.
      Better diet quality in the Healthy Hunger-Free Kids Act and WIC Package reduced childhood obesity.
      The US Department of Agriculture supports the daily intake of a total of 9 servings of fruits and vegetables daily.
      • Barlow SE
      Expert Committee
      Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
      These recommendations were implemented into the Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC) food packages in 2010. Since the implementation of these changes, the incidence of obesity has decreased from 15.9% in 2010 to 13.9% in 2016 among children ages 2 to 4 years enrolled in the WIC program.
      • Pan L
      • Freedman DS
      • Park S
      • Galuska DA
      • Potter A
      • Blanck HM.
      Changes in obesity among US children aged 2 through 4 years enrolled in WIC during 2010-2016.
      Similar to weight loss in adults, weight loss in children and adolescents can occur with decreased energy consumption independent of macronutrient distribution.
      • Browne NT
      • Cuda SE.
      Nutritional and activity recommendations for the child with normal weight, overweight, and obesity with consideration of food insecurity: an Obesity Medical Association (OMA) Clinical Practice Statement 2022.
      Recent recommendations by Brown and Cuda
      • Browne NT
      • Cuda SE.
      Nutritional and activity recommendations for the child with normal weight, overweight, and obesity with consideration of food insecurity: an Obesity Medical Association (OMA) Clinical Practice Statement 2022.
      suggest tailoring macronutrient content to address specific obesity-related complications, but further research is necessary. In general, the choice of macronutrient choice should be individualized to the particular child or adolescent via shared decision-making with the patient's family.

      Conclusion

      Obesity is a complex, multifactorial disease that requires multidisciplinary care for treatment and prevention. Although the foundation of management involves food, in terms of quality and quantity, the perception that obesity is solely addressed through creation of a negative energy balance via diet and physical activity undermines the role other factors, including genetics, environment, and physiology, have in disease development. Depending on disease severity, other tools such as behavior modification, pharmacotherapy, and surgery are essential to obesity treatment.
      Throughout the discussion of “Food as Medicine,” there is no emphasis on one particular diet or eating pattern to promote weight loss. Multiple studies illustrate that the best nutrition practice is one that is sustainable long term. Therefore, a shift to focus on diet quality with increased micronutrient density and consumption of less ultra-processed foods are key to achieving satiety, weight loss, and eventual weight maintenance. In the future, precision nutrition may assist in promotion of one dietary pattern over another based on an individual's genetic background, race, or sex.

      DECLARATION OF INTEREST

      None declared.

      Acknowledgments

      All authors contributed to drafting and revising manuscript, and all authors approved the final version of the manuscript to be published.

      References

      1. Centers for Disease Control and Prevention. Adult Obesity Facts 2021.

        • Jastreboff AM
        • Kotz CM
        • Kahan S
        • Kelly AS
        • Heymsfield SB.
        Obesity as a disease: The Obesity Society 2018 Position Statement.
        Obesity (Silver Spring). 2019; 27: 7-9
        • Kwok S
        • Adam S
        • Ho JH
        • et al.
        Obesity: a critical risk factor in the COVID-19 pandemic.
        Clin Obes. 2020; 10: e12403
      2. Centers for Disease Control and Prevention. Childhood Obesity Facts 2021.

        • Raynor HA
        • Champagne CM.
        Position of the Academy of Nutrition and Dietetics: interventions for the treatment of overweight and obesity in adults.
        J Acad Nutr Diet. 2016; 116: 129-147
      3. Dietary Guidelines for Americans, 2020-2025. 9th Edition ed.

        • Jensen MD
        • Ryan DH
        • Apovian CM
        • et al.
        2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society.
        J Am Coll Cardiol. 2014; 63: 2985-3023
        • Freire R.
        Scientific evidence of diets for weight loss: different macronutrient composition, intermittent fasting, and popular diets.
        Nutrition. 2020; 69110549
        • Westerterp-Plantenga MS
        • Lemmens SG
        • Westerterp KR.
        Dietary protein—its role in satiety, energetics, weight loss and health.
        Br J Nutr. 2012; 108: S105-S112
        • Magkos F.
        The role of dietary protein in obesity.
        Rev Endocr Metab Disord. 2020; 21: 329-340
        • Hall KD
        • Guo J.
        Obesity energetics: body weight regulation and the effects of diet composition.
        Gastroenterology. 2017; 152 (1718-1727.e1713)
        • Li J
        • Armstrong CLH
        • Campbell WW.
        Effects of dietary protein source and quantity during weight loss on appetite, energy expenditure, and cardio-metabolic responses.
        Nutrients. 2016; 8: 63
        • Leidy HJ
        • Carnell NS
        • Mattes RD
        • Campbell WW.
        Higher protein intake preserves lean mass and satiety with weight loss in pre-obese and obese women.
        Obesity. 2007; 15: 421-429
        • Yannakoulia M
        • Poulimeneas D
        • Mamalaki E
        • Anastasiou CA.
        Dietary modifications for weight loss and weight loss maintenance.
        Metabolism. 2019; 92: 153-162
        • Sacks FM
        • Bray GA
        • Carey VJ
        • et al.
        Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates.
        N Engl J Med. 2009; 360: 859-873
        • Schwingshackl L
        • Hoffmann G.
        Long-term effects of low-fat diets either low or high in protein on cardiovascular and metabolic risk factors: a systematic review and meta-analysis.
        Nutr J. 2013; 12: 48
        • Wycherley TP
        • Moran LJ
        • Clifton PM
        • Noakes M
        • Brinkworth GD.
        Effects of energy-restricted high-protein, low-fat compared with standard-protein, low-fat diets: a meta-analysis of randomized controlled trials.
        Am J Clin Nutr. 2012; 96: 1281-1298
        • van Dam RM
        • Seidell JC.
        Carbohydrate intake and obesity.
        Eur J Clin Nutr. 2007; 61: S75-S99
        • Brand-Miller JC
        • Holt SH
        • Pawlak DB
        • McMillan J.
        Glycemic index and obesity.
        Am J Clin Nutr. 2002; 76: 281S-285S
        • Thomas D
        • Elliott EJ
        • Baur L.
        Low glycaemic index or low glycaemic load diets for overweight and obesity.
        Cochrane Database Syst Rev. 2007; 2007CD005105
        • Juanola-Falgarona M
        • Salas-Salvadó J
        • Ibarrola-Jurado N
        • et al.
        Effect of the glycemic index of the diet on weight loss, modulation of satiety, inflammation, and other metabolic risk factors: a randomized controlled trial.
        Am J Clin Nutr. 2014; 100: 27-35
        • Chao AM
        • Quigley KM
        • Wadden TA.
        Dietary interventions for obesity: clinical and mechanistic findings.
        J Clin Invest. 2021; : 131
        • Buddemeyer S
        • Kauwell GP.
        The new nutrition facts label.
        EDIS. 2018; 2018
        • Malik VS
        • Schulze MB
        • Hu FB.
        Intake of sugar-sweetened beverages and weight gain: a systematic review.
        Am J Clin Nutr. 2006; 84: 274-288
        • Chen L
        • Appel LJ
        • Loria C
        • et al.
        Reduction in consumption of sugar-sweetened beverages is associated with weight loss: the PREMIER trial.
        Am J Clin Nutr. 2009; 89: 1299-1306
        • Hu FB.
        Resolved: there is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases.
        Obes Rev. 2013; 14: 606-619
        • Ebbeling CB
        • Feldman HA
        • Steltz SK
        • Quinn NL
        • Robinson LM
        • Ludwig DS.
        Effects of sugar-sweetened, artificially sweetened, and unsweetened beverages on cardiometabolic risk factors, body composition, and sweet taste preference: a randomized controlled trial.
        J Am Heart Assoc. 2020; 9e015668
        • Duffey KJ
        • Poti J.
        Modeling the effect of replacing sugar-sweetened beverage consumption with water on energy intake, HBI score, and obesity prevalence.
        Nutrients. 2016; 8
        • Dahl WJ
        • Stewart ML.
        Position of the Academy of Nutrition and Dietetics: health implications of dietary fiber.
        J Acad Nutr Diet. 2015; 115: 1861-1870
        • Melanson KJ
        • Angelopoulos TJ
        • Nguyen VT
        • et al.
        Consumption of whole-grain cereals during weight loss: effects on dietary quality, dietary fiber, magnesium, vitamin B-6, and obesity.
        J Am Diet Assoc. 2006; 106: 1380-1388
        • Jovanovski E
        • Mazhar N
        • Komishon A
        • et al.
        Can dietary viscous fiber affect body weight independently of an energy-restrictive diet? A systematic review and meta-analysis of randomized controlled trials.
        Am J Clin Nutr. 2020; 111: 471-485
        • Miketinas DC
        • Bray GA
        • Beyl RA
        • Ryan DH
        • Sacks FM
        • Champagne CM.
        Fiber intake predicts weight loss and dietary adherence in adults consuming calorie-restricted diets: the POUNDS Lost (Preventing Overweight Using Novel Dietary Strategies) Study.
        J Nutr. 2019; 149: 1742-1748
        • Sievenpiper JL.
        Low-carbohydrate diets and cardiometabolic health: the importance of carbohydrate quality over quantity.
        Nutr Rev. 2020; 78: 69-77
        • Willems AEM
        • Sura-de Jong M
        • van Beek AP
        • Nederhof E
        • van Dijk G.
        Effects of macronutrient intake in obesity: a meta-analysis of low-carbohydrate and low-fat diets on markers of the metabolic syndrome.
        Nutr Rev. 2021; 79: 429-444
        • Seid H
        • Rosenbaum M.
        Low carbohydrate and low-fat diets: what we don't know and why we should know it.
        Nutrients. 2019; 11: 2749
        • Ge L
        • Sadeghirad B
        • Ball GDC
        • et al.
        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.
        BMJ. 2020; 369: m696
        • Vajdi M
        • Farhangi MA.
        A systematic review of the association between dietary patterns and health-related quality of life.
        Health Qual Life Outcomes. 2020; 18: 337
        • Urquiaga I
        • Echeverría G
        • Dussaillant C
        • Rigotti A.
        [Origin, components and mechanisms of action of the Mediterranean diet].
        Rev Med Chil. 2017; 145: 85-95
        • Altomare R
        • Cacciabaudo F
        • Damiano G
        • et al.
        The Mediterranean diet: a history of health.
        Iran J Public Health. 2013; 42: 449-457
        • Davis C
        • Bryan J
        • Hodgson J
        • Murphy K.
        Definition of the Mediterranean diet; a literature review.
        Nutrients. 2015; 7: 9139-9153
        • Schwingshackl L
        • Morze J
        • Hoffmann G.
        Mediterranean diet and health status: Active ingredients and pharmacological mechanisms.
        Br J Pharmacol. 2020; 177: 1241-1257
        • Romagnolo DF
        • Selmin OI.
        Mediterranean diet and prevention of chronic diseases.
        Nutr Today. 2017; 52: 208-222
        • Castro-Quezada I
        • Román-Viñas B
        • Serra-Majem L.
        The Mediterranean diet and nutritional adequacy: a review.
        Nutrients. 2014; 6: 231-248
        • Abbate M
        • Gallardo-Alfaro L
        • Bibiloni MDM
        • Tur JA.
        Efficacy of dietary intervention or in combination with exercise on primary prevention of cardiovascular disease: a systematic review.
        Nutr Metab Cardiovasc Dis. 2020; 30: 1080-1093
        • Lakkur S
        • Judd SE.
        Diet and stroke: recent evidence supporting a Mediterranean-style diet and food in the primary prevention of stroke.
        Stroke. 2015; 46: 2007-2011
        • Mentella MC
        • Scaldaferri F
        • Ricci C
        • Gasbarrini A
        • Miggiano GAD.
        Cancer and Mediterranean diet: a review.
        Nutrients. 2019; 11
        • De Pergola G
        • D'Alessandro A
        Influence of Mediterranean diet on blood pressure.
        Nutrients. 2018; 10
        • Jennings A
        • Berendsen AM
        • de Groot L
        • et al.
        Mediterranean-style diet improves systolic blood pressure and arterial stiffness in older adults.
        Hypertension. 2019; 73: 578-586
        • Steinberg D
        • Bennett GG
        • Svetkey L.
        The DASH diet, 20 years later.
        JAMA. 2017; 317: 1529-1530
        • Guo R
        • Li N
        • Yang R
        • et al.
        Effects of the modified DASH diet on adults with elevated blood pressure or hypertension: a systematic review and meta-analysis.
        Front Nutr. 2021; 8725020
        • Challa HJ
        • Ameer MA
        • Uppaluri KR.
        DASH Diet To Stop Hypertension.
        StatPearls. StatPearls Publishing, Treasure Island (FL)2021
        • Filippou CD
        • Tsioufis CP
        • Thomopoulos CG
        • et al.
        Dietary Approaches to Stop Hypertension (DASH) diet and blood pressure reduction in adults with and without hypertension: a systematic review and meta-analysis of randomized controlled trials.
        Adv Nutr. 2020; 11: 1150-1160
        • Key TJ
        • Appleby PN
        • Rosell MS.
        Health effects of vegetarian and vegan diets.
        Proc Nutr Soc. 2006; 65: 35-41
        • Craig WJ.
        Nutrition concerns and health effects of vegetarian diets.
        Nutr Clin Pract. 2010; 25: 613-620
        • Medawar E
        • Huhn S
        • Villringer A
        • Veronica Witte A
        The effects of plant-based diets on the body and the brain: a systematic review.
        Transl Psychiatry. 2019; 9: 226
        • Jafari S
        • Hezaveh E
        • Jalilpiran Y
        • et al.
        Plant-based diets and risk of disease mortality: a systematic review and meta-analysis of cohort studies.
        Crit Rev Food Sci Nutr. 2021; : 1-13
        • Szabó Z
        • Erdélyi A
        • Gubicskóné Kisbenedek A
        • et al.
        [Plant-based diets: a review].
        Orv Hetil. 2016; 157: 1859-1865
        • Dinu M
        • Abbate R
        • Gensini GF
        • Casini A
        • Sofi F.
        Vegetarian, vegan diets and multiple health outcomes: a systematic review with meta-analysis of observational studies.
        Crit Rev Food Sci Nutr. 2017; 57: 3640-3649
        • Sanders TA.
        The nutritional adequacy of plant-based diets.
        Proc Nutr Soc. 1999; 58: 265-269
        • Pawlak R
        • Lester SE
        • Babatunde T.
        The prevalence of cobalamin deficiency among vegetarians assessed by serum vitamin B12: a review of literature.
        Eur J Clin Nutr. 2014; 68: 541-548
        • Larpin C
        • Wozniak H
        • Genton L
        • Serratrice J
        [Vegetarian and vegan diets and their impact on health].
        Rev Med Suisse. 2019; 15: 1849-1853
        • Gehring J
        • Touvier M
        • Baudry J
        • et al.
        Consumption of ultra-processed foods by pesco-vegetarians, vegetarians, and vegans: associations with duration and age at diet initiation.
        J Nutr. 2021; 151: 120-131
        • Bakaloudi DR
        • Halloran A
        • Rippin HL
        • et al.
        Intake and adequacy of the vegan diet. A systematic review of the evidence.
        Clin Nutr. 2021; 40: 3503-3521
        • Huang RY
        • Huang CC
        • Hu FB
        • Chavarro JE.
        Vegetarian diets and weight reduction: a meta-analysis of randomized controlled trials.
        J Gen Intern Med. 2016; 31: 109-116
        • Crosby L
        • Rembert E
        • Levin S
        • et al.
        Changes in food and nutrient intake and diet quality on a low-fat vegan diet are associated with changes in body weight, body composition, and insulin sensitivity in overweight adults: a randomized clinical trial.
        J Acad Nutr Diet. 2022;
        • Turner-McGrievy GM
        • Barnard ND
        • Scialli AR.
        A two-year randomized weight loss trial comparing a vegan diet to a more moderate low-fat diet.
        Obesity (Silver Spring). 2007; 15: 2276-2281
        • Templeman I
        • Gonzalez JT
        • Thompson D
        • Betts JA.
        The role of intermittent fasting and meal timing in weight management and metabolic health.
        Proc Nutr Soc. 2020; 79: 76-87
        • Trepanowski JF
        • Kroeger CM
        • Barnosky A
        • et al.
        Effect of alternate-day fasting on weight loss, weight maintenance, and cardioprotection among metabolically healthy obese adults: a randomized clinical trial.
        JAMA Intern Med. 2017; 177: 930-938
        • Trepanowski JF
        • Kroeger CM
        • Barnosky A
        • et al.
        Effects of alternate-day fasting or daily calorie restriction on body composition, fat distribution, and circulating adipokines: secondary analysis of a randomized controlled trial.
        Clin Nutr. 2018; 37: 1871-1878
        • Harvie MN
        • Pegington M
        • Mattson MP
        • et al.
        The effects of intermittent or continuous energy restriction on weight loss and metabolic disease risk markers: a randomized trial in young overweight women.
        Int J Obes (Lond). 2011; 35: 714-727
        • Antoni R
        • Johnston KL
        • Collins AL
        • Robertson MD.
        Intermittent v. continuous energy restriction: differential effects on postprandial glucose and lipid metabolism following matched weight loss in overweight/obese participants.
        Br J Nutr. 2018; 119: 507-516
        • Anderson JW
        • Konz EC
        • Frederich RC
        • Wood CL.
        Long-term weight-loss maintenance: a meta-analysis of US studies.
        Am J Clin Nutr. 2001; 74: 579-584
        • Paixão C
        • Dias CM
        • Jorge R
        • et al.
        Successful weight loss maintenance: a systematic review of weight control registries.
        Obes Rev. 2020; 21: e13003
        • Tran E
        • Dale HF
        • Jensen C
        • Lied GA.
        Effects of plant-based diets on weight status: a systematic review.
        Diabetes Metab Syndr Obes. 2020; 13: 3433-3448
        • Hall KD
        • Kahan S.
        Maintenance of lost weight and long-term management of obesity.
        Med Clin North Am. 2018; 102: 183-197
        • Wing RR
        • Phelan S.
        Long-term weight loss maintenance.
        Am J Clin Nutr. 2005; 82: 222s-225s
        • Kelly AS
        • Barlow SE
        • Rao G
        • et al.
        Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association.
        Circulation. 2013; 128: 1689-1712
        • Schwarzenberg SJ
        • Georgieff MK
        • Comm N.
        Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health.
        Pediatrics. 2018; 141
        • Geserick M
        • Vogel M
        • Gausche R
        • et al.
        Acceleration of BMI in early childhood and risk of sustained obesity.
        N Engl J Med. 2018; 379: 1303-1312
        • Mead E
        • Brown T
        • Rees K
        • et al.
        Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years.
        Cochrane Database Syst Rev. 2017; 6CD012651
        • Cardel MI
        • Atkinson MA
        • Taveras EM
        • Holm J-C
        • Kelly AS.
        Obesity treatment among adolescents: a review of current evidence and future directions.
        JAMA Pediatr. 2020; 174: 609-617
        • Cuda SE
        • Censani M.
        Pediatric obesity algorithm: a practical approach to obesity diagnosis and management.
        Front Pediatr. 2018; 6: 431
        • Jebeile H
        • Gow ML
        • Baur LA
        • Garnett SP
        • Paxton SJ
        • Lister NB.
        Treatment of obesity, with a dietary component, and eating disorder risk in children and adolescents: a systematic review with meta-analysis.
        Obesity Reviews. 2019; 20: 1287-1298
        • Stratbucker W.
        Fad dieting and weight loss in children.
        Pediatr Rev. 2016; 37: 357-359
        • Spear BA
        • Barlow SE
        • Ervin C
        • et al.
        Recommendations for treatment of child and adolescent overweight and obesity.
        Pediatrics. 2007; 120: S254-S288
        • Sadeghirad B
        • Duhaney T
        • Motaghipisheh S
        • Campbell NRC
        • Johnston BC.
        Influence of unhealthy food and beverage marketing on children's dietary intake and preference: a systematic review and meta-analysis of randomized trials.
        Obesity Rev. 2016; 17: 945-959
        • Dong D
        • Bilger M
        • van Dam RM
        • Finkelstein EA.
        Consumption of specific foods and beverages and excess weight gain among children and adolescents.
        Health Aff (Millwood). 2015; 34: 1940-1948
        • Fiechtner L
        • Castro I
        • Cheng ER
        • et al.
        Characteristics of achieving clinically important weight loss in two paediatric weight management interventions.
        Pediatric Obesity. 2021; 16: e12784
        • Apovian CM.
        The obesity epidemic—understanding the disease and the treatment.
        N Engl J Med. 2016; 374: 177-179
        • Dietz WH.
        Better diet quality in the Healthy Hunger-Free Kids Act and WIC Package reduced childhood obesity.
        Pediatrics. 2021; 147e2020032375
        • Barlow SE
        • Expert Committee
        Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
        Pediatrics. 2007; 120: S164-S192
        • Pan L
        • Freedman DS
        • Park S
        • Galuska DA
        • Potter A
        • Blanck HM.
        Changes in obesity among US children aged 2 through 4 years enrolled in WIC during 2010-2016.
        JAMA. 2019; 321: 2364-2366
        • Browne NT
        • Cuda SE.
        Nutritional and activity recommendations for the child with normal weight, overweight, and obesity with consideration of food insecurity: an Obesity Medical Association (OMA) Clinical Practice Statement 2022.
        Obesity Pillars. 2022; 2100012