However, in an environment where high-energy dense foods are readily available and vigorously marketed, and where physical activity is not necessary for most people to get through their daily lives, it is hard to maintain a healthy lifestyle.

For these reasons, we cannot approach obesity solely as an issue of personal responsibility. If we can change the environment to one that less strongly promotes obesity, it is likely that more people will be able to achieve and maintain healthy lifestyles.

On the other hand, we are not likely to be able to change the environment to one where most people can maintain a healthy body weight with little conscious effort. This means that we have to address obesity both as an environmental issue and as an issue of personal responsibility.

Maintaining a fair balance in doing this will be difficult. The issue of personal responsibility is even more sensitive in children, who may lack the knowledge and skills to make appropriate lifestyle choices and may not necessarily have the opportunity to engage in a healthy lifestyle.

For this group, it is critically important to create an environment that promotes healthier lifestyle choices.

However, it is also important for us to help our children develop skills for making lifestyle choices that will help them maintain a healthier weight as adults. The future does not look optimistic in terms of addressing obesity unless we can come together as a society to address behavior and environmental change.

The high rates of childhood obesity that exist today suggest that obesity rates in the United States have not peaked and will continue to increase gradually if we do nothing.

Most overweight children become overweight or obese adults. The worst case scenario is that the entire population becomes obese, and the best case scenario is that we get serious about intervening to reverse the obesity epidemic. However, we have to do this together as a society; if we remain as individuals struggling with the problem, environmental change will not likely occur.

Is there real hope that we can make progress in reversing obesity before we all become obese? The more we learn about our complex system of regulating energy balance, the more we learn that it is operating as it has always operated.

Similarly, I am convinced that better behavior modification techniques alone will not solve the problem. The major influence toward positive energy balance is coming from the environment.

It is operating through behavior and does not elicit strong biological opposition. Put simply, we have a mismatch between our biology and our environment. We cannot attribute the obesity epidemic to abnormal biology or to a sudden rash of bad behavior.

We have to get serious about focusing attention on the environment. We are not likely to change the environment to one that existed before , where it was easier to maintain a healthy lifestyle. To get back to the obesity rates that existed then, individuals are going to have to make a greater conscious effort to manage their weight than they did then.

This does not mean that biological and behavioral research is not important—it is critically important. We still have much to learn about the biological regulation of energy balance and must improve our ability to help people make behavior changes.

However, without devoting at least similar attention toward the environment, we will not succeed in reversing the obesity epidemic. Obesity cannot be addressed solely in the clinic or in the school or in the workplace.

It must be addressed everywhere. We are really talking about social change to make our communities into places where it is easy to make good food choices and to be physically active.

This change can only come from within communities and can only happen if every sector of the community engages in the effort. The good news is that if every member of each sector of the community commits to making small changes, the result can be a big change.

It will not be easy, but we have dealt with other hard social issues such as tobacco smoking, recycling, and seat belt use. It can be done, but it needs to be done quickly. I believe that our best chance of reversing the obesity epidemic is in creating a social change movement focused on small changes—in behavior and in the environment.

The small changes approach allows everyone to play a role in addressing obesity. Our immediate challenge is to first stop the continued increase in the weight of the population, and over time, return obesity rates to pres levels. I thank the many people who have worked in my laboratory over the past 25 yr.

In particular, I thank Drs. John C. Peters, Holly R. Wyatt, and Paul MacLean for their friendship and collaboration and for reviewing this paper. I gratefully acknowledge support from the National Institute of Diabetes and Digestive and Kidney Diseases over the past 25 yr.

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org accessed November Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Energy balance may not be as famous as some extreme celebrity diets but it is the only diet that really works in both the short and long term.

When it comes to diets , we've seen it all: Celebrity diets, extreme starvation plans, intermittent fasting, weird "eat-as-much-as-you-want-but-stay-skinny" programmes, and more.

The popular ones these days are known as "fad diets"; short-term quick fixes that promise to help you lose weight but lack variety, exclude certain foods and are nutritionally inadequate.

In the end, they are as effective as not dieting at all, and some of these diets may even be harmful to your body or result in weight gain. Take the no-carb diet. Fad or no fad, our bodies get energy mostly from carbs.

They fuel our daily activities from simple breathing to intense exercise. Cutting carbohydrates altogether could lead to a negative energy balance — our bodies are not getting enough fuel. If you are keen to lose weight or achieve and maintain a healthy weight, give up on the idea of finding and following extreme celebrity diets that work.

Related: Weight Management. In other words, it focuses on balancing the energy calories you consume and the energy calories you burn through physical activity. To lose weight, the number of calories we consume must be less than the number of calories we burn.

A negative energy balance over time leads to weight loss. Conversely, when we consume more calories per day than we use through physical activity, we gain weight. Energy Balance and Obesity: Over a prolonged period, we may develop obesity.

Obesity increases our risk of stroke, heart attack and, in more serious cases, can lead to organ failure. That means we should consume energy our bodies need and also engage in a healthy level of physical activity.

You can engage in minutes of moderate-intensity aerobic activity in a single session or over a few sessions by setting aside some days of the week for exercise. Remember, it is important that you keep track and balance your energy intake calories consumed and energy output calories burned through exercising to achieve and maintain a healthy weight.

Back Life stages Pregnancy Baby Toddlers and pre-school Children Teenagers Students Women Men Older people. Back Health conditions COVID, nutrition and immunity Heart disease and stroke Overweight, obesity and weight loss Cancer risk Type 2 diabetes Bone and joint health.

Back Putting it into practice Some tips to save money on food Make healthier choices Balancing the diet Food labelling Plant-based diets Keeping active Planning Food, seasons and celebrations. Back Training and events On-demand webinars Conference recordings and Annual Lectures Learning activities.

Health conditions Overweight, obesity and weight loss Energy balance and weight. Health professional. Enlarge Text A A. Energy intake and expenditure. Key points Energy is needed by the body to stay alive, grow, keep warm and move around. Energy is provided by food and drink.

It comes from the fat, carbohydrate, protein and alcohol the diet contains. Energy requirements vary from one individual to the next, depending on factors such as age, sex, body composition and physical activity level.

Energy expenditure is the sum of the basal metabolic rate the amount of energy expended while at complete rest , the thermic effect of food TEF, the energy required to digest and absorb food and the energy expended in physical activity.

To maintain bodyweight, it is necessary to balance the energy derived from food with that expended in physical activity. To lose weight, energy expenditure must exceed intake, and to gain weight, energy intake must exceed expenditure. Energy intake and expenditure A regular supply of dietary energy is essential for life and is required to fuel many different body processes.

What determines how much energy a person needs? Basal metabolic rate The basal metabolic rate BMR is the rate at which a person uses energy to maintain the basic functions of the body — breathing, keeping warm, and keeping the heart beating — when at complete rest.

Physical activity level In addition to their BMR, people also use energy for movement of all types. Physical activity Physical activity should be an important component of our daily energy expenditure.

How much energy do children and adults need? Intake versus expenditure In order for people to maintain their bodyweight, their energy intake must equal their energy expenditure.

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So if weight loss is just a simple equation, then why is it so difficult to lose weight? Because there are many factors that affect both your energy input and your energy output. Things like your medical status, age, and mood affect your energy balance equation every day.

Weight loss is a simple equation, but finding the right balance requires a little bit more work. If you are at the beginning of your weight loss journey, or if you are questioning your current diet and exercise plan, the energy balance equation is a great place to start.

You don't need to buy fancy tools or invest in an expensive weight loss program. Try to make some changes on your own. Evaluate the factors that affect your caloric intake and caloric output. You have control over some factors like activity level and no control over others like your age and sex.

Simply change what you can to tilt the scales of your energy balance equation and reach your weight loss goals. Department of Agriculture. How many calories are in one gram of fat, carbohydrate, or protein?

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Centro de Investigación en Nutrición y Salud, Instituto Nacional de Salud Pública, Cuernavaca, Mexico. Micalis Institute, MGP MetagenoPolis, INRA, AgroParisTech, Université Paris-Saclay, Jouy-en-Josas, France. Genetic and Molecular Epidemiology Unit, Lund University Diabetes Centre, CRC, University hospital Malmö, Malmö, Sweden.

Faculty of Agricultural and Food Science, American University of Beirut, Beirut, Lebanon. Department of Nutrition and the Nutrition Research Institute, The University of North Carolina, Chapel Hill, USA.

Department of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany. Faculty of Medicine, Southampton General Hospital, University of Southampton, Southampton, UK. Nutrition Policy and Scientific Advice NPU , Department of Nutrition for Health and Development NHD , World Health Organization WHO , Geneva, Switzerland.

Office of the Associate Director, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, USA. Faculty of Earth and Life Sciences, Department of Health Sciences, University Amsterdam, Amsterdam, The Netherlands.

Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, Joint Appointments, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, USA.

NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands. Institute of Nutrition, Mahidol University Salaya, Nakhon Pathom, Thailand.

World Cancer Research Fund International, London, UK. Department of Nutrition, Harvard T. Chan School of Public Health, Boston, USA. You can also search for this author in PubMed Google Scholar.

Correspondence to Isabelle Romieu. Open Access This article is distributed under the terms of the Creative Commons Attribution 4. Reprints and permissions. Romieu, I. et al.

Energy balance and obesity: what are the main drivers?. Cancer Causes Control 28 , — Download citation. Received : 21 October Accepted : 06 February Published : 17 February Issue Date : March Anyone you share the following link with will be able to read this content:.

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Energy balance and obesity: what are the main drivers? Download PDF. Abstract Purpose The aim of this paper is to review the evidence of the association between energy balance and obesity.

Methods In December , the International Agency for Research on Cancer IARC , Lyon, France convened a Working Group of international experts to review the evidence regarding energy balance and obesity, with a focus on Low and Middle Income Countries LMIC. Results The global epidemic of obesity and the double burden, in LMICs, of malnutrition coexistence of undernutrition and overnutrition are both related to poor quality diet and unbalanced energy intake.

Conclusion Energy intake that exceeds energy expenditure is the main driver of weight gain. Obesity and Weight Control: Is There Light at the End of the Tunnel? Article 15 May Mediterranean Diet and Obesity-related Disorders: What is the Evidence? Article Open access 30 September The role of the Mediterranean diet on weight loss and obesity-related diseases Article 23 August Use our pre-submission checklist Avoid common mistakes on your manuscript.

Introduction Obesity is defined as a state of excess adiposity that presents a risk to health such as increased risk of chronic diseases including cancer [ 1 — 3 ] and is the consequence of sustained positive energy balance over time.

The International Agency for Research on Cancer IARC of the World Health Organization WHO convened a Working Group Meeting in December to review evidence regarding energy balance and obesity, with a focus on Low and Middle Income Countries LMIC , and to tackle the following scientific questions: 1.

What are the factors that modulate these associations? Table 1 List of topics presented during the working group meeting Full size table. Full size image. Determinants of energy balance: what the evidence tells us With recognition that overweight and obesity are major risk factors for cancer, cardiovascular disease, diabetes, and many other health conditions, the difference between energy intake and expenditure, frequently referred to as energy balance, has become of great interest because of its direct relation to long-term gain or loss of adipose tissue and alterations in metabolic pathways.

Measurements of adiposity Several measures for overweight and obesity have been used in epidemiological studies [ 3 ]; however, it is important to be aware that such measures are imperfect markers of the internal physiological processes that are the actual determinants of cancer development.

Energy intake and energy expenditure Energy balance is the result of equilibrium between energy intake and energy expenditure. Understanding nutritional determinants of obesity Many factors relating to foods and beverages have been shown to influence amounts consumed or energy balance over the short to medium term, such as energy density and portion size [ 36 , 37 ], although the effect of energy density over the longer term is unclear.

Foods and dietary patterns One factor that has been suggested as being obesogenic is a high energy density of foods i. Understanding weight loss In weight loss trials, low carbohydrate interventions led to significantly greater weight loss than did low-fat interventions when the intensity of intervention was similar [ 60 ].

Factors that modulate the association between dietary intake and obesity Physical activity Long-term observational studies fairly consistently show an association between physical activity and weight maintenance, and a position paper from the American College of Sports Medicine ACSM stated that — min per week of moderate intensity physical activity is effective to prevent weight gain [ 62 ].

Genetic and epigenetic factors The patterns and distributions of obesity within and between ethnically diverse populations living in similar and contrasting environments suggest that some ethnic groups are more susceptible than others to obesity [ 70 ]. Microbiota In a healthy symbiotic state, the colonic microbiota interacts with our food, in particular dietary fiber, allowing energy harvest from indigestible dietary compounds.

Determinants of childhood obesity Many factors have contributed to the increase in the prevalence of obesity in children including unhealthy dietary patterns with high consumption of fast foods and highly processed food [ 85 ], of sugar sweetened beverages [ 86 ], lack of PA, an increase in sedentary behaviors e.

Prevention of obesity Numerous policy options to prevent obesity have been explored, and evidence is sufficient to conclude that many are cost effective. The obesity-cancer link: what are the underlying mechanisms?

Conclusions and recommendations The global epidemic of obesity and the double burden of malnutrition are both related to poor quality diet; therefore, improvement in diet quality can address both phenomena. Update on the Obesity Epidemic: After the Sudden Rise, Is the Upward Trajectory Beginning to Flatten?

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Department of Nutrition, Harvard T. Chan School of Public Health, Boston, MA, USA. Department Comprehensive Weight Control Center, Weill Cornell Medicine, New York, NY, USA.

Obesity and Nutrition Science, the Novo Nordisk Foundation, Hellerup, Denmark. Department of Medicine, Weill Cornell Medicine, New York, NY, USA. Life Sciences Institute, University of British Columbia, Vancouver, BC, Canada. Departments of Pediatrics and Medicine, UC San Francisco, San Francisco, CA, USA.

Department of Human Sciences, Ohio State University, Columbus, OH, USA. Department of Medicine, Duke University School of Medicine, Durham, NC, USA. Monell Chemical Senses Center, Philadelphia, PA, USA.

You can also search for this author in PubMed Google Scholar. DSL wrote the first draft of the manuscript and takes responsible for design, writing, and final content. All authors read and approved the final version. Correspondence to David S.

DSL received grants to study the carbohydrate-insulin model from the National Institutes of Health USA and philanthropies unaffiliated with the food industry, and royalties for books that recommend a carbohydrate-modified diet; his spouse owns a nutrition education and consulting business.

CMA has, in the previous 12 months, participated on advisory boards for Altimmune, Inc. LJA received consulting fees from and serves on advisory boards for ERX, Jamieson Wellness, Pfizer, Novo Nordisk, Sanofi, Janssen, UnitedHealth Group Ventures and Gelesis; received research funding from Lilly, Janssen, Allurion, and Novo Nordisk; has an equity interest in Intellihealth, ERX, Zafgen, Gelesis, MYOS, and Jamieson Wellness; and serves on the board of directors for Intellihealth and Jamieson Wellness.

LCC is founder of Faeth Therapeutics, a company that generates diets to enhance responses to cancer drugs. CBE received grants to study the carbohydrate-insulin model from the National Institutes of Health USA and philanthropies unaffiliated with the food industry. SBH is a member of the Scientific Advisory Board for Medifast.

JDJ received research grants to study the role of hyperinsulinemia in metabolism from the Canadian Institute for Health Research; and is co-founder and Board Chair of the Institute for Personalized Therapeutic Nutrition, a registered charity in Canada in which he has no financial interest.

RMK is a member of the Scientific Advisory Boards of Virta Health, Day Two, and Seraphina Therapeutics; and received payments from JumpStartMD. GT received royalties for books that discuss the history, science and therapeutic applications of carbohydrate-restricted eating. JSV received royalties for books on low-carbohydrate diets; is founder and has equity in Virta Health; and serves on the advisory board of Simply Good Foods.

WSY consults for dietdoctor. com by providing scientific review of website content. Other authors declared no conflicts of interest. Open Access This article is licensed under a Creative Commons Attribution 4.

Reprints and permissions. Ludwig, D. Competing paradigms of obesity pathogenesis: energy balance versus carbohydrate-insulin models. Eur J Clin Nutr 76 , — Download citation. Received : 11 April Revised : 24 June Accepted : 28 June Published : 28 July Issue Date : September Anyone you share the following link with will be able to read this content:.

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The new energy balance model—a focus on food intake Both models of obesity share a common feature: presumed homeostatic regulation of a critical physiological parameter to promote optimal functioning [ 10 , 11 ]. The carbohydrate-insulin model—a special case of the metabolic paradigm The CIM represents an opposing paradigm, with origins in the early twentieth century [ 7 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ], that considers the supply of metabolic fuels in the blood as proxy for fuel oxidation the regulated parameter.

Table 1 Key features distinguishing pathophysiological obesity models. Full size table. Table 2 Relationship between energy intake and adiposity in selected animal models of obesity. Table 3 Macronutrient-dependent effects of food processing.

Clinical translation and public adoption Both sides of this debate agree that fundamental changes in the food environment have driven the obesity pandemic. The remaining EBM-specific dietary targets include: Energy density. Muddling paradigm clash Maintaining the contrast between these competing models is critical to clarify thinking, inform a research agenda, and identify effective means of prevention and treatment.

Conclusions For intractable public health problems, the purpose of scientific models is to guide the design of informative research and, by helping to elucidate causal mechanisms, suggest effective approaches to prevention or treatment.

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