A 9-mo randomized clinical trial comparing fat-substituted and fat-reduced diets in healthy obese men: the Ole Study

Reduction in saturated fat intake for cardiovascular disease

BACKGROUND

Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally, it is unclear whether the energy from saturated fats eliminated from the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein.

OBJECTIVES

To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO), polyunsaturated (PUFA), monounsaturated fat (MUFA) and/or protein on mortality and cardiovascular morbidity, using all available randomised clinical trials.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and Embase (Ovid) on 15 October 2019, and searched Clinicaltrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 17 October 2019.

SELECTION CRITERIA

Included trials fulfilled the following criteria: 1) randomised; 2) intention to reduce saturated fat intake OR intention to alter dietary fats and achieving a reduction in saturated fat; 3) compared with higher saturated fat intake or usual diet; 4) not multifactorial; 5) in adult humans with or without cardiovascular disease (but not acutely ill, pregnant or breastfeeding); 6) intervention duration at least 24 months; 7) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed inclusion, extracted study data and assessed risk of bias. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity analyses, funnel plots and GRADE assessment.

MAIN RESULTS

We included 15 randomised controlled trials (RCTs) (16 comparisons, 56,675 participants), that used a variety of interventions from providing all food to advice on reducing saturated fat. The included long-term trials suggested that reducing dietary saturated fat reduced the risk of combined cardiovascular events by 17% (risk ratio (RR) 0.83; 95% confidence interval (CI) 0.70 to 0.98, 12 trials, 53,758 participants of whom 8% had a cardiovascular event, I² = 67%, GRADE moderate-quality evidence). Meta-regression suggested that greater reductions in saturated fat (reflected in greater reductions in serum cholesterol) resulted in greater reductions in risk of CVD events, explaining most heterogeneity between trials. The number needed to treat for an additional beneficial outcome (NNTB) was 56 in primary prevention trials, so 56 people need to reduce their saturated fat intake for ~four years for one person to avoid experiencing a CVD event. In secondary prevention trials, the NNTB was 53. Subgrouping did not suggest significant differences between replacement of saturated fat calories with polyunsaturated fat or carbohydrate, and data on replacement with monounsaturated fat and protein was very limited. We found little or no effect of reducing saturated fat on all-cause mortality (RR 0.96; 95% CI 0.90 to 1.03; 11 trials, 55,858 participants) or cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 10 trials, 53,421 participants), both with GRADE moderate-quality evidence. There was little or no effect of reducing saturated fats on non-fatal myocardial infarction (RR 0.97, 95% CI 0.87 to 1.07) or CHD mortality (RR 0.97, 95% CI 0.82 to 1.16, both low-quality evidence), but effects on total (fatal or non-fatal) myocardial infarction, stroke and CHD events (fatal or non-fatal) were all unclear as the evidence was of very low quality. There was little or no effect on cancer mortality, cancer diagnoses, diabetes diagnosis, HDL cholesterol, serum triglycerides or blood pressure, and small reductions in weight, serum total cholesterol, LDL cholesterol and BMI. There was no evidence of harmful effects of reducing saturated fat intakes.

AUTHORS' CONCLUSIONS

The findings of this updated review suggest that reducing saturated fat intake for at least two years causes a potentially important reduction in combined cardiovascular events. Replacing the energy from saturated fat with polyunsaturated fat or carbohydrate appear to be useful strategies, while effects of replacement with monounsaturated fat are unclear. The reduction in combined cardiovascular events resulting from reducing saturated fat did not alter by study duration, sex or baseline level of cardiovascular risk, but greater reduction in saturated fat caused greater reductions in cardiovascular events.

Reduction in saturated fat intake for cardiovascular disease

BACKGROUND

Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally, it is unclear whether the energy from saturated fats eliminated from the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein.

OBJECTIVES

To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO), polyunsaturated (PUFA), monounsaturated fat (MUFA) and/or protein on mortality and cardiovascular morbidity, using all available randomised clinical trials.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and Embase (Ovid) on 15 October 2019, and searched Clinicaltrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 17 October 2019.

SELECTION CRITERIA

Included trials fulfilled the following criteria: 1) randomised; 2) intention to reduce saturated fat intake OR intention to alter dietary fats and achieving a reduction in saturated fat; 3) compared with higher saturated fat intake or usual diet; 4) not multifactorial; 5) in adult humans with or without cardiovascular disease (but not acutely ill, pregnant or breastfeeding); 6) intervention duration at least 24 months; 7) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed inclusion, extracted study data and assessed risk of bias. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity analyses, funnel plots and GRADE assessment.

MAIN RESULTS

We included 15 randomised controlled trials (RCTs) (16 comparisons, ~59,000 participants), that used a variety of interventions from providing all food to advice on reducing saturated fat. The included long-term trials suggested that reducing dietary saturated fat reduced the risk of combined cardiovascular events by 21% (risk ratio (RR) 0.79; 95% confidence interval (CI) 0.66 to 0.93, 11 trials, 53,300 participants of whom 8% had a cardiovascular event, I² = 65%, GRADE moderate-quality evidence). Meta-regression suggested that greater reductions in saturated fat (reflected in greater reductions in serum cholesterol) resulted in greater reductions in risk of CVD events, explaining most heterogeneity between trials. The number needed to treat for an additional beneficial outcome (NNTB) was 56 in primary prevention trials, so 56 people need to reduce their saturated fat intake for ~four years for one person to avoid experiencing a CVD event. In secondary prevention trials, the NNTB was 32. Subgrouping did not suggest significant differences between replacement of saturated fat calories with polyunsaturated fat or carbohydrate, and data on replacement with monounsaturated fat and protein was very limited. We found little or no effect of reducing saturated fat on all-cause mortality (RR 0.96; 95% CI 0.90 to 1.03; 11 trials, 55,858 participants) or cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 10 trials, 53,421 participants), both with GRADE moderate-quality evidence. There was little or no effect of reducing saturated fats on non-fatal myocardial infarction (RR 0.97, 95% CI 0.87 to 1.07) or CHD mortality (RR 0.97, 95% CI 0.82 to 1.16, both low-quality evidence), but effects on total (fatal or non-fatal) myocardial infarction, stroke and CHD events (fatal or non-fatal) were all unclear as the evidence was of very low quality. There was little or no effect on cancer mortality, cancer diagnoses, diabetes diagnosis, HDL cholesterol, serum triglycerides or blood pressure, and small reductions in weight, serum total cholesterol, LDL cholesterol and BMI. There was no evidence of harmful effects of reducing saturated fat intakes.

AUTHORS' CONCLUSIONS

The findings of this updated review suggest that reducing saturated fat intake for at least two years causes a potentially important reduction in combined cardiovascular events. Replacing the energy from saturated fat with polyunsaturated fat or carbohydrate appear to be useful strategies, while effects of replacement with monounsaturated fat are unclear. The reduction in combined cardiovascular events resulting from reducing saturated fat did not alter by study duration, sex or baseline level of cardiovascular risk, but greater reduction in saturated fat caused greater reductions in cardiovascular events.

Reduction in saturated fat intake for cardiovascular disease

BACKGROUND

Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally it is unclear whether the energy from saturated fats that are lost in the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein. This review is part of a series split from and updating an overarching review.

OBJECTIVES

To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO), polyunsaturated (PUFA) or monounsaturated fat (MUFA) and/or protein on mortality and cardiovascular morbidity, using all available randomised clinical trials.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and EMBASE (Ovid) on 5 March 2014. We also checked references of included studies and reviews.

SELECTION CRITERIA

Trials fulfilled the following criteria: 1) randomised with appropriate control group; 2) intention to reduce saturated fat intake OR intention to alter dietary fats and achieving a reduction in saturated fat; 3) not multifactorial; 4) adult humans with or without cardiovascular disease (but not acutely ill, pregnant or breastfeeding); 5) intervention at least 24 months; 6) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Two review authors working independently extracted participant numbers experiencing health outcomes in each arm, and we performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity analyses and funnel plots.

MAIN RESULTS

We include 15 randomised controlled trials (RCTs) (17 comparisons, ˜59,000 participants), which used a variety of interventions from providing all food to advice on how to reduce saturated fat. The included long-term trials suggested that reducing dietary saturated fat reduced the risk of cardiovascular events by 17% (risk ratio (RR) 0.83; 95% confidence interval (CI) 0.72 to 0.96, 13 comparisons, 53,300 participants of whom 8% had a cardiovascular event, I² 65%, GRADE moderate quality of evidence), but effects on all-cause mortality (RR 0.97; 95% CI 0.90 to 1.05; 12 trials, 55,858 participants) and cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 12 trials, 53,421 participants) were less clear (both GRADE moderate quality of evidence). There was some evidence that reducing saturated fats reduced the risk of myocardial infarction (fatal and non-fatal, RR 0.90; 95% CI 0.80 to 1.01; 11 trials, 53,167 participants), but evidence for non-fatal myocardial infarction (RR 0.95; 95% CI 0.80 to 1.13; 9 trials, 52,834 participants) was unclear and there were no clear effects on stroke (any stroke, RR 1.00; 95% CI 0.89 to 1.12; 8 trials, 50,952 participants). These relationships did not alter with sensitivity analysis. Subgrouping suggested that the reduction in cardiovascular events was seen in studies that primarily replaced saturated fat calories with polyunsaturated fat, and no effects were seen in studies replacing saturated fat with carbohydrate or protein, but effects in studies replacing with monounsaturated fats were unclear (as we located only one small trial). Subgrouping and meta-regression suggested that the degree of reduction in cardiovascular events was related to the degree of reduction of serum total cholesterol, and there were suggestions of greater protection with greater saturated fat reduction or greater increase in polyunsaturated and monounsaturated fats. There was no evidence of harmful effects of reducing saturated fat intakes on cancer mortality, cancer diagnoses or blood pressure, while there was some evidence of improvements in weight and BMI.

AUTHORS' CONCLUSIONS

The findings of this updated review are suggestive of a small but potentially important reduction in cardiovascular risk on reduction of saturated fat intake. Replacing the energy from saturated fat with polyunsaturated fat appears to be a useful strategy, and replacement with carbohydrate appears less useful, but effects of replacement with monounsaturated fat were unclear due to inclusion of only one small trial. This effect did not appear to alter by study duration, sex or baseline level of cardiovascular risk. Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturated fats. The ideal type of unsaturated fat is unclear.

Pharmacological Management of the Obese Patient

Being obese goes beyond moral failure or a character flaw. Obesity has the defining characteristics of a chronic disease for which there is no cure. Treatment may require lifelong treatment which may include pharmacotherapy. Experience with long term use of obesity drugs is limited but evidence suggests that pharmacotherapy can improve patient outcomes and patient outlook. With current obesity drugs, weight loss is usually modest but clinically significant satisfying the FDA threshold for drug effectiveness. This weight loss is associated with clinically significant improvements in many obesity co morbidities and risk factors and could eliminate some risk factors with continued use. When used in conjunction with a comprehensive program for weight management, obesity drugs can reduce appetite or hunger, increase satiety, provide improved control over aberrant eating behaviors and modify food seeking behaviors. Pharmacotherapy can enhance weight loss and compliance during the periods of weight loss and in maintaining that weight loss, increasing physical activity and may enhance a focus on making life long changes.

This article will discuss mechanisms of action of obesity drugs, theories of altered body defense of body weight, Food and Drug Administration (FDA) approved obesity drugs, and off-label use of FDA approved drugs. The value of over-the counter (OTC) medications and diet supplements, as well as fat substitutes in the treatment of obesity drugs will be explored. Obesity drugs awaiting FDA approval and compounds under development will be reviewed. The section on approaches to drug management will include clinical considerations for; who should receive pharmacotherapy and when, length of treatment and drug discontinuation, weight regain and the role of pharmacotherapy.

Energy density, energy intake, and body weight regulation in adults

The role of dietary energy density (ED) in the regulation of energy intake (EI) is controversial. Methodologically, there is also debate about whether beverages should be included in dietary ED calculations. To address these issues, studies examining the effects of ED on EI or body weight in nonelderly adults were reviewed. Different approaches to calculating dietary ED do not appear to alter the direction of reported relations between ED and body weight. Evidence that lowering dietary ED reduces EI in short-term studies is convincing, but there are currently insufficient data to determine long-term effectiveness for weight loss. The review also identified key barriers to progress in understanding the role of ED in energy regulation, in particular the absence of a standard definition of ED, and the lack of data from multiple long-term clinical trials examining the effectiveness of low-ED diet recommendations for preventing both primary weight gain and weight regain in nonobese individuals. Long-term clinical trials designed to examine the impact of dietary ED on energy regulation, and including multiple ED calculation methods within the same study, are still needed to determine the importance of ED in the regulation of EI and body weight.

Effect of reducing total fat intake on body weight: systematic review and meta-analysis of randomised controlled trials and cohort studies

OBJECTIVE

To investigate the relation between total fat intake and body weight in adults and children.

DESIGN

Systematic review and meta-analysis of randomised controlled trials and cohort studies.

DATA SOURCES

Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials to June 2010.

INCLUSION CRITERIA

Randomised controlled trials and cohort studies of adults or children that compared lower versus usual total fat intake and assessed the effects on measures of body fatness (body weight, body mass index, or waist circumference) after at least six months (randomised controlled trials) or one year (in cohorts). Randomised controlled trials with any intention to reduce weight in participants or confounded by additional medical or lifestyle interventions were excluded.

DATA EXTRACTION

Data were extracted and validity was assessed independently and in duplicate. Random effects meta-analyses, subgroups, sensitivity analyses, and metaregression were done.

RESULTS

33 randomised controlled trials (73,589 participants) and 10 cohort studies were included, all from developed countries. Meta-analysis of data from the trials suggested that diets lower in total fat were associated with lower relative body weight (by 1.6 kg, 95% confidence interval -2.0 to -1.2 kg, I(2)=75%, 57,735 participants). Lower weight gain in the low fat arm compared with the control arm was consistent across trials, but the size of the effect varied. Metaregression suggested that greater reduction in total fat intake and lower baseline fat intake were associated with greater relative weight loss, explaining most of the heterogeneity. The significant effect of a low fat diet on weight was not lost in sensitivity analyses (including removing trials that expended greater time and attention on low fat groups). Lower total fat intake also led to lower body mass index (-0.51 kg/m(2), 95% confidence interval -0.76 to -0.26, nine trials, I(2)=77%) and waist circumference (by 0.3 cm, 95% confidence interval -0.58 to -0.02, 15,671 women, one trial). There was no suggestion of negative effects on other cardiovascular risk factors (lipid levels or blood pressure). GRADE assessment suggested high quality evidence for the relation between total fat intake and body weight in adults. Only one randomised controlled trial and three cohort studies were found in children and young people, but these confirmed a positive relation between total fat intake and weight gain.

CONCLUSIONS

There is high quality, consistent evidence that reduction of total fat intake has been achieved in large numbers of both healthy and at risk trial participants over many years. Lower total fat intake leads to small but statistically significant and clinically meaningful, sustained reductions in body weight in adults in studies with baseline fat intakes of 28-43% of energy intake and durations from six months to over eight years. Evidence supports a similar effect in children and young people.

Adult Female Rats Defend “Appropriate” Energy Intake after Adaptation to Dietary Energy

OBJECTIVE

To determine if adult female rats adapt to lower and higher dietary energy density.

RESEARCH METHODS AND PROCEDURES

Study 1 compared high-fat (56%), high-energy density (HD) (21.6 kJ/g) and high-fat (56%), low-energy density (LD) (16.0 kJ/g) diets before surgery (two groups, 2 weeks, n = 16) and after surgery [ovariectomy (O) Sham (S); 2 x 2 factorial, n = 8; 6 weeks]. The second study (no surgery) compared high-fat (60.0%), high-energy (22.0 kJ/g) and low-fat (10.0%), low-energy (15.1 kJ/g) diets (n = 8).

RESULTS

In study 1, food intake was similar for the first 2 weeks, but rats on the LD diet consumed less energy, gained less weight, and had lower nonfasted serum leptin (all p < 0.0001) than rats on the HD diet. After surgery, rats on the LD and HD diets had similar weight gain, but rats on the LD diet consumed more food (p < 0.0001) and less energy (p < 0.009). O rats consumed more food and gained more weight (p < 0.0001) than S rats. Results from study 2 were similar to those from study 1.

DISCUSSION

The results demonstrated that O and S surgery rats and rats with no surgery adjust their food intake to defend a level of energy intake. This defense only occurred after a 2-week adaptation period. The major differences in final body weights and abdominal fat resulted from the initial 2 weeks before adaptation to energy density. Rats fed higher-energy diets seemed to "settle" at a higher level of adiposity, and rats fed lower-energy diets consumed more food to increase energy consumption.

Reduced or modified dietary fat for preventing cardiovascular disease

BACKGROUND

Reduction and modification of dietary fats have differing effects on cardiovascular risk factors (such as serum cholesterol), but their effects on important health outcomes are less clear.

OBJECTIVES

To assess the effect of reduction and/or modification of dietary fats on mortality, cardiovascular mortality, cardiovascular morbidity and individual outcomes including myocardial infarction, stroke and cancer diagnoses in randomised clinical trials of at least 6 months duration.

SEARCH METHODS

For this review update, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, were searched through to June 2010. References of Included studies and reviews were also checked.

SELECTION CRITERIA

Trials fulfilled the following criteria: 1) randomised with appropriate control group, 2) intention to reduce or modify fat or cholesterol intake (excluding exclusively omega-3 fat interventions), 3) not multi factorial, 4) adult humans with or without cardiovascular disease, 5) intervention at least six months, 6) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Participant numbers experiencing health outcomes in each arm were extracted independently in duplicate and random effects meta-analyses, meta-regression, sub-grouping, sensitivity analyses and funnel plots were performed.

MAIN RESULTS

This updated review suggested that reducing saturated fat by reducing and/or modifying dietary fat reduced the risk of cardiovascular events by 14% (RR 0.86, 95% CI 0.77 to 0.96, 24 comparisons, 65,508 participants of whom 7% had a cardiovascular event, I(2) 50%). Subgrouping suggested that this reduction in cardiovascular events was seen in studies of fat modification (not reduction - which related directly to the degree of effect on serum total and LDL cholesterol and triglycerides), of at least two years duration and in studies of men (not of women). There were no clear effects of dietary fat changes on total mortality (RR 0.98, 95% CI 0.93 to 1.04, 71,790 participants) or cardiovascular mortality (RR 0.94, 95% CI 0.85 to 1.04, 65,978 participants). This did not alter with sub-grouping or sensitivity analysis.Few studies compared reduced with modified fat diets, so direct comparison was not possible.

AUTHORS' CONCLUSIONS

The findings are suggestive of a small but potentially important reduction in cardiovascular risk on modification of dietary fat, but not reduction of total fat, in longer trials. Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups, should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturates. The ideal type of unsaturated fat is unclear.

Effects of 4 weight-loss diets differing in fat, protein, and carbohydrate on fat mass, lean mass, visceral adipose tissue, and hepatic fat: results from the POUNDS LOST trial

BACKGROUND

Weight loss reduces body fat and lean mass, but whether these changes are influenced by macronutrient composition of the diet is unclear.

OBJECTIVE

We determined whether energy-reduced diets that emphasize fat, protein, or carbohydrate differentially reduce total, visceral, or hepatic fat or preserve lean mass.

DESIGN

In a subset of participants in a randomized trial of 4 weight-loss diets, body fat and lean mass (n = 424; by using dual-energy X-ray absorptiometry) and abdominal and hepatic fat (n = 165; by using computed tomography) were measured after 6 mo and 2 y. Changes from baseline were compared between assigned amounts of protein (25% compared with 15%) and fat (40% compared with 20%) and across 4 carbohydrate amounts (35% through 65%).

RESULTS

At 6 mo, participants lost a mean (±SEM) of 4.2 ± 0.3 kg (12.4%) fat and 2.1 ± 0.3 kg (3.5%) lean mass (both P < 0.0001 compared with baseline values), with no differences between 25% and 15% protein (P ≥ 0.10), 40% and 20% fat (P ≥ 0.34), or 65% and 35% carbohydrate (P ≥ 0.27). Participants lost 2.3 ± 0.2 kg (13.8%) abdominal fat: 1.5 ± 0.2 kg (13.6%) subcutaneous fat and 0.9 ± 0.1 kg (16.1%) visceral fat (all P < 0.0001 compared with baseline values), with no differences between the diets (P ≥ 0.29). Women lost more visceral fat than did men relative to total-body fat loss. Participants regained ~40% of these losses by 2 y, with no differences between diets (P ≥ 0.23). Weight loss reduced hepatic fat, but there were no differences between groups (P ≥ 0.28). Dietary goals were not fully met; self-reported contrasts were closer to 2% protein, 8% fat, and 14% carbohydrate at 6 mo and 1%, 7%, and 10%, respectively, at 2 y.

CONCLUSION

Participants lost more fat than lean mass after consumption of all diets, with no differences in changes in body composition, abdominal fat, or hepatic fat between assigned macronutrient amounts. This trial was registered at clinicaltrials.gov as NCT00072995.

Review of the effects of dilution of dietary energy with olestra on energy intake

The non-absorbable substitute for dietary triacylglycerol, olestra, has been marketed in the United States for fifteen years. Olestra is comprised of sucrose with six to eight of its hydroxyl groups forming ester links with long-chain fatty acids. Because olestra is not hydrolyzed by fat-splitting enzymes in the small intestine, it is not absorbed from the small intestine into blood and tissues, and therefore provides no energy that can be utilized by the body. The hedonic properties of olestra with a specific fatty acid composition are similar to those of a triacylglycerol with the same fatty acid composition. Its use by consumers has been restricted by federal regulation to the commercial preparation of savory snack food items, principally as a frying medium for potato chips. An important question about the substitution of olestra for absorbable fat in the diet is whether the consumer will sense that a smaller amount of energy has been ingested. If it is sensed, thereby providing no satiation, then consuming additional energy in later meals will compensate for the removal of absorbable energy from the diet. If it is not sensed at all, then there is no compensation, and the person reduces caloric intake. This review first summarizes studies with olestra that have focused on its effect on the physiology of appetite. In general these studies have demonstrated that olestra does not influence signals of satiation including cholecystokinin and stomach emptying. The review then discusses studies of food consumption in experimental animals in which olestra was substituted for fat in the diet. Rodents have been repeatedly observed to compensate completely for the substitution of olestra for normal fat by eating more total diet. Most studies of the effect of olestra on human satiation have found incomplete or no compensation through additional energy consumption when olestra was substituted for dietary fat. In two clinical studies, however, complete compensation was observed, suggesting that experimental conditions and individual variability influence the ability to sense the substitution of olestra for absorbable fat. There is no evidence that dietary olestra causes consumption of more energy than would have been consumed without olestra in the diet. The data from animals and humans strongly suggest that the rodent is not a satisfactory model for the human in the determination of the extent of compensation by substitution of olestra for dietary fat.

Reduced or modified dietary fat for preventing cardiovascular disease

BACKGROUND

Reduction and modification of dietary fats have differing effects on cardiovascular risk factors (such as serum cholesterol), but their effects on important health outcomes are less clear.

OBJECTIVES

To assess the effect of reduction and/or modification of dietary fats on mortality, cardiovascular mortality, cardiovascular morbidity and individual outcomes including myocardial infarction, stroke and cancer diagnoses in randomised clinical trials of at least 6 months duration.

SEARCH STRATEGY

For this review update, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, were searched through to June 2010. References of Included studies and reviews were also checked.

SELECTION CRITERIA

Trials fulfilled the following criteria: 1) randomised with appropriate control group, 2) intention to reduce or modify fat or cholesterol intake (excluding exclusively omega-3 fat interventions), 3) not multi factorial, 4) adult humans with or without cardiovascular disease, 5) intervention at least six months, 6) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Participant numbers experiencing health outcomes in each arm were extracted independently in duplicate and random effects meta-analyses, meta-regression, sub-grouping, sensitivity analyses and funnel plots were performed.

MAIN RESULTS

This updated review suggested that reducing saturated fat by reducing and/or modifying dietary fat reduced the risk of cardiovascular events by 14% (RR 0.86, 95% CI 0.77 to 0.96, 24 comparisons, 65,508 participants of whom 7% had a cardiovascular event, I(2) 50%). Subgrouping suggested that this reduction in cardiovascular events was seen in studies of fat modification (not reduction - which related directly to the degree of effect on serum total and LDL cholesterol and triglycerides), of at least two years duration and in studies of men (not of women). There were no clear effects of dietary fat changes on total mortality (RR 0.98, 95% CI 0.93 to 1.04, 71,790 participants) or cardiovascular mortality (RR 0.94, 95% CI 0.85 to 1.04, 65,978 participants). This did not alter with sub-grouping or sensitivity analysis.Few studies compared reduced with modified fat diets, so direct comparison was not possible.

AUTHORS' CONCLUSIONS

The findings are suggestive of a small but potentially important reduction in cardiovascular risk on modification of dietary fat, but not reduction of total fat, in longer trials. Lifestyle advice to all those at risk of cardiovascular disease and to lower risk population groups, should continue to include permanent reduction of dietary saturated fat and partial replacement by unsaturates. The ideal type of unsaturated fat is unclear.

Impact of adopting a vegan diet or an olestra supplementation on plasma organochlorine concentrations: results from two pilot studies

The aim of these studies was to evaluate the potential of some nutritional approaches to prevent or reduce the body load of organochlorines (OC) in humans. Study 1 compared plasma OC concentrations between vegans and omnivores while study 2 verified if the dietary fat substitute olestra could prevent the increase in OC concentrations that is generally observed in response to a weight-reducing programme. In study 1, nine vegans and fifteen omnivores were recruited and the concentrations of twenty-six OC (beta-hexachlorocyclohexane (beta-HCH), p, p'-dichlorodiphenyldichloroethane (p, p'-DDE), p, p'-dichlorodiphenyltrichloroethane (p, p'-DDT), hexachlorobenzene, mirex, aldrin, alpha-chlordane, gamma-chlordane, oxychlordane, cis-nonachlor, trans-nonachlor, polychlorinated biphenyl (PCB) nos. 28, 52, 99, 101, 105, 118, 128, 138, 153, 156, 170, 180, 183 and 187, and aroclor 1260) were determined. In study 2, the concentrations of these twenty-six OC were measured before and after weight loss over 3 months in thirty-seven obese men assigned to one of the following treatments: standard group (33 % fat diet; n 13), fat-reduced group (25 % fat diet; n 14) or fat-substituted group (1/3 of dietary lipids substituted by olestra; n 10). In study 1, plasma concentrations of five OC compounds (aroclor 1260 and PCB 99, PCB 138, PCB 153 and PCB 180) were significantly lower in vegans compared with omnivores. In study 2, beta-HCH was the only OC which decreased in the fat-substituted group while increasing in the other two groups (P = 0.045). In conclusion, there was a trend toward lesser contamination in vegans than in omnivores, and olestra had a favourable influence on beta-HCH but did not prevent plasma hyperconcentration of the other OC during ongoing weight loss.

The relationship between dietary energy density and energy intake

Much of the research in ingestive behavior has focused on the macronutrient composition of foods; however, these studies are incomplete, or could be misleading, if they do not consider the energy density (ED) of the diet under investigation. Lowering the ED (kcal/g) by increasing the volume of preloads without changing macronutrient content can enhance satiety and reduce subsequent energy intake at a meal. Ad libitum intake or satiation has also been shown to be influenced by ED when the proportions of macronutrients are constant. Since people tend to eat a consistent weight of food, when the ED of the available foods is reduced, energy intake is reduced. The effects of ED have been seen in adults of different weight status, sex, and behavioral characteristics, as well as in 3- to 5-year-old children. The mechanisms underlying the response to variations in ED are not yet well understood and data from controlled studies lasting more than several days are limited. However, both population-based studies and long-term clinical trials indicate that the effects of dietary ED can be persistent. Several clinical trials have shown that reducing the ED of the diet by the addition of water-rich foods such as fruits and vegetables was associated with substantial weight loss even when patients were not told to restrict calories. Since lowering dietary energy density could provide effective strategies for the prevention and treatment of obesity, there is a need for more studies of mechanisms underlying the effect and ways to apply these findings.

Thirst-drinking, hunger-eating; tight coupling?

Although thirst and hunger have historically motivated drinking and feeding, respectively, the high and increasing consumption of energy-yielding beverages and energy-diluted foods may have degraded the predictive value of these sensations on ingestive behavior. Our within subject (ie, multiple responses from the same individuals), observational (ie, free-living, with no intervention) study explored the relationships between thirst, hunger, eating, and drinking patterns in 50 weight-stable adults (39 women and 11 men aged 30+/-11 years with body mass index 26.3+/-5.9). Twenty-four-hour dietary recalls were obtained for a consecutive 7-day period. Appetite ratings were recorded hourly, over the same time period, and correlated with hourly energy and fluid intake from food and beverages. Thirst ratings were not correlated with drinking (r=0.03) or energy intake (r=0.08) during the same hour over the 7-day period. Hunger ratings were significantly, albeit moderately, correlated with energy intake (r=0.30) (P<0.05), but not with drinking (r=0.04). On average, 75% of total fluid intake was consumed during periprandial events. Further, energy-yielding beverages were the main contributor to fluid intake during both periprandial and drink-only events. These data fail to reveal associations between either thirst or hunger and ingestion of energy-yielding beverages, or strong associations between hunger and eating or thirst and drinking. These data raise questions about the predictive power of appetitive sensations for ingestive behavior.

Corrective responses in human food intake identified from an analysis of 7-d food-intake records

BACKGROUND

We tested the hypothesis that ad libitum food intake shows corrective responses over periods of 1-5 d.

DESIGN

This was a prospective study of food intake in women.

METHODS

Two methods, a weighed food intake and a measured food intake, were used to determine daily nutrient intake during 2 wk in 20 women. Energy expenditure with the use of doubly labeled water was done contemporaneously with the weighed food-intake record. The daily deviations in macronutrient and energy intake from the average 7-d values were compared with the deviations observed 1, 2, 3, 4, and 5 d later to estimate the corrective responses.

RESULTS

Both methods of recording food intake gave similar patterns of macronutrient and total energy intakes and for deviations from average intakes. The intraindividual CVs for energy intake ranged from +/-12% to +/-47% with an average of +/-25%. Reported energy intake was 85.5-95.0% of total energy expenditure determined by doubly labeled water. Significant corrective responses were observed in food intakes with a 3- to 4-d lag that disappeared when data were randomized within each subject.

CONCLUSIONS

Human beings show corrective responses to deviations from average energy and macronutrient intakes with a lag time of 3-4 d, but not 1-2 d. This suggests that short-term studies may fail to recognize important signals of food-intake regulation that operate over several days. These corrective responses probably play a crucial role in bringing about weight stability.

Relationships between human thirst, hunger, drinking, and feeding

There is a widely held view that hunger prompts feeding to ensure energy needs are met, while thirst cues drinking to address hydration requirements. However, recent changes in the nature of the food supply and eating patterns have raised questions about the functionality of these relationships with respect to maintaining energy balance. The increasing consumption of energy-yielding beverages and foods with diluted energy density, through the use of ingredients such as high-intensity sweeteners and fat replacers, poses new challenges to presumed homeostatic energy regulatory mechanisms. This review draws on findings from a recent observational study and other published evidence to explore whether shifts of food composition and use patterns may be disrupting relationships between thirst, hunger, drinking, and eating, resulting in positive energy balance (e.g., drinking low satiety, energy-yielding beverages in response to hunger). The observational study entailed collecting hourly appetitive ratings and dietary recalls from 50 adults for seven consecutive days. These data reveal a clear bimodal daily hunger pattern, whereas thirst is stronger and more stable throughout the day. Further, approximately 75% of fluid intake occurs peri-prandially, with the majority derived from energy-yielding beverages. While there is published evidence that drinking is responsive to feeding, support for the view that drinking is the more tightly regulated behavior is stronger. Our data indicates that, due to a number of plausible factors, neither absolute values nor changes of hunger or thirst are strong predictors of energy intake. However, it is proposed that stable, high thirst facilitates drinking, and with the increased availability and use of energy-yielding beverages that have low satiety properties, can promote positive energy balance. There are marked individual differences in mean daily hunger and thirst ratings with unknown implications for energy balance.

Obesity: person and population

Obesity is a problem among all ages and races, in both genders, and across all socioeconomic classes, and the prevalence of obesity has been increasing. Efforts are being made to combat the increasing prevalence, but only modest success has been achieved. Obesity is affected by multiple factors. There are genetic and environmental components involved, yet pinpointing specific genetic and environmental influences has been difficult. Development of treatments has ranged from pharmaceuticals to behavioral modification. Extant treatments aimed at the individual and administered for relatively brief portions of the lifespan have shown only modest results. If we are to make pervasive and enduring changes to population adiposity levels, it is likely that we will need to make pervasive and enduring changes to the ways in which we live across the lifespan.

Consistent relationships between sensory properties of savory snack foods and calories influence food intake in rats

OBJECTIVE

Determine the influence of experience with consistent or inconsistent relationships between the sensory properties of snack foods and their caloric consequences on the control of food intake or body weight in rats.

DESIGN

Rats received plain and BBQ flavored potato chips as a dietary supplement, along with ad lib rat chow. For some rats the potato chips were a consistent source of high fat and high calories (regular potato chips). For other rats, the chips provided high fat and high calories on some occasions (regular potato chips) and provided no digestible fat and fewer calories at other times (light potato chips manufactured with a fat substitute). Thus, animals in the first group were given experiences that the sensory properties of potato chips were strong predictors of high calories, while animals in the second group were given experiences that the sensory properties of potato chips were not predictors of high calories.

SUBJECTS

Juvenile and adult male Sprague-Dawley rats.

MEASUREMENTS

Following exposure to varying potato chip-calorie contingencies, intake of a novel, high-fat snack food and subsequent chow intake were assessed. Body weight gain and body composition as measured by DEXA were also measured.

RESULTS

In juvenile animals, exposure to a consistent relationship between potato chips and calories resulted in reduced chow intake, both when no chips were provided and following consumption of a novel high-fat, high-calorie snack chip. Long-term experience with these contingencies did not affect body weight gain or body composition in juveniles. In adult rats, exposure to an inconsistent relationship between potato chips and calories resulted in increased consumption of a novel high-fat, high-calorie snack chip premeal along with impaired compensation for the calories contained in the premeal.

CONCLUSION

Consumption of foods in which the sensory properties are poor predictors of caloric consequences may alter subsequent food intake.

Olestra is associated with slight reductions in serum carotenoids but does not markedly influence serum fat-soluble vitamin concentrations

BACKGROUND

The 1996 Food and Drug Administration approval of the fat substitute olestra (sucrose polyester) called for active postmarketing surveillance because preapproval studies showed that olestra may lower circulating concentrations of fat-soluble nutrients such as vitamins and carotenoids.

OBJECTIVE

The objective of the Olestra Post-Marketing Surveillance Study was to examine whether customary consumption of olestra-containing savory snacks was associated with changes in serum fat-soluble vitamin and carotenoid concentrations among free-living persons in geographically and ethnically distinct US cities.

DESIGN

Adults (n = 2535) and their children aged 12-17 y (n = 272) in Baltimore, Minneapolis, and San Diego attended clinic visits during which data were collected on diet, savory snack consumption, lifestyle, and anthropometric indexes. Blood samples were drawn to assay carotenoids and vitamins A, D, E, and K. Data and blood samples were collected both before and after the nationwide introduction of olestra. General estimating equations were used in multivariate-adjusted models that examined olestra's association with the specified serum nutrients.

RESULTS

Compared with no intake, the top 2 tertiles of olestra use in adults were associated with circulating carotenoid concentrations that were modestly but significantly lower (4.3% to 22.4%). There were no significant associations of olestra with any serum nutrients among adolescents.

CONCLUSIONS

This active postmarketing surveillance study of a food additive suggests that small decreases in serum fat-soluble nutrients are attributable to olestra use. Although health outcomes were not measured here, it is unlikely that these small changes in nutrient measures would adversely affect health.

Effects of variation in protein and carbohydrate intake on body mass and composition during energy restriction: a meta-regression 1

BACKGROUND

It is unclear whether low-carbohydrate, high-protein, weight-loss diets benefit body mass and composition beyond energy restriction alone.

OBJECTIVE

The objective was to use meta-regression to determine the effects of variations in protein and carbohydrate intakes on body mass and composition during energy restriction.

DESIGN

English-language studies with a dietary intervention of > or =4200 kJ/d (1000 kcal/d), with a duration of > or =4 wk, and conducted in subjects aged > or =19 y were considered eligible for inclusion. A self-reported intake in conjunction with a biological marker of macronutrient intake was required as a minimum level of dietary control. A total of 87 studies comprising 165 intervention groups met the inclusion criteria.

RESULTS

After control for energy intake, diets consisting of < or =35-41.4% energy from carbohydrate were associated with a 1.74 kg greater loss of body mass, a 0.69 kg greater loss of fat-free mass, a 1.29% greater loss in percentage body fat, and a 2.05 kg greater loss of fat mass than were diets with a higher percentage of energy from carbohydrate. In studies that were conducted for >12 wk, these differences increased to 6.56 kg, 1.74 kg, 3.55%, and 5.57 kg, respectively. Protein intakes of >1.05 g/kg were associated with 0.60 kg additional fat-free mass retention compared with diets with protein intakes < or =1.05 g/kg. In studies conducted for >12 wk, this difference increased to 1.21 kg. No significant effects of protein intake on loss of either body mass or fat mass were observed.

CONCLUSION

Low-carbohydrate, high-protein diets favorably affect body mass and composition independent of energy intake, which in part supports the proposed metabolic advantage of these diets.

Daily intake of multivitamins during long-term intake of olestra in men prevents declines in serum vitamins A and E but not carotenoids

The objective of this study was to determine whether vitamin supplementation during long-term (36 wk) ingestion of olestra supplemented with vitamin E could prevent decreases in vitamin E, vitamin A, and carotenoids. This was a 36-wk study of 37 healthy males randomly assigned to consume a control diet composed of 33% energy from fat, a similar diet in which one third of the energy from fat had been replaced with olestra, or a fat-reduced (25% of energy from fat) diet. Subjects also ingested a daily multivitamin (Centrum). Serum concentrations of alpha-tocopherol, retinol, beta-carotene, lycopene, and lutein + zeaxanthin were analyzed by HPLC. Subjects eating the olestra-containing diet had substantial decreases in serum beta-carotene, lycopene, and lutein + zeaxanthin, which occurred by 12 wk; these changes were found despite correcting for serum total cholesterol or BMI. Serum beta-carotene and lycopene concentrations were below the lower limit of the reference range (<0.186 and <0.298 mumol/L, respectively) at one or more time points. The slight decline in serum alpha-tocopherol concentration, significant at 24 wk, was caused by the decline in serum cholesterol. Retinol concentrations decreased with time in all 3 groups, but were not affected by olestra. We conclude that supplementation with a multivitamin containing vitamins A and E was adequate to prevent olestra-induced decrease in serum alpha-tocopherol and retinol. Olestra-induced decreases in serum beta-carotene, lycopene, and lutein + zeaxanthin were not prevented by the vitamin supplement used in this study.

Position of the American Dietetic association: fat replacers

It is the position of the American Dietetic Association that the majority of fat replacers, when used in moderation by adults, can be safe and useful adjuncts to lowering the fat content of foods and may play a role in decreasing total dietary energy and fat intake. Moderate use of low-calorie, reduced-fat foods, combined with low total energy intake, could potentially promote dietary intake consistent with the objectives of Healthy People 2010 and the 2005 Dietary Guidelines for Americans . The obesity epidemic in the nation has been attributed to energy imbalance, mainly because of increased food consumption and/or sedentary lifestyle, or both. Evidence suggests that lowering total energy intake along with a reduction in total fat intake can have a substantial impact on body weight and risk of chronic diseases. Fat replacers are used to provide some or all of the functional properties of fat, while providing fewer calories than the fat being replaced, and are used in a variety of products, from baked goods to frozen desserts. Fat replacers can be effective only if they lower the total caloric content of the food and if the consumer uses these foods as part of a balanced meal plan. Consumers should not be led to believe that fat- and calorie-reduced products can be consumed in unlimited amounts. Fat replacers are most useful when they help with calorie control and when their use encourages the consumption of foods delivering important nutrients.

Pharmaceutical approaches to the treatment of obesity

The recent increase in pharmaceutical companies' efforts toward the treatment of obesity reflects recognition of the related health risks, the growth of knowledge about mechanisms that control energy balance, and the potential market for new compounds. The current patent literature gives a picture of the targets that are available for pharmaceutical intervention; these include signals of satiety and signals related to fat storage that act in the hypothalamus. The regulation of energy use and storage in adipocytes and the reduction of intestinal absorption of energy are also pharmaceutical focus areas. The multiplicity of targets illustrates not only the many potential approaches to the treatment of obesity but also the complexity and redundancy of the processes that regulate energy storage in the body.

Diet and obesity

PURPOSE OF REVIEW

Obesity continues to increase in the United States and worldwide. There is controversy surrounding different dietary patterns used to promote weight loss, and none has emerged as clearly more effective. This paper briefly reviews the factors that influence energy intake and dietary treatments used to promote weight loss.

RECENT FINDINGS

Increasing portion size, eating away from home, and consuming a variety of high-energy dense foods appear to increase energy intake. Hormonal influences on diet continue to be explored. Very-low-calorie diets and low-carbohydrate diets lead to greater initial weight loss, but long-term results are no better than more moderate calorie-restricted diets. A program using meal replacements appears to lead to weight loss slightly greater than calorie-restricted diets and offers one option to treat obesity. Dietary patterns low in energy density and glycemic index have potential in treating obesity and should be studied further.

SUMMARY

Clearly, a dietary pattern that prescribes a lower total energy intake is necessary for weight loss, and this pattern should be sustainable to maintain weight loss. Although many dietary programs can achieve short-term loss of weight, dietary treatment should be recommended that emphasizes lifestyle changes and is consistent with other dietary guidelines to promote long-term health. Features consistent with this are a dietary pattern low in total calories, saturated fat, and refined carbohydrate; moderate in whole grains; and high in low-energy dense vegetables and fruits. Future studies should explore dietary strategies and combination therapies that contribute to weight loss, long-term weight maintenance, and improved health.

Consumption of a controlled low-fat diet containing olestra for 9 months improves health risk factors in conjunction with weight loss in obese men: the Ole' Study

OBJECTIVE

To compare the effects of a standard American diet, a traditional low-fat diet, and a low-fat diet containing the fat substitute olestra on risk factors for heart disease and diabetes.

DESIGN

A 9-month, double-blind, randomized, parallel-arm, feeding study comparing three diets: (1). control (33% fat), (2). fat-reduced (FR; 25% fat), and (3). fat-substituted (FS) where olestra replaced 1/3 of dietary fat (33% lipid and 25% digestible fat). Subjects were allowed to adjust their total energy intake as desired, allowing weight to fluctuate.

SUBJECTS

A total of 37 healthy, obese men (age 36.7+/-1.3 y; body mass index 30.8+/-0.4 kg/m(2)).

MEASUREMENTS

Body weight and composition by dual-energy X-ray absorptiometry, blood pressure, serum lipids, lipoproteins, hemostatic factors, glucose, insulin, and leptin at baseline and every 3 months.

RESULTS

The FS group lost 6.27 kg of body weight by 9 months vs 4.0 kg in the control and 1.79 kg in the FR groups. There was a significant diet main effect on cholesterol (P=0.002), low-density lipoprotein cholesterol (P=0.003), and triglycerides (P=0.01), all of which decreased in the FS group but not the other groups by 9 months. Apolipoprotein B (ApoB) increased in the FR and control groups but was unchanged in the FS group (diet main effect P=0.04). High-density lipoprotein (HDL) cholesterol increased in all groups over 9 months (time main effect P=0.0001). Time main effects were also observed for cholesterol, ApoA1, ApoB, Factor VII, diastolic blood pressure, and glucose. After adjustment for % fat loss at 9 months, the effects of diet on change in risk factors remained significant only for triglycerides.

DISCUSSION

Consumption of a low-fat diet containing olestra for 9 months produced significant improvement in cardiovascular risk factors, an effect largely explained by weight loss. Long-term low-fat diet consumption with or without olestra does not decrease HDL cholesterol.

Is olestra consumption associated with changes in dietary intake, serum lipids, and body weight?

OBJECTIVES

There is considerable controversy regarding the effects of fat substitutes (such as the non-caloric fat substitute, olestra) on Americans' diet and health. This report gives associations of olestra consumption (in savory snacks) with changes in nutrient intake, serum lipid concentrations, and body weight 1 y after these snacks became available nationally in the United States.

METHODS

Participants were 1178 adults recruited from three large U.S. cities. At baseline (before the availability of olestra), participants attended a clinic visit and completed questionnaires (including a food-frequency questionnaire), provided fasting blood samples, and had height and weight measured. The clinic visit was repeated about 1 y later, after the introduction of olestra-containing snacks in the marketplace. Olestra consumption was categorized as "none," "very low" (>0 to <0.4 g/d), "low" (>/=0.4 to <2.0 g/d), and "moderate/high" (>/=2.0 g/d).

RESULTS

Twenty-five percent of participants reported consuming olestra-containing savory snacks in the preceding month, but only 2% were categorized as moderate/high consumers. Men reported nearly twice as much olestra consumption as women (1.22 versus 0.68 g/d, P = 0.01). Among moderate/high olestra consumers, total energy and carbohydrate intakes increased by 209 kcal/d and 37 g/d, compared with decreases of 87 kcal/d and 14 g/d, respectively, among non-consumers (both Ps for trend = 0.01), corresponding to non-significant changes in percentages of energy from carbohydrate and total fat. Olestra consumption was not associated with statistically significant changes in serum lipids or body weight.

CONCLUSIONS

This study found very modest changes in total diet, but no changes in serum lipids or body weight, associated with consumption of olestra-containing savory snacks. However, the low use of olestra by the study sample limited the ability of this study to detect significant effects.

Dietary fat and body weight control

The global obesity epidemic has heightened the debate about dietary factors contributing to weight gain. Media stories have promulgated the notion that obesity has increased despite reductions in dietary fat intake. Some have even speculated that lower dietary fat levels may be driving the rapid rise in weight gain within the population. A close examination of the science reveals a different picture and supports the hypothesis that dietary fat, within the context of the total dietary composition consumed by many populations, promotes obesity. Hence, dietary fat control is still an important strategy as part of an overall approach to body weight management in our modern environment. Dietary fat increases the energy density of foods. Abundant evidence from preclinical and clinical studies indicates that fat promotes excess energy intake and positive energy balance. Dietary fat does not promote its own oxidation in the body and is stored efficiently, promoting a positive fat balance. Thus, both the behavioral and metabolic responses to dietary fat increase the probability of positive energy balance and body fat gain. Restoring fat balance when consuming diets rich in fat requires increasing the size of the body fat mass, increasing physical activity, or reducing dietary fat intake. Numerous epidemiologic, preclinical, and controlled clinical studies have shown that body fat is positively associated with dietary fat intake and that dietary fat manipulation leads to appropriate changes in body fat mass. Finally, data from the National Weight Control Registry, a database of > 3000 individuals who have successfully maintained a substantial weight loss, indicate that moderating dietary fat intake is a key strategy for long-term management of body weight.

Low-fat diets are preferred

This short review summarizes 4 main reasons for which low-fat diets are preferred to limit excessive weight gain: (1) For metabolic reasons, fat intake does not measurably stimulate fat oxidation; dietary fat above energy requirements is stored in adipose tissue. (2) Diets that are high in fat or are energy dense have a weak satiating effect and promote a passive overconsumption of energy relative to need. (3) A recent meta-analysis on the effect on body weight loss of low-fat diets followed for >2 months showed a significant weight difference of 3.3 kg between the diet and the control groups. A low-fat diet may also be beneficial in helping maintain weight loss. (4) Low-fat diets are also advocated to lower the risk of coronary heart disease and certain forms of cancer. There is no evidence showing that the small physiologic reduction of plasma highdensity lipoprotein cholesterol levels with a low-fat diet is detrimental.

Biomarkers and functional foods for obesity and diabetes

Obesity has reached epidemic proportions in many countries around the world. Because of the close relationship between obesity and type 2 diabetes, an epidemic of diabetes is close behind the obesity epidemic. Preventing and treating obesity is becoming an increasing priority. In the United States, over 60 % of the adult population is overweight or obese and thus at increased risk of developing diabetes and cardiovascular disease. While the aetiology of obesity and diabetes is complex, diet clearly plays an important role both in the development and management of these diseases. There is interest in functional foods that could help in prevention and/or management of obesity and type 2 diabetes. This could involve food products that help management of 'hunger' or that increase 'satiety'. It could also involve foods that contribute to more inefficient use of ingested energy (i.e. foods that stimulate energy expenditure more than would be expected from their energy content). As the concept of insulin sensitivity becomes generally more accepted by health care professionals and the public, foods may be targeted towards maximizing insulin sensitivity and towards 'prevention' of diabetes. In addition to foods that impact upon body weight, these may include foods that affect the glucose and/or insulin levels that are seen either following the ingestion of food or later in the day. The present paper reviews the complex aetiology of obesity and diabetes and considers a potential role for functional foods in prevention and treatment of obesity and diabetes.

A role for olestra in body weight management

Olestra is a fat substitute made from fatty acids esterified to sucrose and can be used in the preparation of virtually any food made with fat. Foods made with olestra retain the mouthfeel, palatability and satiating effects of their full-fat counterparts without providing any digestible energy. Because olestra provides no energy, it has the potential to be a useful tool in weight loss and weight maintenance. Short-term studies of olestra replacement in foods demonstrate that fat replacement leads to a net reduction in fat intake. When excess total energy is available, fat replacement also reduces total energy intake in lean and obese men and women. In longer-term studies in which olestra is incorporated into the daily diet, there is an incomplete compensation for the fat energy replaced by olestra. When overweight men consumed olestra as part of a varied diet over nine months, weight loss continued for the duration of the study, whereas individuals receiving a typical low-fat diet regained most of the initial weight lost. Other studies are underway to examine the usefulness of olestra in long-term weight maintenance following weight loss. Post-marketing surveillance of olestra foods in the United States indicates that substitution of olestra for only 1-2 g of fat d-1 may be sufficient to prevent the average weight gain reported in adults of 0.5-1.0 kg year-1.