Fasting, Intermittent Diets, and Weight Loss The rates of obesity have almost doubled in the last twenty-five

years (Healthy People, 2010). Two-thirds of the United States population is now considered overweight, and one-third is obese (Ogden, Carroll, Kit, Flegal, 2012). Obesity is quickly becoming a local, national, and foreign issue of concern. With the increase in obesity, and the impact it can have on the health of the community and economy, practitioners are searching for new and different approaches to weight loss (Finkelstein, Trogdon, Cohen, and Dietz, 2009). In addition, as obesity is a chronic disorder, there is a need to further develop treatment strategies that result in long-term maintenance of weight loss (World Health Organization, 2000). Such strategies have included fasting and intermittent diets. Currently, intermittent fasting is often promoted as a fashionable detox diet (Johnstone, 2006). Often times coupled with intermittent fasting, a very low calorie diet (VLCD) has been well recognized in the treatment of obesity. VLCDs are known to produce a rapid and profound initial weight reduction (Lantz, Peltonen, Agren & Torgerson, 2003). While is can be assumed that this form of weight loss is temporary, Hartman, Stroud, Sweet & Saxton (1992), conducted a two to three year study that found several correlations between successful weight maintenance following a fasting type diet. Despite the fact that it is a highly controversial subject amongst health care professionals, fasting and intermittent diets can have beneficial and long-term effects on weight loss. According to Websters Dictionary, the definition of a fast is to eat sparingly or abstain from some foods. Fasting is a type of diet that limits, or completely cuts

out the food and beverages you consume (Livestrong.com). In doing so, people often tend to lose a rapid amount of weight in a short period of time. Fasting is also used for religious purposes such as Ramadan, a month in which Muslims abstain from drinking or eating food, and on Yom Kippur a day of atonement for Jews. Novel treatments in fasting include VLCDs and intermittent/alternate day fasts. Although it may be concluded that weight loss in VLCD and intermittent fasting subjects is temporary, studies such as Johnstone (2006), Hartman, Stroud, Sweet & Saxton (1992), Lantz, Peltonen, Agren & Torgerson (2003), and Varady, Bhutani, Church & Klempel (2009), provide short and long-term studies that state otherwise. Short Term Studies Short-term studies have been conducted on weight loss in those fasting for religious reasons. Two studies look at fasting in relation to Ramadan, a Muslim observance, and Yom Kippur a day of fasting observed by Jews. In both studies it is concluded that weight loss is achieved, however, Yom Kippur is a 25 hour fast, and although Mosek and Korczyn (1999), reflect a loss of .97-1.7kg, they also state that this usually reflects dehydration. The fast of Ramadan is more closely studied in relation to weight loss, because of similarities to intermittent fasting. In a study conducted by Khaled and Belhraouet (2009), overweight, type 2 diabetics were observed during, and one month after the month of Ramadan. Two meals were consumed each day, one before dawn, and one after sunset. Results indicated that overweight subjects lost significantly (p<0.01, 3.12kg) more, than normal or underweight people. Loss of weight was contributed to loss of caloric intake, due to a restricted amount of meals served in a day. What was found most interesting in

the study was the increase in fat intake during Ramadan, coupled with weight loss. Additionally, there was a decrease in total carbohydrates eaten, which had a positive impact on blood glucose concentrations and improved insulin action (Khaled and Belhraouet, 2009). The study concludes that Ramadan fasting represents a good opportunity for patients studied to lose weight and induced significant weight loss, although patients did regain weight one month later. This was only seen because they fell back into old dietary habits. It can be speculated that in accordance with counseling and nutrition education, subjects would have retained weight loss. In a study conducted by Varady, Bhutani, Church & Klempel (2009), participants are put on an alternate day fasting diet (ADF) for eight weeks. The first four weeks included an ADF with a controlled food intake phase, and the second four weeks included an ADF with a self-selected food intake phase. Significant weight loss (P<0.001) was reported during the control phase (0.67-0.69 kg/wk) and remained consistent through the self-selected phase. Participants consumed 25% of their caloric needs on ADF days, and through counseling were able to maintain doing so through the self-selected phase of the study. Registered dietitians also counseled participants weekly during this second, four week phase. In summary, the studys findings indicate that ADF may be implemented as an effective diet strategy and should therefore be considered a viable option for obese patients who wish to lose weight and decrease CAD health risks through dietary restrictions (Varady, Bhutani, Church & Klempel, 2009). This short-term study demonstrates the positive effect that an intermittent diet can have on weight loss, and further proves that with proper guidance, results can possibly maintained in the long term.

In an article recently published by USA Today, author Mark Bialek mentions a study conducted by Mark P. Mattson and colleagues at the National Institute on Aging. This study demonstrated the health benefits found in mice eating every other day regardless of overall caloric intake. In addition, increased health benefits are seen in ADF diets compared to those based on calorie restriction alone. While this article specifically talked about the health benefits of ADF or intermittent dieting, and not its specific effect on weight loss, it none-the-less shows the benefit in suggesting these types of restrictive diets to overweight and obese patients. Long Term Studies While short-term studies may not provide enough evidence in terms of weight loss adherence and maintenance when on a VLCD or intermittent fasting diet, long-term studies may give us more insight into their sustainability. In a randomized two year clinical trial, Lantz, Peltonen, Agren & Torgerson (2003), studied and compared two (VLCD)-based weight maintenance strategies. Participants were put on a VLCD for four months. After four months participants in an intermittent diet group were told to use the VLCD for two weeks every three months. The other participants, part of the on-demand group, were instructed to only use the VLCD when their weight reached an individualized cut-off point. All participants were scheduled to meet with a registered dietitian eleven times, and with a study nurse twenty-one times over the course of the trial. Results indicated that there were no significant differences in weight change between the two groups at the end of the two-year study. In addition, both groups were able to maintain significant weight loss (P<0.001). Patients at the end of this two-year trial

maintained an average of 7% weight reduction, which also falls into the range that is shown to have beneficial effects on several obesity related CVD risk factors (Lantz, Peltonen, Agren & Torgerson, 2003). Whether a VLCD diet was used every few months or when needed, this study confirms that the use of a VLCD to initiate rapid weight loss and its maintenance, in accordance with counseling sessions provided by health professionals, can lead to a sustainable positive weight loss outcome. In another long-term study conducted by Hartman, Stroud, Sweet & Saxton (1992), participants were evaluated two to three years following a treatment on a VLCD and behavioral therapy program. Subjects were encouraged to partake in a variety of maintenance programs including nutrition education, cooking classes, topics reviewed when fasting, and exercise programs. Both men and women fasted for an average of 22wks and lost an average of 25kg and 34kg respectively. Women maintained an average of 10kg of weight loss and men maintained an average of 15kg of weight loss at the two to three year follow up. The study also indicates that those that chose not to participate in a follow up maintenance program lost significantly less weight than those who joined. The study concludes that those who were most successful in long-term weight loss adhered to a maintenance and exercise program for at least eight months after the VLCD ended. This study not only implicates the long term positive effect that a VLCD can have on weight reduction, but emphasizes the importance of continued exercise and counseling in terms of weight loss maintenance. While stating the short and long term weight loss benefits seen with the use of VLCDs and intermittent fasting, it is encouraged that patients be under the special

care of their primary physician (Johnstone, 2006). Fasting is not a suitable method for everyone, and there can be some side effects. Side effects of fasting can include lightheadedness, postural hypotension, constipation, elevated uric acid levels, abnormal liver function tests, and transient nausea (Cerrato, 1989). Fasting can also cause blood sugar to drop, which if prolonged, can lead to muscle tissue breakdown (Livestrong.com). Short and long-term studies that have been mentioned used a trial period of VLCDs and ADF diets to reach a desired weight in overweight and obese patients. Most VLCDs did not exceed five months. The trend seems to be a shift from VLCDs used in the late 80s and 90s to intermittent/ADF diets seen in more recent studies of the late 2000s. The ADF diets coupled with counseling seem to result in longer weight loss maintenance and an increase in health benefits as seen in studies conducted by Lantz, Peltonen, Agren & Torgerson (2003), and Varady, Bhutani, Church & Klempel (2009). With increased rates of obesity in the United States, researchers are looking into alternative methods to weight loss. Methods such as VLCD and intermittent/alternative day fasting diets were reviewed. Short and long term studies seem to indicate a positive correspondence between these weight loss methods while coupled with nutritional guidance and counseling, for overall weight loss maintenance. While restrictive calorie and fasting diets are not suitable for everyone, they seem to have a positive effect in terms of rapid weight loss, weight loss maintenance and overall health benefits.

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