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JAMA Netw Open. 2019 Oct 2;2(10):e1913733. doi: 10.1001/jamanetworkopen.2019.13733.

Effect of Weight Loss via Severe vs Moderate Energy Restriction on Lean Mass and Body Composition Among Postmenopausal Women With Obesity: The TEMPO Diet Randomized Clinical Trial.

Author information

The Boden Collaboration for Obesity, Nutrition, Exercise, and Eating Disorders, Faculty of Medicine and Health, Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia.
School of Human Movement and Nutrition Sciences, Centre for Research on Exercise, Physical Activity and Health, The University of Queensland, Brisbane, Queensland, Australia.
Faculty of Health Sciences, The University of Sydney, Lidcombe, New South Wales, Australia.
Metabolism and Obesity Services, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
Bone Biology Program, Garvan Institute of Medical Research, St Vincent's Hospital Clinical School, University of New South Wales, Sydney, New South Wales, Australia.
Division of Endocrinology, Department of Medicine, Harbor-University of California Los Angeles Medical Center and Los Angeles BioMedical Research Institute, Los Angeles.
Sydney Translational Imaging Laboratory, Heart Research Institute, Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia.
Department of Radiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
Sunshine Coast Mind and Neuroscience-Thompson Institute, University of the Sunshine Coast, Queensland, Australia.
School of Health Sciences, College of Health and Medicine, University of Tasmania, Launceston, Tasmania, Australia.



Severely energy-restricted diets are the most effective dietary obesity treatment. However, there are concerns regarding potential adverse effects on body composition.


To compare the long-term effects of weight loss via severe vs moderate energy restriction on lean mass and other aspects of body composition.

Design, Setting, and Participants:

The Type of Energy Manipulation for Promoting Optimum Metabolic Health and Body Composition in Obesity (TEMPO) Diet Trial was a 12-month, single-center, randomized clinical trial. A total of 101 postmenopausal women, aged 45 to 65 years with body mass index (calculated as weight in kilograms divided by height in meters squared) from 30 to 40, who were at least 5 years after menopause, had fewer than 3 hours of structured physical activity per week, and lived in the Sydney metropolitan area of New South Wales, Australia, were recruited between March 2013 and July 2016. Data analysis was conducted between October 2018 and August 2019.


Participants were randomized to either 12 months of moderate (25%-35%) energy restriction with a food-based diet (moderate intervention) or 4 months of severe (65%-75%) energy restriction with a total meal replacement diet followed by moderate energy restriction for an additional 8 months (severe intervention). Both interventions had a prescribed protein intake of 1.0 g/kg of actual body weight per day, and physical activity was encouraged but not supervised.

Main Outcomes and Measures:

The primary outcome was whole-body lean mass at 12 months after commencement of intervention. Secondary outcomes were body weight, thigh muscle area and muscle function (strength), bone mineral density, and fat mass and distribution, measured at 0, 4, 6, and 12 months.


A total of 101 postmenopausal women were recruited (mean [SD] age, 58.0 [4.2] years; mean [SD] weight, 90.8 [9.1] kg; mean [SD] body mass index, 34.4 [2.5]). Compared with the moderate group at 12 months, the severe group lost more weight (effect size, -6.6 kg; 95% CI, -8.2 to -5.1 kg), lost more whole-body lean mass (effect size, -1.2 kg; 95% CI, -2.0 to -0.4 kg), and lost more thigh muscle area (effect size, -4.2 cm2; 95% CI, -6.5 to -1.9 cm2). However, decreases in whole-body lean mass and thigh muscle area were proportional to total weight loss, and there was no difference in muscle (handgrip) strength between groups. Total hip bone mineral density (effect size, -0.017 g/cm2; 95% CI, -0.029 to -0.005 g/cm2), whole-body fat mass (effect size, -5.5 kg; 95% CI, -7.1 to -3.9 kg), abdominal subcutaneous adipose tissue (effect size, -1890 cm3; 95% CI, -2560 to -1219 cm3), and visceral adipose tissue (effect size, -1389 cm3; 95% CI, -1748 to -1030 cm3) loss were also greater for the severe group than for the moderate group at 12 months.

Conclusions and Relevance:

Severe energy restriction had no greater adverse effect on relative whole-body lean mass or handgrip strength compared with moderate energy restriction and was associated with 2-fold greater weight and fat loss over 12 months. However, there was significantly greater loss of total hip bone mineral density with severe vs moderate energy restriction. Therefore, caution is necessary when implementing severe energy restriction in postmenopausal women, particularly those with osteopenia or osteoporosis.

Trial Registration: Identifier: 12612000651886.

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