Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Behavior, Psychology and Sociology

The effect of a very low calorie diet on subjective depressive symptoms and anxiety: meta-analysis and systematic review


There are conflicting findings regarding the effect very low calorie diets (VLCDs) have on self-reported depressive symptoms and anxiety levels. Some studies have reported decreased subjective depressive symptoms and anxiety post-diet, whereas other studies have not. Further complicating matters, the protocol for VLCDs vary substantially across studies, which could account for the mixed findings. The primary goal of this meta-analysis and systematic review was to determine the effect VLCDs have on subjective depressive symptoms and anxiety pre- to post-diet. In addition, potential moderators (the presence/absence of behavioral therapy, duration of diet, inclusion/exclusion of low intensity exercise, and amount of weight lost) were examined to assess the effect of procedural deviations across VLCD studies on depressive symptoms and anxiety. A random-effects model was used for the meta-analysis and included nine studies with 16 independent samples. To further explain the results, study rigor was examined in the systematic review, which included 11 studies with 20 independent samples. Depressive symptoms significantly decreased pre- to post-diet when behavioral therapy was implemented during the diet, the duration of the diet was relatively long (8–16 weeks), low intensity exercise was included, and the dieters lost 14.1 kg or more post-diet. However, no difference in depressive symptoms were observed pre- to post-diet when behavioral therapy was not included, the diet was shorter (1–7 weeks), no exercise was implemented and dieters lost <14 kg of weight post-diet. There was no change in anxiety pre- to post-diet. Health care providers involved in supervising VLCDs should consider using a VLCD of at least 8 weeks that includes behavioral therapy and low intensity exercise in order to enhance the potential benefits of VLCDs on depressive symptoms. More research is required to examine the effect of VLCDs on anxiety.

This is a preview of subscription content, access via your institution

Relevant articles

Open Access articles citing this article.

Access options

Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1
Fig. 2

References (*Studies included in the final sample of the meta-analysis and systematic review are marked with an asterisk.)

  1. Chen S, Yan E. Very-low-calorie diet revisited. Obes Manag. 2006;2:31–32.

    Article  Google Scholar 

  2. Tsai AG, Wadden TA. The evolution of very-low-calorie diets: an update and meta-analysis. Obesity. 2006;14:1283–93.

    Article  Google Scholar 

  3. Saris WHM. Very-low-calorie diets and sustained weight loss. Obes Res. 2001;9:295S–301S.

    Article  Google Scholar 

  4. Parretti HM, Jebb SA, Johns DJ, Lewis AL, Christian-Browng AM, Aveyard P. Clinical effectiveness of very-low-energy diets in the management of weight loss: a systematic review and meta-analysis of randomized controlled trails. Obes Rev. 2016;17:225–34.

    Article  CAS  Google Scholar 

  5. Sumithran P, Proietto J. Very-low-calorie diets (VLCDs) for the treatment of obesity. In: Gill T(ed). Managing and preventing obesity. Cambridge: Woodhead Publishing; 2015. p. 231–42.

    Chapter  Google Scholar 

  6. Henry RR, Wiest-Kent TA, Scheaffer L, Kolterman OG, Olefsky JM. Metabolic consequences of very-low-calorie diet therapy in obese non-insulin-dependent diabetic and nondiabetic subjects. Diabetes. 1986;35:155–64.

    Article  CAS  Google Scholar 

  7. Lewis MC, Phillips ML, Slavotinek JP, Kow L, Thompson CH, Toouli J. Change in liver size and fat content after treatment with Optifast very low calorie diet. Obese Surg. 2006;16:697–701.

    Article  Google Scholar 

  8. Chida Y, Steptoe A. Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosom Med. 2008;70:741–56.

    Article  Google Scholar 

  9. Beck AT, Ward CM, Mendelson M, Mock JE, Erbaugh JK. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561–71.

    Article  CAS  Google Scholar 

  10. Spielberger CD, Gorsuch RL. Manual for the state-trait anxiety inventory. Palo Alto: Consulting Psychologists Press; 1983.

  11. Carey M, Small H, Yoong SL, Boyes A, Bisquera A, Sanson-Fisher R. Prevalence of comorbid depression and obesity in general practice: a cross-sectional survey. Br J General Pract. 2014;64:e122–e127.

    Article  Google Scholar 

  12. Grundy A, Cotterchio M, Kirsh VA, Kreiger N. Associations between anxiety, depression, antidepressant medication, obesity and weight gain among Canadian women. PLoS ONE. 2014;9:e99780.

    Article  CAS  Google Scholar 

  13. Pan A, Sun Q, Czernichow S, Kivimaki M, Okereke OI, Lucas M, et al. Bidirectional association between depression and obesity in middle-aged and older women. Int J Obes. 2012;36:595–602.

    Article  CAS  Google Scholar 

  14. Wadden TA, Stunkard AJ. Social and psychological consequences of obesity. Ann Intern Med. 1985;103:1062–7.

    Article  CAS  Google Scholar 

  15. Stunkard AJ, Wadden TA. Psychological aspects of severe obesity. Am J Clin Nutr. 1992;55:524S–532S.

    Article  CAS  Google Scholar 

  16. Sysko R, Devlin MJ, Hildebrandt TB, Brewer SK, Zitsman JL, Walsh T. Psychological outcomes and predictors of initial weight loss outcomes among severely obese adolescents receiving laparoscopic adjustable gastric banding. J Clin Psychiatry. 2012;73:1351.

    Article  Google Scholar 

  17. Ukkola A, Maki M, Kurppa K, Pekka C, Huhtala H, Kekkonen L, et al. Diet improves perception of health and well-being in symptomatic, but not asymptomatic, patients with celiac disease. Clin Gastroenterol Hepatol. 2011;9:118–23.

    Article  Google Scholar 

  18. Lasikiewicz N, Myrissa K, Hoyland A, Lawton CL. Psychological benefits of weight loss following behavioural and/or dietary weight loss interventions. A systematic research review. Appetite. 2014;72:123–37.

    Article  CAS  Google Scholar 

  19. *Wadden TA, Foster GD, Letizia KA. One-year behavioral treatment of obesity: comparison of moderate and severe caloric restriction and the effects of weight maintenance therapy. J Consult Clin Psychol. 1994;62:165–71.

    Article  CAS  Google Scholar 

  20. *de Zwaan M, Mitchell JE, Crosby RD, Mussell MP, Raymond NC, Specker SM, et al. Short-term cognitive behavioral treatment does not improve outcome of a comprehensive very-low-calorie diet program in obese women with binge eating disorder. Behav Ther. 2005;36:89–99.

    Article  Google Scholar 

  21. *Snel M, Sleddering MA, Peijl ID, Romijn JA, Pijl H, Meinders E, et al. Quality of life in type 2 diabetes mellitus after a very low calorie diet and exercise. Eur J Intern Med. 2012;23:143–9.

    Article  Google Scholar 

  22. *Cheskin LJ, Hess JM, Henningfield J, Gorelick DA. Calorie restriction increases cigarette use in adult smokers. Psychopharmacol (Berl). 2005;179:430–6.

    Article  CAS  Google Scholar 

  23. *Buffenstein R, Karklin A, Driver HS. Beneficial physiological and performance responses to a month of restricted energy intake in healthy overweight women. Physiol Behav. 2000;68:439–44.

    Article  CAS  Google Scholar 

  24. Kitto GC. Predicting attrition and adherence in a very low calorie diet behaviorally based treatment program for obesity. PhD [dissertation]. Kansas: Kansas State University; 1992. Available from: ProQuest Dissertations Publishing.

  25. *Wadden TA, Stunkard AJ. Controlled trial of very low calorie diet, behavior therapy, and their combination in the treatment of obesity. J Consult Clin Psychol. 1986;54:482–8.

    Article  CAS  Google Scholar 

  26. Swencionis C, Wylie-Rosett J, Lent MR, Ginsberg M, Cimino C, Wassertheil-Smoller S, et al. Weight change, psychological well-being, and vitality in adults participating in a cognitive-behavioral weight loss program. Health Psychol. 2013;32:439–46.

    Article  Google Scholar 

  27. Wadden TA, Foster GD, Wang J, Pierson RN, Yang MU, Moreland K, et al. Clinical correlates of short-and long-term weight loss. Am J Clin Nutr. 1992;56:271S–274S.

    Article  CAS  Google Scholar 

  28. Atkinson RL, Fuchs A, Pastors JG, Saunders JT. Combination of very-low-calorie diet and behavior modification in the treatment of obesity. Am J Clin Nutr. 1992;56:199S–202S.

    Article  CAS  Google Scholar 

  29. Wise TN, Mann LS, Cooper JN, Rustigi EB. Patient characteristics and treatment results in a protein-modified fasting diet. Int J Eat Disord. 1986;5:1089–94.

    Article  Google Scholar 

  30. Palmeira AL, Branco TL, Martins SC, Minderico CS, Silva MN, Vieira PN, et al. Change in body image and psychological well-being during behavioral obesity treatment: Associations with weight loss and maintenance. Body Image. 2010;7:187–93.

    Article  Google Scholar 

  31. National Institute of Diabetes and Digestive and Kidney Disease. Very low-calorie diets [internet]. National Institute of Diabetes and Digestive and Kidney Disease; 2012 Dec [cited 2018 May 21].

  32. Carek PJ, Laibstain SE, Carek SM. Exercise for the treatment of depression and anxiety. Int J Psychiatry Med. 2011;41:15–28.

    Article  Google Scholar 

  33. Williamson DF, Serdula MK, Anda RF, Levy A, Byers T. Weight loss attempts in adults: goals, duration, and rate of weight loss. Am J Public Health. 1992;82:1251–7.

    Article  CAS  Google Scholar 

  34. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. Comprehensive meta-analysis: a computer program from research synthesis (version 3). Englewood: Biostat Inc; 2014.

  35. Fabricatore AN, Wadden TA, Higginbotham AJ, Faulconbridge LF, Nguyen AM, Heymfield SB, et al. Intentional weight loss and changes in symptoms of depression: A systematic review and meta-analysis. Int J Obes. 2011;35:1363–76.

    Article  CAS  Google Scholar 

  36. Wong G, Greenhalgh T, Westhorp G, Buckingham J, Pawson R. RAMESES publication standards: Realist synthesis. BioMed Cent Med. 2013;11:1–14.

    Google Scholar 

  37. Liu JJW, Ein N, Vickers K. Subjective and physiological responses to the 35% carbon dioxide challenge in healthy and non-clinical control populations: A meta-analysis and systematic review. 2018.

  38. *LaPorte DL. A fatiguing effect in obese patients during partial fasting: Increase in vulnerability to emotion-related events and anxiety. Int J Eat Disord. 1990;9:345–55.

    Article  Google Scholar 

  39. Clark LA, Watson D. Tripartite model of anxiety and depression: psychometric evidence and taxonomic implications. J Abnorm Psychol. 1991;100:316–36.

    Article  CAS  Google Scholar 

  40. Clark LA, Watson D. Theoretical and empirical issues in differentiating depression from anxiety. In: Becker J, Kleinman A, editors. Psychosocial aspects of depression. Hillsdale: Lawrence Erlbaum Associates, Inc; 1990. p. 39–65.

  41. Starr LR, Davila J. Cognitive and interpersonal moderators of daily co-occurrence of anxious and depressed moods in generalized anxiety disorder. Cogn Ther Res. 2012;36:655–69.

    Article  Google Scholar 

  42. Levin-Aspenson HF, Watson D. Mode of administration effects in psychopathology assessment: analyses of gender, age, and education differences in self-rated versus interview-based depression. Psychol Assess. 2018;30:287–95.

    Article  Google Scholar 

  43. Beck AT, Steer RA, Brown GK. BDI-II: Beck Depression Inventory Manual, 2nd edn. San Antonio: Psychological Corporation; 1996.

  44. Wang YP, Gorenstein C. Assessment of depression in medical patients: a systematic review of the utility of the Beck Depression Inventory-II. Clinics. 2013;68:1274–87.

    Article  Google Scholar 

  45. Health Canada. Estimated energy requirements [internet]. Health Canada; 2014 [cited 2018 May 21].

  46. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans 2015–2020, 8th edition [internet]. U.S. Department of Health and Human Services and U.S. Department of Agriculture; 2015 Dec [cited 2018 May 21].

  47. Stice E, Fairburn CG. Dietary and dietary-depressive subtypes of bulimia nervosa show differential symptom presentation, social impairment, comorbidity, and course of illness. J Consult Clin Psychol. 2003;71:1090–4.

    Article  Google Scholar 

  48. National Institute for Clinical Excellence. Obesity: identification, assessment and management of overweight and obesity in children, young people and adults: Partial update of CG43. London: National Institute for Health and Care Excellence; 2014.

  49. *Foster GD, Wadden TA, Peterson FJ, Letizia KA, Bartlett SJ, Conill AM. A controlled comparison of three very-low-calorie diets: effects on weight, body composition, and symptoms. Am J Clin Nutr. 1992;55:811–7.

    Article  CAS  Google Scholar 

  50. *Wadden TA, Stunkard AL, Brownell KD, Day SC. A comparison of two very-low-calorie diets: protein-sparing-modified fast versus protein-formula-liquid diet. Am J Clin Nutr. 1985;41:533–9.

    Article  CAS  Google Scholar 

  51. *Wadden TA, Stunkard AJ, Brownell KD, Day SC. Treatment of obesity by behavior therapy and very low calorie diet: a pilot investigation. J Consult Clin Psychol. 1984;52:692–4.

    Article  CAS  Google Scholar 

  52. Sandoz Nutrition. The OPTIFAST CORE Program Group Leader Guide, vol I and II. Minneapolis: Sandoz Nutrition, 1987.

  53. Sandoz Nutrition. The OPTIFAST CORE program patient manual. Minneapolis: Sandoz Nutrition, 1987

  54. Brownell, KD. The LEARN program for weight control. American Health Publishing Co: Dallas; 1989.

  55. Stunkard AJ, Berthold HC. What is behavior therapy? Am J Clin Nutr. 1985;41:821–3.

    Article  CAS  Google Scholar 

  56. Lindner PG, Blackburn GL. Multidisciplinary approach to obesity utilizing fasting modified by protein-sparing therapy. Obes/Bariatr Med. 1976;5:198–216.

    Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Kristin Vickers.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Electronic supplementary material

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ein, N., Armstrong, B. & Vickers, K. The effect of a very low calorie diet on subjective depressive symptoms and anxiety: meta-analysis and systematic review. Int J Obes 43, 1444–1455 (2019).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:

This article is cited by


Quick links