07.06.

2020 Diets - Disorders of Nutrition - Merck Manuals Consumer Version

MERCK MANUAL
Consumer Version
The trusted provider of medical information since 1899

Diets
By Adrienne Youdim , MD, David Geffen School of Medicine at UCLA

Last full review/revision Aug 2019| Content last modified Aug 2019

A diet is whatever a person eats, regardless of the goal—whether it is losing weight, gaining weight, reducing fat intake,
avoiding carbohydrates, or having no particular goal. However, the term is often used to imply a goal of losing weight,
which is an obsession for many people.
Standard healthy diets for children and adults are based on the needs of average people who have certain
characteristics:
They do not need to lose or gain weight.

They do not need to restrict any component of the diet because of disorders, risk, or advanced age.

They expend average amounts of energy through exercise or other vigorous activities.

Thus, for a particular person, a healthy diet may vary substantially from what is recommended in standard diets. For
example, special diets are required by people who have diabetes, certain kidney or liver disorders, coronary artery
disease, high cholesterol levels, osteoporosis, diverticular disease, chronic constipation, or food sensitivities. There are
special dietary recommendations for young children, but little guidance is available for other age groups, such as older
people.

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Spotlight on Aging: Nutrition

The best diet for older people has not been determined. However, older people may benefit from changing
some aspects of their diet, based on the way the body changes as it ages. No changes are required for some
nutrients such as carbohydrates and fats.
Calories: As people age, they tend to be less active and thus use less energy, making it easier to gain

weight. If they try to consume fewer calories to avoid weight gain, they may not get all the nutrients

needed—particularly vitamins and minerals. If older people stay physically active, their need for calories
may not change.

Protein: As people age, they tend to lose muscle. If older people do not consume enough protein, they

may lose even more muscle. For older people who have problems eating (for example, because of

difficulty swallowing or dental disorders), protein can be consumed in foods that are easier to chew than
meat, such as fish, dairy products, eggs, peanut butter, beans, and soy products.

Fiber: Eating enough fiber can help counter the slowing of the digestive tract that occurs as people age.
Older people should eat 8 to 12 servings of high-fiber foods daily. Getting fiber from foods is best, but

fiber supplements, such as psyllium, may be needed.

Vitamins and minerals: Older people may need to take supplements of specific vitamins and minerals

in addition to a multivitamin. Calcium, vitamin D, and vitamin B12 are examples. Getting enough calcium

and vitamin D from the diet is difficult. These nutrients are needed to maintain strong bones, which are

particularly important for older people. Some older people do not absorb enough vitamin B12, even

though they consume enough in foods, because the stomach and intestine become less able to remove
vitamin B12 from food or to absorb it. Older people with this problem can absorb vitamin B12 better

when it is given as a supplement.

Water: As people age, they are more likely to become dehydrated because their ability to sense thirst

decreases. Thus, older people need to make a conscious effort to drink enough fluids rather than wait

until they feel thirsty.

Older people are more likely to have disorders or take drugs that can change the body’s nutritional needs or
the body’s ability to meet those needs. Disorders and drugs can decrease appetite or interfere with the
absorption of nutrients. When older people see their doctor, they should ask their doctor whether the
disorders they have or the drugs they take affect nutrition in any way.

Weight Loss Diets

Weight loss requires consuming fewer calories than the body uses. People are usually advised to consume 500 to 1000
fewer calories per day to lose about 1 to 2 pounds per week. One pound of body fat stores about 3,500 calories.
However, there is no guarantee that each 3,500 calories eliminated from the diet will cause a pound of weight loss
because many factors affect how much weight is lost (or gained), as in the following examples:
As people lose weight, the body starts using energy more efficiently (possibly intended to guard against
starvation), so that fewer calories are burned and less fat is broken down for energy.

How much fat and weight are lost, even when the same number of calories is eliminated, varies a great deal
from one person to another.

Thus, predicting how much fat and weight a person will lose is difficult.
Most conservative weight loss diets involve consuming at least 1,200 to 1,400 calories a day. When rapid weight loss is
needed, fewer than 1,000 calories may be consumed. Such diets should be used only if prescribed and supervised by a
doctor. Then the doctor can make sure that the diet contains enough essential nutrients, including protein. Consuming
fewer than 800 calories is hard to tolerate and is not recommended without doctor supervision.

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To be healthy, weight loss diets should provide about the same volume of food (by including more fiber and fluids) as
the normal diet. They should also be low in saturated fat and sugar and include essential nutrients, including
antioxidants.

Food Nutrition Label

The following general guidelines may help people lose weight:

Reading food labels: People learn what nutrients and how many calories food, including beverages, contains.
Then, people can plan their diet more effectively.

Counting calories: People keep track of the number of calories they eat. This strategy helps people control
calorie intake.

Choosing nutrient-rich, low-calorie foods: When fewer calories are consumed, getting the needed nutrients—
particularly vitamins and minerals—is more difficult. So people should choose foods that contain many nutrients
but not many calories. For example, beans and legumes provide many nutrients without providing many
calories. These foods are also high in fiber and bulk and thus help people feel full and satisfied. Eating fruits and
vegetables in a variety of colors (such as strawberries, peaches, broccoli, spinach, and squash) is a way to get a
variety of recommended nutrients and antioxidants.

Eating certain types of foods at certain times of the day: For example, fast-energy foods, such as
carbohydrates, are best eaten when the body needs a large supply of energy—that is, in the morning and during
vigorous exercise. The body’s need for energy is lowest at night, so avoiding carbohydrates in the evening may
help.

Using sugar and fat substitutes: Such substitutes and foods that contain them can sometimes help people
reduce calorie intake.

Exercising: Combining increased exercise with dieting greatly enhances weight loss because exercise increases
the number of calories the body uses. For example, vigorous walking burns about 4 calories per minute, so that
1 hour of brisk walking per day burns about 240 calories. Running is even better, burning about 6 to 8 calories
per minute. Physical activity helps preserve the amount of muscle tissue (muscle mass) people have, and
resistance exercises may increase muscle mass. Because muscle tissue, even at rest, burns more calories than
fat tissue, having more muscle increases the metabolic rate (the amount of calories the body burns while at rest)
and the number of calories people need.

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Did You Know...

Regardless of the weight loss diet followed,

people must consume fewer calories than

the body uses to lose weight.

High-protein/low-carbohydrate diets
Diets high in protein and low in simple carbohydrates have become popular as a way to lose weight. Most of these
diets usually also restrict fat because each gram of fat supplies so many calories. However, some high-protein/low-
carbohydrate diets, such as the Atkins diet, do not restrict fat.
The theory behind these diets is that slower-burning energy sources—protein and fat—provide a steady supply of
energy and thus are less likely to lead to weight gain. In addition, people tend to feel full longer after eating protein
more than other macronutrients, and doing so helps to preserve lean body mass while dieting. On the other hand,
carbohydrates empty from the stomach quickly and are digested quickly. Carbohydrates also stimulate insulin
production, which promotes fat deposition and increases appetite.
Experts disagree about whether or not avoiding foods with a high glycemic index helps with weight loss, particularly in
low-carbohydrate diets. The effect of the glycemic index is less important when only a small percentage of total
calories is carbohydrates. In a low-carbohydrate diet, the difference between how fast the carbohydrates in various
foods (with their different glycemic indexes) are digested is sometimes so small that it makes little difference to most
dieters. Avoiding foods with a high glycemic index also sometimes eliminates foods with valuable vitamins and
minerals. Experts also disagree on how important the glycemic load (the glycemic index plus the amount of
carbohydrate in a food) is for weight loss.
Some experts do not recommend following a high-protein diet for a long time. Some evidence suggests that over
years, very high protein diets impair kidney function and may contribute to the decrease in kidney function that occurs
in older people. People with certain kidney and liver disorders should not consume a high-protein diet. Also, high-
protein diets can speed the body’s processing of certain drugs and thus may affect how well the drug works.
Very low carbohydrate diets (of less than 100 grams a day) can lead to the accumulation of keto acids (ketosis). When
people do not consume enough energy for the body’s needs and have no carbohydrates stored in the body to use for
energy, the body breaks down fats. As part of this process, the body produces keto acids. In small amounts, keto acids
are easily excreted by the kidneys without causing symptoms. However, in large amounts, they can cause nausea,
fatigue, bad breath, and even more serious symptoms, such as dizziness (due to dehydration) and abnormal heart
rhythms (due to electrolyte imbalances). People following a low-carbohydrate diet (or any other weight loss diet)
should drink large amounts of water to help flush keto acids from the body.
Low-carbohydrate diets tend to cause large amounts of weight to be lost during the first week or so, as the body
converts stored carbohydrates (glycogen) to energy. As glycogen is broken down, the body also excretes large amounts
of water, adding to the weight loss. However, once the body begins to use stored fat for energy, weight loss slows.
People following a low-carbohydrate diet may substitute fats for the carbohydrates they are avoiding. In such cases,
the diet may be so high in fat that the total caloric intake exceeds what the body uses. In such cases, weight loss stops
after glycogen is used up.
Three popular high-protein/low-carbohydrate diets aimed mainly at weight loss are the keto diet, paleo diet, and
Atkins diet.
The keto (ketosis) diet is based on severely restricting carbohydrate intake to less than about 50 grams a day and, in
doing so, mobilizing fat as a source of energy for the brain. Calories are not restricted to any prespecified level but are
obtained by consuming protein and fat but very limited carbohydrate, including limited amounts of fruits and
vegetables. It is proposed that not feeling hungry and appetite control are due to the high protein intake and
formation of ketones, which are made in the liver from fat when carbohydrate intake is low. This diet may be superior
to low-fat diets for weight loss. Side effects of the keto diet include "keto flu," which includes symptoms such as
fatigue, irritability, and trouble thinking. Long term it can result in kidney stones and bone loss. People with chronic
medical conditions including diabetes and kidney failure should not go on this diet without medical supervision.
The paleo diet is a low-carbohydrate diet based on the foods that might have been eaten during the Paleolithic era. It
consists of protein, fruits, vegetables, nuts, and seeds and eliminates grains, dairy, potatoes, sugar, and processed
food. This diet may be easier to follow than the keto diet because it is less restrictive; however, it may still be a
challenge to sustain weight loss.
The Atkins diet is based on limiting calories to about 2,000 calories a day by restricting carbohydrates but not limiting
fats and protein.

Low-fat diets
Fat supplies a large number of calories per gram and is more readily deposited as body fat than are proteins and
carbohydrates. A reduction of only 10 grams of fat per day saves about 90 calories. Thus, reducing the amount of fat
rather than the amount of protein or carbohydrate might seem a faster way to lose weight. However, such a diet may
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not work unless overall caloric intake is reduced. For example, people on low-fat diets may consume more
carbohydrates and protein than normal and thus ultimately consume more calories.
In addition, not all fats are alike. Reducing the amount of saturated and trans fat in the diet is a good idea because
doing so helps lower cholesterol levels in the blood. Lowering cholesterol levels benefits most dieters because excess
weight increases their risk of atherosclerosis, which can lead to heart attacks or stroke. However, greatly reducing
polyunsaturated and monounsaturated fats may be harmful because doing so decreases the level of high-density
lipoprotein (HDL)—the good—cholesterol. Having a low HDL level can increase risk of atherosclerosis.
The Pritikin diet is a low-fat/low-protein diet based on consuming whole, unprocessed, and natural carbohydrate-rich
foods, such as grains, vegetables, and fruit.

High-fiber diets
Fiber indirectly helps with weight loss in several ways:
It provides bulk, which makes people feel full faster.

It slows the rate at which the stomach empties so people feel full longer.

It requires more chewing, forcing people to eat more slowly and perhaps less.

High-fiber foods, such as fruits and vegetables, wheat bread, and beans, are filling without providing many calories.
Eating more high-fiber foods may enable people to eat fewer less filling, high-calorie foods, such as high-fat foods.
However, fiber supplements, such as guar gum and cellulose, are not effective for weight loss.

Liquid diets
Many people use liquid diets to lose weight, mainly because they are convenient. However, the contents of such liquids
vary, and many are unlikely to be of much help in losing weight.
Some commercially available liquid diets are well-balanced, with appropriate proportions of protein, carbohydrates,
and fat plus supplemental vitamins and minerals, as are most liquid diets obtained from a doctor. Using such products
to replace one to three meals daily can help people limit the number of calories they consume and thus lose weight or
maintain their weight.
However, other liquid diets may contain a large proportion of carbohydrates, producing a sweet and tasty drink, and
are not necessarily low in calories. Such liquid diets are more useful as a supplement to other foods for people who
are trying to gain weight.

Commercial diet programs

There are various weight loss commercial programs, many of which are not backed by scientific evidence for weight
loss. Some popular and commercial diets are effective in the short term, but people often regain the weight because of
difficulty adhering to the diet long term. Following are three popular commercial diet programs currently marketed.
TOPS or Take Pounds Off Sensibly is a behavioral program that promotes a calorie-restricted, portion-controlled meal
plan with behavioral and educational support in the form of in-person meetings and online tools. More than 60% of
participants have lost and maintained weight loss for 7 years when they stay in the program.
WW (formerly known as Weight Watchers) is a commercial weight loss program that consists of a calorie-restricted,
portion-controlled dietary plan with behavioral support in the form of weekly group meetings. Studies show that
referral to WW can be a beneficial addition to weight loss therapy provided by a physician and results in greater weight
loss and adherence to a higher quality diet quality as compared to as compared to other low calorie dietary
interventions.
Meal replacement diets are an effective strategy for weight loss and weight maintenance. Meal replacement-based
commercial weight loss programs (eg, Jenny Craig) have demonstrated successful weight loss as have other dietary
plans that include commercial meal replacements. Weight loss is greater if the number of meal replacements is higher.

Fad diets
There are many fad diets, including some of the above. Many fad diets promise quick weight loss and do not provide
any scientific evidence of their effectiveness. Some require extreme reductions in the number of calories consumed.
Others rely on supplements alleged to help burn fat. Still others are based on eating a single type of food.
These diets have not been shown to lead to sustained weight loss, and many are dangerous. Some provide inadequate
amounts of essential nutrients and, over time, can lead to serious metabolic disturbances, such as loss of bone density
and strength (including osteoporosis), problems with menstruation, abnormal heart rhythms, high cholesterol levels,
kidney stones, and worsening of gout.

Diets aimed at promoting overall health

Some diets have been rigorously studied and shown to be effective in promoting health—for example, by reducing the
risk of atherosclerosis (including coronary artery disease), which can lead to heart attacks or stroke. These diets
include the Mediterranean diet and the DASH diet.

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The Mediterranean diet contains large amounts of olive oil, fruits, vegetables, nuts, and grains. It includes fish and
poultry (but in smaller amounts than fish). Consumption of dairy, meats such as beef and pork, and sweets is limited.
Drinking wine in moderation is encouraged.
Studies have shown that the Mediterranean diet helps reduce the risk of atherosclerosis, including coronary artery
disease. This diet significantly reduces the risk of death due to coronary artery disease, as well as the risk of having a
heart attack, a stroke, and angina (chest pain that occurs when the heart does not get enough blood and oxygen).
When the number of calories consumed is reduced, the Mediterranean diet may result in greater weight loss than a
low-fat diet. This type of diet may be especially helpful for people who are overweight, have diabetes or a heart
disorder, or have risk factors for atherosclerosis (and coronary artery disease).
The DASH (Dietary Approaches to Stop Hypertension) diet emphasizes eating lots of fruits and vegetables and
using low-fat dairy products. Thus, the diet is low in saturated fat and cholesterol. It includes poultry, fish, whole
grains, and nuts and limits consumption of red meats, sweets, and salt.
The DASH diet can reduce blood pressure in people with and without high blood pressure, even if weight is not lost,
and can reduce blood sugar levels and improve cholesterol levels. This diet can benefit people with high blood
pressure and may benefit those who are overweight, have diabetes or a heart disorder, or have risk factors for
atherosclerosis (and coronary artery disease).

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