RESEARCH
Review
Continuing Education Questionnaire, page 1782
Meets Learning Need Codes 2070, 5000, 5370, and 9020
Carbohydrate Quantity and Quality in Relation
to Body Mass Index
GLENN A. GAESSER, PhD
ABSTRACT
The increased prevalence of overweight and obesity in the
United States since approximately 1980 is temporally
associated with an increase in carbohydrate intake, with
no appreciable change in absolute intake of fat. Despite
speculation that both carbohydrate quantity and quality
have contributed significantly to excess weight gain, the
relationship between carbohydrate intake and body mass
index (BMI) is controversial. A review of relevant litera-
ture indicates that most epidemiologic studies show an
inverse relationship between carbohydrate intake and
BMI, even when controlling for potential confounders.
These observational studies are supported by results
from a number of dietary intervention studies wherein
modest reductions in body weight were observed with an
ad libitum, low-fat, high-carbohydrate diet without em-
phasis on energy restriction or weight loss. With few
exceptions, high glycemic load is associated with lower
BMI, even when adjusted for total energy intake. Data on
the association between glycemic index and BMI are not
as consistent, with more studies showing either no asso-
ciation or an inverse relationship, rather than a positive
relationship. Whole-grain intake is generally inversely
associated with BMI; refined grain intake is not. Because
overall dietary quality tends to be higher for high-carbo-
hydrate diets, a low-fat dietary strategy with emphasis
on fiber-rich carbohydrates, particularly cereal fiber, may
be beneficial for health and weight control.
J Am Diet Assoc. 2007;107:1768-1780.
G. A. Gaesser is a professor of exercise physiology, De-
partment of Human Services, University of Virginia,
Charlottesville.
Address correspondence to: Glenn A. Gaesser, PhD,
210 Emmet St S, PO Box 400407, Charlottesville, VA
22904-4407. E-mail: gag2q@virginia.edu
Copyright © 2007 by the American Dietetic
Association.
0002-8223/07/10710-0013$32.00/0
doi: 10.1016/j.jada.2007.07.011
1768 Journal of the AMERICAN DIETETIC ASSOCIATION
A
n estimated 66% of adult Americans are considered
overweight, with a body mass index (BMI; calcu-
lated as kg/m2) of 25 to 29.9, or obese, with a BMI
ⱖ30 (1). Average weights of American workers aged ⬎18
years increased at a rate of 0.61% per year from 1986 to
1995; from 1997 to 2002, the rate increased 0.95% per
year (2). Contributing causes of this weight gain are
largely environmental (3). Per capita food energy in the
US food supply has increased steadily over the past 40
years, from about 3,100 kcal/day in 1965 to an all-time
high of 3,900 kcal/day in 2000 (Figure 1) (4). This coin-
cides with National Health and Nutrition Examination
Surveys data that indicated an increase in reported daily
energy intake between 1971 and 2000 of 168 kcal in men
and 335 kcal in women (Figure 2) (5). Because levels of
leisure-time physical activity among US adults remained
stable or increased slightly between 1990 and 2004 (6,7),
increased energy intake likely explains much of the
weight gain experienced by Americans during this time.
The increase in reported energy intake since 1970 oc-
curred in conjunction with an increase in the consump-
tion of carbohydrates, which rose by 60 to 70 g/day (5). By
contrast, reported intake of fat remained relatively stable
between 1971 and 2000 (Figure 3) (5). Consequently, fat
intake, as a percentage of total energy, actually decreased
slightly during this period. Because the increase in obe-
sity prevalence occurred during a period in which public
health messages encouraged low-fat eating, proponents of
low-carbohydrate diets attributed Americans’ weight
gain to carbohydrates. As a result, a variety of low-car-
bohydrate diets became popular in the past 10 years
(8-11). However, popularity of low-carbohydrate diets has
waned considerably since their peak in 2004, in much the
same manner that interest in these diets all but disap-
peared in the mid-1970s after nearly a decade of popu-
larity (12-14). Loss of enthusiasm for carbohydrate-re-
strictive eating plans most likely is attributable to their
lack of sustainability (15,16).
The role of diet composition in weight control and obe-
sity remains controversial (17,18). Carbohydrate quality
and quantity has received considerable attention (19-23).
Several reports suggest that diets with a high glycemic
index or glycemic load, or that are high in refined carbo-
hydrates, increase risk of obesity and associated health
problems (19-22), although the hypothesized link be-
© 2007 by the American Dietetic Association
Figure 1. Increase in daily food energy in the US food supply, per
capita per day: 1909 to 2000. (Reprinted from reference 4.)
Figure 2. Mean energy intake among adults aged 20 to 74 years by
sex from the National Health and Nutrition Examination Surveys, United
States, 1971 to 2000. (Data from reference 5.)
tween carbohydrate quality and quantity and either obe-
sity and disease risk is controversial (23).
To examine the relevant literature on the association
between both carbohydrate quantity and quality and
BMI, the Institute for Scientific Information’s Web of
Science was searched using key words body mass index
and body weight matched separately to carbohydrates,
glycemic index, glycemic load, and grains (whole and re-
fined). Bibliographies of extracted citations were also
used to identify relevant publications. The primary focus
was on epidemiological studies that provided information
on BMI stratified across quartiles/quintiles of carbohy-
drate intake, glycemic index, glycemic load, and either
whole- or refined-grains. Because several reviews of the
influence of ad libitum, low-fat diets on body weight have
been published (24-28), additional intervention studies
wherein participants were assigned to an ad libitum,
low-fat diet, without focus on energy restriction, were
also examined.
EPIDEMIOLOGIC EVIDENCE
Carbohydrate Intake
Most epidemiologic studies show an inverse association
between carbohydrate consumption and BMI (29-41). In
Figure 3. Mean intake of carbohydrate (CHO) and fat among adults
aged 20 to 74 years from the National Health and Nutrition Examination
Surveys, United States, 1971 to 2000. (Data from reference 5.)
the seven women cohorts presented in Table 1, the mean
BMI of the group with the highest carbohydrate intake is
between 0.5 and 3.0 BMI units lower than that of the
group with the lowest carbohydrate intake. For the four
male cohorts the mean BMI is between 0.6 and 1.3 BMI
units lower for men with the highest compared to the
lowest carbohydrate intake. Carbohydrate intake was
found to be inversely related to body weight and percent
body fat in Danish men and women (40). Among women
in the Cancer Prevention Study II Nutrition Cohort,
higher carbohydrate intake was associated with lower
risk of obesity (41).
The limitation of these observational data is that cause
and effect cannot be established. However, longitudinal
observational studies are consistent with these findings.
In the Baltimore Longitudinal Study of Aging the dietary
pattern characterized by the highest carbohydrate con-
sumption (61.9% of total energy) had the lowest annual
gain in BMI and waist circumference (37).
Methodologic Considerations
Underreporting of food intake is well documented (42).
This is especially true for the semiquantitative food
frequency questionnaire used in most studies (eg, 31-
36,39,41). Of additional concern is the observation that
underreporting is inversely related to BMI (42). However,
two of the studies listed in Table 1 used interviewer-
administered 24-hour dietary recall (29,30), which mini-
mizes underreporting (42). In the Continuing Survey of
Food Intakes by Individuals (30), the US Department of
Agriculture multiple-pass 24-hour recall method was
used. An observational validation study of this method in
men revealed no differences between actual and reported
energy intake and that accuracy of recall was not related
to BMI (43). Inasmuch as the inverse association between
carbohydrate intake and BMI in the Continuing Survey
of Food Intake by Individuals is similar to that of the
other studies in Table 1 (that used the food frequency
October 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1769
 Table 1. Relationship between carbohydrate intake and body mass index among men and women in eight cohorts revieweda
Quintile (Quartile) of Carbohydrate Intake
Cohort I II III IV V

Women
NHANESb (29) 26.3⫾0.2c 26.4⫾0.3c 26.1⫾0.4 25.9⫾0.2c 25.5⫾0.2c
n⫽6,125 35.6d 44.6d 50.4d 56.4d 66.8d
CSFIIe (30) 26.7⫾0.5c 26.0⫾0.2c 25.7⫾0.1c 25.2⫾0.2c
n⫽4,711 0 to 30d 30 to 45d 45 to 55d ⬎55d
NHSf I (31) 25.2⫾4.6g 25.2⫾4.6g 25.1⫾4.6g 24.9⫾4.6g 24.7⫾4.5g
n⫽71,919 34.8d 39.5d 42.2d 46.5d 55.1d
NHS II (34) 26 25 23
n⫽90,655 41.2d 50.1d 59.4d
WHSh (35) 26.7⫾5.4g 26.3⫾5.0g 26.1⫾5.0g 25.7⫾4.8g 25.2⫾4.7g
n⫽38,446 41.7d 46.8d 50.5d 54.6d 63.6d
PLCOi (39) 27.4⫾5.6g 27.2⫾5.6g 26.5⫾5.2g
n⫽18,341 44.1d 51.9d 59.0d
Canadian NBSSj (36) 25.2⫾10.2g 25.1⫾10.2g 24.7⫾10.2g 24.6⫾10.2g 24.3⫾10.2g
n⫽49,111 28.5d 35.3d 38.8d 42.1d 47.9d

Men
NHANES (29) 26.8⫾0.3c 26.5⫾0.2c 26.4⫾0.2c 26.3⫾0.2c 26.2⫾0.3c
n⫽5,730 33.2d 42.7d 48.5d 54.3d 64.3d
CSFII (30) 26.8⫾0.4c 26.8⫾0.2c 26.3⫾0.1c 26.0⫾0.2c
n⫽5,075 0 to 30d 30 to 45d 45 to 55d ⬎55d
HPFSk (31) 26.1⫾3.4g 25.9⫾3.3g 25.6⫾3.2g 25.3⫾3.2g 24.8⫾3.2g
n⫽39,926 37.5d 43.6d 47.7d 52.5d 61.5d
PLCO (39) 28.1⫾4.4g 27.6⫾4.1g 26.8⫾3.9g
n⫽20,172 39.5d 47.6d 55.9d
a
Not all studies reported standard error of the mean or standard deviation.
b
NHANES⫽National Health and Nutrition Examination Survey.
c
Body mass index⫾standard error of the mean.
d
Mean or range of carbohydrate intake as a percentage of total energy within each quintile/quartile.
e
CSFII⫽Continuing Survey of Food Intakes by Individuals.
f
NHS⫽Nurses’ Health Study.
g
Body mass index⫾standard deviation.
h
WHS⫽Women’s Health Study.
i
PLCO⫽Prostate, Lung, Colorectal, and Ovarian Screening Study.
j
NBSS⫽National Breast Screening Study.
k
HPFS⫽Health Professionals Follow-up Study.

questionnaire), it is unlikely that underreporting would
entirely undermine this relationship.
Although some studies report that high carbohydrate con-
sumption is associated with lower total energy intake (29-
31), most studies suggest that lower BMI among high-car-
bohydrate consumers is not related to lower total energy
intake (32,34-37,44-46). In the Nurses’ Health Study (NHS)
II cohort the highest quintile of carbohydrate consumption
had a mean BMI three units lower (ie, 26 vs 23) than women
in the lowest quintile of carbohydrate consumption, even
when adjusted for total energy intake (34).
Lower BMI in high-carbohydrate/energy consumers
may be related to higher reported physical activity
(35,46). However, in the Framingham Offspring Study
the lower BMI associated with high carbohydrate and
total energy consumption was not attributable to differ-
ences in physical activity (45). Furthermore, the lower
BMI (1.1 units) among the highest quintile (compared to
lowest quintile) of carbohydrate consumption in an anal-
ysis of combined NHS I and II cohorts was not attribut-
able to either lower reported energy intake or higher
reported physical activity (32).
High consumption of carbohydrates tends to be associ-
ated with higher intake of dietary fiber, which has been
reported to a have a favorable effect on BMI (34,47-49). In
the NHS II cohort, the difference in BMI between the
highest and lowest quintiles of total fiber intake (one BMI
unit) was much less than the difference between the
highest and lowest quintiles of carbohydrate consump-
tion (three BMI units) (34). This suggests that dietary
fiber intake does not entirely explain the generally in-
verse relationship between carbohydrate consumption
and BMI (Table 1).
CARBOHYDRATE QUALITY
Coincident with heightened interest in low-carbohydrate
diets, a distinction between carbohydrates has been em-

1770 October 2007 Volume 107 Number 10

phasized, with recommendations for increased consump-
tion of complex, fiber-rich carbohydrates with a low
glycemic index, and decreased consumption of high-
glycemic, refined carbohydrates (19-22). Although justifi-
cation for consumption of fiber-rich carbohydrates is well
documented, the relationship between carbohydrate
quality (eg, glycemic index, refined grains) and BMI re-
mains controversial.
GLYCEMIC INDEX AND GLYCEMIC LOAD
Glycemic index (GI) reflects carbohydrate quality,
whereas the glycemic load (GL) reflects the total carbo-
hydrate burden by considering both GI and the amount of
carbohydrates ingested (19,20). Increased consumption of
low-GI foods has been recommended to help prevent and
treat obesity (19-21), and GI is a key feature of several
diet books (eg, 9,50). Some studies have reported in-
creased satiety with low-GI foods (19), but others have
not (51).
Intervention Studies
Results from intervention studies are mixed (52-56). No
difference in mean weight loss was noted in three studies
comparing low-fat diets either low or high in GI (52-54). A
comparison of four diets varying in carbohydrate, protein
and GI revealed nonstatistically different weight losses
after 12 weeks (55). In this study female subjects lost
more weight and body fat after a low-GI (GI⫽40), mod-
erately-high-carbohydrate diet compared to a high-GI
(GI⫽70) diet equal in macronutrient composition (55).
However, a low-GI (GI⫽44), high-protein diet resulted in
less total weight and fat mass loss than a high-protein
diet of equal macronutrient composition but much higher
GI (GI⫽59), suggesting that GI per se may not have been
the critical feature accounting for the weight loss differ-
ences (55). The effect of GI on body weight is complex, and
in addition to possible gender differences (55), metabolic
status may play a role (56). In the Comprehensive As-
sessment of Long-term Effects of Restricting Intake of
Energy trial, a low-GI diet facilitated weight loss in over-
weight persons with high insulin secretion but not in
overweight persons with low insulin secretion (56).
Epidemiologic Studies
GI. Some studies show higher BMI associated with in-
creasing GI of the diet (57-61), although most do not
(33,35,36,39,40,62-68). Three large cohorts of women
(33,35,36), and one large (62) and one small (64) cohort of
men, reveal an inverse association between GI and BMI,
with BMI in the highest quintile of GI up to 1.5 BMI units
lower (35) compared to the lowest quintile (Table 2). The
one study of men and women combined (63) is confounded
by disproportionately lower percentages of women across
quintiles of increasing GI. Nevertheless, data from both
whites and African Americans in this cohort provide no
evidence that GI adversely affects BMI.
Although within each study the range of GI across
tertiles/quintiles is fairly small, when viewed collectively
the data do not support the notion that a high-GI diet is
predictive of higher BMI. To the contrary, several large
cohort studies suggest the opposite (33,35,36,62).
GL. With few exceptions (58,60), most studies indicate
that GL is either unrelated to BMI (59,61,65-68), or is
inversely associated with BMI (31-36,39,69). In Table 3,
all eight women cohorts, and two of three cohorts of men
indicate inverse associations, with the BMI of the highest
quintile being 0.3 to 2.1 BMI units lower than that of the
lowest quintile. These differences are evident even after
adjusting for total energy intake and other potentially
confounding factors. In an analysis of data from both
NHS I and II cohorts combined, mean BMI was 1.1 units
lower among the highest quintile of GL (compared to the
lowest quintile of GL), despite no difference in physical
activity and a lower prevalence of smoking (32). The
majority of epidemiologic evidence does not support the
notion that GL is predictive of adiposity. Most studies
suggest that higher-GL diets may be beneficial for weight
control.
Methodologic Considerations
One major methodologic issue is the actual determination
of GI and GL of diets. Researchers have used a variety of
sources, ranging from the 2002 international table of GI
and GL values (70) to various earlier published reports
(71,72). Not all foods have published GI values, and some
GI values have been modified to suit different populations
(eg, Japanese [59]). Also, some of the studies used total
carbohydrate rather than available carbohydrate, which
can alter both dietary GI and GL values (68).
It is also important to control for energy intake and
possible confounding from low-energy reporters (60). Re-
cent data from the Inter99 Study indicated a positive
relationship between BMI and both GI and GL only when
adjusted for total energy intake (60). In contrast, data
from the Insulin Resistance Atherosclerosis Study dem-
onstrated that GI was not related to adiposity even when
adjusted for energy intake (65,66). Furthermore, the
inverse relationship between GI/GL and BMI in the
studies presented in Tables 2 and 3 was evident after
adjusting for total energy intake. Most studies, how-
ever, have used the food frequency questionnaire, which
is prone to underreporting, especially among those with a
high BMI (42). Thus, studies demonstrating relationships
between GI and/or GL and BMI should be interpreted
with caution (60).
WHOLE AND REFINED GRAINS
With few exceptions (73), an inverse relationship between
whole-grain intake and BMI has been reported (74-84)
(Table 4). This is not unexpected, as whole-grain intake
correlates with consumption of total carbohydrate and
dietary fiber, both of which vary inversely with BMI (47-
49,75,76,78). The generally inverse relationship for the
combined men and women cohorts in Table 4 likely un-
derestimates the steepness of the gradient due to the
lower percentage of women in the higher quintiles of
whole-grain intake.
Refined-grain intake is not consistently linked to
higher BMI (44,45,73,76,79,83,84) (Table 5). Two cohorts
of women (76,79) revealed a positive relationship between
refined-grain consumption and BMI, although in one of
these (79) the difference was only 0.2 BMI units between
October 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1771
 Table 2. Relationship between glycemic index and body mass index among men and women in eight cohorts revieweda
Quintile (Tertile) of Glycemic Index
Cohort I II III IV V

Women
NHSb I (57) 24.7 25.1 25.2 25.3 25.4
n⫽65,173 62.9c 68.1c 70.7c 73.4c 77.9c
NHS II (33) 24.7⫾5.0d 24.6⫾5.3d 24.5⫾5.5d
n⫽91,249 69.9c 76.9c 83.1c
WHSe (35) 26.7⫾5.4d 26.3⫾5.0d 26.1⫾5.0d 25.7⫾4.8d 25.2⫾4.7d
n⫽38,446 50c 52c 53c 54c 55c
Canadian NBSSf (36) 25.2⫾10.2d 25.1⫾10.2d 24.7⫾10.2d 24.6⫾10.2d 24.3⫾10.2d
n⫽49,111 72.5c 78.4c 79.7c 81.7c 84.3c
JMETSg (59) 23.7⫾0.2h 23.9⫾0.2h 23.8⫾0.2h 24.2⫾0.2h 24.4⫾0.2h
n⫽1,354 61c 65c 67c 69c 72c

Men
HPFSi (62) 25.7 25.5 25.5 25.4 25.3
n⫽42,759 65.1c 69.7c 72.6c 75.3c 79.3c
Zutphen (64) 26.0 25.1 24.9
n⫽646 77c 82c 85c

Men/Women
ARICj (white) (63) 26.7⫾4.5d 26.7⫾4.5d 26.5⫾4.5d 26.6⫾4.5d 26.6⫾4.7d
n⫽9,529 69.1c 74.5c 77.2c 79.7c 83.4c
63.7k 55.9k 51.6k 47.2k 49.3k
ARIC (African American) (63) 29.8⫾6.2d 29.0⫾5.8d 28.9⫾6.0d 29.0⫾5.7d 28.9⫾6.3d
n⫽2,722 71.7c 77.6c 80.2c 82.6c 86.6c
76.6k 66.2k 61.0k 57.9k 52.3k
a
Not all studies reported standard error of the mean or standard deviation.
b
NHS⫽Nurses’ Health Study.
c
Mean glycemic index within each glycemic index quintile/tertile.
d
Body mass index⫾standard deviation.
e
WHS⫽Women’s Health Study.
f
NBSS⫽National Breast Screening Study.
g
JMETS⫽Japanese Multicentered Environmental Toxicants Study.
h
Body mass index⫾standard error of the mean.
i
HPFS⫽Health Professionals Follow-up Study.
j
ARIC⫽Atherosclerosis Risk in Communities Study.
k
Percentage of women study participants.

the lowest (four servings per week) and highest (30 serv-
ings per week) quintile of refined-grain intake. In the one
male cohort refined-grain intake was unrelated to BMI
(44) (Table 5). Data on combined men and women are
confounded due to the decreasing percentage of women
across higher quartiles/quintiles of refined-grain intake
(Table 5) and, hence, should be interpreted with caution.
Despite this bias toward finding a positive relationship,
data from the Framingham Offspring Study revealed no
trend between refined-grain intake and BMI (45).
In the Physician’s Health Study (82), intake of refined-
grain (as well as whole-grain) breakfast cereal was asso-
ciated with lower BMI and was inversely associated with
body weight gain over 8 years. Similarly, in the Women’s
Health Study (35), servings/day of refined grain was in-
versely related to BMI. Thus, current data from cohort
studies are not sufficiently consistent to conclude that
refined grain intake has a deleterious affect on BMI.
DIETARY FIBER
The inverse association between carbohydrate intake and
BMI may be due in part to dietary fiber (33,34,44,47-
49,78,85-87). Cereal fiber, in particular, appears to play a
beneficial role in weight control (33,85,87-92). In the NHS
I and II cohorts, the highest quintile of cereal fiber con-
sumption had a mean BMI 0.7 (NHS I) and 1.5 (NHS II)
units less than that of the lowest quintile of cereal fiber
consumption (33,85). Breakfast cereal consumption is
predictive of lower BMI (81,88-91). The number of Amer-
icans who skipped breakfast between 1965 and 1991 rose
from 14% to 25% (88). Since 30% of the US Department of
Agriculture’s recommended three or more whole-grain
servings per day are delivered in the form of breakfast
foods, reversing the trend of skipping breakfast may also
increase the low percentage of Americans who comply
with the US Department of Agriculture’s recommenda-
tion (92).

1772 October 2007 Volume 107 Number 10

 Table 3. Relationship between glycemic load and body mass index among men and women in nine cohorts revieweda
Quintile of Glycemic Load
Cohort I II III IV V

Women
NHSb I (31) 25.2⫾4.6c 25.2⫾4.6c 25.1⫾4.6c 24.9⫾4.6c 24.7⫾4.5c
n⫽71,919 107d 132d 144d 156d 181d
NHS II (33) 25.7⫾5.8c 24.5⫾5.1c 23.6⫾4.8c
n⫽91,249 133d 171d 217d
WHSe (35) 26.7⫾5.4c 26.3⫾5.0c 26.1⫾5.0c 25.7⫾4.8c 25.2⫾4.7c
n⫽38,446 92d 106d 117d 127d 143d
PLCOf (39) 27.4⫾5.6c 27.2⫾5.6c 26.5⫾5.2c
n⫽18,341 89.7d 117.1d 142.8d
Canadian NBSSg (36) 25.2⫾10.2c 25.1⫾10.2c 24.7⫾10.2c 24.6⫾10.2c 24.3⫾10.2c
n⫽49,111 98.6d 129.5d 147.2d 164.5d 196.0d
JMETSh (59) 24.2⫾0.3i 23.8⫾0.2i 24.0⫾0.2i 24.2⫾0.2i 23.8⫾0.3i
n⫽1,354 69d 80d 87d 95d 107d
SMCj (69) 24.9 24.7 24.7 24.6 24.6
n⫽61,433 157d 167d 179d 190d 207d
Health ABCk (68) 27.4⫾5.4b 26.7⫾5.4 27.8⫾5.6 26.2⫾4.9 27.1⫾5.7
n⫽1,169 88.5d 108.7d 118.2d 128.0d 148.3d

Men
HPFSl (31) 26.1⫾3.4c 25.9⫾3.3c 25.6⫾3.2c 25.3⫾3.2 24.8⫾3.2c
n⫽39,926 131d 163d 181d 198d 231d
PLCO (39) 28.1⫾4.4c 27.6⫾4.1c 26.8⫾3.9c
n⫽20,172 106.6d 144.7d 182.8d
Health ABC (68) 26.7⫾4.2c 26.8⫾4.0c 26.8⫾3.4c 26.6⫾4.2c 26.7⫾3.4c
n⫽1,079 107.4d 132.7d 143.9d 156.8d 185.3d
a
Not all studies reported standard error of the mean or standard deviation.
b
NHS⫽Nurses’ Health Study.
c
Body mass index⫾standard deviation.
d
Mean glycemic load within the quintile.
e
WHS⫽Women’s Health Study.
f
PLCO⫽Prostate, Lung, Colorectal, and Ovarian Screening Study.
g
NBSS⫽National Breast Screening Study.
h
JMETS⫽Japanese Multicentered Environmental Toxicants Study.
i
Body mass index⫾standard error of the mean.
j
SMC⫽Swedish Mammography Cohort.
k
Health ABC⫽Aging and Body Composition.
l
HPFS⫽Health Professionals Follow-up Study.

INTERVENTION STUDIES An argument could be made that similar weight reduc-

A substantial body of literature on dietary intervention
supports the role of carbohydrates in weight control. Sev-
eral systematic reviews and meta-analyses have evalu-
ated the effectiveness of ad libitum, low-fat diets on body
weight (24-28). They include approximately 70 trials, and
in a number of them participants were instructed to re-
duce dietary fat intake without emphasis on total energy
restriction (see Astrup and colleagues [26,27] for re-
views). The duration of these studies was relatively short
(⬍1 year), but a consistent modest weight loss of 1 to 4 kg
was evident in nearly all of them. These meta-analyses
indicated that every 1% reduction in dietary fat was
associated with about a 0.27- to 0.44-kg weight loss of
over a period of ⬍1 year, with greater weight loss ob-
served among initially overweight or obese subjects
(24,26-28). Although this represents a relatively small
degree of weight loss, a decrease of this magnitude could
significantly reduce the prevalence of obesity (26,93).
tions can be observed with ad libitum, low-carbohydrate
dietary approaches. However, in studies of low-carbohy-
drate diets lasting ⱖ6 months, the primary outcome mea-
sure has always been weight loss (15,94). Thus any study
that has weight loss as a primary outcome measure might
naturally be biased toward finding weight reduction after
any dietary intervention, regardless of macronutrient
composition. It is important to note that in 12 of the ad
libitum, low-fat trials included in the systematic reviews
cited above, weight loss was not a primary outcome mea-
sure (26,27). In these studies, the primary outcome mea-
sure was typically blood lipids. More recently, the
large-scale Women’s Health Initiative (WHI) study also
demonstrated weight loss on a low-fat diet, even
though weight loss was not the focus of the study (95).
It is unlikely that voluntary caloric restriction contrib-
uted to the observed weight loss in these studies
(26,27). Yet in these studies ad libitum consumption of

October 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1773

 Table 4. Relationship between whole-grain intake and body mass index among men and women in nine cohorts revieweda
Quintile (Quartile) of Whole-Grain Intake
Cohort I II III IV V

Women
NHSb I (76) 24.9⫾5c 24.9⫾5c 24.5⫾4c
n⫽74,091
NHS I (Diabetic) (78) 30.9 29.8 28.4
n⫽902
NHS II (46) 24.9⫾0.5d 24.3⫾0.4d 23.9⫾0.5d
n⫽470 5.9 to 10.8 g/de 20.8 to 23.5 g/de 39.8 to 49.2 g/de
IWHSf (79) 27.2 27.0 27.0 26.6 26.9
n⫽34,492 1.5 s/wke 6.0 s/wke 8.5 s/wke 13.0 s/wke 22.5 s/wke

Men
HPFSg (44) 25.7 25.6 24.9
n⫽42,540 0.2 s/de 1.1 s/de 3.4 s/de

Men/Women
FOSh (45) 27.0 26.9 27.3 26.7 26.6
n⫽2,941 0.9 s/wke 3.5 s/wke 6.4 s/wke 9.5 s/wke 20.5 s/wke
48i 52i 59i 58i 55i
Finnish (74) 26.7⫾4.3c 26.5⫾4.0c 26.3⫾3.8c 26.4⫾3.7c
n⫽4,316 79 g/de 136 g/de 198 g/de 303 g/de
56i 48i 43i 41i
Boston (83) 26.4 25.5 25.3 25.2
n⫽535 0.31 s/de 0.86 s/de 1.49 s/de 2.90 s/de
69i 67i 71i 59i
TLGSj (84) 26.4⫾4.8c 25.8⫾5.1c 25.1⫾4.8c 24.7⫾4.9c
n⫽827 ⱕ10 g/de 10 to ⬍71 g/de 71 to ⬍143 g/de ⱖ143 g/de
58i 61i 54i 48i
a
Not all studies reported standard error of the mean or standard deviation.
b
NHS⫽Nurses’ Health Study.
c
Body mass index⫾standard deviation.
d
Body mass index⫾standard error of the mean.
e
Mean or range of whole-grain intake, in g/d, servings/d (s/d), or servings/wk (s/wk).
f
IWHS⫽Iowa Women’s Health Study.
g
HPFS⫽Health Professionals Follow-up Study.
h
FOS⫽Framingham Offspring Study.
i
Percentage of women study participants.
j
TLGS⫽Tehran Lipids and Glucose Study.

a low-fat diet consistently resulted in spontaneous
weight loss.
In a number of ad libitum, low-fat diet interventions in
which weight loss was one of several outcome measures,
weight loss was not encouraged (96-99). Some of these
studies either discouraged weight loss or modified caloric
intake in an effort to prevent weight loss (without suc-
cess) (100,101). In the Carbohydrate Ratio Manipulation
in European National Diets Study, subjects consuming
an ad libitum, low-fat, complex-carbohydrate diet lost 4.5
kg after 6 months despite no encouragement to actively
reduce caloric intake (96). In view of the concern about
the potential contribution of simple carbohydrates to obe-
sity, it is important to note that increasing consumption
of simple carbohydrates over the 6-month trial did not
lead to weight gain (96).
Ad libitum, low-fat diets may result in weight loss
despite efforts to prevent this from occurring. In a study
of premenopausal women consuming an ad libitum, 20%
fat diet, systematic adjustments in energy intake de-
signed to prevent weight loss were unsuccessful (101).
During a 20-week period, despite increases in energy
intake to maintain weight throughout the study, women
lost an average of 2.8% of body weight and 11.3% of fat
weight. Thus, weight loss on a low-fat diet, even when not
encouraged, may reflect imprecision in food-intake con-
trol when the energy density of the diet is altered (97,101-
104).
WEIGHT MAINTENANCE
Long-term weight-loss maintenance is poor (105). Be-
cause ad libitum, low-fat diets lead to only modest weight
loss, the greatest potential advantage for advocating a
low-fat, high-carbohydrate diet is in prevention of weight
gain (95,106,107). In the WHI (95), 48,835 women were

1774 October 2007 Volume 107 Number 10

 Table 5. Relationship between refined grain intake and body mass index among men and women in six cohorts revieweda
Quintile (Quartile) of Refined-Grain Intake
Cohort I II III IV V

Women
NHSb I (76) 24.6⫾4c 24.9⫾5c 25.2⫾5c
n⫽74,091
IWHSd (79) 26.9 26.8 26.9 27.0 27.1
n⫽34,492 4.0 s/wke 8.0 s/wke 12.0 s/wke 18.0 s/wke 30.0 s/wke

Men
HPFSf (44) 25.4 25.5 25.4
n⫽42,540 0.6 s/de 1.7 s/de 4.3 s/de

Men/Women
FOSg (45) 26.9 26.8 26.9 27.0 26.8
n⫽2,941 6.9 s/wke 11.8 s/wke 16.7 s/wke 23.6 s/wke 38.9 s/wke
61h 58h 57h 52h 46h
Boston (83) 25.4 25.4 25.5 26.2
n⫽535 1.6 s/de 2.9 s/de 4.1 s/de 6.1 s/de
77h 78h 65h 45h
TLGSi (84) 24.9⫾4.2c 25.5⫾4.7c 26.2⫾5.2c 26.9⫾5.3c
n⫽827 ⬍125 g/de 125 to 203 to ⱖ281 g/de
⬍203 g/de ⬍281 g/de
62h 64h 53h 45h
a
Not all studies reported standard error of the mean or standard deviation.
b
NHS⫽Nurses’ Health Study.
c
Body mass index⫾standard deviation.
d
IWHS⫽Iowa Women’s Health Study.
e
Mean or range of refined grain intake, in g/d, servings/d (s/d), or servings/wk (s/wk).
f
HPFS⫽Health Professionals Follow-up Study.
g
FOS⫽Framingham Offspring Study.
h
Percentage of women study participants.
i
TGLS⫽Tehran Lipids and Glucose Study.

randomized to assess the long-term benefits and risks of
a low-fat dietary pattern on breast and colorectal cancers
and cardiovascular disease. The intervention did not en-
courage weight loss or energy restriction. Average weight
decreased by 2.2 kg during the first year, which was
significantly more than that of the control group. Al-
though the 2.2-kg difference in weight between interven-
tion and control groups diminished during the 7.5-year
follow-up, the difference in weight remained significant
during the entire follow-up period.
Because weight gain during adulthood is common in
the United States, an ad libitum, low-fat diet could assist
weight control by limiting weight gain. Behavioral Risk
Factor Surveillance System surveys (108) indicated adult
weight gain averaged about 1 lb/year during the 1990s
(ie, during which time much of the WHI was conducted).
Data from the WHI suggest that an ad libitum, low-fat
diet might attenuate this weight gain (95).
Low-fat, high-carbohydrate diets seem to be most com-
mon among people who successfully maintain weight loss
(109). Lower fat intake was a predictor of both initial and
sustained weight loss in persons with obesity consuming
an ad libitum diet (110), and a low-fat, high-fiber diet
predicted long-term (3 years) weight reduction in initially
overweight persons with impaired glucose tolerance
(111). In addition, an ad libitum, low-fat, high-carbohy-
drate diet was more effective than a fixed-energy intake
for maintaining weight after a major weight loss (112).
Two years after a 12- to 13-kg weight loss, the ad libitum,
low-fat, high-carbohydrate group maintained three times
as much weight loss as the fixed-energy group (8.0 kg vs
2.5 kg), and more subjects maintained a weight loss of ⱖ5
kg (65% vs 40%).
Ad libitum, low-fat diets may help those with unre-
strained eating behavior maintain body weight (113).
Whereas individuals who consume hypocaloric diets gen-
erally experience increased hunger, subjects consuming
ad libitum, low-fat diets do not (26,96,100). This may be
attributable in part to lower energy density of low-fat,
high-carbohydrate diets (114,115). A low-fat, high-carbo-
hydrate diet may also increase sensitivity to leptin and
avoid the increase in ghrelin caused by energy restriction
(116). Weigle and colleagues (116) reported that 12 weeks
of an ad libitum, low-fat, high-carbohydrate diet resulted
in a spontaneous decrease in energy intake without an
increase in 24-hour area-under-curve for ghrelin. Al-
though leptin 24-hour area-under-curve was decreased,
there was an increase in the percentage change between
nadir and peak 24-hour leptin levels, which was strongly
correlated to the absolute change in both weight and fat

October 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1775

mass. Thus, an ad libitum, low-fat, high-carbohydrate
diet may result in hormonal adaptations that facilitate
weight-loss maintenance (116).
HEALTH IMPLICATIONS OF HIGH-CARBOHYDRATE DIETS
Biomarkers
Diets high in either GI or GL have been associated with
increased levels of a number of cardiovascular disease
biomarkers, including increased plasma triglycerides,
glucose, insulin, glycated hemoglobin, and C-reactive pro-
tein, and reduced high-density lipoprotein cholesterol lev-
els (59,117-119). Other studies have shown no association
between GI or GL and fasting insulin (64,68), fasting
glucose (64,66,68), glycated hemoglobin (66,68), and var-
ious blood lipids (59,64).
Meta-analyses of the effect of low-GI diets on cardio-
vascular disease risk markers are inconclusive (120,121).
One found that low-GI diets induced significant reduc-
tions in total and low-density lipoprotein cholesterol in
patients with type 2 diabetes, but had no effect on tri-
glycerides and high-density lipoprotein cholesterol (120).
Another revealed no evidence for a favorable effect of
low-GI diets on low-density lipoprotein or high-density
lipoprotein cholesterol levels, triglyceride levels, fasting
glucose or fasting insulin levels, and weak evidence for
small reductions in total cholesterol and glycated hemo-
globin levels (121).
Disease Incidence and Mortality
Diets high in GI, GL, and/or refined grains have been
reported to be associated with increased risk for cardio-
vascular disease, type 2 diabetes, metabolic syndrome,
and certain cancers (19-22,33,35,57,58,62,68,119,122).
These findings contrast with reports suggesting no health
risk associated with either GI or GL, or refined-grain
intake. A number of large cohort studies have found that
GI and GL were not predictive of type 2 diabetes (33,62,63,
65,66,86), insulin resistance (123), cardiovascular disease
(64), stroke (124), eye cataracts (31), breast cancer (34-
36,41), stomach cancer (69), colorectal adenomas (39), or
colorectal cancer (125,126). The American Diabetes Asso-
ciation contends that there are insufficient data to deter-
mine if there is a relationship between either GI or GL
and the development of diabetes (127). Furthermore, a
number of reports indicate no association between refined
grain intake and risk of type 2 diabetes (44,73,86), insulin
resistance (119), cardiovascular disease (45,74,79,82),
ischemic stroke (128), breast cancer (80), and all-cause
mortality (74).
It may be premature to conclude that diets high in
either GI or GL pose a health risk. In addition to their
potential to facilitate weight control, high-carbohydrate
diets tend to be associated with higher overall diet quality
(29,30,129,130). Health benefits of fiber-rich carbohy-
drates are well established (131). Although the link be-
tween refined-grain intake and a number of health out-
comes remains unclear, the positive health benefits of
whole grains are well established (132). Grain consump-
tion is associated with ingestion of many nutrients, in-
cluding fiber, antioxidants, and vitamins (132,133), and
grains are likely the most dependable source of phy-
toestrogens (134). High-carbohydrate diets are associated
1776 October 2007 Volume 107 Number 10
with higher intake of folate (30,75,85). Although folate
comes from a variety of foods, including fruits and vege-
tables, breakfast cereal is one of the best food sources of
folate (135), possibly helping to explain the lower homo-
cysteine concentrations reported to be associated with
both whole- and refined-grain intake (136). Total grain
intake also has been reported to be associated with lower
concentrations of C-reactive protein, thus possibly reduc-
ing risk of inflammation (137). Whole-grain consumption
is associated with reduced progression of coronary artery
atherosclerosis (138) and lower risk of type 2 diabetes
(44-46,73,86), metabolic syndrome (83), cardiovascular
disease (44,45,74,79,82,83), and all-cause mortality (139).
CONCLUSIONS AND RECOMMENDATIONS
A substantial body of epidemiologic evidence reveals an
inverse relationship between carbohydrate intake and
BMI. Data from ad libitum, low-fat diet interventions,
without emphasis on energy restriction or weight loss,
show modest “spontaneous” weight loss, and thus support
the findings from observational studies and suggest that
a nonenergy-restrictive, low-fat diet strategy may avoid
adherence problems characteristic of energy-restricted
diets. The greatest potential role for low-fat diets in
weight control may be in the attenuation of unhealthful
adult weight gain.
Glycemic load is inversely associated with BMI, even
when adjusted for total energy intake. The role of carbo-
hydrate quality, reflected by dietary GI, is mixed; current
evidence from cohort studies suggests that a high-GI diet
is just as likely, if not more so, to be associated with lower
BMI than higher BMI. Whole-grain, but not refined-
grain, intake is consistently associated with lower BMI.
High-carbohydrate diets are frequently associated with
higher intake of dietary fiber and greater overall diet
quality. Cereal fiber in particular appears to be associ-
ated with lower BMI and reduced risk of type 2 diabetes
and cardiovascular disease. Public health recommenda-
tions to increase consumption of whole-grain, fiber-rich
foods should have multiple positive health benefits, facil-
itate weight-control efforts, and possibly reduce preva-
lence of overweight and obesity.
Consuming sufficient quantities (ie, three or more serv-
ings per day) of whole-grain foods rich in cereal fiber may
obviate the need to be cognizant of the glycemic proper-
ties of foods. Health benefits of whole-grain and cereal
fiber consumption are seen despite being associated with
high GI or GL (33,34,44,75-77). Diabetes risk associated
with either high GI or GL is attenuated or eliminated by
cereal fiber (33,57,62). Nevertheless, despite insufficient
data to warrant universal recommendations for use of GI,
it must be noted that low-GI diets (that are not low in
carbohydrate) are not associated with adverse health ef-
fects. Certain populations, such as sedentary (33,40) and
overweight/obese (34,55,122) women, and insulin resis-
tant individuals (58), may benefit from low-GI diets. If
carbohydrate-rich foods are not whole grain, it might be
prudent to choose low-GI alternatives (118).
Additional Research Needed
Randomized controlled trials with proper control for con-
founding dietary variables (eg, total and cereal fiber) and
behavioral factors (eg, physical activity) are needed to
elucidate the independent effect of GI/GL on BMI and
health outcomes. The postprandial period may be impor-
tant in the development of cardiovascular disease
(117,140). This is especially relevant to GI and thus more
research is needed on postprandial metabolic responses of
meals varying in GI/GL. Physical activity may affect the
relationship between GI and BMI, especially in women
(40). Further research is needed to help explain possible
sex differences (40,55), and to establish whether or not
physical activity intervention modifies acute responses
and chronic adaptations to diets differing in GI.
Preparation of this manuscript was supported in part by
a grant from the Grain Foods Foundation.
The author is a member of the Grain Foods Foundation
clinical advisory board.
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