ReviewAssociations between dietary energy density and obesity: A systematic review and meta-analysis of observational studies
Introduction
Between 1980 and 2010, the global prevalence of obesity doubled, becoming a leading global health problem [1]. The worldwide prevalence of obesity in men (body mass index [BMI] ≥30 kg/m2) increased from 4.8% in 1980 to 9.8% in 2008. Corresponding values for women rose from 7.9% in 1980 to 13.8% in 2008 [1]. Globally, obesity and overweight are contributors to at least 2.8 million deaths each year [2]. Additionally, increased risk for various chronic diseases as a consequence of obesity has been well established [3]. Given the high prevalence of obesity in both developed and developing countries, dietary factors that are responsible for this epidemic are highly relevant.
Evaluation of the overall effect of diet is frequently preferred to assessment of individual dietary components. Among dietary factors, dietary energy density (DED), as a measure of overall diet, has been at the focus of many recent studies. The Western dietary pattern is mainly loaded by high-energy-dense foods [4] and is known as an “obesity-inducing dietary pattern” [5]. High-energy-dense diets are rich in fat and energy, but low in fiber, fruits, and vegetables [6], [7]. Moreover, higher DED is inversely related to diet quality [8], which may encourage weight gain. Research has shown that higher DED increases the risk of metabolic syndrome as well as its components [9], [10] and diabetes [11].
The link between DED and weight status has been assessed in several epidemiologic and intervention studies in different age groups. However, results have been inconsistent, and it has not been possible to establish a conclusive relation between DED and obesity. While some epidemiologic data has revealed a positive link between DED and body weight in both adults and children [12], [13], [14], [15], others have failed to find significant associations [16], [17], [18]. Among some longitudinal studies, direct associations between weight gain and DED were observed only in subjects who were initially overweight or obese [19], [20]. Conversely, some investigators have found an inverse relationship between weight gain and DED in normal-weight women, while no significant association has been observed in men [20]. Furthermore, although not a primary aim, several studies assessing the association of DED with various chronic diseases have also presented data on anthropometric measures in secondary analyses or as general participant characteristics. As far as we know, there has been one metaanalysis on the topic of DED and obesity summarizing six observational studies published before September 1, 2008 [21]. This study, by Wilks et al., limited its search to human studies in the English language. Their findings revealed no association between DED and subsequent change in adiposity in children. It is not clear if the inconsistent findings in the literature to date are attributable to differences in methods of calculating DED, in assessment of anthropometric measures, or in variation among study populations (e.g., sex, BMI, age) or physical activity levels. Our goals were to perform a systematic review and a metaanalysis to examine whether evidence from observational studies overall show a direct link between DED and obesity, and to calculate an estimate of the risk. We included both studies that evaluated this directly as a primary aim and those that provided data on these relationships either in baseline measurements or as general characteristics or covariates.
Section snippets
Search strategy and inclusion criteria
We searched for articles that were published before January 2015 in ScienceDirect, ProQuest, MEDLINE, and Google Scholar databases. Articles were included that used energy density, energy-density, energy dense, calorie density, caloric density, calorie dense, energy concentration, or calorie concentration in the title, abstract, or keywords (a MeSH term was not defined for Energy density).
Exclusion criteria
We excluded studies that did not consider DED for the whole diet and that included patients with cancer or
Results
We reviewed 5876 articles according to inclusion and exclusion criteria and, finally, 37 [8], [9], [10], [11], [12], [13], [14], [15], [19], [20], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49] studies were included in the present systematic review (Fig. 1). Characteristics of the eligible studies are reported in Table 1. Fourteen studies were conducted on subjects <18 y old [15],
Discussion
This meta-analysis found that in cohort studies, higher DED was directly associated with weight gain, adjusted means for BMI (in men and women, separately), and adiposity risk. Despite a positive association between DED and elevated BMI, heterogeneity was considerable between studies. No significant association was observed in cross-sectional studies between DED and weight and elevated odds of abdominal obesity. Due to a limited number of studies in some subgroups, our findings should be
Conclusion
In conclusion, the current systematic review and meta-analysis revealed that a high-energy-dense diet was directly associated with weight gain and risk of elevated adiposity, but not elevated BMI. However, heterogeneity among studies was significant. Although our findings were based on analyses of cohort and cross-sectional studies, results related to increases in body weight were based on cohort studies, suggesting possible causal inference.
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The authors appreciate the financial support for this study provided by the Research Council of the Food Security Research Center, Isfahan University of Medical Sciences.
MHR, FH, PJS, and LA contributed to the conception, design, statistical analyses, data interpretation, and manuscript drafting of this study. MHR and FH contributed to the search and data analysis. All authors approved the final manuscript for submission. LA supervised the study.