Effects of 4:3 Intermittent Fasting on Eating Behaviors and Appetite Hormones: A Secondary Analysis of a 12-Month Behavioral Weight Loss Intervention

Abstract

Background/objectives: Daily caloric restriction (DCR) is a common dietary weight loss strategy, but leads to metabolic and behavioral adaptations, including maladaptive eating behaviors and dysregulated appetite. Intermittent fasting (IMF) may mitigate these effects by offering diet flexibility during energy restriction. This secondary analysis compared changes in eating behaviors and appetite-related hormones between 4:3 intermittent fasting (4:3 IMF) and DCR and examined their association with weight loss over 12 months.

Methods: Adults with overweight or obesity were randomized to 4:3 IMF or DCR for 12 months. Both randomized groups received a matched targeted weekly dietary energy deficit (34%), comprehensive group-based behavioral support, and a prescription to increase moderate-intensity aerobic activity to 300 min/week. Eating behaviors were assessed using validated questionnaires at baseline and months 3, 6, and 12. Fasting levels of leptin, ghrelin, peptide YY, brain-derived neurotrophic factor, and adiponectin were measured at baseline and months 6 and 12. Linear mixed models and Pearson correlations were used to evaluate outcomes.

Results: Included in this analysis were 165 adults (mean ± SD; age 42 ± 9 years, BMI 34.2 ± 4.3 kg/m², 74% female) randomized to 4:3 IMF (n = 84) or DCR (n = 81). At 12 months, binge eating and uncontrolled eating scores decreased in 4:3 IMF but increased in DCR (p < 0.01 for between-group differences). Among 4:3 IMF, greater weight loss was associated with decreased uncontrolled eating (r = -0.27, p = 0.03), emotional eating (r = -0.37, p < 0.01), and increased cognitive restraint (r = 0.35, p < 0.01) at 12 months. There were no between-group differences in changes in fasting appetite-related hormones at any time point.

Conclusions: Compared to DCR, 4:3 IMF exhibited improved binge eating and uncontrolled eating behaviors at 12 months. This may, in part, explain the greater weight loss achieved by 4:3 IMF versus DCR. Future studies should examine mechanisms underlying eating behavior changes with 4:3 IMF and their long-term sustainability.

Keywords: appetite regulation; behavioral intervention; binge eating; caloric restriction; uncontrolled eating.

Figure 1

Changes in eating behavior questionnaire scores by intervention group over 12 months. Panels show mean (±95% CI) at months 0, 3, 6, and 12 for binge eating (A), uncontrolled eating (B), emotional eating (C), cognitive restraint (D), and reward-based eating (E) between 4:3 IMF and DCR. Statistical effects of time, group, and group-by-time interaction are displayed in the top right corner of each panel; significant effects (p < 0.05) are shown in bold.

Figure 2

Correlations between changes in body weight, TFEQ-R18, BES, and RED-13 scores over 12 months by intervention group. Panels show scatter plots of individual participants with change in body weight (month 12–month 0) plotted against change in eating behavior scores (month 12–month 0). Data are shown for 4:3 IMF (uncontrolled eating, (A); emotional eating, (C); cognitive restraint, (E), BES, (G); and RED-13, (I)) and DCR (uncontrolled eating, (B); emotional eating, (D); cognitive restraint, (F); BES, (H); and RED-13, (J)). Pearson correlation coefficients (r) and p-values are shown in the lower corners of each panel, with significant p-values (p < 0.05) in bold. Abbreviations are as follows: 4:3 Intermittent Fasting (4:3 IMF), Daily Caloric Restriction (DCR), Binge Eating Scale (BES), Reward-based Eating Drive Scale, Revised 13-item (RED-13).