The energy balance model of obesity: beyond calories in, calories out

A recent Perspective article described the “carbohydrate-insulin model (CIM)” of obesity, asserting that it “better reflects knowledge on the biology of weight control” as compared to what was described as the “dominant energy balance model (EBM)” that fails to consider “biological mechanisms that promote weight gain”. Unfortunately, the Perspective conflated and confused the principle of energy balance, a law of physics which is agnostic as to obesity mechanisms, with the EBM as a theoretical model of obesity that is firmly based on biology. In doing so, the authors presented a false choice between the CIM and a caricature of the EBM that does not reflect modern obesity science. Here, we present a more accurate description of the EBM where the brain is the primary organ responsible for body weight regulation operating primarily below our conscious awareness via complex endocrine, metabolic, and nervous system signals to control food intake in response to environmental influences as well as the body's energy needs. We also describe the recent history of the CIM and show how the latest “most comprehensive formulation” abandons a formerly central feature that required fat accumulation in adipose tissue to be the primary driver of positive energy balance. As such, the new CIM may be considered a special case of the more comprehensive EBM but with a narrower focus on high dietary glycemic load as the primary factor responsible for common obesity. We review data from a wide variety of studies that address the validity of each model and demonstrate that the EBM is a more robust theory of obesity than the CIM.

https://doi.org/10.1093/ajcn/nqac031