Why Drinking a Smoothie isn’t the Same as Eating the Food Contained in it

People are busy. I “get” that, and morning routines are often the most challenging. Taking time to have breakfast is often seen as “one more thing to do”, so the idea of making a smoothie and “taking it with” may seem like a good idea. But is it? Is drinking a smoothie the same as eating the foods it is made out of? It isn’t.

In an earlier article, I covered the effect of various types of food processing (including mechanical processing such as pureeing fruit in a smoothie) on blood glucose. While 60g of whole apple, 60 g of apple that has been pureed, and 60g of apple that has been juiced have the same amount of amount of carbohydrate and a very similar Glycemic Index (GI) [1], neither the carbohydrate content nor GI tell us anything about how high blood sugar is going to go when eating or drinking them. Glycemic Index only indicates how slowly or quickly foods will increase blood sugar, not how much higher blood sugar will go [2].

A raw apple has a GI of 36  ± 2, and apple juice has a GI of 41  ± 2, so factoring in the error range, raw apple can have a GI of 38, and apple juice a GI of 39. A medium apple (3″ across) has ~25 g of carbs, and even when we make it into unsweetened apple sauce, it still has the same amount of carbs. If we press it into juice, the amount of carbohydrate in it doesn’t change. But we know from a 1977 study published in the Lancet that when fruit is pureed fruit or juiced and then eaten, the glucose response 90 minutes later is significantly higher, than if the fruit were eaten whole [3]. This is because the blender or juicer has done some of the work of digesting the food for us!

Most people think that digestion begins in the stomach, but it doesn’t. It begins in the mouth when we chew food.

When we eat a bowl of berries for example, chewing makes the glucose (sugar) in the berries that we chewed more available to the body — but when we put the same amount of berries in a blender and whir them up, the contents of all the berries are now completely available for the body to act on. We never chew food as fine as a blender makes it, so blending food results in a faster spike in blood sugar than the whole food, eaten intact. This is one reason why drinking a smoothie is not the same as eating the same food it is made from.

The order we eat foods in during a meal also makes a big difference on blood sugar and on the insulin response to eating (or drinking) carbohydrate-containing food. We know from a 2015 study about the effect of food order on the response of glucose and insulin that if the carbohydrate-containing food is eaten last, the glucose curve will be ~74% smaller than if it were eaten first! Likewise, if we eat the carbohydrate-containing food last, the insulin spike will be 49% smaller, than if we eat it first [4]!

Having a smoothie for breakfast instead of a meal made out of the same foods means there is no way of having the carbs last!

Final Thoughts…

It really doesn’t take very long to eat the some veggies (like snap peas or baby carrots) and a dish of yogurt and berries for breakfast and the response on blood sugar and demand on our pancreas for insulin is significant!  This is why I tell people who come to me seeking to loose weight and improve their metabolic health to eat their food, not drink it — because it does matter!

This is also one of the reasons that I felt Diabetes Canada’s “7-day Low Carb Meal Plan” which had a 30g of carbs (and only 9 g of protein) was not the best recommendation for people with diabetes to have for breakfast 3 days per week.

More Info?

If you would like more information about how I can support your nutritional needs, please click on the Services tab above to learn more.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

References

  1. Atkinson FS, Foster-Powell K, Brand-Miller JC, “International tables of glycemic index and glycemic load values”, Diabetes Care 31(12); 2281-2283
  2. Harvard Health Publishing, Glycemic index for 60+ foods (from American Diabetes Association, 2008), https://www.health.harvard.edu/diseases-and-conditions/glycemic-index-and-glycemic-load-for-100-foods
  3. Haber GB, Heaton KW, Murphy D, Burroughs LF. Depletion and disruption of dietary fibre. Effects on satiety, plasma-glucose, and serum-insulin. Lancet. 1977 Oct 1;2(8040):679-82. doi: 10.1016/s0140-6736(77)90494-9. PMID: 71495
  4. Shukla AP, Iliescu RG, Thomas CE, Aronne LJ. Food Order Has a Significant Impact on Postprandial Glucose and Insulin Levels. Diabetes Care. 2015;38(7):e98-e99. doi:10.2337/dc15-0429

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

A Therapeutic Ketogenic Diet – treatment and adjunct treatment

therapeutic diet is one that is used in the treatment of a medical condition and can be prescribed by a physician and implemented by them, or prescribed by a physician and implemented by a dietitian. When implemented by a dietitian, a therapeutic diet is referred to as Medical Nutrition Therapy (MNT) [1]. 

A ketogenic diet is a very high fat diet that induces and sustains a state of ketosis, which is a natural metabolic state where the body burns fat as its primary fuel, rather than carbohydrate. Ketosis is where the ketone body betahydroxybutyrate (BHB) reaches levels between 0.5 – 3.0 mmol/L known as nutritional ketosis [2] — right up to levels of 4.0 mmol/L for specific therapeutic ketogenic diets used in the treatment of epilepsy[3] and seizure disorder, or levels of up to 3.0 mmol/L when used as adjunct treatment along with chemo and radiation, in glioblastoma [4,5,6]*.

*Just because a therapeutic diet may be useful in glioblastoma, one should not assume it is an appropriate adjunct treatment for all types of cancer, or in all types of glioblastoma. Some types of cancer feed on glucose, whereas other feed on ketone bodies. 

Types of Therapeutic Ketogenic Diets

Ketogenic diets are a subtype of a low carbohydrate  diets.

Low carbohydrate diets are ones where carbohydrate intake is limited to <130 g per day or < 26% of total energy intake[7] but that level of carbohydrate intake is much too high for therapeutic purposes in the treatment of epilepsy or seizure disorder, or as adjunct treatment of glioblastoma but are used in the treatment of type 2 diabetes. 

Moderate carbohydrate diets are where carbohydrate intake is limited to 130–225 g per day or 26–45% of total energy intake [7] and while this level of carbohydrate intake can be helpful in the treatment of type 2 diabetes and obesity, a much lower level of carbohydrate intake is required for the treatment of epilepsy, seizure disorder or as adjunct treatment in glioblastoma.

A very low carbohydrate diet is also called a “ketogenic diet” and is one where carbohydrate intake is limited to 20-50 g per day or 10% of total energy intake[7]. It can be used safely and effectively in the treatment of type 2 diabetes and obesity [2], and is also used the treatment of epilepsy, seizure disorder [3], and as adjunct treatment in glioblastoma [4,5,6]. The carbohydrate content of the diet is kept very low, so as a result protein and/or fat need to be increased significantly.

In therapeutic ketogenic diets used for obesity management and for seeking remission from the symptoms of type 2 diabetes, protein intake can range from 15% of calories as protein right up to 35-40% of calories. Since it is a very high fat, low carbohydrate diet it induces a state of nutritional ketosis where the primary ketone of interest, betahydroxybutyrate (BHB) can range from 0.5 -3.0 mmol/L[2].

For the treatment of epilepsy and seizure disorder or as adjunct treatment in glioblastoma, a much lower level of protein is required so that for therapeutic purposes, levels of betahydroxybutyrate (BHB) can reach between 3.0 and 4.0 mmol/L (depending on the specific condition and length of time the person has been following a therapeutic ketogenic diet).

Therapeutic Ketogenic Diets for Epilepsy, Seizure Disorder and Adjunct Treatment in Glioblastoma

A therapeutic ketogenic diet has been used prior to the 1920s by Dr. Russell Wilder for the treatment of diabetes and later for the treatment of epilepsy, in fact it was Wilder himself who is credited with coining the term “ketogenic diet”. The precise percentage of carbohydrate, fat and protein in what is now called the “classic” Ketogenic Diet (KD) was worked out by Dr. M.G. Peterman in 1925 [8], and are the same ratios used today. 

Therapeutic ketogenic diets used in epilepsy and seizure disorder and as adjunct treatment in glioblastoma are very high fat, low protein and low carbohydrate diets — ranging from 4 : 1 ratio (4 parts fat for every 1 part protein plus carbohydrate) to a 3 : 1 ratio (3 parts fat for every 1 part protein plus carbohydrate) — and for maintenance may be as low as a 2 : 1 ratio (2 parts of fat for every 1 part protein plus carbohydrate).

The Diet Prescription

Based on the diet prescription written by the doctor, the amount of energy (calories) that the person needs will be calculated based on the person’s weight and height, activity level, and nutritional requirements and whether there is a goal to avoid weight loss, such in glioblastoma treatment.

Given the very high fat, low carbohydrate content of a 4 : 1 and 3 : 1 ketogenic diet, and the very small amount of protein, Meal Plan design is time-consuming and challenging. It’s not that easy to come up with palatable food combinations that meet the precise macros (amount of protein, fat and carbohydrate) of the diet. Each meal has to have the exact amount — as it is a diet prescription.  In a therapeutic diet, the amount and types of food are an integral part of treatment. Just as medication has a “dosage”, the specific and exact amount of food on the diet prescription is like the “food dosage”.

Vitamin, mineral, and trace element supplementation (such as potassium citrate) are also necessary to avoid nutritional deficiencies and recommendations are provided along with the Meal Plan.

In working with adults who are trialing a 4 : 1 or 3 : 1 ketogenic diet for seizure disorder, or during chemo and radiation for glioblastoma,  I do the diet calculations, and then design a simple breakfast-lunch-and-dinner Meal Plan for them to use during the initial 6 weeks. Sometimes people with  will want an extra dinner meal to alternate with. 

If things go well and the diet is improving their symptoms, those with seizure disorder may decide to stay on the therapeutic diet over an extended period of time, and in such a case, I may be asked to design a few lunch and dinner options — with most people content to eat the same breakfast.

Those with glioblastoma will usually ask me to design a 2 : 1 Modified Atkins Diet for them to follow between rounds of chemo and radiation, which I will do for them.  This allows for more protein in their diet (while still keeping the carbohydrate content low) and provides a pleasant ‘break’ for those who have been finding the restrictive meals of a 4 : 1 or 3 : 1 ketogenic diet difficult. The other advantage is that since it is unknown whether the type of glioblastoma involved may feed on ketones, alternating between a high ketone and low ketone diet in this manner minimizes providing high ketone levels when not taking the chemo- or radiation treatment.  

What is challenging for those first starting out in eating a therapeutic ketogenic diet for epilepsy or as an adjunct treatment in glioblastoma, is that the amount of food on the final Meal Plan must be precisely and accurately weighed — as even the smallest amount of vegetable (which has some protein and some carbohydrate in it) can affect the macros, and thus reduce the therapeutic benefit of the diet. Everything needs to be weighed to the gram.

In addition, at the beginning there is the need for daily monitoring of blood ketone levels to determine when the person has achieved the desired therapeutic range, which for epilepsy and seizure disorder is often where betahydroxybutyrate (BHB) is between 3.0 and 4.0 mmol/L. Once they are able to keep it there by maintaining the diet, testing less frequently is possible. 

Classic Ketogenic Diet (KD) – 4 : 1

In the classic Ketogenic Diet (KD), the total amount of calories are matched to the number of calories the person needs. Protein is usually determined as being 1 g of protein per kg body weight, 10-15 g of carbohydrate per day total, and the remainder of calories provided as fat. For very young children, the diet may be prescribed based on body weight (e.g. 75-100 calories for each kg (2.2 pounds) of body weight.

Since the 1920s, several other therapeutic ketogenic for the treatment of epilepsy and seizure disorder have been developed, including the Modified Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD). They are all very low carbohydrate diets high fat diets which is by definition what makes them ketogenic, differ in the amount of protein they contain.

As well as their use in epilepsy and seizure disorder, any of the above therapeutic ketogenic diets may be prescribed for patients as adjunct treatment in glioblastoma, or as adjunct treatment in Alzheimer’s disease.

The classic Ketogenic Diet (KD) has a 4:1 ratio i.e. 4 parts of fat for every 1 part protein and carbs. That is, for every 5 grams of food there are 4 grams of fat and 1 gram of protein and/or carbohydrate.

In the classic Ketogenic Diet, 80% (i.e. 4÷5=80%) of calories come from fat and 20% (i.e. 1÷5=20%) from a combination of protein and carbohydrate.

Protein may be set at 15% of calories with a maximum of 5% of calories coming from carbohydrate, or protein may be set lower at 10%, and carbohydrate as high as 10%.

Modified Ketogenic Diet (MKD) – 3 : 1 ratio

The Modified Ketogenic Diet (MKD) has a 3:1 ratio i.e. 3 parts fat for every 1-part protein and carbohydrate. In a Modified Ketogenic Diet, 75% of calories come from fat and 25% from a combination of protein and carbohydrate. Protein may be set at 15% of calories with a maximum of 10% of calories coming from carbohydrate[5].

Modified Atkins Diet (MAD) – 2 : 1 ratio

The Modified Atkins Diet (MAD) has a 2 : 1 ratio, with 2 parts fat for every 1-part protein and carbohydrate. In a Modified Atkins Diet, carbohydrates are restricted to <15 g / day for children, <20 g / day for adults. In a Modified Atkins Diet for adults, 60% of calories come from fat, 30% of calories come from protein, and 10% of calories come from carbohydrate[5].

“Chasing Ketones” – betahydroxybutyrate, the therapeutic goal

The therapeutic goal of a 4 : 1 or 3 : 1 therapeutic ketogenic diet is to get the person’s blood ketone level (as measured with an accurate meter!) to measure 3.0 mmol/L betahydroxybutyrate (BHB) as soon as possible — and to have them sustain it at that level (or in some cases, up to 4.0 mmol/L). Since it is the ketones that provide the therapeutic benefit, not adding anything to the diet that isn’t part of the diet prescription is important.

I usually recommend for a person starting out on a therapeutic ketogenic diet get a Abbott Precision Freestyle Neo meter from their pharmacy, as it measures both blood glucose and ketones, is very accurate and reliable (unlike some purchased online and used by people following the popularize “keto diet” or weight loss) and is provided at no cost when purchasing 100 glucose strips (~$1 each).  I then recommend they purchase 30 ketone strips for the same monitor ($3 each) — so the strips will last a month with checking blood glucose 3x / day and checking ketones 1 x / day. 

Blood glucose should not go below 4.0 mmol/ L when measured using the glucose strip in the meter, and blood ketone levels should ideally measure 3.0 mmol/L (and as high as 4.0 mmol/Lin epilepsy and seizure disorder – but not over). If ketones exceed 4.0 mmol/L, the person should contact their doctor — and if they go much higher, should seek medical help immediately.

People diagnosed with glioblastoma ideally begin a 4 : 1 (or 3 : 1) therapeutic ketogenic diet upon discharge from hospital so that they begin chemo and radiation treatment already at a ketone level of 3.0 mmol/L betahydroxybutyrate.  For seizure disorder, the neurologists that refer their patients to me are seeking levels as close to 4.0 mmol/L as possible — because that is where the most benefit is seen.  Once seizures have ceased, people can begin to try gradually eating a 3 : 1, then a 2 : 1 diet — so long as their seizures remain in remission.  There is a lot of trial and error involved, but for those seeking to extend their life (as in glioblastoma) or improve their quality of life (as in epilepsy or seizure disorder), it may be worth it.

While people following the popularized “keto diet” for weight loss or remission of type 2 diabetes are often teased about “chasing ketones” — when their goal is fat loss or improved blood sugar (and not producing high levels of ketones!), for those following a therapeutic ketogenic diet for the treatment of epilepsy or seizure disorder, “chasing ketones” between 3.0 mmol/L and 4.0 mmol/L may be desirable.

NOTE: (April 13, 2021): While some research papers indicate that advanced gliomas do not use ketones as a fuel source, a research paper from September 2020 was brought to my attention which calls this into question.  According to this paper, there are different types of glioblastoma cells  and some oxidize fatty acids and use ketones for energy. Since it appears that when glucose levels are decreased, some types of glioblastoma cells may adapt by partially shifting their metabolism to use oxidized fatty acids and ketones, seeking lower level of ketone production may be advantageous.
[Sperry J, Condro MC, Guo L, et al, Glioblastoma Utilizes Fatty Acids and Ketone Bodies for Growth Allowing Progression during Ketogenic Diet Therapy, iScience  Volume 23, Issue 9, 25 September 2020, 101453].

Many thanks to Cliff Harvey, PhD. for rounding out this understanding.

More Info?

If you would like more information about how I support adults with epilepsy or seizure disorder, or those diagnosed with glioblastoma who are seeking to use a therapeutic ketogenic diet as adjunct treatment (along with chemo and radiation), please send me a note through the Contact Me form.

If you are newly diagnosed with glioblastoma, I will fit you in even when I have no openings for the next several weeks. Your clinical needs are a priority.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

References

  1. U.S. Department of Health and Human ServicesFinal MNT regulationsCMS-1169-FCFederal Register1 November 200142 CFR Parts 405, 410, 411, 414, and 415
  2. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
  3. Meira ID, Romao TT, Pires do Prado HJ, Ketogenic Diet and Epilepsy: What We Know So Far, Front. Neurosci., 29 January 2019, https://doi.org/10.3389/fnins.2019.00005
  4. van der Louw EJTM, Olieman JF, van den Bemt PMLA, et al. Ketogenic diet treatment as adjuvant to standard treatment of glioblastoma multiforme: a feasibility and safety study. Ther Adv Med Oncol. 2019;11, 2019 Jun 21. doi:10.1177/1758835919853958
  5. Schwartz KA, Noel M, Nikolai M, Investigating the Ketogenic Diet As Treatment for Primary Aggressive Brain Cancer: Challenges and Lessons Learned, Front. Nutr., 23 February 2018 | https://doi.org/10.3389/fnut.2018.00011
  6. Klein P, Tyrlikova I, Zuccoli G, Tyrlik A, Maroon JC. Treatment of glioblastoma multiforme with “classic” 4:1 ketogenic diet total meal replacement. Cancer Metab. 2020;8(1):24. Published 2020 Nov 9. doi:10.1186/s40170-020-00230-9
  7. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1–13
  8. Peterman MG, The Ketogenic Diet, JAMA. 1928;90(18):1427–1429. doi:10.1001/jama.1928.02690450007003

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

A Simple Guide to Different Types of Diet and Macros

People on social media argue about which is the “best diet” for humans — vegan or carnivore? Low carb or keto? Vegetarian or vegan? I avoid these “diet wars” largely because I don’t believe there is a “best” diet for everybody. Some diets are preferable over others for a variety of reasons, including religious constraints, ethical reasons and specific health conditions — so the “best diet” is one that meets an individual’s personal health goals and objectives, and that is consistent with their belief system. 

One of my clients mentioned that the more they read about different types of diets, the more confused they became and wanted to know if I could write an article to explain them simply. That is the purpose of this post.

Macros

Macros defined

Foods are made up of protein, fat and carbohydrate in different ratios, and these together are commonly referred to as “macros“. This term is shortened from “macronutrients“, where macro means “big” in Greek. Micronutrients is the term used for all the vitamins and minerals, where micro means “small” in Greek.

Macros refer to the three categories of nutrients (protein, carbohydrates and fat) that make up the food that people eat, and which together provide them with their source of energy, as calories.

When people are “counting macros” or “calculating their macros”, they are counting the grams of proteins, carbohydrate (carbs) and fat they are eating.

Different Diet Types

This is not an exhaustive list of all the different diet types, but a summary of popular categories.

Standard American Diet

Standard American Diet

The average American (or Canadian diet) is often referred to as the “SAD Diet” — which is a shortened form of the “Standard American Diet“.

The Standard American Diet is one where the majority of calories come from carbohydrate and fat — mostly vegetable fat, as recommended by both the American and Canadian dietary guidelines. Vegetable fats are also called “seed oils” and include soybean, canola, and corn oil.

Carbohydrate (“carbs”) are most commonly thought of in terms of various types of bread, rolls, pizza, pasta, rice, and potatoes (French fries, mashed, baked potato, boiled potato), but also include fruit (other than berries which are eaten on a low carb diet), as well as fruit juice, and milk (but not cheese or yogurt that are low in carbs). Milk is included as “carbs” because of its high carbohydrate content.

Vegetarians and Vegans

Vegetarians

Vegetarian

Vegetarians are those that don’t eat meat, fish or poultry, but do eat eggs and milk.  These are also known as ovo-lacto vegetarians, as they eat eggs (“ovo” meaning eggs) and milk (“lacto” meaning milk).

Pescatarians are vegetarians that eat fish.

People who eat a vegetarian or pescatarian diet can also eat low carb or very low carb (keto). They are not mutually exclusive.

Vegans

Vegan

Vegans don’t eat any food of animal origin, including eggs, milk, butter or cream (and products made from them) may do so for religious or ethical reasons. Vegans are sometimes considered a subclass of vegetarian, or an entirely different category. 

They often refer to themselves eating an entirely “plant-based” diet.

A vegan diet can be done low carb, but to obtain adequate nutrients takes a great deal of time and knowledge, but it can be done.

“Low Carb” – LCHF

Low Carb – LCHF

In a research context [1] and in the clinical guidelines of the American Diabetes Association [2] and Diabetes Canada [3], low carbohydrate diets (“low carb”) are those where carbohydrate intake is limited to <130 g per day or < 26% of total energy intake[1].

These are also referred to as low carb high fat diets (LCHF) or low carb healthy fat diets (also LCHF).

Moderate carbohydrate diets are where carbohydrate intake is limited to 130–225 g per day or 26–45% of total energy intake [1].

A “Paleo diet” is modelled after what is understood to have been the diet of our ancient hunter-gatherer ancestors. It varies considerably between individuals, but is essentially a low carbohydrate diet that uses protein and fat sources that have been known to mankind for millennia.

A Keto Diet

“Keto” Diet

A keto diet is a subtype of low carb diet and in a research context [1], and in the clinical guidelines of the American Diabetes Association [2] and Diabetes Canada [3] are referred to as “very low carbohydrate diets“. A “very low carbohydrate diet”, or “keto diet” is one where carbohydrate intake is limited to 20-50 g per day or 10% of total energy intake [1,2,3].

They are called “keto” diets because at this very low level of carbohydrate intake, blood ketones (by-products of the body burning fat for energy) increase at or above 0.5 mmol/L, resulting in a state known as “ketosis”.

Keto diets used predominantly for weight loss or improving symptoms of type 2 diabetes are where ketone levels are usually set with betahydroxybutyrate (BHB) levels between 1.5-3.0 mmol/L [4].

There is no one “keto diet” but some versions of the popularized high fat keto diet are associated with Dr. Jason Fung and Diet Doctor.

Therapeutic Ketogenic Diet

Therapeutic Ketogenic Diets

The first therapeutic ketogenic diet was used prior to the 1920s by Dr. Russell Wilder for the treatment of diabetes and later, for epilepsy.

The percentage of carbohydrate, fat and protein in what has since become called the “classic” Ketogenic Diet (KD) was worked out by Dr. M.G. Peterman in 1925 [4], and are the same as used today. 

In the classic KD, the total amount of calories are matched to the number of calories the person needs. Protein is usually determined as being 1 g of protein per kg body weight, 10-15 g of carbohydrate per day total, and the remainder of calories provided as fat.  For very young children, the diet may be prescribed based on body weight (e.g. 75-100 calories for each kg (2.2 pounds) of body weight.

Since the 1920s, several other therapeutic ketogenic for the treatment of epilepsy and seizure disorder have been developed, including the Modified Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD). They are all very low carbohydrate diets high fat diets which is by definition what makes them ketogenic, differ in the amount of protein they contain. 

As well as their use in epilepsy and seizure disorder, any of the above therapeutic ketogenic diets may be prescribed for patients as adjunct treatment in glioblastoma, or as adjunct treatment in Alzheimer’s disease.

The classic Ketogenic Diet (KD) has a 4:1 ratio i.e. 4 parts of fat for every 1 part protein and carbs. That is, for every 5 grams of food there are 4 grams of fat and 1 gram of protein and/or carbohydrate. 

In the classic Ketogenic Diet, 80%  (i.e. 4÷5=80%) of calories come from fat and 20% (i.e. 1÷5=20%) from a combination of protein and carbohydrate.

Protein may be set at 15% of calories with a maximum of 5%  of calories coming from carbohydrate, or protein may be set lower at 10%, and carbohydrate as high as 10%.

The Modified Ketogenic Diet (MKD) has a 3:1 ratio i.e. 3 parts fat for every 1-part protein and carbohydrate. In a Modified Ketogenic Diet, 75% of calories come from fat and 25% from a combination of protein and carbohydrate. Protein may be set at 15% of calories with a maximum of 10% of calories coming from carbohydrate[5].

The Modified Atkins Diet (MAD) has a 2:1 ratio, with 2 parts fat for every 1-part protein and carbohydrate.  In a Modified Atkins Diet, carbohydrates are restricted to <15 g / day for children, <20 g / day for adults. In a Modified Atkins Diet for adults, 60% of calories come from fat, 30% of calories come from protein, and 10% of calories come from carbohydrate[5].

These high fat diets are not weight loss diets. These are therapeutic ketogenic diets used with the goal of producing high amounts of ketones (> 4.0 mmol/L / 40 mg/dl) for therapeutic reasons.

Carnivore

Carnivore

Carnivores are people who eat only protein and fat of animal origin, including any edible part of mammals (including organ meats), birds of many types including poultry such as chicken and turkey as well as their eggs, and fish and seafood. Fats include butter, rendered chicken or duck fat, beef fat (tallow), and lard (rendered pig fat).

Carnivores and vegans are polar opposites — one eating ONLY animal products and the other not eating any animal products.

Protein to Energy (P:E)

Protein to Energy (P:E)

Protein to Energy (P:E) is an entirely new class of diet created by Dr. Ted Naiman. It focusses on eating the most amount of protein for the least amount of energy (calories).

It is not a low carbohydrate diet as the P:E calculator recommend carbohydrate intake  >130 g per day, which is the cut-off for low carb in most of the literature.

This article elaborates on the how the protein intake in the P:E diet differs from a regular “low carb” diet and the popularized “keto diet”, and this article compares the popularized “keto diet” (best known through Diet Doctor and Dr. Jason Fung), the ‘higher protein, lower fat’ dietary approach of Drs. Phinney and Volek (described in their book The Art and Science of Low Carbohydrate Living) and the Protein to Energy (P:E) ratio diet of Dr. Ted Naiman in terms of;

  • Is protein adequate based on the RDA?
  • Is protein enough to sustain someone who is physically active?
  • Is protein enough for an older adult?
  • Is protein within the safe upper limit?
  • Does protein exceed the maximum level of amount of
    protein based on the disposal of ammonia in urea in the urine?

Final Thoughts…

There is no “best diet” for everyone. The “best diet” is an individual is one that meets their personal health goals and objectives and that is consistent with their beliefs.

More Info?

If you would like more information about my services, please have a look around my web page and if you have questions, please send me a note through the Contact Me form.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

Please read the terms and conditions (link below) regarding use of images on this web page.

References

  1. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1–13
  2. Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
  3. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
    Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
  4. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

Researcher Paid by Sugar Industry Influenced 1977 US Dietary Goals

Three years ago (March 12, 2018) I wrote about an article that appeared in the Journal of the American Medical Association in September 2016 [1] that revealed that the sugar industry had funded three renowned Harvard researchers to write a series of articles that downplayed, discredited or ignored known research that demonstrated sugar was a contributor to heart disease — and instead put the blame on fat, especially saturated fat.

When I read it, I was stunned at its significance — and it made me wonder how much of what I learned in my training needed to be revisited in a current light.

As written about in my initial post, two of the three Harvard researchers paid by the sugar industry were the late Dr. Fredrick Stare, chair of Harvard’s School of Public Health Nutrition Department and the late Dr. D. Mark Hegsted, a professor in the same department [2]. I only found out after I had posted the article in March 2018 that one of the 3 Harvard researchers, Dr. D. Mark Hegsted was directly involved in the development of the 1977 US Dietary Goals [4] —which was by Hegsted and his staff at the newly-created Office of Nutrition of the Department of Agriculture as the basis for the 1980 Dietary Guidelines for Americans. These were the first Guidelines that called for Americans to decrease consumption of meat and saturated fat with the belief that it would lower the risk of heart disease. 

I planned to go back at some point and write an updated post that included the historic paper trail, but never did. Today when I was posting on social media about the ~300 articles I have written the last 5 years (under the Food For Thought tab), I realized I inadvertently omitted three articles — with one of them being the one about the sugar industry’s sponsorship of the Harvard researchers. That article was too important to leave off — and it still needed to be updated.

Today, instead of taking the stat holiday off, I rewrote the earlier article with inclusion of documentation of Hegsted’s role — both in writing the sugar industry sponsored papers in 1967, and his role in advising the Select Committee on Nutrition and Human Needs on the 1977 Dietary Goals.

This is the resulting article.


In the mid-1960’s, the Sugar Research Foundation (SRF), the predecessor to the Sugar Association wanted to counter research that had been published at the time which suggested that sugar was a more significant contributor of atherosclerosis, than dietary fat. The Sugar Research Foundation invited Dr. Stare of Harvard’s School of Public Health Nutrition Department to join its scientific advisory board, and then approved $6,500 in funds ($50,000 in 2016 dollars) “to support a review article that would respond to the research showing the danger of sucrose[1]”.

From the 2016 Kearn’s et al article [1],

“On July 13, 1965, the Sugar Research Foundation (SRF)’s executive committee approved Project 226, a literature review on Carbohydrates and Cholesterol Metabolism by Hegsted and Robert McGandy, overseen by Stare.”

According to the article, letters were exchanged between the Sugar Research Foundation and the three Harvard researchers that tasked them preparing “a review article of the several papers which find some special metabolic peril in sucrose [sugar] and, in particular, fructose [1]”.

In a letter written to Dr. DM Hegsted, the Sugar Research Foundation made its agenda clear [1];

“Our particular interest had to do with that part of nutrition in which there are claims that carbohydrates in the form of sucrose make an inordinate contribution to the metabolic condition, hitherto ascribed to aberrations called fat metabolism. I will be disappointed if this aspect is drowned out in a cascade of review and general interpretation.[2]”

Hegsted replied to the Sugar Research Federation on behalf of the three Harvard researchers, saying;

“We are well aware of your particular interest in carbohydrate and will cover this as well as we can [1].”

Project 226, sponsored by the Sugar Research Foundation resulted in a 2-part literature review by McGandy, Hegsted and Stare that was published in the New England Journal of Medicine in 1967 titled “Dietary Fats, Carbohydrates and Atherosclerotic Disease”. There was no mention of the Sugar Research Federation sponsorship of the research [1].

McGandy, RB, Hegsted DM, Stare,FJ. Dietary fats, carbohydrates and atherosclerotic vascular disease. New England Journal of Medicine. 1967 Aug 03;  277(5):242–47

 

The first part of the two-part review article written by Drs. Stare, Hegsted and McGandy stated;

“Since diets low in fat and high in sugar are rarely taken, we conclude that the practical significance of differences in dietary carbohydrate is minimal in comparison to those related to dietary fat and cholesterol.”

The report concluded;

“the major evidence today suggests only one avenue by which diet may affect the development and progression of atherosclerosis. This is by influencing the levels of serum lipids[fats], especially serum cholesterol.

The Harvard researchers continued;

there can be no doubt that levels of serum cholesterol can be substantially modified by manipulation of the fat and cholesterol of the diet

…and concluded;

“on the basis of epidemiological, experimental and clinical evidence, that a lowering of the proportion of dietary saturated fatty acids, increasing the proportion of polyunsaturated acids and reducing the level of dietary cholesterol are the dietary changes most likely to be of benefit.

Stare, Hegsted and McGandy did not disclose that they were paid by the Sugar Research Foundation for the two-part review that vindicated sugar and blamed fat — most notably dietary saturated fat. 

Dr. Marion Nestle, Professor of Nutrition, Food Studies and Public Health at New York University wrote an editorial which appeared in the same issue of the Journal of the American Medical Association as the Kearn’s article [1] where she said that the documents provided “compelling evidence” that the sugar industry initiated Project 226 research “expressly to exonerate sugar as a major risk factor for coronary heart disease”[4].

Nestle notes;

The investigators knew what the funder expected, and produced it. Whether they did this deliberately, unconsciously, or because they genuinely believed saturated fat to be the greater threat is unknown [4].”

The story doesn’t end there.

Dr. DM Hegsted went on to play a significant role in advising the Select Committee on Nutrition and Human Needs that oversaw the development of the 1977 Dietary Goals for the United States — and ultimately oversaw the writing of the first Dietary Guidelines for Americans that called for a reduction in saturated fat consumption in order to lower the risk of coronary heart disease. 

Below is front page of the Dietary Goals for the United States from the Select Committee on Nutrition and Human Needs from December 1977 [5], and directly below that is a page from this book that refers to Dr. D.M. Hegsted’s role in advising the Select Committee on Nutrition and Human Needs on the US Dietary Guidelines [5].

Dietary Goals for the United States, Select Committee on Nutrition and Human Needs, United States Senate. Washington : U.S. Govt. Print. Off., 1977. http://hdl.handle.net/2027/uiug.30112023368936, title page

 

Here is the quote about Dr. Hegsted’s role in the Committee that oversaw the 1977 Dietary Goals for the United States;

Dr. Hegsted has worked very closely and patiently with the committee staff on this report, devoting many hours to review and counselling. He feels very strongly about the need for public education in nutrition and the need to alert the public to the consequences of our dietary trends. He will discuss these trends and their connection with our most killing diseases. [5]”

Dietary Goals for the United States, Select Committee on Nutrition and Human Needs, United States Senate. Washington : U.S. Govt. Print. Off., 1977. http://hdl.handle.net/2027/uiug.30112023368936 – page X1V introduction

There were 8 hearings of the Committee titled “Diet Related to Killer Diseases” that were held from July 1976 until October 1977 [7] and which provided an opportunity for US senators to hear from leading scientists, government officials, and business representatives about the risks of diet on heart disease, cancer, and other chronic diseases. 

“Of those who gave testimony at the first hearings, perhaps the two most important were assistant secretary for health and former director of the National Heart and Lung Institute, Theodore Cooper, and Professor Hegsted” [7].

Hegsted admits to committee that the primary evidence for ‘killer diseases’ is “epidemiologic” (photo added April 4, 2021)

Hegsted admitted to the Committee that the primary evidence for an association between diet and ‘killer diseases’ was “epidemiologic” [the weakest form of scientific data] [8], and not rooted in clinical studies*. He felt that there was “a clear linkage between plasma serum lipids, atherosclerosis and coronary disease” and that it was “clear that diet controls cholesterol levels”[8].

*[Note: April 04, 2021] – There were only 8 randomized clinical trials available at the time with only 2,467 male subjects, and no female subjects [9] and there was no supporting evidence from those studies that reduced total dietary fat or dietary saturated fat decreased death from all causes or death from cardiovascular disease [9]. This is why the “primary evidence was epidemiologic”.

Several researchers pleaded with the Committee to wait for more research. The director of the National Heart, Lung and Blood Institute, Dr. Robert Levy said “no one knew if eating less fat would prevent heart attacks“. Dr. Robert Olson of St. Louis University said, “I plead in my report and will please again orally here for more research on the problem before we make announcements to the American public” and Dr. Peter Ahrens said “advising Americans to eat less fat on the strength of such marginal evidence was equivalent to conducting a nutritional experiment with the American public as subjects“.

Committee Chairman Sen. McGovern responded

Senators don’t have the luxury that the research scientist does of waiting until every last shred of evidence is in.

Hegsted believed there could be “no risks” to recommending that the American public eat less meat, less fat — particularly saturated fat, and less cholesterol.

What are the risks to eating less meat … fat, particularly saturated fat … cholesterol …(and) more unsaturated fat … fruits, vegetables, and cereal products, particularly those made of whole grain cereal. There are none that can be identified and important benefits can be expected.  “[8]

[Note April 4, 2021] The epidemiological data that Hegsted relied on was from Ancel Keys’ yet-unpublished Seven Country Study [9] where he collected data from men aged 40-59 from the USA, Finland, the Netherlands, Yugoslavia, Greece and Japan from 1958 – 1964. The Seven Country Study data has been criticized for several reasons, including the fact that Keys did not choose countries such as Switzerland or France who were known to have very high saturated fat consumption, yet low rates of heart disease.  Data from Greece, Italy and Yugoslavia were thought to have not been representative of what they normally ate, since these countries were still facing poverty post WWII.

Keys had been alleging since 1952 that there was a direct association between saturated fat and heart disease based on a graph that he drawn in a 1952 presentation at Mt. Sinai Hospital in New York, and later published in 1953, in which he plotted CVD deaths per 1000 people (y-axis) against Percent Calories from Fat (x-axis), for six countries; Japan, Italy, England and Wales, Australia, Canada, the USA. The 6 points were a subset of data from a 21 country study published by Yerushalamy and Hilleboe more than a decade earlier [11] – and while the 6 points that Keys’ selected showed a nice linear relationship between fat intake and heart disease, the full data from Yerushalamy and Hilleboe was not linear at all.  Undeterred, Keys set out in his Seven Country Study to demonstrate a relationship between saturated fat intake and heart disease.

“Hegsted was urging action on the basis not of evidence of a demonstrated relationship between exposure and outcome, but a combination of limited studies, prevailing scientific opinion, and risk-benefit probabilities[7].” ~Dr. Marion Nestle

Final Thoughts…

The significance of the sugar industry’s sponsorship of the three Harvard researchers to write review papers vindicating sugar and blaming fat —especially saturated fat for heart disease is important in and by itself. The fact that one of those researchers, Dr. DM Hegsted was a major influencer of the 1977 US Dietary Goals — and then oversaw the writing of the Dietary Guidelines for Americans that called for reducing saturated fat consumption and increasing consumption of cereal products cannot be understated.  Basing national dietary guidelines on epidemiologic studies made the general public the equivalent of subjects in a huge, unplanned experiment.

For 40+ years, we’ve had low fat dietary guidelines in the US and Canada that were based largely on the hypotheses of a link between dietary saturated fat and heart disease. They were not based on clincal research, but weak epidemiological studies such as Ancel Keys’ Seven Country Study that was conducted many years before it was published in 1980. Furthermore, the dietary recommendations arrogantly assumed that decreasing meat and saturated fat consumption and increasing grains and cereals came without risk. 

How have these low fat dietary guidelines turned out?

Heart disease is still the number one killer in the US, and second in Canada, obesity is through the roof, and rates of type 2 diabetes continue to rise.

There were consequences to recommending Americans reduce meat, fat and saturated fat consumption and increase consumption of grain and cereal products — and that is that the subsequent rise in carbohydrate consumption directly contributed to the current obesity epidemic and the metabolic diseases that accompany it. 

A report published in June 2020 in the Journal of the American College of Cardiology based on meta-analysis of randomized control trials (the strongest data available), as well as observational studies found no beneficial effect on either cardiovascular disease (CVD) or death of lowering saturated fatty acid intake and that saturated fat intake is actually protective against stroke [5].

Without industry influence, it is time that the role of sugar and refined carbohydrate consumption on obesity and metabolic disease informs reevaluation of dietary guidelines. 

More Info?

If you would like information about what I do, please have a look around my web page and if you have questions, please send me a note through the Contact Me form.

To your good health!

Joy

You can follow me at:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

References

  1. Kearns C, Schmidt LA, Glantz SA, et al. Sugar Industry and Coronary Heart Disease Research: A Historical Analysis of Internal Industry Documents. JAMA Intern Med. 2016 Nov 01; 176(11):1680-1685.
  2. Husten, L, How Sweet: Sugar Industry Made Fat the Villain, Cardio|Brief, 2016 Sept 13.
  3. McGandy, RB, Hegsted DM, Stare,FJ. Dietary fats, carbohydrates and atherosclerotic vascular disease. New England Journal of Medicine. 1967 Aug 03;  277(5):242–47
  4. Nestle M. Food Industry Funding of Nutrition ResearchThe Relevance of History for Current DebatesJAMA Intern Med. 2016;176(11):1685–1686. doi:10.1001/jamainternmed.2016.5400
  5. Dietary Goals for the United States, Select Committee on Nutrition and Human Needs, United States Senate. Washington : U.S. Govt. Print. Off., 1977. http://hdl.handle.net/2027/uiug.30112023368936
  6. Astrup AMagkos FBier, DM, et al, Saturated Fats and Health: A Reassessment and Proposal for Food-based Recommendations: JACC State-of -the-Art Review, J Am Coll Cardiol. 2020 Jun 17. Epublished DOI:10.1016/j.jacc.2020.05.077
  7. Oppenheimer GM, Benrubi ID. McGovern’s Senate Select Committee on Nutrition and Human Needs versus the meat industry on the diet-heart question (1976-1977). Am J Public Health. 2014 Jan;104(1):59-69. doi: 10.2105/AJPH.2013.301464. Epub 2013 Nov 14. PMID: 24228658; PMCID: PMC3910043.
  8. United States. Congress. Senate. Select Committee on Nutrition and Human Needs. (1977). Diet related to killer diseases: hearings before the Select Committee on Nutrition and Human Needs of the United States Senate, Ninety-fifth Congress, first session. Washington: U.S. Govt. Print. Off..
  9. Keys A. Coronary heart disease in seven countries. 1970. Nutrition. 1997 Mar;13(3):250-2; discussion 249, 253. doi: 10.1016/s0899-9007(96)00410-8. PMID: 9131696.
  10. Harcombe, Z., An examination of the randomised controlled trial and epidemiological evidence for the introduction of dietary fat recommendations in 1977 and 1983:   A systematic review and meta-analysis. 2015, University of the West of Scotland.
  11. Yerushalmy J, Hilleboe HE, Fat in the diet and mortality from heart disease; a methodologic note. N Y State J Med, 1957. 57(14): p. 2343-54.

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

Why Is Type 2 Diabetes Still Called “a Progressive, Lifelong Disease”?

[NOTE: This is a combination Science Made Simple article and editorial, expressing my opinion.]

This past Wednesday March 24, 2021, Dr. James Muecke, a South Australia ophthalmologist who was the 2020 Australian of the Year, posted on Facebook that Diabetes Australia reworded their webpage from “Type 2 diabetes is a progressive condition” to “Type 2 diabetes is often a progressive condition” — wording that Dr. Muecke calls;

a small, but significant change that will give some degree of hope to the 280 Australians diagnosed [with type 2 diabetes] every day“. 

Diabetes Australia’s change in phraseology occurred shortly after Diabetes Victoria  removed the words “Type 2 diabetes is a progressive condition” entirely from its Type 2 Diabetes webpage — replacing it with nothing. This, Dr. Muecke said;

“gives tremendous hope to patients that their newly diagnosed condition can potentially be put into remission.”

I was curious what Diabetes Canada’s web site said and was saddened to discover that it stated that Type 2 diabetes is a progressive, life-long disease“.

Diabetes Canada: “Type 2 diabetes is a progressive, lifelong disease” (https://guidelines.diabetes.ca/docs/patient-resources/type-2-diabetes-the-basics.pdf)

We don’t tell people diagnosed with cancer they have “a progressive, lifelong disease” — but speak to them instead about treatment options and the possibility of remission. While some types of cancer are incurable and untreatable, in general people diagnosed with cancer are not told they have a “progressive, lifelong disease”. Why are people with type 2 diabetes told this? 

I think calling type 2 diabetes a progressive, lifelong disease is a vestige from before there was evidence that it could be put into remission. I think we need to change our terminology to reflect that it is now possible.

In February 2018, one year data from Virta Health’s outpatient study using a ketogenic diet intervention demonstrated that reversal of type 2 diabetes symptoms is sustainable over the long term — with HbA1c level at baseline being 7.6% ± 1.5% being reduced by 1.0% and the percentage of individuals with a HvA1C of <6.5% was 56% [1].

Virta Health’s 2-year data indicated that there were improvements in body weight and that improved blood sugar control was also largely sustained, and that significant metabolic markers and health improvements occurred while using a ketogenic approach in an outpatient setting, over the usual care model approach [2]. On average after one year, participants in the intervention (ketogenic) group lowered HbA1c from 7.7% to 6.3% and at two years, HbA1C of participants in the intervention group increased slightly to 6.7%. By comparison, HbA1C of the usual care control group was 7.5% at baseline, 7.6% at one-year, and 7.9% at two years.

Even a 2019 study using an calorie-restricted diet found that remission of type 2 diabetes within 1-year can be achieved at a cost below the annual cost of diabetes, including complications [3].

There is no cure for diabetes — at least not yet, but there are three documented ways to put type 2 diabetes into remission;

  1. a ketogenic diet [1,2]
  2. a low calorie energy deficit diet [4,5,6]
  3. bariatric surgery (especially use of the roux en Y procedure) [7,8]

Since there is evidence that both a well-designed ketogenic diet and a well-designed calorie-restricted diet put type 2 diabetes into remission (i.e. maintaining blood glucose  below the diabetes cut-offs),  we need to stop referring to type 2 diabetes as “a progressive, lifelong disease” — as if it is always the case. 

It can be a progressive, lifelong disease for those who would rather not make the significant dietary and lifestyle changes that are required to put it into remission (and as I outline in this article, this is a valid choice, too!)

People can choose to live WITH diabetes or to seek remission FROM it  — but they deserve to know that remission is possible.

More Info?

If you would like more information about how I can support you in aiming to put type 2 diabetes into remission, please let me know.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

References

  1. Hallberg, S.J., McKenzie, A.L., Williams, P.T. et al. Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study. Diabetes Ther 9, 583–612 (2018). https://doi.org/10.1007/s13300-018-0373-9
  2. Athinarayanan SJ, Adams RN, Hallberg SJ, McKenzie AL, Bhanpuri NH, Campbell WW, Volek JS, Phinney SD, McCarter JP. Long-Term Effects of a Novel Continuous Remote Care Intervention Including Nutritional Ketosis for the Management of Type 2 Diabetes: A 2-Year Non-randomized Clinical Trial. Front Endocrinol (Lausanne). 2019 Jun 5;10:348. doi: 10.3389/fendo.2019.00348. PMID: 31231311; PMCID: PMC6561315.
  3. Xin Y, Davies A, McCombie L, Briggs A, Messow CM, Grieve E, Leslie WS, Taylor R, Lean MEJ. Type 2 diabetes remission: economic evaluation of the DiRECT/Counterweight-Plus weight management programme within a primary care randomized controlled trial. Diabet Med. 2019 Aug;36(8):1003-1012. doi: 10.1111/dme.13981. PMID: 31026353.
  4. Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia2011;54:2506-14. doi:10.1007/s00125-011-2204-7 pmid:21656330
  5. Steven S, Hollingsworth KG, Al-Mrabeh A, et al. Very low-calorie diet and 6 months of weight stability in type 2 diabetes: pathophysiological changes in responders and nonresponders. Diabetes Care2016;39:808-15. doi:10.2337/dc15-1942 pmid:27002059
  6. Lean ME, Leslie WS, Barnes AC, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet2018;391:541-51.
  7. Cummings DE, Rubino F (2018) Metabolic surgery for the treatment of type 2 diabetes in obese individuals. Diabetologia 61(2):257–264.
  8. Madsen, L.R., Baggesen, L.M., Richelsen, B. et al. Effect of Roux-en-Y gastric bypass surgery on diabetes remission and complications in individuals with type 2 diabetes: a Danish population-based matched cohort study, Diabetologia (2019) 62: 611. https://doi.org/10.1007/s00125-019-4816-2

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

Assessing Insulin Resistance – Homeostasis Model Assessment (HOMA)

In November 2018, the American Association of Clinical Endocrinologists (AACE) released a Position Statement [1] which identified four separate disease stages associated with an abnormal glucose response, including Type 2 Diabetes;

Stage 1: Insulin Resistance
Stage 2: Prediabetes
Stage 3: Type 2 Diabetes
Stage 4: Vascular Complications — including retinopathy, nephropathy and neuropathy

Long before blood sugar becomes abnormal in the stage known as prediabetes, the progression to type 2 diabetes has already begun in the form of insulin resistance — and identifying insulin resistance at this stage (while blood glucose is still normal) enables people to implement dietary changes to avoid the progression to pre-diabetes, and type 2 diabetes.

Discovering insulin resistance in those who lack the more obvious outward signs can be especially helpful — including those who appear slim, but who may have visceral or ectopic fat  (so-called TOFIs, “thin on the outside, fat on the inside”), or those who may have undetected hyperinsulinemia due to their abnormal response to dietary carbohydrate. Some people that fall in this category may include those with a significant family history of type 2 diabetes, or previous gestational diabetes, even though they currently appear healthy.

The Homeostatic Model Assessment (HOMA-IR) is a test that uses a simultaneous fasting blood glucose test and fasting insulin test to accurately estimate the degree of insulin resistance (IR) and β-cell function (the cells of the pancreas that produce insulin). Alternatively, HOMA-IR can also be determined from a simulteous fasting blood glucose test and a fasting C-peptide test [2]. C-peptide is released in proportion to insulin, so it can be used to estimate insulin.

The Homeostatic Model Assessment (HOMA) equations have been widely used in research to estimate insulin resistance and the two equations which use fasting blood levels of insulin and glucose are as follows, with HOMA-IR used to assess insulin resistance and HOMA-B used to assess pancreatic β–cell  (beta-cell) function [3,9]. 

HOMA-IR= (glucose in mmol/L x insulin in mIU/mL)/22.5
HOMA-B= (20 x insulin in mIU/mL)/(glucose in mmol/L – 3.5)

Individual results are best compared to local population cut off values for HOMA1-IR [3] (1985) or the updated HOMA2-IR* [4] (1998).

HOMA2-IR* is easily and accurately calculated using the online HOMA2 calculator released by the Diabetes Trials Unit, University of Oxford available at http://www.dtu.ox.ac.uk/homacalculator/index.php.

The original HOMA1-IR equation proposed by Matthews in 1985 [3] was widely used due to its simplicity, however it was not always reliable because it did not consider the variations in the glucose resistance of peripheral tissue and liver, or increases in the insulin secretion curve for blood glucose concentrations above 10 mmol/L (180 mg/dL), or the effect of circulating levels of pro-insulin. [5]. The updated HOMA2-IR computer model [6] mentioned above and available from Oxford University has been used since 1998 and corrects for these — and estimates both insulin resistance and β-cell function.

Cut-off for insulin resistance using the original Matthews values (1985) [3] for HOMA-IR ≥ 2.7

  • Insulin sensitive is considered less than 1.0
  • Healthy is considered 0.5-1.4
  • Above 1.8 is early insulin resistance
  • Above 2.7 is considered significant insulin resistance

Cuff-off values for insulin resistance using the HOMA2-IR calculator (1998) [6] is HOMA2-IR ≥ 1.8. Three population based studies found the same or very close cut-offs applied, including a 2009 Brazilian study [6] which found HOMA2-IR ≥ 1.8, a 2014 Venezuelan study [7] which found HOMA2-IR ≥ 2.0 and a 2014 Iranian study [8] which found HOMA2-IR ≥ 1.8.

Use of HOMA-IR to Assess Insulin Resistance and β-cell Function in the Individual

HOMA-IR has been used to assess Insulin Resistance (IR) and β-cell function as a one-off measures in individuals in >150 epidemiological studies of subjects of various ethnic origins, with varying degrees of glucose tolerance [9].

In the Mexico City Study which used single glucose-insulin pairs (not the mean of three samples at 5-min intervals) [10], β-cell function and insulin resistance were assessed using HOMA-IR in ~1500 Mexicans with normal or impaired glucose tolerance (IGT). Subjects were followed up for 3.5 years for the incidence of diabetes and to examine any possible relationship with baseline β-cell function and IR. At 3.5 years, ~4.5% of subjects with normal glucose tolerance at baseline and ~23.5% with impaired glucose tolerance at baseline had progressed to type 2 diabetes. That is, the development of diabetes was associated with higher HOMA-IR at baseline.

The use of HOMA-IR on an individual basis enables clinicians to quantify both the degree of insulin sensitivity and β-cell function on assessment — before the person makes any dietary changes. Once the individual understands the significance of their HOMA-IR results, it can provide significant motivation for them to make dietary changes in order to prevent the progression toward abnormal glucose tolerance, or type 2 diabetes. When HOMA-IR is repeated 6 months into dietary changes, it provides significant feedback to the individual regarding the effectiveness of dietary changes, and the motivation to continue.

“HOMA-IR can be used to track changes in insulin sensitivity and β-cell function longitudinally in individuals. The model can also be used in individuals to indicate whether reduced insulin sensitivity or β-cell failure predominates[10].

Assessing HOMA2-IR is the reason I may request a simultaneous fasting blood glucose and fasting insulin from those that come to me and who have insulin resistance and/or hyperinsulinemia. My goal is to find out even when blood sugar results are still normal in order find out if their pancreas is working too hard in order to keep them that way.

More Info?

If you would like more information about how I can support you in meeting your health and nutrition goals, please have a look around my web page, or send me a note through the Contact Me form.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

Note: In British Columbia, family MDs may decline to order the fasting insulin test for the investigation of insulin resistance as the BC government does not authorize payment for that use, but many physicians will if they feel it is clinically warranted. Alternatively, a fasting C-peptide test can be ordered without restriction and can be used to determine HOMA2-IR using the Oxford calculator.

People also have the option to self-pay for these tests.

References

  1. American Association of Clinical Endocrinologists Announces Framework for Dysglycemia-Based Chronic Disease Care Model, November 28, 2018, AACE Online Newsroom, url: https://media.aace.com/press-release/american-association-clinical-endocrinologists-announces-frameworkdysglycemia-based-c
  2. Crofts, C., Understanding and Diagnosing Hyperinsulinemia. 2015, AUT University: Auckland, New Zealand. p. 205.
  3. Matthews, D. R; Hosker, J. P; Rudenski, A. S; Naylor, B. A; Treacher, D. F; Turner, R. C; ―Homeostasis model assessment: insulin resistance and β-cell function from fasting plasma glucose and insulin concentrations in man‖; Diabetologia; July, 1985; Volume 28, Number 7: Pp 412-419
  4. Levy JC, Matthews DR, Hermans MP. Correct homeostasis model assessment (HOMA) evaluation uses the computer program. Diabetes Care. 1998;21:2191–2192
  5. Song YS, Hwang Y-C, Ahn H-Y, Comparison of the Usefulness of the Updated Homeostasis Model Assessment (HOMA2) with the Original HOMA1 in the Prediction of Type 2 Diabetes Mellitus in Koreans, Diabetes Metab J. 2016 Aug; 40(4): 318–325
  6. Geloneze B, Vasques AC, Stabe CF et al, HOMA1-IR and HOMA2-IR indexes in identifying insulin resistance and metabolic syndrome: Brazilian Metabolic Syndrome Study (BRAMS), Arq Bras Endocrinol Metabol. 2009 Mar;53(2):281-7
  7. Bermúdez V, Rojas J, Martínez MS et al, Epidemiologic Behavior and Estimation of an Optimal Cut-Off Point for Homeostasis Model Assessment-2 Insulin Resistance: A Report from a Venezuelan Population, Int Sch Res Notices. 2014 Oct 29;2014:616271
  8. Tohidi M, Ghasemi A, Hadaegh F, Age- and sex-specific reference values for fasting serum insulin levels and insulin resistance/sensitivity indices in healthy Iranian adults: Tehran Lipid and Glucose Study, Clin Biochem. 2014 Apr;47(6):432-8
  9. Wallace TM, Levy JC, Matthews DR, Use and Abuse of HOMA Modeling, Diabetes Care 2004 Jun; 27(6): 1487-1495. https://doi.org/10.2337/diacare.27.6.1487
  10. Haffner SM, Kennedy E, Gonzalez C, Stern MP, Miettinen H: A prospective analysis of the HOMA model: the Mexico City Diabetes Study. Diabetes Care 19:1138–1141, 1996

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

A Dietitian’s Journey – rewriting the script of my life

INTRODUCTION: We CAN change the storyline of our lives and this is a short post about how I set out 4 years ago to put my type 2 diabetes, high blood pressure and obesity into remission. I met that goal 2 years ago, and 2 years later I’m achieving things I never thought possible!

Remember, everyone’s health recovery journey will be different. This is my story.


March 5, 2017, I was obese, had type 2 diabetes for 8 years and had dangerously high blood pressure. In the previous 6 months I had two girlfriends die — one of a heart attack and one of a stroke and like me, both were in healthcare. I new that unless I changed what I was doing, I stood the risk of being next. I began following a low carbohydrate meal pattern, then lowered it to a ketogenic level and two years later (March 4, 2019) I was normal body weight, with optimal waist circumference, normal blood pressure, and was in remission of type 2 diabetes. In addition, with my doctor’s oversight  I had gotten off 12 different types of prescription medication.

Today, March 4, 2021 is the 4th anniversary since I began to reclaim my health and my life, and to celebrate the two years that I am in remission and off meds, I have put together two 30-second video clips that capture it best.

The first 30 second video clip was taken just 3 weeks into “A Dietitian’s Journey” in March 2017 where it is very obvious that I can barely walk and talk at the same time.

Hear past the huffing and puffing, to the voice of determination.

The second short video clip was taken this past summer when I was a guest on Laban Ditchburn’s Become Your Own Superhero podcast*.

Listen to my response when I was introduced.

It say’s it all…

 

* you can find a links to the podcasts I have been a guest on under the About Me tab.

Rewriting the Script of My Life

January 26, 2021

The photo on the left is me hiking in North Vancouver this winter.

Four years ago I could barely walk and talk and now I am hiking! If someone would have told me then that this was possible, I would not have believed them.

Golden Ears Provincial Park, December 19, 2020

The photo on the right is me hiking in Golden Ears Provincial Park in Maple Ridge, BC.

West Vancouver, January 23, 2021

While I can’t get back the years I spent overweight and sick, I can live today and the days I have ahead enjoying my health and celebrating life to the fullest.

I am continuing to re-write the script of my life one day at a time and having the joy of helping others do the same.

 

More Info?

If you would like to know how I support others in their health-recovery journey, please have a look around my web page and if you want more information, feel free to send me a note through the Contact Me form.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

 

 

 

Protein Intake in Popular Low Carbohydrate / Keto Diets for Weight Loss

While there are many different types of low carbohydrate and  “keto” diets circulating on the internet, how do the three most common compare in terms of protein intake, adequacy or excess, namely;

(a) the high fat “keto” diet best known through Diet Doctor and Dr. Jason Fung,

(b) the higher protein, lower fat dietary approach used for weight loss by Drs. Phinney and Volek in their book The Art and Science of Low Carbohydrate Living

and 

(c) the very high protein, low fat Protein to Energy (P:E) ratio diet of Dr. Ted Naiman.

For healthy people*, how do each of these diets compare? Is protein adequate compared to the RDA? Is protein enough to sustain someone who is physically active or enough for an older adult? Is protein within the safe upper limit or does it exceed the maximum level of amount of protein based on the disposal of ammonia in urea in the urine? 

*response to different macro levels may be different in those with type 2 diabetes.

Note: this article is Part 2 of 2.  Be sure to read the preceding article titled How Much Protein is Best Depends on Different People’s Needs.

Each of these diets will be evaluated in terms of:

  • Is protein adequate based on the RDA?
  • Is protein enough to sustain someone who is physically active?
  • Is protein enough for an older adult?
  • Is protein within the safe upper limit?
  • Does protein exceed the maximum level of amount of
    protein based on the disposal of ammonia in urea in the urine? 

√ – meets the criteria
X
– does not meet the criteria

A – Protein Intake in the High Fat “Keto Diet”

The well-known high fat “keto” diet that is 75% fat,  10% carbs and 15% protein is only one of many keto diets. The amount of protein is not based on body weight, but is a percentage of energy. A diet which is 75% fat means there is lots of added fat in the form of whipping cream, avocado, bacon and fatty meat in order to make up for the very low carbohydrate intake (10%) and only 15% of calories allotted to protein. 

A 100 kg man (220 pounds) with an energy consumption of 2500 kcal/day would be eating 1875 calories / 208g as fat, 250 calories / 62g as carbs and 375 calories / 94g as protein.

A 60 kg woman (132 pounds) with an energy consumption of 2000 kcals/day would be eating 1500 calories / 166 g as fat, 150 calories / 37.5 g as carbs and 225 calories / 56g as protein.

Does this amount meet people’s needs? 

For the 100 kg man;

Is protein adequate based on the RDA? His protein intake based on the RDA of 0.8 g protein / kg body weight [1] so his basic needs are only 80g, so this diet is adequate at 94 gRemember, this is the minimum amount of protein needed to meet the needs of 97-98% of healthy individuals, not an optimal amount.

X Is protein enough to sustain someone who is physically active? Based on the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine[2] which recommends and intake of 1.2–2.0 g protein / kg per day, his protein intake needs to be 120 g – 200 g per day to sustain physical activity, so is inadequate at 94g.

X Is protein enough for an older adult? Based on recent position papers [3,4] his protein intake needs to be between 1.0 and 1.5 g protein / kg per day, which is 100 – 150 g per day, and is inadequate at 94g.

Is protein within the safe upper limit? The highest end of the range of safe intake of protein is 2.5 g protein/ kg per day and at 94 g of protein, his intake is below 250 g protein per day based on his weight, so it is safe.

Does protein exceed the maximum level of amount of protein based on the disposal of ammonia in urea in the urine? A 100 kg man (220 pounds) with 20% body fat would have 80 kg lean mass and would have a maximum protein ceiling of ~256g/day (based on the maximum amount of ammonia disposal of 3.21 g of protein / kg of lean body mass). His intake is only 94 g or protein, so it is safe.

For the 60 kg woman;

Is protein adequate based on the RDA? Her protein intake based on the RDA of 0.8 g protein / kg body weight [1] needs to be only be 48g, so is adequate at 56 g to prevent deficiency.

X Is protein enough to sustain someone who is physically active? Based on the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine[2] which recommends and intake of 1.2–2.0 g protein / kg per day, her protein intake would need to be 72 g – 120 g per day to sustain physical activity, so is inadequate at 56g.

X Is protein enough for an older adult? Based on recent position papers [3,4] her protein intake would need to be between 1.0 and 1.5 g protein / kg per day, which is 60 – 90 g protein per day, so is inadequate at 56 g.

Is protein within the safe upper limit? The highest end of the range of safe intake of protein is 2.5 g protein/ kg per day and at 56 g of protein, her intake is below 150g protein per day based on her weight, so it is safe.

√  Does protein exceed the maximum level of amount of protein based on the disposal of ammonia in urea in the urine? A 60 kg (132 pound) woman with 25% body fat, would have 45 kg of lean mass, and based on energy consumption of 2000 kcals/ day would have a maximum protein ceiling of 144 g/day. Her intake of 56 g of protein in safe.

B – The Higher Protein, Lower Fat Ketogenic Dietary approach

This approach used for weight loss by Drs. Phinney and Volek in their book The Art and Science of Low Carbohydrate Living works out to approximately 60% fat, up to 30% protein and 10% carbohydrate, but the macros are determined based on ideal body weight, which is estimated by lean body mass.

From page 210 of their book [6];

“…our studies of muscle retention and function during carbohydrate restriction, we recommend daily protein intakes between 1.5 and 2.5 grams per day per kg of reference body weight [6].”

What would this amount of protein look like in terms of intake?

A man who is 5’9″ (1.75 m) tall and weighs 100 kg ( 220 pounds) has an IBW (lean body mass) of 155 pounds (70 kg), so protein intake should be 105 g – 175.0 g protein.

A woman who is 5′ 4 ″(1.63 m) tall and weighs 60 kg (132 pounds) has an IBW (lean body mass) of 127 pounds (55 kg), so protein intake according to Phinney and Volek should be between 82.5 g 137.5 g protein.

For the 100 kg man;

Is protein adequate based on the RDA? His protein intake based on the RDA of 0.8 g protein / kg body weight [1] would need only be 80g, so is adequate between 105 g – 175 g protein. 

 Is protein enough to sustain someone who is physically active? Based on  the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine[2] which recommends and intake of 1.2–2.0 g protein / kg per day, his protein intake would need to be 120 g – 200 g per day to sustain physical activity, so is adequate between 105 g – 175 g protein. 

  Is protein enough for an older adult? Based on recent position papers [3,4] his protein intake would need to be between 1.0 and 1.5 g protein / kg per day, which is 100 – 150 g per day, and is adequate between 105 g – 175 g protein. 

Is protein within the safe upper limit? The highest end of the range of safe intake of protein is 2.5 g protein/ kg of total weight per day, so is safe at 2.5 g protein IBW (i.e. 70 kg / 155 pounds) which is total intake of 105 g – 175 g protein. 

Does protein exceed the maximum level of amount of protein based on the disposal of ammonia in urea in the urine? A 100 kg man (220 pounds) with 20% body fat would have 80 kg lean mass, so would have a maximum protein ceiling of ~256g/day (based on the maximum amount of ammonia disposal of 3.21 g of protein / kg of lean body mass). His intake between 105 g – 175 g protein is safe.

For the 60 kg woman;

Is protein adequate based on the RDA? Her protein intake based on the RDA of 0.8 g protein / kg body weight [1] would need only be 48g, so is adequate at 82.5 g – 137.5 g protein. Remember, this is the minimum amount of protein needed to meet the needs of 97-98% of healthy individuals.

 Is protein enough to sustain someone who is physically active? Based on the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine[2] which recommends and intake of 1.2–2.0 g protein / kg per day, her protein intake would need to be 72 g – 120 g per day to sustain physical activity, so is adequate at 82.5 g – 137.5 g protein.

 Is protein enough for an older adult? Based on recent position papers [3,4] her protein intake would need to be between 1.0 and 1.5 g protein / kg per day, which is 60 – 90 g per day, and is adequate at 82.5 g – 137.5 g protein.

Is protein within the safe upper limit? The highest end of the range of safe intake of protein is 2.5 g protein/ kg per day and at 82.5 g – 137.5 g protein her intake is below 150g protein per day based on her weight, so it is safe.

√  Does protein exceed the maximum level of amount of protein based on the disposal of ammonia in urea in the urine? A 60 kg (132 pound) woman with 25% body fat, would have 45 kg of lean mass, and based on energy consumption of 2000 kcals/ day would have a maximum protein ceiling of 144 g/day. Her intake of 82.5 g – 137.5 g protein is safe.

C – Very High Protein, Low Fat Protein to Energy (P:E) Ratio Diet

According to the P:E ratio calculator located at www.p2eq.com:

A man who is 5’9″ (1.75 m) tall should weigh 155 pounds (70 kg). According to this calculator and assuming this man is metabolically healthy, he should should eat 1,860 kcals as 186 g protein (2.66 g pro/kg IBW), 62 g of fat and 140 g of total carbs.

A woman who is 5′ 4″ (1.63 m) should weigh 120 pounds (55 kg). According to this calculator and assuming she is metabolically healthy, this hypothetical woman should eat 1,440 kcals per day as 144 g protein (2.67 g protein /kg IBW), 48 g of fat and 108 g of total carbs.

For the 100 kg man;

Is protein adequate based on the RDA? His protein intake based on the RDA of 0.8 g protein / kg body weight [1] would need only be 80g, so is more than adequate at 186g. 

 Is protein enough to sustain someone who is physically active? Based on the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine[2] which recommends and intake of 1.2–2.0 g protein / kg per day, his protein intake would need to be 120 g – 200 g per day to sustain physical activity, so is more than adequate at 186g.

 Is protein enough for an older adult? Based on recent position papers [3,4] his protein intake would need to be between 1.0 and 1.5 g protein / kg per day, which is 100 – 150 g per day, and is more than adequate at 186g.

Is protein within the safe upper limit? The highest end of the range of safe intake of protein is 2.5 g protein/ kg per day and at 186 g of protein, his intake is below 250g protein per day based on his weight, so it is safe.

Does protein exceed the maximum level of amount of protein based on the disposal of ammonia in urea in the urine? According to the online calculator, a man who is 5’9″ (1.75 m) tall should weigh 155 pounds (70 kg), and eat 1,860 kcals as 186 g protein but in this case, he weighs 100 kg (220 pounds) and has 30% body fat. Safe intake is based on his LBM so the fact that he is overweight makes no difference.  Based on the maximum amount of ammonia disposal of 3.21 g of protein / kg of lean body mass his maximum amount of protein would be 225 g / day, so 186 g protein is safe.

For the 60 kg woman;

Is protein adequate based on the RDA? Her protein intake based on the RDA of 0.8 g protein / kg body weight [1] would need only be 48g, so is more than adequate at 144 g

 Is protein enough to sustain someone who is physically active? Based on the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine[2] which recommends and intake of 1.2–2.0 g protein / kg per day, her protein intake would need to be 72 g – 120 g per day to sustain physical activity, so is more than adequate at 144 g

 Is protein enough for an older adult? Based on recent position papers [3,4] her protein intake would need to be between 1.0 and 1.5 g protein / kg per day, which is 60 – 90 g per day, and is more than adequate at 144 g

Is protein within the safe upper limit? The highest end of the range of safe intake of protein is 2.5 g protein/ kg per day and at 144 g of protein, her intake is below 150g protein per day based on her weight, so it is safe.

√ / X? Does protein exceed the maximum level of amount of protein based on the disposal of ammonia in urea in the urine? According to the online calculator, a woman who is 5′ 4″ (1.63 m) should weigh 120 pounds (55 kg). should eat 1,440 kcals per day as 144 g protein (576 kcal / 1440 kcals = 40% protein). Based on the maximum amount of ammonia disposal of 3.21 g of protein / kg of lean body mass, her maximum amount of protein is 144 g / day, so she is at the very high end of the safe range

Note: When a high protein diets include supplementation with whey protein (such as the P:E ratio encourages by listing it as one of the best protein to energy sources) it is much easier to exceed the upper limit of protein and exceed the capacity of the body to excrete the ammonia as urea. It should be noted that this is much more difficult to do eating only real, whole food.

Final Thoughts…

Which low carbohydrate dietary approach is best for you will depend on your protein needs. If you want to make sure to have enough protein to be very active or to preserve muscle as an older adult, then the popularized high fat “keto” diet would not necessarily be the best approach.

If you don’t want to exceed the safe range of protein intake and the capacity of your body to get rid of ammonia, yet want to eat a very high protein, low fat diet, then be sure to do the calculations.

I think that the safest approach is the one Drs. Phinney and Volek recommend and which meet the needs of a wide range of people from the very active to older adults and with protein intakes that are well within the safe range of protein intake and a outlined in a recent article, Drs. Phinney and Volek along with Dr. Brittanie Volk updated their recommendations for protein in 2018 to be between 1.5 and 1.75 grams of protein per kg of reference body weight [7] from the earlier 1.5 and 2.5 grams per day per kg of reference body weight [6] — which puts protein recommendations well within the safe range, while meeting or exceeding the needs of a wide range of people.

More Info?

If you would like more information about my services then please have a look under the tab of that name or send me a note through the Contact Me form.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

References

  1. National Academies Press, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005)
  2. Thomas DT, Erdman KA, Burke LM. American College of Sports Medicine Joint Position Statement. Nutrition and Athletic Performance [published correction appears in Med Sci Sports Exerc. 2017 Jan;49(1):222]. Med Sci Sports Exerc. 2016;48(3):543-568. doi:10.1249/MSS.0000000000000852
  3. Fielding RA, Vellas B, Evans WJ, Bhasin S, et al, Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc. 2011 May;12(4):249-56
  4. Bauer J1, Biolo G, Cederholm T, Cesari M, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013 Aug;14(8):542-59
  5. Rudman D, DiFulco TJ, Galambos JT, Smith RB 3rd, Salam AA, Warren WD. Maximal rates of excretion and synthesis of urea in normal and cirrhotic subjects. J Clin Invest. 1973;52(9):2241-2249. doi:10.1172/JCI107410
  6. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

How Much Protein is Best Depends on Different People’s Needs

I often hear the question, “how much protein is best?” but that depends for whom. Different people have a different protein needs. A healthy man or woman seeking to build muscle has a different protein need than an older adult wanting to reduce the risk of sarcopenia (muscle loss) or someone simply wanting to prevent deficiency. The amount of protein someone needs depends on many factors, including whether a person is growing, pregnant or lactating (breastfeeding), or has been sick or just had surgery. Even for those who aren’t in these special circumstances, protein needs may be calculated to prevent deficiency, to sustain exercise or to preserve muscle mass in older adults, and each of these calculations are different.

Protein needs are calculated as grams of protein per kilogram of body weight of the person, and not as a percentage of daily calories (energy). As explained below, 40% of calories as protein may be safe for one person and be in excess for someone else. For this reason, protein must be calculated as grams of protein per kilogram of body weight.

Note: this article is Part 1 of 2.  Be sure to read the following article titled Protein Intake in Popular Low Carbohydrate / Keto Diets for Weight Loss.

Basic Needs – the Recommended Daily Allowance (RDA) for Protein

The Recommended Daily Allowance (RDA) for any nutrient is the average  daily dietary intake level that is sufficient to meet the needs of 97-98 % of healthy people. It is important to keep in mind that the RDA is not the optimal requirement, but the absolute minimum to prevent deficiency.

The RDA for protein for healthy adults is calculated at 0.8 g protein / kg of body weight [1]. A sedentary 70 kg / 154 pound man needs a minimum of 56 g of protein and a sedentary 60 kg / 132 pound woman needs a minimum of 48 g protein per day.

Protein Needs for Active Healthy Adults

For those who are physically active, the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine[2] recommend a protein intake of 1.2–2.0 g protein / kg per day to optimize recovery from training, and to promote the growth and maintenance of lean body mass.

Protein Needs for Older Adults

There have been several position statements issued by those that work with an aging population indicating that protein intake between 1.0 and 1.5 g protein / kg per day may best meet the needs of adults during aging [3,4].

For the average, healthy 70 kg / 154 pound sedentary man this would be daily protein intake of 70 -105 g per day and for the average, healthy 60 kg / 132 pound sedentary woman this would be a protein intake of 60-90 g protein per day.

Range of Safe Intake

As I wrote about in an earlier article, according to Dr. Donald Layman, PhD, Professor Emeritus, of Nutrition from the University of Illinois, the highest end of the range of safe intake of protein is 2.5 g protein/ kg per day.

For the average 70 kg / 154 pound sedentary man this would be a maximum daily protein intake of 175 g per day and for the average 60 kg / 132 pound sedentary woman, this would be a maximum protein intake of 150 g/ day.

Someone eating on occasion above their safe range is a different scenario than someone eating above or at the very high end of that range on a regular basis. The body has a flexible capacity to tolerate higher protein intake on occasion, but regularly eating too much protein can result in protein toxicity.

Maximum Amount of Protein the Body can Safely Process

[Special thanks to Richard Morris, research biochemist from Canberra, Australian for the information contained in this section.]

When protein is eaten, the body needs to get rid of the ammonia that results and this is done by turning the ammonia into urea and excreting it in the urine.

The disposal rate of ammonia isn’t able to be calculated because ammonia is literally given off by the lungs and skin, and tracer studies suggest that the disposal rate is higher than the rate that urea appears in urine. This means that there are probably several reservoirs for ammonia (such as urea building up in circulation before filtration in the kidneys) and this ‘elastic’ or flexible capacity for ammonia enables us to survive high protein days interspersed with low protein days.

The rate limit for maximal disposal of urea through urine is 0.53 g of N per kilo of 3/4 body weight[4], as a proxy for lean body mass. The ratio of molecular weights between a nitrogen atom and the average molecular weight of amino acids is a factor of 6.05x, so the effective rate limit for maximal disposal of urea through urine is .53 x 6.05 = 3.21 g of protein/kg lean body mass. If someone were to eat above that amount of protein for too long, they will have filled their ‘elastic’ (flexible) reservoirs with urea, and would then be at risk of ammonia intoxication.

This calculation for determining the maximum amount of protein based on urea clearance requires know a person’s energy consumption (in kcals / calories), as well as lean body mass (LBM).  Note that this is lean body mass, not total body weight. Lean body mass is essentially one’s total body weight minus the amount of fat they have.

Lean body mass can be assessed using a DEXA scan, or estimated by using relative fat mass (RFM). The amount of fat someone has can be estimated from total body weight (taken on a scale), minus their estimated RFM as described in this article

Once we know a person’s lean body mass, we can use the equation (3.21 g of protein / kg lean body mass) to determine the maximum amount of protein they can eat on an ongoing basis while being able to safely dispose of the ammonia via urea through urine.

Here are some examples of calculations;

Example 1:

A 100 kg man (220 pounds) with 20% body fat would have 80 kg lean mass, so would have a maximum protein ceiling of ~256g/day (based on the maximum amount of ammonia disposal of 3.21 g of protein / kg of lean body mass). Assuming his energy consumption is 2500 kcal/day, 256 g of protein is ~41% of total energy.

A 60 kg woman with 25% body fat, would have 45 kg of lean mass, so would have a maximum protein ceiling of 144 g/day. Assuming her energy consumption is 2000 kcal/day, 144 g of protein would be 29% of total energy as protein. The maximum amount of protein that this woman could regularly eat based on the disposal rate of ammonia in urea is only 29% of energy as protein.  

Since the amount of protein one can eat is tied to the amount of lean body mass, what if this woman were leaner, say at the very lowest end of the body fat range? Could she eat 40% protein on an ongoing basis and excrete all the resulting ammonia as urea in her urine?

The same 60 kg woman at only 10% body fat would have 54 kg lean mass, with a maximum protein ceiling of 173 g protein / day. Assuming her energy consumption is the same 2000 kcal/day, 173 g pro/ day would be 35% of total energy as protein.

While this woman can safely have a higher percentage of energy as protein because she has more lean body mass, the maximum amount of protein based on disposal of ammonia is still only 35% of energy as protein.

It is important to note that 10% body fat for a woman is at the very low end of essential fat range and could result in amenorrhea (loss of menstrual cycles).

Final thoughts…

To know if a diet has adequate protein, one needs to ask ‘adequate for whom’. If you are an older adult trying to preserve muscle mass to avoid the increased risk of falls that comes with sarcopenia (loss of muscle mass) then your protein needs will be very different than if you just want to make sure your protein intake is adequate, or if you are about to train for a half-marathon.

When evaluating diets and whether they have adequate protein, they should at least meet the bare minimum requirements of the RDA. Then, ask yourself if the diet has enough protein to sustain someone who is physically active or enough for an older adult? Finally, make sure that the amount of protein is within the safe upper limit and does it exceed the maximum level of amount of protein based on the disposal of ammonia in urea in the urine.

If you are unsure how much protein you need, and how much and what type of fats and carbohydrate are most suitable for you, then please reach out for assistance.

More Info?

If you would like more information about my services then please have a look under the tab of that name or send me a note through the Contact Me form.

Be sure to read the following article titled Protein Intake in Popular Low Carbohydrate / Keto Diets for Weight Loss which is Part 2 of this one.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

References

  1. National Academies Press, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005)
  2. Thomas DT, Erdman KA, Burke LM. American College of Sports Medicine Joint Position Statement. Nutrition and Athletic Performance [published correction appears in Med Sci Sports Exerc. 2017 Jan;49(1):222]. Med Sci Sports Exerc. 2016;48(3):543-568. doi:10.1249/MSS.0000000000000852
  3. Fielding RA, Vellas B, Evans WJ, Bhasin S, et al, Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc. 2011 May;12(4):249-56
  4. Bauer J1, Biolo G, Cederholm T, Cesari M, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013 Aug;14(8):542-59
  5. Rudman D, DiFulco TJ, Galambos JT, Smith RB 3rd, Salam AA, Warren WD. Maximal rates of excretion and synthesis of urea in normal and cirrhotic subjects. J Clin Invest. 1973;52(9):2241-2249. doi:10.1172/JCI107410

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

A Ketogenic Diet was Used First in Diabetes Then Epilepsy

Some believe that a ketogenic diet was first used to treat epilepsy and that the diet was later adapted for use in treating those with diabetes, but as the previous article titled A Hundred Years of Treating Diabetes with a Low Carb and Ketogenic Diet points out, Dr. Russell Wilder who coined the term “ketogenic diet” and who is famous for his application of the diet in epilepsy, remains virtually unknown for his earlier use of a ketogenic diet for the treatment of diabetes. This short article provides the historic evidence that a ketogenic diet was used first in diabetes treatment, and later applied to the treatment of epilepsy.

Wilder’s First Musings About Use of a Ketogenic Diet in Epilepsy

On July 27, 1921, Dr. Russell Wilder wrote a short article in The Clinic Bulletin of the Mayo Clinic where he explained his thinking regarding Geyelin’s use of fasting in epilepsy, and why he thought that a ketogenic diet could work just as well. Note the highlighted “as has long been known” which alludes to his and other’s previous use of a ketogenic diet in the treatment of diabetes.

Wilder (1921) The Effect of Ketonemia on the Course of Epilepsy

Wilder’s First Use of a Ketogenic Diet in Diabetes

In 1958, Wilder’s published “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919-1950” in which he said;

“The nine editions of the little book A Primer for Diabetic Patients, the first written in 1921, the last in 1950, provide a panorama of diabetic therapy in that interval. The first printing was based on mimeographed instruction sheets prepared in 1920 for the diabetic patients. 

pg 257-8 “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919-1950”

 

While the first printing of the book A Primer for Diabetic Patients was in 1921, it is clear from what Wilder wrote in “Recollections and Reflections” (1958) that a ketogenic diet was already being used by Dr. Frederick M. Allen to treat those with diabetes (prior to 1920):

“The nine editions of the little book A Primer for Diabetic Patients, the first written in 1921, the last in 1950, provide a panorama of diabetic therapy in that interval. The first printing was based on mimeographed instruction sheets prepared in 1920 for the diabetic patients. We were then following the generally accepted treatment of that time, which was based on the research of Dr. Frederick M. Allen at the Rockefeller Institute in New York. It involved an initial period of starvation and the effort afterward to maintain control of glycosuria by a very rigidly restricted diet and periodic fast days.

A book titled “The Starvation Treatment of Diabetes Mellitus” written by Dr. Walter R. Steiner was published in 1916 and outlines the treatment protocol of Dr. Frederick M. Allen on which Dr. Russell Wilder based his method at the Mayo Clinic.

[Note: Special thanks to Doug Gilliland, Engineer of Connellsville, Pennsylvania for bringing this book to my attention.]

P 176 – Steiner (1916) – details of fasting and ketogenic diet method of Dr. Frederick M. Allen

 

Note: The following protocol should not be attempted on one’s own.  This was used in a supervised hospital setting.

As outlined on page 177-179 of Steiner’s book, Dr. Allen’s treatment consisted of first fasting the patient for 2-4 days (up to 8-10 days) while the patient could drink as much water, coffee, tea and meat broth as they wished.

Once the patient’s urine was free of sugar for a period of 24-hours, they were given 150g of low carbohydrate vegetables (5 g carbohydrate) that were boiled three times and the water discarded to further reduce the amount of carbohydrate in them. Then 5 grams of carbohydrate was added every other day from the list of low carb vegetables (5 grams carbohydrate), then medium carbohydrate vegetables (10 gram carbohydrate) and finally high carbohydrate vegetables (15 grams carbohydrate). Finally, the carbohydrate content of the diet was gradually titrated up by adding fruit, potato, oatmeal and bread — provided that no sugar appears in the urineOnce the urine has been sugar free for 2 days, protein was added in the form of 3 eggs and then 15 grams of protein were added per day until the patient is receiving 1 gram of protein per kilogram body weight. Once protein tolerance (1 gram protein per kilogram body weight) was reached) 25 grams of fat were added daily until the patient stopped losing weight — or until 40 calories per kilogram body weight was reached.

Dr. Frederick Allen’s ketogenic diet was in use prior to 1916 when Dr. Walter Steiner published his book, and Dr. Russell Wilder later based his treatment protocol on Allen’s “generally accepted treatment”.

The first printing was based on mimeographed instruction sheets prepared in 1920 for the diabetic patients. We were then following the generally accepted treatment of that time, which was based on the research of Dr. Frederick M. Allen at the Rockefeller Institute in New York which involved an initial period of starvation and the effort afterward to maintain control of glycosuria by a very rigidly restricted diet and periodic fast days.

A ketogenic diet was used in treating diabetes prior to 1916 — several years before Dr. Wilder proposed using it in epilepsy in July 1921.

P 176 – Steiner (1916) – details of fasting and ketogenic diet method of Dr. Frederick M. Allen
Pg 177 The Starvation treatment of diabetes mellitus – outline of Dr. Frederick Allen’s method – from Steiner 1916
Pg 178 The Starvation treatment of diabetes mellitus – outline of Dr. Frederick Allen’s method – from Steiner 1916

Wilder’s Outline of the Timeline of Use of a Ketogenic Diet – from treatment of diabetes to use in epilepsy

Page 243 of “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919-1950” Dr. Russell Wilder clearly spells out the timeline that use of a ketogenic diet in diabetes came first, then his idea that a ketogenic diet might also have application in epilepsy. 

 

pg 243, “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919-1950”

 

“At an Atlantic City meeting, I had heard Gehelin’s report of the benefit in epilepsy of periods of absolute fasting and was led thereby to look into the effect of prescribing a diet so designed that it would provoke ketosis— that is, a diet very high in fat and rigidly restricted in its content of carbohydrate.”

This is what Wilder wrote about in July 27, 1921 in The Clinic Bulletin– at least a year after he was already using a ketogenic diet in the treatment of diabetes (see above) .

Final Thoughts…

People think of a “keto diet” to treat diabetes as something new — as a “fad” even, but it has been used for over 100 years to do just that. Its therapeutic application in the treatment of epilepsy is rarely disputed yet its therapeutic use in the treatment of diabetes remains a hotly debated topic. This ought not to be.

While not everyone with type 2 diabetes wants to seek remission, those with diabetes who want choose a diet-first approach to treating the disease should be made aware that (1) such a choice exists, and as outlined in previous articles posted on this website (2) is considered safe and effective by Diabetes Australia, the American Diabetes Association (ADA), the European  Association for the Study of Diabetes (EASD), as well as Diabetes Canada. In addition, those with diabetes (3) should have the support of their healthcare team to implement such a diet with medical oversight and where needed to have their physician adjust their dosage of insulin / insulin analogues and to adjust / gradually deprescribe their oral diabetes medications, as carbohydrates are decreased.

More Info?

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To your good health!

Joy

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Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Wilder RM, The Clinic Bulletin Vol 2. No. 307, The Effect of Ketonemia on the Course of Epilepsy, July 27, 1921, https://www.neslazeno.cz/wilder-1921-the-effect-of-ketonemia-on-the-course-of-epilepsy/
  2. Wilder, Russell M. “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919-50.” Perspectives in Biology and Medicine, vol. 1 no. 3, 1958, p. 237-277. Project MUSEdoi:10.1353/pbm.1958.0019.
  3. Steiner WR, The Starvation Treatment of Diabetes Mellitus, Transactions of the Connecticut State Medical Society, 1916
  4. Wilder RM, Foley MA, Ellithorpe D, A Primer for Diabetic Patients – a brief outline of the principles of diabetic treatment, sample menus and food tables,  The Mayo Clinic, W.B. Saunders Company Publishing, 1922

A Hundred Years of Treating Diabetes with a Low Carb and Ketogenic Diet

A hundred years ago, Dr. Russell M. Wilder and two Dietitians from the Mayo Clinic wrote a 69-page book titled “A Primer for Diabetic Patients – A Brief Outline of The Principles of Diabetic Treatment, Sample Menus and Food Tables[1]” which outlined the treatment of diabetes using different levels of a low carbohydrate and very low carbohydrate (ketogenic) diet, as well as short periods (12-48 hours) of fasting.

“The effect of ketonemia on the course of epilepsy” (1921), Russell M. Wilder

So how is it that until yesterday, I only knew of Dr. Russell M. Wilder as the physician who in 1921 proposed that a very low carbohydrate high fat diet which resulted in the body’s production of ketones could be used in the treatment of epilepsy in order to produce the same benefits as fasting[2]?

This is the first of two articles on the origins of a ketogenic diet for the treatment of diabetes. The second one can be read here

It was Wilder himself who is credited with coining the term “ketogenic diet” — and his version of the classic 4:1 ketogenic diet (KD) is still used today in the management of epilepsy, as well as in adjunct treatment for glioblastoma (a very aggressive type of brain cancer) — along with chemo and radiation, as well as in some neurological disorders.  But his first work using the diet was in diabetes.

How is it that Wilder is so famous for being a very early implementer of a ketogenic diet for epilepsy, yet virtually unknown for his earlier use of low carbohydrate and ketogenic diet for the treatment of diabetes? Could it be that the discovery of insulin a little later that same year by Dr. Fredrick Banting and medical student Charles Best[3], and its manufacture by Eli Lilly [3] relegated the use of a low carbohydrate diet in diabetes to the pages of history?

Note (February 16, 2021): As I outline below, that is exactly what happened.

While it makes total sense that use of insulin as treatment of those with type 1 diabetes (where a person’s pancreas produces little or no insulin) took a front and center role to keep them from literally wasting away without it, it is unfathomable to me that Wilder’s dietary recommendations did not continue to be widely used in the management of type 2 diabetes —  an impairment in the way the body uses glucose and which results in too much sugar circulating in the blood. Perhaps it was because type 2 diabetes wasn’t identified as being entirely different than type 1 diabetes until Harold Percival Himsworth differentiated between the two in 1936.

Oral diabetes medications such as Metformin and other biguanide derivatives, as well as sulfonylurea such as Carbutamide and Tolbutamide were not developed until 1955-1956,  so prior to 1955 insulin was the only drug treatment for type 2 diabetes[4]. 

ADDENDUM ( February 16, 2021) – A paper published in 1958 by Dr. Russell Wilder provides some much needed understanding as how the discovery of insulin and its free provision to those with diabetes by the drug company Eli Lilly shaped the use of low carb diets in diabetes treatment.

“Insulin at that time cost five cents a unit in the market. However, the patients in our early cases received theirs gratis (i.e. free) for a period of several years, thanks to the Eli Lilly Company.” (p.247-8 [4])

In Wilder’s 1958 paper, he outlines how the A Primer for Diabetic Patients [1] (the book on which this article is based) went from being a diet-first approach to the treatment of diabetes prior to the discovery of insulin to a diet that was indistinguishable from the carbohydrate and protein rich diet of non-diabetics, as the result of the use of insulin.

“The nine editions of the little book A Primer for Diabetic Patients, the first written in 1921, the last in 1950, provide a panorama of diabetic therapy in that interval. The first printing was based on mimeographed instruction sheets prepared in 1920 for the diabetic patients. We were then following the generally accepted treatment of that time, which was based on the research of Dr. Frederick M. Allen at the Rockefeller Institute in New York. It involved an initial period of starvation and the effort afterward to maintain control of glycosuria by a very rigidly restricted diet and periodic fast days. The second edition (1923 ) introduced insulin and diets made more liberal in fat. The pre-insulin diets were continued because of the cost of insulin—5 cents a unit then—and because of a disinclination to give more of this new drug than was absolutely necessary, since it was not yet known whether ill effects would result from the continued use of insulin. As the years went by, greater and greater liberality was permitted, until, in the later editions of the book, the diets recommended, although still controlled as to composition, provided almost as much protein and carbohydrate as would be contained in the well-selected diets of normal persons [4].”

Perhaps the reason diabetes has been considered a “chronic and progressive disease” is because dietary treatment had been all but forgotten after the discovery of insulin.

In 1921, Wilder understood that;

“Diabetes is a disease which in manifested by excretion of sugar in the urine. This sugar comes from the foods which the patient eats, but which is body, owing to the disease, is unable to utilize.”

and his treatment recommendations (pg.12) were;

suiting the diet to the condition of the patient and feeding no more sugar-forming foods than the patient’s body is able to use.

The concept of “eat what you want and cover it with insulin” simply wasn’t an option for those with diabetes, as insulin hadn’t been discovered yet. Diet was the only choice for managing symptoms of the disease — which begs the question, for those with type 2 diabetes who want to get off of diabetes medications now, why isn’t carbohydrate restriction offered as a choice?

No one denies the safety and efficacy of a ketogenic diet for the treatment of epilepsy, yet many deny that a low carb or ketogenic diet appropriate for those with diabetes — when both have been used safely for 100 years! While there is an absolute need to manage the dosage of oral hypoglycemic medications before and during reduction in the amount of carbohydrate in the diet there is no reason that we cannot support a diet-first, not drug-first approach to diabetes treatment and management when people want.

Determining Carbohydrate Tolerance

Diabetes is at its very essence “carbohydrate intolerance” and Wilder describes ‘tolerance‘ as ‘the amount of sugar-forming foods which a person can eat in twenty-four hours without causing sugar in the urine’.

“The tolerance of a given patient is ascertained by feeding foods of known composition in weighed and gradually increasing amounts.”

“The actual procedure will vary with different patients, but, in general, foods of known composition in weighted amounts are fed, the total intake of carbohydrate, protein and fat being increased very gradually as high as possible without the return of sugar in the urine.”

“Some patients will be found to have low tolerance, others may stand 100 gm. of carbohydrate. Every patient should be treated as an individual case, but for convenience in prescribing diets, the following arbitrary grouping is made:

Group A — tolerance below 40 gm. carbohydrate

Group B — tolerance between 40 and 60 gm. carbohydrate

Group Ctolerance between 60 and 100 gm. carbohydrate

Group Dtolerance above 100 gm. of carbohydrate

Use of Fasting and Protein Sparing Modified Fasts

Wilder’s approach incorporates short fasts of 12 – 24 hours as part of the management of blood sugar and up to 2-days if spilling sugar in the urine (i.e. exceeding their carbohydrate tolerance).

Those in Group A who have carbohydrate tolerance of less than 40 grams of carbohydrate (ketogenic level for women and men) are instructed to “interrupt their diet by a “fast day” once a week” — but its not a complete fast.  They are told to “take liberally of liquids”, including beef broth and coffee or tea.

Those in Group B who have carbohydrate tolerance between 40 and 60 grams of carbohydrate are instructed to “institute weekly days of half-fasts” on which they restrict their diet to 20 grams of carbohydrate, as well as 12 grams of protein and 12 grams of fat.

On the appearance of sugar in the urine at any time, the patient, irrespective of his group, must institute a fast day. If the sugar persists, a second fast day should follow the first.

Of interest,  if sugar persists in the urine Wilder’s recommendations are to institute what would be known today as a “protein sparing modified fast“;

If sugar persists, the patient should return to one-half of his diet, continue on this for a week, and then again try the effect of a fast day. After the urine is again sugar-free, he can return gradually to his previous diet.”

Wilder cautions that “longer fasts should never be attempted outside of an institution”, but it’s important to keep in mind that there was no distinction at this point between type 1 and type 2 diabetes.

There is no fasting protocol for those whose carbohydrate tolerance is between 60 and 100 grams.

Daily Macros

Those in Group A who have a carbohydrate tolerance of less than 40 grams of carbohydrate (ketogenic level for women and men) are instructed to eat breakfast, lunch and dinner such that the value of three such meals has 20 grams of carbohydrate, 70 grams of protein and 100 grams of fat (pg. 30 [1]).

Those in Group B who have carbohydrate tolerance between 40 and 60 grams of carbohydrate are instructed to eat breakfast, lunch and dinner such that the value of three such meals has 40 grams of carbohydrate, 70 grams of protein and 100 grams of fat (pg. 33 [1]).

Those in Group C who have carbohydrate tolerance between 60 and 100 grams of carbohydrate are instructed to eat breakfast, lunch and dinner such that the value of three such meals has 60 grams of carbohydrate, 70 grams of protein and 100 grams of fat (pg. 37 [1]).

Those in Group D who have carbohydrate tolerance above 100 grams of carbohydrate are instructed to eat breakfast, lunch and dinner such that the value of three such meals 100 grams of carbohydrate, 70 grams of protein and 140 grams of fat (pg. 41 [1]).

At 70 grams of protein per day irrespective of a person’s weight or gender, these low carb / ketogenic diets provided plenty of satiety and this amount is above the current DRIs of 46 g protein for the average sedentary woman, and 56g protein per day for the average sedentary man.

Fat sources in the sample menus were butter, cream, cheese and eggs and the fat found in the protein.

Carbohydrate sources in the diets were mainly from recipes for something called “Hepco Cakes” made from eggs, cream, Hepco flour, butter and water or from “Cullu-flour Griddle Cakes” made from eggs, salt, water and cellu-flour. Very low carb meals included low carb vegetables and a little bit of fruit, and the higher carbohydrate meals included low carb vegetables, root vegetables such as onion and beet, as well as a bit of fruit.

Wilder’s Low Carb / Keto Diet for Diabetes – a summary

Wilder understood that diabetes is a disease of carbohydrate intolerance and that each person with diabetes “should be treated as an individual“.

He was aware that some people with diabetes will have very low carbohydrate tolerance of less than 40 grams per day requiring a ketogenic level of intake, while others can tolerate up to 100 grams of carbohydrate per day.

Wilder did not restrict  protein, as he did in the 4:1 ketogenic diet he later developed for epilepsy.

Final Thoughts…

My experience in clinical practice over the last 5 years teaching low carb and ketogenic diets is that each person with type 2 diabetes has different levels of carbohydrate tolerance.

When I first started teaching low carbohydrate and ketogenic diets 5 years ago, unless someone was already on a ketogenic diet, I would start those with type 2 diabetes (who were not on any of the medications previously mentioned) at 130 grams of carbohydrate per day and gradually lower carbohydrates until clinical outcomes were reached.

In the past two or three years I came to the realization that none of my clients with type 2 diabetes were tolerating carbohydrate intakes above 100 grams per day — which interestingly is consistent with Wilder’s categories.

Conclusion

People think of the “keto diet” to treat diabetes as something new, but it has been around for over 100 years. When medications have been around for a long time (such as “ASA” i.e. Aspirin), they are given GRAS status (Generally Recognized As Safe) and considered safe by experts, without the need for additional evaluation.

Given that use of both low carbohydrate and a ketogenic diets in the treatment of diabetes along with short periods of therapeutic fasting was developed over 100 years ago, why is this approach not also generally recognized as safe — with specific qualifiers in place for those taking certain medications such as oral hypoglycemic medications?

For those who insist that a ketogenic diet was first used in the treatment of epilepsy, here is the link to the second part of this article which documents clinical use in diabetes treatment prior to 1916 — and likely what Wilder was referring to in his “… as has long been known” statement in July 1923 when he suggested its use in epilepsy.

More Info?

If you would like more information about how I might be able to support your needs, please have a look under the Services tab or send me a note through the Contact Me form.

To your good health!

Joy

Special recognition to Jan Vyjidak of London, England, Founder and CEO at Neslazeno.cz for finding A Primer for Diabetic Patients (1922)!

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Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Wilder RM, Foley MA, Ellithorpe D, A Primer for Diabetic Patients – a brief outline of the principles of diabetic treatment, sample menus and food tables,  The Mayo Clinic, W.B. Saunders Company Publishing, 1922
  2. Wheless JW. History of the ketogenic diet. Epilepsia. 2008 Nov;49 Suppl 8:3-5. doi: 10.1111/j.1528-1167.2008.01821.x. PMID: 19049574.
  3. The History of Insulin, diabetes.co.uk, diabetes.co.uk/insulin/history-of-insulin.html
  4. Krochmal M, 10 Facts About the History of Diabetes, https://type2diabetes.com/living/10-facts-history-diabetes/
  5. Wilder, Russell M. “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919-50.” Perspectives in Biology and Medicine, vol. 1 no. 3, 1958, p. 237-277. Project MUSEdoi:10.1353/pbm.1958.0019.

High Protein Low Carb Diet – preferred alternative to low carb high fat?

Note (February 12, 2021): This article is provided for nutrition information only and is not an endorsement of any specific type of low carbohydrate diet. Everyone’s nutritional needs are different.

Except for specific conditions such as epilepsy, seizure disorder and glioblastoma — or for those seeking the specific benefits of high ketones,  I tend to recommend a higher protein, lower fat version of a ketogenic diet when helping people with weight loss. The main reason is that for weight loss, the high fat version is normally paired with frequent- or extended-periods of fasting which, as I will outline below has some key drawbacks. 

The popularized keto diet which is 75% fat has, by definition lots of added fat in the form of whipping cream, avocado, bacon and fatty meat to make up for the lower protein of 15%, as well as very low carbs (10%). While it is enticing to eat this way, ~1/3 of my clients come to me for dietary support after either failing to lose more than a little initial weight, or gaining weight. I think that is because they may have ‘missed’ that a high fat keto diet for weight loss necessarily goes along with frequent periods of fasting, but not everyone “gets” that message or even wants to ‘fast’. 

Often times people will implement the ‘high fat keto diet part’ without implementing the ‘regular or extended fasting part’ —  adding tons of dietary fat to food. This approach will not enable someone to reduce their own body fat stores, which is why in such cases I will recommend a slightly lower fat, higher protein approach.

Something I have observed over the last several years is that the very high fat approach often does not work well for peri- and post-menopausal women.  I hypothesize that it is the change in  hormones — especially estrogen at menopause that may lower metabolic rate and thus contribute to a slowing of weight loss. Combined with lots of added fat, this becomes a recipe for failure with many peri- and post-menopausal women. I’ve also noticed that in some older women, a very high fat approach triggers cravings for ‘fat bombs’ and high-fat “keto treats” and I think this may be related to the dopamine release associated with either high fat or high carb intake — and which becomes substantially higher when with foods with both fat and carbs are eaten together.  Many of these women became obese eating high-fat high-carb foods, which leads me to believe that the reward-centre of the brain may be triggering that same desire via eating lots of high fat foods. 

I have discovered from those who come to me after eating a high fat keto diet that they came to believe from what they’ve read online that (1) dietary fat is “the” source of satiety (no longer feeling hungry) and that (2) that when “eating “keto”, calories don’t count”

In this article I will address these two beliefs, starting with the second.

Calories Don’t Count When Eating “Keto” 

Proponents of the popularized keto diet are often heard to say that the “calories in calories out (CICO) model” is irrelevant, and that counting calories doesn’t apply “when eating keto”.

The problem is that calories are thought of as a “thing”, rather than a process. A calorie isn’t counted, but is calculated from heat and work. 

A calorie was originally defined as “the amount of heat required to raise the temperature of 1 gram of water by 1° Celsius at a standard atmospheric pressure”.  Since the amount of heat required to raise the temperature of 1 gram of water by 1° Celsius is known to vary by as much as 1% at different temperatures, a calorie (small “c”) is defined as “the amount of heat that will raise the temperature of 1 gram of water from 14.5° to 15.5° Celsius. This is based on the first  law of thermodynamics (Law of Conservation of Energy) — that energy cannot be created or destroyed. 

The number of calories in a given food is determined by burning that food in a bomb calorimeter, which is a box with two chambers, one inside the other. A sample of the food is weighed, put on a dish in the inner chamber of the calorimeter., and burned. When the food burns, if the temperature of the water goes up 1 degree Celsius per kilogram, the food is said to have 1 calorie.

As Professor Dr. Richard Feinman said recently on social media, it’s impossible to keep track of ‘grams-in of food’ and ‘grams-out of energy’ (CO2 and exhaled water) in daily life, so in that sense the “calories in calories out model” isn’t meaningful.

The law of thermodynamics doesn’t stop applying because one is eating a keto diet. In fact, when using therapeutic ketogenic diets for conditions such as epilepsy, seizure disorder and glioblastoma, diets such as the classic Ketogenic Diet (KD) with a 4:1 ratio of fat to protein, a Modified Ketogenic Diet (MKD) with a 3:1 ratio of fat to protein, and a Modified Atkins Diet (MAD) with a 2:1 ratio of fat to protein are all calculated based on the caloric needs of the individual. These high fat diets are intended to produce large amounts of ketones for therapeutic purposes and calories definitely count when following a ketogenic (keto) diet. 

The popularized keto diet which is usually thought of as being ~75% fat, 15% protein and 10% carbohydrate is basically a hybrid between the Modified Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD) — neither of which are weight loss diets. In fact, these diets were specifically designed to not result in weight loss. Unless the popularized high fat ‘keto’ diet is combined with frequent periods of fasting <24 hours and/or extended periods of fasting >24 hour, weight loss is unlikely to occur. This is why the two main proponents of the high fat ‘keto’ diet, Dr. Jason Fung and Diet Doctor both promote the high fat ‘keto’ diet together with periods of fasting. While many people are successful losing weight this way, the question is does weight loss occur because of the fasting?

Many who follow this type of diet will say that it is the high fat that makes the fasting possible, and point to fat providing “satiety” (feeling of not being hungry) but as I will elaborate on below, high fat is not the only — or even the best way to increase satiety.  Not only is protein far better at providing satiety, the amount of protein recommended by Dr. Stephen Phinney, MD, PhD and Dr. Jeff Volek, PhD, RD in their 2011 book the Art and Science of Low Carbohydrate Living is up to double the amount of the popularized keto diet.

Fat (9 calories per gram) is more than twice the calories of carbohydrate and protein (4 calories per gram each), so unless one is fasting frequently and/or for extended periods of time, it makes absolutely no sense to eat a high added fat diet if one is seeking weight loss and fasting has its drawbacks.

Frequent and/or Extended Fasting

The problem with fasting for periods longer than 24 hours is there is a loss of lean body mass (muscle) that goes along with it.

According to a 1979 research article published in the American Journal of Clinical Nutrition[1], protein is lost during extended fasting beginning on day 1 and continues until it reaches at maximum on day 3, then slowly declines. These results are validated in other studies, including one from Owen and Cahill in 1969 [2,3]. 

from Virta Health: https://www.virtahealth.com/blog/science-of-intermittent-fasting

This graph from Virta Health [3] based on the same research [1] shows the losses in grams of nitrogen per day, where each gram represents the loss of about 1 ounce of lean tissue.

This graph also from Virta Health [3] and based on the same research shows the long-term loss of body nitrogen (protein) as % of pre-fasting value. While loss of protein slows somewhat after day 10, it continues right up to 60 days.

Based on this data, healthy overweight adults who fast for 10 days will lose 5 pounds of lean muscle [3].

According to a 1983 study by by Cahill, normal protein breakdown is ~75 g per day and while protein breakdown will eventually slow by ~25% when people are fasting long term in order to spare muscle, this is only as the “final stage of adaptation” and only “once ketoacid levels (ketones) reach a plateau and the brain is preferentially using ketoacids as fuel [4]“.  

This time frame is consistent with the research above [1,2] showing that the slowing of muscle loss only occurs after 10 days of fasting, when ketones become the preferred fuel.

For older adults — especially post-menopausal women who are already at risk of sarcopenia (muscle loss), I do not recommend fasting longer than 24 hours.

Dietary Fat or Dietary Protein as the Source of Satiety

Proponents of the high fat ‘keto’ diet say that it is the high dietary fat that makes them so much less hungry, which makes them able to fast frequently and for extended period of time, and which results in them eating less over all.  I don’t doubt this, but fat is not the only — or even the best source of satietyProtein is far better at producing satiety and at less than half the calories of fat!

According to a 2010 study titled Energy Density of Foods: Effect on Energy Intake [3];

“when the satiating effects of macronutrients on appetite and energy intake (EI) are compared as nutrients come in the diet (and fat contributes disproportionately to energy density (ED), Joule-for-Joule, protein is consistently (at doses above 1.2 to 1.4 MJ) more satiating than carbohydrate (CHO), which is more satiating than fat.

When energy density (ED) is controlled, protein is still far more satiating than fat or carbohydrate.”

Given that protein produces more satiety than fat and has less than half the calories as fat, it makes much more sense if someone is seeking weight loss, to provide substantially more protein in the diet and significantly less dietary fat.

But how much protein?

Protein Intake in a Ketogenic Diet

In their classic 2011 book the Art and Science of Low Carbohydrate Living, Dr. Stephen Phinney, a physician with a PhD and Dr. Jeff Volek, a Dietitian with a PhD recommend that during weight loss, fat intake be 60% of calories and protein intake be to up to 30% of calories, with carbohydrate intake be 7.5-10% of calories for men, 2.5-6.5% of calories for women [4].  This mix of 60% fat, up to 30% protein and ~10% carbohydrate has up to twice the protein intake of the popularized ‘keto’ diet (75% fat, 15% protein, 10% carbohydrate).

NOTE (February 8, 2021): A ketogenic diet that is 30% protein might have most of its fat in the meat, eggs, and cheese that comprise it — and need not have any “added fat”. It is definitely not “low fat” (<30% fat) but is approximately ~60% fat. A ketogenic diet that has only 15% protein has to have lots of added fat (75%) to make up the rest of calories, because carbs are limited to 10%.

In relation to protein intake, Phinney and Volek write on page 210;

“…our studies of muscle retention and function during carbohydrate restriction [27,78,87], we recommend daily protein intakes between 1.5 and 2.5 grams per day per kg of reference body weight [6].”

What would this amount of protein look like in terms of intake?

A woman who is 5′ 4.25″(1.63 m) tall has an IBW (lean body mass) of 127 pounds (55 kg), so protein intake according to Phinney and Volek should be between 82.5 g protein (at 1.5 g/kg) to 137.5 g protein (at 2.5 g/kg).

A man who is 5’9″ (1.75 m) tall has an IBW (lean body mass) of 155 pounds (70 kg), which means that based on of reference body weight which is the half according to Phinney and Volek, protein intake should be 105 g protein (at 1.5 per kg) to 175.0 g protein (at 2.5 g/kg).

In a more recent 2018 article published online by Drs. Phinney and Volek along with Dr. Brittanie Volk, who is also a Dietitian with a PhD write;

“While a precise analysis of dose-response to varying protein intakes during nutritional ketosis has not been done in humans, we have performed a number of studies indicating that most healthy humans maintain lean body mass and function during a ketogenic diet providing between 1.5 and 1.75 grams of protein per kg of ‘reference body weight’ (Phinney 1983, Davis 1990). Furthermore, there are no convincing human studies showing any benefit from dietary protein above 2.0 g/kg reference weight for adults following a ketogenic diet.” [7]

Reference body weight is considered to be “roughly normal lean body mass, rather than total body weight. [7].

So what does this updated recommendation look like in terms of intake?

A woman who is 5′ 4.25″(1.63 m) tall has an IBW (lean body mass) of 121 pounds (55 kg), so protein intake during nutritional ketosis according to Phinney, Volek and Volk should be between 82.5 g protein (at 1.5 g/kg) to 96.25 g protein (at 1.75 g/kg).

A man who is 5’9″ (1.75 m) tall has an IBW (lean body mass) of 155 pounds (70 kg), which means that according to Phinney, Volek and Volk should be 105 g protein (at 1.5 per kg) to 122.5 g protein (at 1.75 g/kg).

Protein to Energy (P:E) Ratio

In 2019, I was following with interest the evolving thoughts of Dr. Ted Naiman with regards to the amount of protein he was thinking that we should be eating.

As I wrote about in a 2019 article, his “P:E” ratio determines the Protein to Energy ratio of a food — with a focus on eating the most amount of protein for the least amount of energy (calories).

The P:E Diet was published as a book in 2020 and can best be described as a high protein, low fat and low-ish carb diet.  I say “low-ish” carb because some calculations recommend carbs >130 g per day, which is the cut-off for low carb in most of the literature.  On his web site the macros are clearly represented as being for healthy people without metabolic conditions, but I question whether they could even be considered for use in those with type 2 diabetes because of the higher carb intake.  After all, type 2 diabetes is the end-state of an inability to appropriately handle carbohydrates in the diet.

After listening to a recent talk of Dr. Naiman’s last week on YouTube, I have begun following his posts on social media to try to understand his implementation of these recommended macros. It is important to keep in mind that Dr. Naiman’s focus is on healthy individuals seeking optimal muscle / lean body mass and not for those seeking remission of metabolic conditions, such as type 2 diabetes.

I was curious what the P:E calculator (available at p2eq.com) would assess the macros for the sample woman and sample man, above.

Note: Since it was not possible to select 5.4.25 in the tool for the height of the sample woman, I chose 5’4.5″ — the closest match.

According to the P:E ratio, a woman who is 5′ 4.5″ (1.64 m) should weigh 121 pounds (55 kg). According to this calculator and assuming she is metabolically healthy, this hypothetical woman should eat 1,470 kcals per day as 147 g protein (2.67 g protein /kg IBW), 49 g of fat and 110 g of total carbs.

According to Dr. Naiman’s P:E ratio, a man who is 5’9″ (1.75 m) tall should weigh 155 pounds (70 kg). According to this calculator and assuming this man is metabolically healthy, he should should eat 1,860 kcals as 186 g protein (2.66 g pro/kg IBW), 62 g of fat and 140 g of total carbs.

In this calculation, the amount of protein recommended for both the woman and the man in the P:E ratio at ~2.66 g protein/kg IDW is higher than the range that Phinney and Volek determined in their 2011 book, The Art and Science of of Low Carbohydrate Living, which is based on 2.0 g protein/kg of ideal body weight.

As I wrote about in an earlier article, according to Dr. Donald Layman, PhD, Professor Emeritus, University of Illinois, the highest end of the range of safe intake of protein is 2.5 g protein/ kg per day (maximum of 200 g / day).

The high end of Phinney and Volek’s recommendations from their 2011 book of 2.5 g protein/kg IDW are at what Dr. Layman indicates is the high end of the safe range. While Dr. Naiman’s recommendations at 2.66 g protein/kg IDW is slightly higher than the 2.5 g protein/kg IDW, it is not in terms of the absolute number of grams of protein (>200 g/day).

NOTE (February 23, 2021): 

HOW MUCH PROTEIN IS TOO MUCH?

The upper limit for using protein for energy is the determined by the disposal of ammonia from the protein, as urea in the urine. Humans apparently saturate disposal at ~3.21 g of protein / kg of lean body mass. Therefore, a safe upper limit of protein as a percentage of total energy requires knowing lean mass and estimated energy consumption (i.e. how many calories need to remain weight stable.

Example 1:

A 100 kg man with 20% body fat would have 80 kg lean mass, so would have a maximum protein ceiling of ~256g/day (based on the maximum amount of ammonia disposal of 3.21 g of protein / kg of lean body mass). Assuming his energy consumption is 2500 kcal/day, 256 g of protein is around 41% of total energy.

Example 2:

(a) A 60 kg woman with 25% body fat, would have 45 kg of lean mass, so would have a maximum protein ceiling of 144 g/day. Assuming her energy consumption is 2000 kcal/day, 144 g of protein would be 29% of total energy.

BUT

(b) The same 60 kg woman who has only 10% body fat would have 54 kg lean mass, so would have a maximum protein ceiling of 173 g pro/day (2000 kcal/day) which would be 35% of energy. The woman is the same size, but her amount of lean mass is greater, so she can safely have a higher percentage of energy as protein.

[special thanks to Richard Morris, research biochemist for the information on ammonia disposal rates in humans.]

Final Thoughts…

People seeking follow a low carb diet come with very different needs. Some people can’t necessarily afford to eat “keto” without fasting (as it reduces costs if one is not eating every day, or is only eating a few days per week) — so if that is the only way they can afford to do it, then one has to weigh the effect of fasting on lean body mass versus the risk of them remaining obese or diabetic.

A person seeking weight loss and/or improved metabolic health has a wide range of low carb and ketogenic options to choose from, with a choice of protein intake ranging from 1.5 g protein – 2.5 g protein per kilogram of ideal body weight.

NOTE (February 8, 2021): I should make it clear that Phinney and Volek do not use ideal body weight as a means to determine what a person’s weight should be, but as a means for determining the amount of protein one should eat, based on their lean body mass (with IBW being a good estimate). In my practice, I use ideal body weight the same way. Since my focus is on metabolic health, I use waist to height ratio as the primary determinant, along with optimal lab results.  When people reach a waist-to-height ratio of 0.50 with optimal lab markers, then I consider everything else a matter of aesthetics.

How much protein is best?
Is 1.5 g protein/kg ideal body weight? What about 1.75 g protein/kg ideal body weight  or 2.0 g protein/kg of ideal body weight? When is it appropriate to aim for the high end of 2.5 g protein/kg ideal body weight. It depends on “best” for whom for whom.
Each individual’s macro needs (calories, protein, fat and carbohydrate) vary depending on the person’s age, gender, stage of life, health conditions and activity level — as well as what the person is seeking to accomplish. What are the person’s goals? Is it weight loss? Is it lowering blood sugar levels or putting type 2 diabetes into remission? Is it building lots of lean muscle? Different goals within the context of their health will impact how macros are set initially, and how they change as people achieve it.

The “best macros” are the one’s based on your individual needs and health- and weight-loss goals.

Note (February 9, 2021):

If someone is metabolically healthy and seeking to build lean body mass (muscle), then a diet that is 40% protein and 30% fat and 30% carbs may be appropriate.

If someone is overweight, obese or lean (e.g. TOFI – thin on the outside, fat on the inside), but has diabetes or prediabetes, then a diet that is 40% protein BUT 30% carbs would not be such a great idea. 

If someone prefers to seek weight loss or the benefits of ketone production — and is not at risk for sarcopenia (muscle loss), then a  ketogenic diet which is only 15% protein and which uses the combination of a high fat diet (75%) with regular periods of fasting may be the way to go.

Someone preferring up to 30% protein instead of only 15% protein may prefer a ketogenic diet with only 60% fat due to protein having the highest satiety.

There is no one-sized-fits-all low carb or keto diet.

More Info?

If you would like more information about my services then please have a look under the tab of that name or send me a note through the Contact Me form.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. G B Forbes, E J Drenick, Loss of body nitrogen on fasting, The American Journal of Clinical Nutrition, Volume 32, Issue 8, August 1979, Pages 1570–1574, https://doi.org/10.1093/ajcn/32.8.1570
  2. Owen OE, Felig P, Morgan AP, Wahren J, Cahill GF Jr. Liver and kidney metabolism during prolonged starvation. J Clin Invest. 1969 Mar;48(3):574-83. doi: 10.1172/JCI106016. PMID: 5773093; PMCID: PMC535723.
  3. Phinney SD, Volek JS, To Fast of Not to Fast: what are the Risks of Fasting?, December 5, 2017, Virta Health, https://www.virtahealth.com/blog/science-of-intermittent-fasting
  4. Cahill GF Jr. President’s address. Starvation. Trans Am Clin Climatol Assoc. 1983;94:1-21.
  5. Stubbs J, Ferres S, Horgan G, Energy Density of Foods: Effects on Energy Intake, Critical Reviews in Food Science and Nutrition, 40:6, 481-515, 2010
  6. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
  7. Phinney SD, Volek JS, Volk B, How Much Protein Do You Need In Nutritional Ketosis? February 21, 2018, Virta Health, https://www.virtahealth.com/blog/how-much-protein-on-keto

 

A Choice: Living With Diabetes, Seeking Remission From Diabetes

People come to me as a Dietitian with different goals with respect to type 2 diabetes. Most people who have been diagnosed with type 2 diabetes come to see me in my low carb division seeking to put their diabetes into remission — that is, to no longer meet the criteria for diagnosis. 

As stated throughout this web site and on my forms, I do not counsel people with type 1 diabetes, or with insulin-dependent type 2 diabetes because I am not a Certified Diabetes Educator (CDE). 

As explained in this earlier article, the American Diabetes Association has defined partial remission, complete remission and prolonged remission from type 2 diabetes, as follows;

    • Partial remission is having blood sugar that does not meet the classification for Type 2 Diabetes; i.e. either HbA1C < 6.5% and/or fasting blood glucose 5.5 – 6.9 mmol/l (100–125 mg/dl) for at least 1 year while not taking any medications to lower blood glucose.*

* some studies such s those from Virta Health define partial remission as a HbA1C < 6.5% and fasting blood glucose ≤ 5.5 (100 mg/dl) while taking  no medication, or only generic Metformin.

    • Complete remission is a return to normal glucose values i.e. HbA1C <6.0%, and/or fasting blood glucose < 5.6 mmol/L (100 mg/dl) for at least 1 year while not taking any medications to lower blood glucose.
    • Prolonged remission is a return to normal glucose values (i.e.
      HbA1C <6.0%, and/or fasting blood glucose < 5.6 mmol/L (100 mg/dl) for at least 5 years while not taking any medications to lower blood glucose.

Complete and prolonged remission can be achieved after bariatric surgery such as the roux-en-y procedure, and partial remission and complete remission have been documented with dietary and lifestyle changes, including a very low calorie diet and a very low-carbohydrate (ketogenic diet). To date, there is limited long-term data of 5 years or more documenting prolonged remission with dietary and lifestyle changes alone, although there are case studies.

I support people with a wide-range of goals when it comes to diabetes through my long-standing general dietetic practice, BetterByDesign Nutrition, and for those seeking remission through either that division or my low carbohydrate focussed practice, The Low Carb Healthy Fat Dietitian.  

    • Some people come to me with a diagnosis of pre-diabetes wanting to implement dietary changes to avoid getting type 2 diabetes.
    • Others come to me once they are diagnosed with type 2 diabetes, wanting to better control their blood sugar level through dietary changes and avoid complications.
    • Those who found me searching for a Dietitian with experience with low carbohydrate- and very low carbohydrate (ketogenic) diets most often are coming to avoid developing diabetes after a pre-diabetes diagnosis, or to have me help them put the disease into remission.

These are each valid goals.

Those who know that remission of type 2 diabetes is entirely possible find it difficult to understand that not everyone with type 2 diabetes wants to put the disease into remission.

Some people simply don’t known that this is even a possibility — believing that the disease is automatically both chronic (long-term) and progressive (getting worse with time). This type of a situation gives me the opportunity to explain to them that type 2 diabetes can be put into remission, and the different ways that I can support them in aiming to achieve that.

Other people may simply want to ‘manage’ their blood sugar levels to keep them from getting higher in order to avoid complications. They don’t want to have normal blood sugar, but want to avoid losing toes or going blind. These people have every right to choose these goals and to be supported by their healthcare team including me, in meeting them. I will make sure that they know that it is possible to achieve remission (because many don’t know), but if they don’t want to make the significant lifestyle changes required, then I will help them manage their diet to keep their blood sugar from getting higher. That said, they before they even begin services with me, they know that the Meal Plan I will design for them will not be “high carb” by any stretch of the imagination. Since type 2 diabetes is, in essence end-stage carbohydrate intolerance, the amount and type of carbohydrate on a Meal Plan that I will design for them will be limited, and specific. 

Note: Those coming to me on SGLT2 medication, such as Jardiance and Victosa or ACE inhibitors for high blood pressure will be asked to first consult with their doctor to have them monitor their dosages, as the carbohydrate content of their diet is gradually reduced.

For those coming to me to avoid having their pre-diabetes progress to type 2 diabetes or seeking to put their type 2 diabetes into remission, I will present to them the various dietary options available and explain how I am best able to support them in each. In my long-standing general dietetic practice I support three main approaches, including a very low calorie diet (including time-restricted eating), a whole-food predominately plant-based (vegetarian) diet, a modified DASH diet, a Mediterranean diet, and a very low carbohydrate / ketogenic diet. Through my low carb division, I offer a low carb and very low carbohydrate / ketogenic diet which can be tailored to someone being a vegetarian, if that is their preference. To those coming to me for support in following a carnivore diet (all meat / animal product consumption) or a vegan diet (one devoid of any animal products), I recommend they seek the support of another Dietitian with expertise in those areas.  I simply don’t feel equipped to ensure a nutritionally-adequate diet following either of those approaches.

The byline of my low carb division (The Low Carb Healthy Fat Dietitian) is “there is no one-sized-fits-all low carb or ketogenic diet” — because there isn’t.  A high-fat moderate protein ketogenic diet may be appropriate in some circumstances, whereas a higher lean protein, moderate fat approach may be better suited in others. Everyone’s medical conditions, risk factors and personal preferences are different, so I go over the different options and make my recommendations while explaining my reasons for them and let the person decide for themselves. Nothing is carved in stone.  Meal Plans can be changed or “tweaked” to best meet the individual’s needs.

The byline of my long-standing general dietetic practice is “Nutrition is BetterByDesign“. This emphasises the same conviction that Meal Plans need to be designed for the individual.  A person who doesn’t eat meat for religious, cultural or ethical considerations, for example needs to have an individual Meal Plan that helps them achieve their health goals — in the same way that someone who eats meat does. Those who choose to live with diabetes have just as much right to dietary support to meet those goals, as someone who desires to seek remission from diabetes. It doesn’t matter that remission is possible if they don’t want to achieve that, or they don’t want to make the lifestyle changes necessary to make that a possibility. They are free to make that decision. As a Dietitian, my responsibility is to support them in meeting their goals, and not to try and convince that other goals are “better”.  As long as they know that the possibility for remission exists and how that can be accomplished, I will whole-heartedly support them in their desire to live better with diabetes.

One of the reasons why I continue to maintain both my long-standing dietetic practice, BetterByDesign Nutrition (BBDNutrition), as well as my low carb division, The Low Carb Healthy Fat Dietitian is to providing people with different dietary approaches to type 2 diabetes. The other reason is that some people come to me seeking support for GI disorders or food allergies / sensitivities, or for nutritional support in pregnancy or for their children, which I do only through BBDNutrition. My two divisions give people options. People who want only low carb and ketogenic dietary support in a practice that does nothing else have that at the Low Carb Healthy Fat Dietitian.

Individuals have different goals and various needs. People are also at different stages of change when it comes to them having type 2 diabetes. Some may start with wanting to manage their symptoms — and only later arrive at a point where they want to seek remission.  If and when they do, I support them in doing that.

This is why I do, what I do, the way I do.

Please let me know if I can help.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

Diabetes Canada’s “Low Carb” Meal Plan – a closer look

As a follow up to the previous article about Diabetes Canada’s “Low Carb” 7-day Meal Plan, I was curious how much food there was at each meal, as well as  the total amount of carbs per day. I decided to analyze Day 1, Day 3 and Day 5 to get a rough idea and this article is about what I found. Yes, these meals are <130 g of carbs per day — so technically “low carb”, but they are also “low fat”, and low or inadequate protein.  

Note: This article is classified as both “science made simple” and an “editorial”, because the “Summary” and “Observations” are my commentary.

Where a recipe was not provided as part of the menu, I looked up the food item in Cronometer and used the nutritional information for the specified quantity.

Day 1

Breakfast on Day 1 had a small glass of the “smoothie” (28.4 g carbs, 8.9 g pro, 5.2 g fat) and that was it until lunch! Given the high amount of ground-up* fruit in it as well as the low amount of fat and protein, the first thing I thought of was how soon an adult with diabetes would be ravenous after drinking this. Then I wondered how high would their blood sugar go?

[Note: February 5, 2021]: In an earlier article, I covered the effect of various types of food processing on blood glucose, including mechanical processing such as the pureeing of the fruit in this smoothie. While 60g of whole apple, 60 g of pureed apple, and 60g of juiced apple have the same amount of carbohydrate and similar Glycemic Index neither of these indicate how blood glucose responds to eating pureed fruit, versus intact fruit. We know from a 1977 study published in the Lancet (reference below) that when pureed fruit or juiced fruit is consumed, the glucose response 90 minutes later is significantly higher than if the fruit were eaten whole.

[Haber GB, Heaton KW, Murphy D, Burroughs LF. Depletion and disruption of dietary fibre. Effects on satiety, plasma-glucose, and serum-insulin. Lancet. 1977 Oct 1;2(8040):679-82. doi: 10.1016/s0140-6736(77)90494-9. PMID: 71495]

This is typical of what is seen with any ultra-processed carbohydrate. So, the first problem with someone with diabetes having a fruit smoothie such as this as a meal is that the fruit is ground up, and not whole. A smoothie will spike blood glucose much more than if the same food was eaten not pureed. 

We also know from a 2015 study on the effect of food order on the response of glucose and insulin, that if carbs are eaten last, the glucose curve will be approximately 74% smaller, with a 49% smaller insulin spike.

[Shukla AP, Iliescu RG, Thomas CE, Aronne LJ. Food Order Has a Significant Impact on Postprandial Glucose and Insulin Levels. Diabetes Care. 2015;38(7):e98-e99. doi:10.2337/dc15-0429]

The second problem with someone with diabetes drinking a fruit smoothie like this for breakfast with no other food is that there is no way of having the carbs last!

Lunch on Day 1 was a small serving of vegetable frittata (3 g carbs, 13.6 g pro, 14.9 g fat), 1 slice whole-grain bread (13.2 g carbs, 4.5 g pro, 1.3 g fat) and 1 cup unsweetened plant based beverage such as Silk plain Oat milk (7.6 g carbs, 0.4 g pro, 0.3 g fat). A slice of frittata, a slice of plain bread and a glass of oat milk and that’s it for lunch. Maybe a nice lunch for child home from school?

Observations: The frittata is a great start to an actual low-carb lunch.  Why not pair it with a nice big salad, with a bit of crumbled cheese, a few pumpkin seeds and a bit of avocado, and skip the bread? If they want, they can drink the plant-based drink or skip it, as it hardly provides a significant source of protein. Maybe instead of the plant-based beverage, have 3/4 cup of Greek yogurt with a few berries instead, which provides significantly more protein for the same amount of carbs?

Dinner was 1 cup of Indonesian tofu stew with vegetables (8 g carbs, 5 g pro, 8 g fat) and ½ cup (125 mL) cooked brown rice (24.2 g carbs, 2.8 g pro, 1.0 g fat). That’s it. This might be an adequate serving for an older adult with a small appetite.

ObservationsWhat I would be concerned about is that a typical adult eating this for dinner would want to eat something before bed, because they would be hungry. While their blood sugar would go up slowly after this meal, dampened by the fiber in the rice as well as the few cooked veggies in the stew, it is simply not enough food. For a plant-based meal, double the serving of tofu stew, make it with regular coconut milk, add a nice Asian-style cucumber salad on the side, and forget the rice. 

So what did this day provide in terms of carbohydrate and total protein?

Well, it was low carb (84.4 g) but it was also inadequate in protein — having only 35.2 g PRO. Based on “average” body weight and a minimum 0.36 g of protein per pound of body weight (0.8 g protein per kg), this is less than the 46g protein required for the average sedentary woman, and much less than the 56g of protein required for the average sedentary man.

Day 3

Breakfast was small glass of the same smoothie (28.4 g carbs, 8.9 g pro, 5.2 g fat) and that was it until lunch!

Observations:  since this is the second time the person would be having this for breakfast, they would already be wondering what else they could eat (or bring along with them to eat later) because they would have remembered how hungry they were an hour or so later, the last time!

Since they would have had Greek yogurt for breakfast a day earlier, why not suggest a nice omelette made with some leftover cooked veggies from the night before? They could even add an ounce of sharp cheddar to it, which would easily get them through to lunch. 

Lunch was a “cup” of low fat cream of cauliflower soup that was actually only 3/4 cup / 175ml in size ( 10 g carbs, 7g PRO,  2g fat), 3.5 oz / 100 g grilled chicken breast (0 carbs, 41.7 g pro, 6.1 g fat) and a cup of unsweetened plant based beverage (7.6 g carbs, 0.4 g pro, 0.3 g fat). No salad, no side of veggies, that was it.

Observations: As part of a low carb meal, the cauliflower soup with a splash of cream and the grilled chicken breast would go every well with a nice helping of steamed veggies or mixed greens on the side — and why not? They are low carb, and high in micronutrients. The cooked ones would taste great with a dab of butter and the raw ones, with a squeeze of lemon and some extra virgin olive oil. Now there’s lunch!

Dinner was 1 serving (3 oz) of grilled fish fillet (pink salmon – 0 g carbs, 17.4 g pro, 3.7 g fat), ½ cup (125 mL) cooked quinoa (17.1 g carbs, 4.1 g pro, 1.8 g fat) and 1.5 cups green salad* with dressing (2.8 g carbs, 0.8 g pro, 2.5 g fat). What adult would find a small piece of fish, a small serving of quinoa and a small salad enough for supper — unless they had a big lunch?

*amount of salad chosen to bring total carb count for meal to the stated 20 g

Observations: I would probably encourage them to have more fish — especially a fatty fish like salmon, skip the quinoa entirely, and have a nice serving of grilled asparagus or roasted Brussel sprouts with it, along with the salad.  Their blood glucose would be much more stable and the person would not be hungry before bed.

What did this day provide, in terms of carbohydrate and total protein? Well, it was low carb (65.9 g) and adequate (71.4 g) protein, but had very few vegetables, little healthy fat, and very small portions.

Day 5

Breakfast was small glass of the same smoothie (28.4 g carbs, 8.9 g pro, 5.2 g fat) and that was it.

Observation: since the person would have had eggs the day before, they could have a nice big bowl of unsweetened Greek yogurt (which provides lots of protein), along with 1/2 of berries on top and a tablespoon or so of hemp hearts.  This would provide them with lots of protein to keep them satiated, and the intact berries and yogurt prevent the glucose spike of the acellular (ground up) smoothie.

Lunch was 1 egg on 3/4 cup of Mexican baked black beans (19 g carbs, 12 g pro, 9 g fat) and 1 cup unsweetened plant based beverage (7.6 g carbs, 0.4 g pro, 0.3 g fat). Nothing else. No veggies, no salad, not even a dollop of guacamole!

Observations: The same black bean recipe could be made with black soybeans which have huge amounts of protein, and few carbs. Served with the eggs, a dollop of homemade guacamole and a nice Mexican-style salad, this could be a lovely low carb lunch.

Dinner was 1 serving (3.5 oz) of beef or pork meatballs without sauce (10.5 g carbs, 19.3 g pro, 16.6 g fat) and ¾ cup (150 mL) of plain cooked pasta (30.5 g carbs, 6.1 g pro, 1.0 g fat). How is this an appropriate “low carb” dinner for someone with diabetes? How is this a complete meal?

Observations: Sure, make the meatballs (homemade is always better) and serve them with a nice sauce made with sautéed mushrooms and a bit of tomato sauce and throw in some dried (or fresh) herbs. Skip the plain pasta and serve the meatballs on top of spiralized zucchini that is cooked quickly in the microwave, with top with nice grating of parmesan. 

It was low carb (96.0 g) and adequate (46.7 g) protein for a sedentary woman but inadequate protein for even a sedentary man. It had few vegetables, very little healthy fat, and very small portions.

IMPORTANT NOTE: As I point out in the article “Don’t Try This at Home- the need for medication supervision“, if you are taking certain types of medication, do not begin to follow a very low carb (keto) diet — including the one which results with the example modifications above without first consulting with your doctor. These medications include;
(1) insulin
(2) medication to lower blood glucose such as sodium glucose co-transporter 2 (SGLT2) medication including Invokana, Forxiga, Xigduo, Jardiance, etc. and other types of glucose lowering medication such as Victoza, etc.
(3) medication for blood pressure such as Ramipril, Lasix (furosemide), Lisinopril / ACE inhibitors, Atenolol / β₁ receptor antagonists
(4) mental health medication such as antidepressants, medication for anxiety disorder, and mood stabilizers for bipolar disorder and schizophrenia.

Tying it all Together

There are parts of this menu that are certainly usable, and it can be modified to make it into a lovely low-carb meal plan.

The frittata, for example could be a great start to a low-carb lunch when paired with a nice big salad, with a bit of crumbled cheese, a few pumpkin seeds and a bit of avocado — and skip the bread!

Double the amount of tofu stew and vegetables, and make a nice Asian style cucumber salad on the side and skip the rice!

The cauliflower soup with a splash of cream and the grilled chicken breast would go every well with a nice helping of steamed veggies or mixed greens on the side — and why not? They are low carb, and high in micronutrients. The cooked ones would taste great with a dab of butter and the raw ones, with a squeeze of lemon and some extra virgin olive oil. Now there’s lunch!

And why on earth would a person with diabetes be encouraged to drink that smoothie 3 times per week if not to promote the product of one of the menu’s sponsors?  Why not suggest an omelette made with some leftover cooked veggies from the night before — and they could even add an ounce of sharp cheddar to it, which would easily get them through to lunch. Or, how about a bowl of Greek yogurt with 1/2 cup of blueberries and a tablespoon of hemp heart? That is a high protein breakfast with far fewer carbs than the smoothie and will keep a person going with stable blood sugars until lunch.

Ditch the carbs.  Who needs the bread and pasta and rice — especially on a “low carb” meal plan?

People can get all the B-vitamins they need, including B1 (thiamine), B2 (riboflavin), B3 (niacin) and folate from real, whole food such as chicken liver, sardines, eggs and sunflower seeds. They can plenty of the most bioavailable iron from seafood and meat and get ample magnesium from nut, seeds, dark chocolate and avocados, and selenium from Brazil nuts and eggs.

Final thoughts…

The American Diabetes Association understands that a low carbohydrate diet “limits sugar, cereals, pasta, bread, fruit & starchy vegetables” and “consist mostly of protein foods like meat and dairy, fatty foods like oil, nuts, seeds, avocado, and butter, and non-starchy vegetables” [2].

 

 

Canadian with diabetes deserve to have a low carb menu based on these same principals, and which provides them with adequate protein, a good source of healthy fats and adequate size servings of food.

Final thoughts…

In Diabetes Canada’s Position Statement released this past May, they acknowledged that a low carb and very low carb (keto) diet is both safe and effective for adults with both type 1 and type 2 diabetes to follow. Under the Five Recommendations, it states;

“Healthy low carb or very-low-carb diets can be considered as one healthy eating pattern for individuals living with type 1 and type 2 diabetes for weight loss, improved blood sugar control and/or to reduce the need for blood sugar lowering medications.”

How does the “low carb” meal plan that Diabetes Canada has released help people with diabetes with improved blood sugar control or a reduced need for blood sugar lowering medication?

We can do better.

Canadians with diabetes deserve better.

More Info?

If you would like more information about how what I do and how I do it, please have a look under the Services tab.

To your good health!

Joy

You can follow me on:

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Reference

  1. Diabetes Canada, 7-day low carbohydrate meal plan, https://diabetes.ca/nutrition—fitness/meal-planning/7-day-low-carbohydrate-meal-plan
  2. American Diabetes Association, Diabetes Food Hub, Meal Prep: meals for any eating pattern, Low Carb, https://www.diabetesfoodhub.org/articles/meal-prep-meals-for-any-eating-pattern.html

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

Diabetes Canada – “healthy” low carbohydrate meal plan

In May of last year, Diabetes Canada released a new Position Statement acknowledging that a low carb and very low carb (keto) diet is both safe and effective for adults with diabetes. The purpose of the Position Statement was to summarize the evidence for the role of low carbohydrate diets (<51-130g carbohydrate/day) or very low- carbohydrate diets (<50g carbohydrate/day) in the management of people diagnosed with type 1 and type 2 diabetes.

In their Position Statement, Diabetes Canada made five recommendations;

Diabetes Canada’s Five Recommendations

  1. Individuals with diabetes should be supported to choose healthy eating patterns that are consistent with the individual’s values, goals and preferences.
  2. Healthy low carb or very-low-carb diets can be considered as one healthy eating pattern for individuals living with type 1 and type 2 diabetes for weight loss, improved blood sugar control and/or to reduce the need for blood sugar lowering medications. Individuals should consult with their health-care provider to define goals and reduce the likelihood of adverse effects.
  3. Health-care providers can support people with diabetes who wish to follow a low-carbohydrate diet by recommending better blood glucose monitoring, adjusting medications that may cause low blood sugar or increase risk for diabetic ketoacidosis and to ensure adequate intake of fibre and nutrients.
  4. Individuals and their health-care providers should be educated about the risk of diabetic ketoacidosis while using SGLT2 inhibitors along with a low carbohydrate diet, and be educated in lowering this risk.
  5. People with diabetes who begin a low carbohydrate diet should seek support from a dietitian who can help create a culturally appropriate, enjoyable and sustainable plan. A dietitian can propose ways to modify carbohydrate intake that best aligns with an individual’s values, preferences, needs and treatment goals as people transition to- or from a low carbohydrate eating pattern.

Since that time, I hadn’t seen any announcements from Diabetes Canada providing support for Canadians with diabetes to follow a low carb or very low carb (ketogenic) diet — until this week, when I saw the following ad on Facebook:

Diabetes Canada – healthy low carb meal plan (low glycemic and plant-based), January 23, 2021

Clicking on the link associated with the ad, the text reads;

“Current evidence suggests that a low-carbohydrate diet can be safe and effective for people with diabetes. This dietary pattern can help with weight loss and blood sugar management. Keep in mind that a low-carbohydrate diet can also reduce the need for certain diabetes medications. People living with diabetes who want to follow a low-carbohydrate diet should seek professional advice from their healthcare provider to avoid any adverse effects, such as hypoglycemia (low blood sugar) or an increased risk for diabetic ketoacidosis (DKA).

This meal plan features healthy plant-based foods, low glycemic index carbohydrates, and less than 130 grams carbohydrates per day. [1]”

At the bottom of the meal plan it indicates;

sponsors of Diabetes Canada’s 7-day low carbohydrate meal plan [1]

Diabetes Canada’s 7-day Low-Carbohydrate Meal Plan

While the promotion of Diabetes Canada’s meal plan on Facebook indicates that it features ‘plant-based foods’, it is not a plant-based menu. It includes eggs and yogurt, fish (tuna, fish fillet, salmon),  a (bun-less) cheeseburger, beef or pork meatballs, and chicken breast — along with tofu, legumes such as chick peas and black beans. Not surprisingly given one of the sponsors of the menu, each day includes servings of plant-based beverages.

At least once per day, there are meals which include sides of starches such as bread, potato, rice, pasta or legumes — none of which are considered part of any established “low carb” diet. Starches like bread, pasta and rice are just long chains of sugar molecules strung together like pearls on a thread and as I explain below, even usual servings of “whole grain” ones do not have a low glycemic load, just lower than the refined white version.

Breakfast on day 1, 3 & 5 of the menu features a smoothie made with 200 ml Silk Soy Original Beverage, a sugar-sweetened soy beverage manufactured by one of the menu’s sponsors, along with 2 kinds of pureed fruit. This is hardly the best way for someone with diabetes to begin the day. While the recipe boasts that is has 7 g of fiber, subtracting the fiber from total carbohydrate is only appropriate in intact, whole foods, not acellular foods (i.e. ground up) such as a smoothie. As elaborated on in a previous post, The Perils of Food Processing  a whole apple, the same-sized apple pureed into apple sauce, or the same-sized apple turned into apple juice have a very different effect on blood sugar — with the juiced fruit causing the largest blood sugar  and insulin spike (see Perils of Food Processing Part 1 and Part 2). If not to promote the product of one of the sponsors, why else why would such a smoothie be recommended to someone with diabetes to have 3 times a week for breakfast? 

Lunches and Dinners include either a slice of whole-grain bread, 1 small baked potato, 1/2 cup cooked brown rice, 3/4 cup (150 ml) cooked pasta, 1/2 cup (125 ml) mashed sweet potato or chick peas or black beans. First of all these are not “low carb” foods — not on any established low carbohydrate diets. Second of all, even so-called “low glycemic foods” such as brown rice has a glycemic load of 20 per cup, which most people consider a usual serving. The same is true with spaghetti (which on this menu isn’t specified as being whole grain or white). One cup of cooked whole grain spaghetti (which most people consider to be a usual serving) has a glycemic load of 14, compared to white spaghetti with a glycemic load of 25 — which is still high, just lower than white spaghetti. Someone following this menu could easily choose 1/2 cup of white spaghetti for a glycemic load of 12.5, which is considered high, not low.

Note: One usual serving of a food is considered to have a very high glycemic load if it is ≥20, a high glycemic load if it is between 11-19 and a low glycemic goad if it is ≤10.

Sure, small amounts of sweet potato can be appropriate as part of a real, whole food low carbohydrate meal plan, and a small amount of chick peas or black beans can be included from time to time, but there is no established “low carb” diet that includes bread, rice or pasta, nor does it need to. 

In addition, given the other sponsor of this plan, it is understandable why food is recommended to be cooked using ‘vegetable oil’ (i.e. canola oil) or that canola oil in particular is specified. Why not leave people to choose avocado oil or olive oil or some other fat, except to promote the product of one of the sponsors?

Diabetes Canada – reduced sodium, lower fat, optional added sugar, dairy substitutes

A closer look at the recipes in this 7-day menu indicate that ingredients are specified as being reduced-sodium* and light**lower fat, and include the optional inclusion of granulated sugar***.

When specified, beverages at meals feature soy or oat plant-based beverages and while I understand the reason for this given that one of the sponsors is a plant-based beverage producer, why the emphasis on reduced sodium, and reduced fat ingredients?

* recipes specify the use of canned reduced-sodium diced tomatoes, reduced-sodium chicken broth or reduced-sodium vegetable broth, and reduced-sodium black beans.

**the Indonesian Tofu Stew specifies using “light” (i.e. reduced fat) coconut milk.

***the stir-fried eggplant with miso recipe includes 1½ tbsp. (23 mL) granulated sugar, although it is listed as ‘optional’.

What is the basis for recommending lower fat coconut milk when a state of the art review published last year in the Journal of the American College of Cardiology reported no beneficial effect on either cardiovascular disease (CVD) or death of lowering saturated fatty acid (SFA) intake, and that saturated fat intake was found to be protective against stroke [2]? A meta-analysis of 43 cohort or nested case-control studies published in 2019 did not find that higher saturated fat intake was associated with higher risk of cardiovascular disease (CVD) events [3], and data from the November 2017 Prospective Urban and Rural Epidemiological (PURE) Study [4] — the largest prospective epidemiological study to date involving 90,000 people from 18 different countries found that dietary saturated fat was actually beneficial; with those who ate the largest amounts of saturated fat having significantly reduced death rates, and that those that ate the lowest amounts of saturated fat (6-7% of calories) had increased risk of stroke [4].

Why the recommendation for using reduced-sodium ingredients, when the 2018 results from the Prospective Urban and Rural Epidemiological (PURE) Study mentioned directly above found that average intakes of three to five grams of sodium per day were not linked with higher rates of blood pressure or stroke [5]?

Why the recommendation for the daily inclusion of carbohydrate-centric foods such as bread, potato, rice or pasta in a “low carb” diet? What other established “low carb” diet includes these foods? Including these continues to perpetuate the belief that somehow carbohydrate-based foods are ‘necessary’ — even though the Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids[6] has established there there no requirement for eating carbohydrate provided that adequate amounts of protein and fat are consumed (more about that here). For what it’s worth, carbohydrates in a well-designed low carbohydrate meal plan are available in the servings of low-carbohydrate vegetables and small servings of starchy vegetables (such as squash and yam). Bread, pasta, and rice need not be added.

We Can Do Better – changing the paradigm

A low carbohydrate meal plan of <130 g carbohydrate per day (and a very low carbohydrate / ketogenic meal plan) can easily be designed centering on real, whole foods. — I do it all the time!

Breakfast can be built around eggs dishes including a frittata or omelette, or Greek yogurt with a few berries.

Lunches and dinners can feature a wide variety of low-carb vegetables, small servings of higher carbohydrate vegetables such as yam or squash, along with servings of animal- or plant-based protein. These are meals that are consistent with Diabetes Canada’s first recommendation that “individuals with diabetes should be supported to choose healthy eating patterns that are consistent with the individual’s values, goals and preferences”. Certainly, there is no need to encourage those with diabetes to use cane sugar sweetened milk substitutes with two types of fruit to start their first meal of the day! We can do better.  We need to do better.

Except for those with very specific health conditions outside of type 2 diabetes, there is no need for Diabetes Canada to recommend that people choose “low fat” or “light” products, or “reduced-sodium” foods. Real, whole food as outlined above is naturally high in potassium and low in sodium — furthermore, when people lower their carbohydrate intake to less than 130 g per day, the body loses sodium in the urine and there is a need to add sodium to replace it. Studies do not support that for most people, eating the fat that comes naturally with animal-based foods such as cheese, meat or coconut milk poses any health risk. Coffee can be enjoyed with a splash of cream if someone chooses or with a plant-based substitute, if that is their choice.

Without article “sponsorship”, people following a low-carbohydrate diet can be encouraged to choose from a a wide range of cooking fats — from avocado oil and butter to coconut oil (which is not, as some claim, “pure poison”) — without the need to consider using a sponsor’s seed oils.

Final Thoughts…

We need to communicate that there is a wide range of low carb options available, including plant-based ones for those with that preference — while not perpetuating the outdated paradigm that saturated fat and sodium are automatically “bad”, or that carb-based food such as bread, pasta and rice are an essential part of a meal, even a “low carb” meal.  

Canadians with diabetes deserve much more appropriate low carb guidance than this industry-sponsored meal plan provides.


UPDATE (February 1, 2021):

The American Diabetes Association’s definition of a “low carb” meal plan is very different than Diabetes Canada’s.
The American Diabetes Association understands that a low carb meal plan “limits sugar, cereals, pasta, bread, fruit & starchy vegetables.
 
YET
 
Diabetes Canada’s new “low carb” meal plan includes these types of foods daily
 
Why? 
 

More Info?

If you would like more information about how I design low carb and very low carb Meal Plans, please have a look under the Services tab or in the Shop.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

References

  1. Diabetes Canada, 7-day low carbohydrate meal plan, https://diabetes.ca/nutrition—fitness/meal-planning/7-day-low-carbohydrate-meal-plan
  2. Astrup A, Magkos F, Bier, DM, et al, Saturated Fats and Health: A Reassessment and Proposal for Food-based Recommendations: JACC State-of -the-Art Review, J Am Coll Cardiol. 2020 Jun 17. Epublished
  3. Zhu Y, Bo Y, Liu Y, Dietary total fat, fatty acids intake, and risk
    of cardiovascular disease: a dose-response meta-analysis of cohort studies, Lipids in Health and Disease (2019) 18:91, https://doi.org/10.1186/s12944-019-1035-2
  4. Dehghan M, Mente A, Zhang X et al, The PURE Study – Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. Lancet. 2017 Nov 4;390(10107):2050-2062
  5. Mente A, O’Donnell M, Rangarajan S, et al. Urinary sodium excretion, blood pressure, cardiovascular disease, and mortality: a community-level prospective epidemiological cohort study. Lancet (London, England). 2018 Aug;392(10146):496-506. DOI: 10.1016/s0140-6736(18)31376-x.
  6. National Academies Press, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005), Chapter 6 Dietary Carbohydrates: Sugars and Starches”, pages 265-275

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

 

A Dietitian’s Journey – to Covid and back

It’s been a while since I wrote an update to A Dietitian’s Journey but it’s “time”. A lot has happened since then.  Last year at this time, I wrote one of my last updates about my most recent lab tests and coming to terms with what 55 pounds of weight looks like as compared to a 5 pound fat model I had purchased for use in my practice. Not quite 2 weeks later, I posted the first of several articles about a novel coronavirus that was discovered in Vancouver, in someone who had not visited China. At this point, the virus did not yet have a name — a name we all know too well now, Covid.

How the world has changed since then.

We have all been through many changes. Some of us have had family succumb to Covid, others of us have had people we know live through it, and some of us have had it ourselves.  We’ve all had our movements limited to varying degrees, and have faced shortages of everything from food to bathroom tissue. Some have lost their businesses, their homes and their sense of security due to Covid, while many of us haven’t seen loved ones in what seems like way to long, because it is.

And we’re not “done” it seems.

Even with the two mRNA Covid vaccines that are currently being given, we are being told that it may only keep the person themselves from getting sick, but that they still may be able to transmit the virus. We’ve also become aware recently that the studies are based on a specific timing between the first and second dose — something other than what reality is dictating. We wonder if the arbitrary timings, or the mix and match vaccines will be anywhere “as effective” as studies indicated, or effective at all.

Shifting Gears

In mid-July, after making the decision to close my in-person professional office, I had a photoshoot to get ready to re-launch my Dietetic practice as on-line only. Due to Covid, the photographer wore a mask the entire time. Whenever I went out to get groceries, I too wore a mask and sanitized my hands frequently. Nevertheless, two week’s later I was sicker than I had been in years.  Because of Covid being “a thing” and the unusualness of my symptoms, as I did with my weight- and health-recovery journey, I kept notes about my symptoms and how long they lasted. While I never had a fever or a cough, I found out at the time that only 50% people get either. That’s not what I had thought until I looked it up — in fact all the “warning” information at the time listed fever and cough as ‘first’.

Covid – not what I would have expected

I had symptoms that I didn’t think were ‘typical’  of Covid, including back pain, and a non-stop headache.  While the temperature outside had soared to the mid-30s°C  (~100° F), I had blue lips and just couldn’t stop shivering. The headaches wouldn’t let up, and then there were the muscle aches that had set in. I called my doctor and let him know I was self-isolating but since the line-up for a nasal swab at that point in time was ~ 6 hours, there was no way I was up to doing that. He recommended that I continue to self-isolate for 2 weeks in total and assume that I was positive, which is what I did. The muscle pain and weakness and tingling and numbness in my fingertips left me unable to do much else, anyways. I still worked part days and when I wasn’t working, I was resting. After 3 weeks, I stopped keeping notes, because the lingering symptoms were the same.

Lingering Disability

After all was said and done, what remained was muscle weakness and joint pain. The joint pain I understood having been under the care of a rheumatologist for a year after being diagnosed with post-viral arthritis after contracting rubella in my early 20s. At that point, the pain was in my hands, feet and hips, not my knees, but since both post viral arthritis and reactive-arthritis are both documented post Covid, it made sense.  The lingering muscle pain did not.

I went from being reasonably active and fit in the spring, to finding it difficult to even walk up or down a flight of stairs by August. I expected it somewhat while I was sick, but what I didn’t expect was to have come very close to losing my mobility. This scared me. No one loses mobility that quickly!

The some pieces started to come together. I stumbled across an article about Covid that was written by an MD from UT Southwestern Medical Center in Texas and which indicated that pain and muscle weakness is known to be related to actual muscle damage resulting from the illness [1]. 

“A study published in Emerging Infectious Diseases found that rhabdomyolysis, a breakdown of muscle tissue, may be a late side effect of the virus. During this breakdown, enzymes such as creatine kinase and lactate dehydrogenase enter the bloodstream.”

At the time I was telling friends and family members that it felt as if I had ‘lactic acid build up in my muscles’, except that I didn’t do any exercise. The article resonated. Lactic acid IS lactate dehydrogenase. It was like a bread-crumb trail in which the various pieces ‘fit’.

The Road to Recovery

Once I was well enough, I began to go for walks, even though it was very hard. Just walking the stairs was hard. I forced myself to walk.  My first walks were literally around the block, and were difficult.  I kept at it.  One of my young adult sons kept encouraging me to walk, and would go with me.  As my legs became stronger, walks turned into short ‘hikes’. I discovered I really liked being out in the woods, even though it remained very hard to step up onto rocks, or step down from them.  I dug out my wood hiking staff that I brought with me when I moved from California and put it into service. Wearing winter boots wasn’t working out, so after my first ‘hike’, I ordered my first pair of hiking boots. It ended up being the beginning of several orders in order to get the ‘essentials’.

November 21, 2020 – Hike # 3 – Golden Ears Provincial Park, East Canyon

My hiking stick, along with my fuchsia rain gear has become somewhat of an identifier– but the truth is, without the hiking stick, I could not have possibly begun to hike.

Each week, I pushed myself a little harder and did a little more.

On hike #3 to Golden Ears Provincial Park, I met Jackie and her husband and found out from her about a local ladies hiking group, and joined as soon as I got home. There are no group hikes currently for obvious reasons, but those days will come.

Hike #4, November 28, 2020, Buntzen Lake

On November 28, 2020, I did hike #4 at Buntzen Lake. It was 12 km and was really beyond what I was capable of, but with frequent stops and the encouragement of one of my young adults sons, I did it.

I had to. My son couldn’t exactly carry me back.

I came home exhausted, but feeling very satisfied.  I had almost lost my mobility, but I didn’t.

That day, I felt as though I had ‘won’.

When I got home, I decided to invest in myself and ordered some more essential hiking gear.

Hike #5 – December 5, 2020, UBC Malcolm Knapp & Golden Ears East Canyon

At the beginning of December, I hiked the Red Trail at Malcolm Knapp, but found it too short, so then hiked the Yellow trail, too. I found them easy and there was still time before it would start to get dark. My legs were stronger than they had been in ages, so I drove over to Golden Ears to do the East Canyon again, which was my first real “hike”.

It felt amazing!!

For the first time since I got sick, I felt like “me” again.

December 12, 2020 was hike #6 to North Vancouver, and the Lower Lynn Valley Trail.

We didn’t expect to encounter snow when we set out up the trail, but there was plenty of it about half way up and it got heavier. It made things slippery. I hadn’t yet bought mud or ice ‘crampons’, but I soon realized I would need these next.

Even though it wasn’t that cold, I experienced some numbness in my fingertips — like I did when I had the virus. I tried to ignore it, but found it very disconcerting.

Hike #6, Dec. 12, 2020, Lynn Valley Loop, North Vancouver

I borrowed a pair of heavily insulated gloves, but it took a good hour before I could feel my fingers again. Little reminders like this pop up now and then, reminding me that what I had was nothing like anything I had experienced before.

December 19th was just a local hike along the Coquitlam River, to Crystal Falls.  It had been raining a lot the previous week, and the trail was very muddy. Each hike presents new challenges to my recovering muscles — sometimes trails are rocky, other times made from bark and peat moss, then there is snow and ice, and slippery mud.  Each change in the environment forces me to use muscles that I hadn’t in previous hikes or use them in different ways — and this is exactly what I have needed to recover my strength and mobility.

As I had to do in my first hike at Golden Ears, this trail had streams to cross by stepping on rocks.  It required some degree of co-ordination and agility that I used to have, but had lost. It was perfect “rehab”.

I misstepped and totally soaked one foot, but thankfully the hiking socks I had bought did their job. Nothing was going to deter me.  This was therapy — both for my  body and soul.

Hike #8 January 16, 2021, Jug Island

Hike #8 on January 16, 2021 was the first of the new year. It had been two weeks that I hadn’t hiked and I was apprehensive that I wouldn’t make it. It started out very steep and I almost chickened out.  My son encouraged me that “we are here now” and so I pushed myself on.  It was hard. There were step-ups that I couldn’t do, but I was determined to make myself do them by engaging my core, my knee muscles and my glutes.  When all else failed, there was my hiking stick!

 

There were three ascents on the trail and when I completed the final one, I caught view of the salt water of Indian Arm and Jug Island.  The view was beautiful and so serene.

I made it! 

Of course, I still had to hike all the way back. Again, what choice did I have? I was there and had to go back.  Since there was no way of backing out, I just did it. It felt like I conquered something, even if it wasn’t impressive by anyone else’s standards.

This past weekend I did Hike #9 at Lighthouse Park, in West Vancouver.

We took a wrong turn on the trail and ended up on some other trail than the one we planned but it served the purpose of exercising my legs, knees and glutes.  Then we headed over to the coast to enjoy the sound of the water lapping on the shore and the clear winter sun.

Hike #9, January 23, 2021, Lighthouse Park, West Vancouver

With difficulty, I managed to hike down on the large rocks and between the crevices and when all else failed, there was my trusty hiking stick.

Nothing was going to stop me.

Not the virus. Not the after effects and not my discouragement.

 

 

 

UPDATE (January 31, 2021): Reality and determination are separate things.  I am reluctantly learning to balance the ‘work’ needed to rebuild the muscle that supports my knees, with the ‘rest’ required due to post-viral arthritis in the joints themselves. I am just hoping the latter doesn’t take the year it did when I was in my early 20s, after I contracted rubella.

In a way, my current “health recovery” is not unlike the one I began 3 years ago in March. It requires the determination of doing it as if my life depends on it, because it does.

While I got through half of the pandemic without weight gain, the month long virus and residual symptoms took their toll.

Like many others, I am 19 pounds up — my Covid 19.

Without access to antibody testing, it is officially unknown what I had but presumed to have been Covid. Given the symptoms I had and especially the residual effects, I think it’s reasonable to suspect what it was. At some point, I will know for sure.

Losing My Covid-19

This morning I decided to take pictures of what I look like currently, and have started on a new goal of re-attaining my previous weight by what would have been my father (of blessed memory)’s birthday.

By May 1, 2021 (13 weeks from now) I intend to lose the weight that I gained which is mainly sitting in the worse place possible health-wise — around my middle. 

I am posting this to encourage others that while re-gaining lost weight is not ideal, life happens.

The last year has been anything but normal. Just as I lived my “journey” out in the open from beginning to end — from being an obese Dietitian with type 2 diabetes and high blood pressure, to being normal body weight and waist circumference and in remission of those metabolic conditions, I am doing the same this time. I am not letting my current weight discourage or dissuade me. It is what it is.

If you’ve put on weight during the pandemic — regardless the reason, I invite you to join me on the road back.

To our good health!

Joy

 

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

References

Barker, Kim MD, Life after coronavirus: Physical Medicine and Rehabilitation (PM&R) helps patients beat muscle weakness, brain fog,  UT Southwestern Medical Center, June 4, 2020.

Jin M, Tong Q. Rhabdomyolysis as Potential Late Complication Associated with COVID-19. Emerg Infect Dis. 2020;26(7):1618-1620. https://dx.doi.org/10.3201/eid2607.200445

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

 

 

Individual Meal Plan versus Personalized Online Meal Plans

Why would someone seek out my professional services to design a low carb or ketogenic meal plan for them, when there are any number of online services that will make ‘personalized’ or ‘customized’ meal plans for free- or only for the cost of a monthly membership?

There is a big difference between an Individual Meal Plan designed for someone by a professional and which is specific to their health background and risk factors, and personalizing or customizing an existing meal plan to a person’s goals, likes and dislikes, using a computerized algorithm.

There are a number of websites that encourage people to use their tools to reach their weight loss goals faster.

One email I received said recently read;

“Tell us what your health goals are and what you like to eat. In minutes, you’ll have a custom-made keto or low-carb meal plan. It’s the perfect meal plan for you.”

This site and other similar types of websites calculate the protein, carbs, fat and total calories for a person to reach their weight goals based on their own computer algorithm, and then provide recipes based on the person’s likes and dislikes that fit those “macros”. The question is will it be the perfect meal plan for you?

It may, or it may not.

Those Without Pre-Existing Conditions

If you have not been diagnosed with type 2 diabetes or pre-diabetes, have normal blood pressure and cholesterol, and have not been diagnosed with any other health conditions and just want to lose weight, then one of these online diets that can be personalized or customized with your likes and dislikes may be a good way to get started. Speak with your doctor before beginning any diet, including one I may design for you.

Some sites and algorithms may be better than others, so look around. In general, I would consider whether a website provides scholarly references in their blogs as possibly being a better place to start, over websites that don’t list their source of information (more about that in this article).

It has been my experience that ~1/3 of clients end up coming to me after doing one of these online low carb or keto diets. Some reach out when they find themselves stuck in a long-term weight-stall, after initially losing some weight. Others, especially peri- and post-menopausal women come to me after they don’t lose weight or in some cases, gain weight. The “macros” may fit the particular website’s algorithm, but not them.

There are also some people who lose weight just fine using an online diet, but end up contacting me after their follow-up lab tests indicate that their cholesterol has gone up a lot, and their doctor wants to put them on medication. Then what?

…and of course, there are those who lose weight successfully with no negative outcomes whatsoever and that is great stuff!

The question is, are online meal plans a good approach for you?

Those With Pre-Existing Conditions

If you have been diagnosed with type 2 diabetes or pre-diabetes, have high blood pressure or cholesterol, then working with a professional is important — especially if you are taking medication. As outlined in a previous article, people should not begin a low carb or very low carb (keto) diet if they are taking certain types of medication, especially:

(1) insulin

(2) medication to lower blood glucose such as sodium glucose co-transporter 2 (SGLT2) medication including Invokana, Forxiga, Xigduo, Jardiance, etc. and other types of glucose lowering medication such as Victoza, etc.

(3) medication for blood pressure such as Ramipril, Lasix (furosemide), Lisinopril / ACE inhibitors, Atenolol / β₁ receptor antagonists

(4) mental health medication such as antidepressants, medication for anxiety disorder, and mood stabilizers for bipolar disorder and schizophrenia.

When people approach me for services and are taking insulin or insulin analogues, I refer them to someone with CDE certification who can help them to adjust their dosage, as carbohydrates are gradually reduced. I am not a CDE and do not see people taking insulin or insulin analogues. That said, I have worked with people’s doctors who have gradually deprescribed insulin, as their patients begin to follow a low carbohydrate Meal Plan that I have designed for them.

For those who are taking some of the other medications listed above and with people’s written permission, I coordinate care with their doctors who oversee their patient’s care and adjust medication dosages, as the quantity of carbohydrate is gradually reduced.

This is definitely not something people should do on their own!

As outlined in the article referred to just above, depending on the medication there can be serious side effects.

But what if you don’t have any health conditions and don’t take any medications? Does that mean you are “fine”? Maybe, maybe not.

Very Few People Are Metabolically Healthy

A study published in November 2018 in the journal Metabolic Syndrome and Related Disorders found that 88% of people are already metabolically unhealthy[1].

If you have not been told you have diabetes or pre-diabetes, high blood pressure or high cholesterol, then how do you know if you are among the 12% that are still metabolically healthy?

Here are a few questions that you can ask yourself to help you determine if you may be part of the small metabolically healthy group of people — or part of the 88% that are already metabolically unhealthy:

Are you carrying excess weight around the middle? If you are a guy and your waist circumference > 40 inches or 102 cm or are a woman and your waist circumference >34.5 inches (88 cm) then the answer is you are already part of those who would be considered metabolically unhealthy [1].

An even easier way is to measure your waist-to-height ratio as described in this article, and if the result is more than 0.50 then you are at increased risk of cardiovascular disease[2]. If you have already been told that you have type 2 diabetes or pre-diabetes, high blood pressure or high cholesterol, then your risk is even higher.

Do you have blood pressure higher than 120/70? If either the top number (systolic blood pressure) is larger than 120 and the bottom number (diastolic blood pressure) is larger than 70, then you are part of those who would be considered metabolically unhealthy, based on this study.

Do you have high fasting blood sugar? Is your blood sugar measured first thing in the morning after not eating anything for 10 or 12 hours  > 5.5 mmol/L (100 mg/dL)? If yes, you are already part of those who would be considered metabolically unhealthy.

If your fasting blood glucose test comes back normal, does this mean everything’s “fine”? Maybe yes, maybe no. This previous article explains the different stages that exist before people are diagnosed as having pre-diabetes –when their fasting blood sugar is fine, but their ability to regulate blood sugar is already ‘not fine’.

What about your insulin response? A large-scale 2016 study found that 75% of those with normal fasting blood sugar and normal blood sugar after a 2 hour Oral Glucose Tolerance Test had abnormal blood sugar results between 30 minutes and 60 minutes — indicating that they were at increased risk of being diagnosed with type 2 diabetes, even though their 2 hour Oral Glucose Test results were still normal.

Is your three-month estimated average blood sugar (HbA1C) high? If your HbA1C is > 5.7% then you are already showing signs of being metabolically unhealthy.

Do you have “high cholesterol”? Are your triglycerides > 1.7 mmol/l ((150 mg/dl) or your HDL (good cholesterol) < 1.00 mmol/L (<40 mg/dl) if you are a man or >1.30 mmol/L (50 mg/dl) if you are a woman, then based on this study you are already considered metabolically unhealthy.

Getting an Individual Meal Plan?

If you have already been diagnosed with any of the conditions mentioned above — and especially if you are taking medication for them, then speak with your doctor about working with a Registered Dietitian such as myself to design an Individual Meal Plan for you. Some physicians and other healthcare professionals who are familiar with the therapeutic benefits of a low carb or very low carb (keto) diet refer their patients to me, and we work together to coordinate care, as described above.

I design people’s Meal Plan based on their specific macronutrient needs, taking into account their age, gender, stage of life, health history and previous diagnoses, lab work, any medications taken, food likes and dislikes, religious preferences, time constraints, as well as cooking ability. I design each person’s Meal Plan in such a way as to be as close to how they like to eat, with the “fixes” built in.

For those who don’t know if they are metabolically healthy or not, we find out in the course of me assessing them as I look at all of the parameters outlined above. If they are already showing signs of being metabolically unhealthy, then I will design their Meal Plan in such a way as to enable them to make dietary- and lifestyle changes that may delay- or even prevent diagnosis of some of the conditions mentioned above.

Final Thoughts

The “best macros” are the ones designed for each person in light of any health conditions and risk factors.

There is no one-sized-fits-all low carb or keto diet©

More Info?

If you would like more information about my services, then please have a look under the tab of that name or send me a note through the Contact Me form.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

References

  1. Araújo J, Cai J, Stevens J. Prevalence of Optimal Metabolic Health in American Adults: National Health and Nutrition Examination Survey 2009–2016. Metabolic Syndrome and Related Disorders Vol 20, No. 20, pg 1-7, DOI: 10.1089/met.2018.0105
  2. Ashwell M, Gunn P, Gibson S (2012) Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review and meta-analysis. Obes Rev 13: 275–286

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

How Much Protein Interferes with Ketosis or Stresses the Kidneys?

This past week there was an online post about the need to restrict protein when following a keto diet because too much protein will lead to lower levels of ketosis.  Other online sites that many people think of as credible say that eating too much protein causes the body to use glucose instead of ketones, knocking a person out of ketosis [2] — and will refer to ‘experts’ they’ve spoken to as sources. Do we need to limit protein and carbs? Who should we believe?

This is the post from social media that I saw this week that resulted in much discussion online, but I have edited out the name of the site because I have no issue with the website, or the author of the article.  I am only using it as an example of the type of information that is being widely circulated, often without references.  It reads;

“Too much protein can lead to lower levels of ketosis. Make sure that you track what you eat and monitor the amount of protein you’re eating. The average person only needs about 70-90 g of protein per day.”

The article from the same web site[1] , presumably to which the post refers says that ‘ideal protein intake’ depends on genetics, gender, current macro intake, insulin sensitivity, how long you’ve been on keto, activity levels, current body composition and body composition goals[1], but that there is “no need to plug all these factors into a complex algorithm to figure out how much protein you can get away with eating”. They say that “most keto dieters”  can follow the general protein recommendations they outline, namely:

Sedentary — consume 0.6 – 0.8g of protein per pound of lean body mass

Regularly active — have 0.8 – 1.0g of protein per pound of lean body mass

Lift weights — eat 1.0 – 1.2g of protein per pound of lean body mass

No references are provided in the article for the above recommendations, so how do we know?

What are evidence-based protein recommendations for those following a non-therapeutic ketogenic diet* ?

*I define therapeutic ketogenic diets as one used in the treatment of a disease, such as the classic Ketogenic Diet (KD), the Modified Ketogenic Diet (MKD), the Modified Atkins Diet (MAD). You can read more about those here.

More on that below, but first a few words about how to determine if a source of information is credible.

Scholarly Sources / References

When I cite references in my articles, it is to support the evidence for what I am writing about. As much as possible, I prefer to cite academic, peer-reviewed research papers — which means that not only are they written by experts in the field, the papers are first reviewed by other experts in the field (i.e. peer-reviewed) before the findings are published in a journal.

I also refer to published standards such as the Dietary Reference Intakes, for example and will also refer to books written by experts in the field who have previous publications in peer-reviewed journals or books for which references can be found.

I cite scholarly sources because I don’t want people to take my word for it, even though I am a published researcher with academic credentials. My readers can check the references in my articles and verify that they say what I wrote.

All too frequently, people online will say they got their information from a Mayo Clinic article, Healthline or a ‘keto’ website where the person writing the article is neither a researcher with academic credentials, nor cites scholarly sources.

There is no way to verify what is claimed as there is no trail to follow.

It may the writer’s opinion, or the opinion of an ‘expert’ they talked to, but if one can’t read the academic source of the claim, then it should be assumed to be the writer’s opinion, not evidence-based science.

Recommended Protein in a Well-Designed Ketogenic Diet

As written about in the previous article, A Keto Diet is NOT About How Much Fat it Contains, Dr. Stephen Phinney, MD, PhD and Dr. Jeff Volek, RD, PhD in their 2011 book, the Art and Science of Low Carbohydrate Living  recommend that carbohydrate intake be 7.5-10% of calories for men, 2.5-6.5% of calories for women, protein intake to up to 30% of calories during weight loss and 21% during weight maintenance and fat intake to 60% of calories during weight loss and 65-72% during weight maintenance [2].

In relation to protein intake alone, Phinney and Volek elaborate that;

“…our studies of muscle retention and function during carbohydrate restriction [27,78,87], we recommend daily protein intakes between 1.5 and 2.5 grams per day per kg of reference body weight* [5].”

*reference body weight is an estimate of lean body mass — and is essentially the midpoint of the ideal body weight IBW range, by gender. 

That book was written in 2011, so this morning I decided to look into what their current protein recommendations are — in light of their ongoing research in the field of ketogenic diets.

The excerpt below is from an article written by Dr. Stephen Phinney, MD, PHD, Dr. Jeff Volek, RD, PhD and Brittany Volk, PhD, RD on the Virta Health page, in an article titled “How Much Protein Do You Need In Nutritional Ketosis?”[4]

NOTE: While this is from an article, peer-reviewed academic references are provided and it is written by well-established researchers in the field. On that basis, I consider this to be a credible source of information.

“While a precise analysis of dose-response to varying protein intakes during nutritional ketosis has not been done in humans, we have performed a number of studies indicating that most healthy humans maintain lean body mass and function during a ketogenic diet providing between 1.5 and 1.75 grams of protein per kg of ‘reference body weight’ (Phinney 1983, Davis 1990). Furthermore, there are no convincing human studies showing any benefit from dietary protein above 2.0 g/kg reference weight for adults following a ketogenic diet.

.
.
.

Once through the first few weeks of keto-adaptation, there does not appear to be any reason to change one’s dietary protein intake either with further time of adaptation or cumulative weight loss. The exception would be if blood ketones remain low (i.e., below 0.5 mM) despite tight carbohydrate restriction, in which case reducing protein from the 2.0 to 1.5 g/kg or even to 1.2 g/kg reference weight range might be reasonable.”

How Much Protein Interferes with Ketosis?

There is a reason Phinney, Volek and Volk do not recommend protein intakes in excess of 2.0 grams protein / kg reference body weight per day for those following a ketogenic diet:

“Protein has a moderate insulin stimulating effect; and though less than the impact of a similar amount of carbohydrate consumption, high protein intakes can drive down ketone production in the liver (Marliss 1978). In fact, specific amino acids like alanine are potently anti-ketogenic. Additionally, when consumed to excess, protein can upset gastro-intestinal function and place a stress on the kidneys to remove the additional nitrogen.”

That is, protein intake above 2.0 grams protein / kg reference body weight per day is not recommended for those following a ketogenic diet as it may reduce the amount of ketones the liver produces, and it may put stress the kidneys to remove the excess protein. But 2.0 grams of protein / kg of reference body weight per day is a huge amount of protein (more on that, below).

The Recommended Dietary Allowance (RDA) for protein is 0.8 grams of protein per kg per day, which is the level that is sufficient to meet the requirements of 97 – 98 % of healthy people. This is not the optimum requirement but the minimum.

As outlined in a previous article based on a lecture by Dr. Donald Layman, PhD, Professor Emeritus, University of Illinois, the maximum of the range of safe intake is ~200 gram protein per day and is based on >2.5 grams protein per kilogram per day.  According to Dr. Layman, a high protein diet doesn’t start “until well above 170 g / day“.

Recommended Daily Allowance (RDA) for Protein [slide from Dr. Donald Layman, PhD – The Evolving Role of Dietary Protein in Adult Health]
Just how much protein-based food does one actually have to eat to get even 100 grams of protein, let alone more? It’s a lot more than commonly thought.

How many grams of protein is in what we call ‘protein foods’? Here are some examples from a previous article.

Egg (1 large) – 6.3 grams

Sausage, pork link (14 gm / 0.5 oz each) – 2.5 grams

American cheese (28 gm / 1 oz.) – 7 grams

Cottage cheese (250 ml / 1 cup) – 28.1 grams

Salmon (170 gm / 6 oz.) – 33.6 grams

Ham (170 gm / 6 oz.) – 35.4 grams

Tuna (170 gm / 6 oz.) – 40.1 grams

Chicken, breast (170 gm / 6 oz.) – 37.8 grams

Broiled Beef steak (170 gm / 6 oz.) – 38.6 grams

Hamburger (170 gm / 6 oz.) – 48.6 grams

Turkey, dark meat (170 gm / 6 oz.) – 48.6 grams

Pork Chop (170 gm / 6 oz.) 49 grams

Beef (170 gm / 6 oz.) – 54 grams

Final Thoughts

As outlined in many previous articles,  a low carbohydrate or ketogenic diet is defined by how little carbohydrate it contains, not how much fat or protein it has.

It is a myth that there is such as thing as THE keto diet. There are many types of keto diets, with the popularized very high fat ‘keto diet’ promoted widely in the media being one type.

It is also a fallacy that the average healthy person following a low carbohydrate or ketogenic diet for weight loss or health improvements needs to limit protein.

Each individual’s macro needs (energy, protein, fat and carbohydrate) are different and vary depending on a person’s age, gender, stage of life, health conditions and activity level, so choosing the appropriate level of protein, fat and carbs in a low carbohydrate or ketogenic diet needs to be based on those — and what a person is seeking to accomplish. Is it weight loss? Is it lowering blood sugar levels? Is it optimizing health? Different goals also influence how macros are established.

We should not fear carbohydrates. They are part of real, whole foods such as low carb vegetables and fruit — and even higher carbohydrate vegetables such as yam or squash can be included in reasonable quantities in a well-designed low carbohydrate or non-therapeutic ketogenic diet and when we eat them in a meal can significantly lower their impact on blood sugar and insulin levels. We limit them to achieve our weight-loss and health-goals, but we need not nor should not avoid them.

There is no need to limit protein or in most cases to even count it except when ensuring it is adequate based on individual need. Older adults, for instance need more not less protein to lower the risk of sarcopenia, which is muscle loss as we age.  It is very hard to exceed the range of safe intake for protein while eating real, whole food. There are individual cases where someone may need to monitor intake such as in pre-existing chronic kidney disease, but for the average person following a well-designed low carb or ketogenic diet, this is unnecessary.

What are “the perfect macros”?  They are the one’s based on your needs and your goals.

There really is no one-sized-fits-all low carb or keto diet.

More Info?

If you would like more information about my services then please have a look under the tab of that name or send me a note through the Contact Me form.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Clarke, Craig, ruled.me, November 30, 2020, Is Too Much Protein Bad For Ketosis [THE TRUTH], https://www.ruled.me/too-much-protein-bad-for-ketosis/
  2. Kimberly Holland, Healthline, People are Trying a ‘Lazy Keto’ Diet. Experts Aren’t Impressed, https://www.healthline.com/health-news/what-is-lazy-keto
  3. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
  4. Phinney SD, Volek JS, Volk B, How Much Protein Do You Need In Nutritional Ketosis? February 21, 2018, Virta Health, https://www.virtahealth.com/blog/how-much-protein-on-keto

A Keto Diet is NOT About How Much Fat it Contains

The myth persists that a “keto” diet is all about the fat…bacon, heavy whipping cream, and fat bombs. It’s about adding butter and MCT oil to coffee, about eating fatty cuts of meat and lots of avocado. While the amount of fat is very important for therapeutic ketogenic diets written about previously, it plays no role in the definition of “keto”, as most people know it. 

What makes a diet “low carb” or “keto” is only how little carbohydrate it contains NOT how much fat it contains.

Defining “Low Carb” and “Keto” Diets

Different individuals and groups define “low carb” and “keto” (very low carb) in various ways. Feinman et al [1] defined three categories of reduced-carbohydrate diets;

(a) very low carbohydrate / ketogenic diet: carbohydrate limited to 20–50 g per day or < 10% of total energy intake

(b) low carbohydrate diet: carbohydrate limited to < 130 g per day or < 26% of total energy intake

(c) moderate carbohydrate diet: carbohydrate limited to 130–225 g per day or 26–45% of total energy intake.

In its Consensus Report of April 18, 2019, the American Diabetes Association and the European Association for the Study of Diabetes (EASD) defined a low carbohydrate diet as having 26-45% of total daily calories as carbohydrate (a combination of a low carbohydrate diet and a moderate carbohydrate diet defined by Feinman et al), and defined a very low carbohydrate (ketogenic) diet as 20-50 g carbs per day. In its 2020 Standards of Medical Care in Diabetes, the American Diabetes Association continued to define low carb and very low carb the same way.

Diabetes Canada also defines a low carbohydrate diet as less than <130 g of carbohydrate per day or <45% energy as carbohydrate, and very low carbohydrate (ketogenic) diet as <50 g of carbohydrate per day in its April 2020 Position Statement [3].

What defines a low carbohydrate or very low carbohydrate (“keto”) diet is ONLY the amount of carbohydrate it contains. There isn’t even any mention of how much fat it contains!

How Much Carbohydrate is Essential in the Diet?

The Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005) which forms the basis for dietary recommendations in both the US and Canada reads;

“The lower limit of dietary carbohydrate compatible with life apparently is zero, provided that adequate amounts of protein and fat are consumed[4].

There are essential amino acids and essential fatty acids that we need to take in through the diet because the body can’t make these, but there is no essential carbohydrate because the body can make any carbohydrate it needs from amino acids (from protein) or fat.

How Much Fat in a Keto Diet?

There is nothing magical or mystical about how much fat or protein is required in a “low carb” or “keto” diet.

Whether one starts a low carb diet at 130 g of carbohydrate per day or a “keto” diet of 20-50 g carbohydrate per day, the remainder of daily calories is provided as protein and fat.

As outlined below, the popularized “keto” diet sets the amount of fat at approximately 75% of daily calories as fat, but this is only one type of “keto” diet.

It is a misconception is that to be a “keto” diet, most of daily calories needs to be as fat. 

It is also a misconception that added fat that is part of a low carb or “keto” diet must be animal fat.  Added fat as food or to cook with, or to put on salad can be provided by high fat fruit such as avocado or olives (fruit or oil), coconut (meat or oil), and nuts and seeds. If people choose, they can be low carb or “keto” and eat a predominantly whole-food plant-based (vegetarian) meal pattern.

Popularized “Keto” Diet

The popularized “keto” diet promoted widely on the internet is described as 75% fat, 15% protein and 10% carbohydrate, but is only ONE “keto diet” and not “THE keto diet”.

There are other “keto” diets, including the low carb, high protein, moderate fat ketogenic diet called Protein Power published in 1997 by Dr. Michael Eades and his wife Dr. Mary Dan Eades [5], the 2010 New Atkins For a New You [6] — which is a redesign of the original “Atkins Diet” from the 1970s written by Dr. Eric Westman, Dr. Stephen Phinney MD PhD, and Dr. Jeff Volek RD PhD which is only a very high fat ketogenic diet (20-50 g carbs per day) for phase one which lasts only the first two weeks, and there is also Real Meal Revolution [7] by Tim Noakes, Sally-Ann Creed, Jonno Proudfoot. Phinney and Volek’s approach in their 2011 book, the Art and Science of Low Carbohydrate Living has been to establish carbohydrate intake at 7.5-10% of calories for men, 2.5-6.5% of calories for women, protein intake at up to 30% of calories during weight loss, 21% during weight maintenance and fat intake to 60% of calories during weight loss and 65-72% during weight maintenance. Fat intake at 60% of calories during weight loss is NOT the same as the 75% calories as fat of the popularized “keto” diet.

The popularized “keto” diet is based largely on the two 2016 books by Dr. Jason Fung titled the Obesity Code [8] and The Complete Guide to Fasting [9], and the 2017 book titled by Dr. Andreas Eenfeldt, the founder of the popular “Diet Doctor website”, titled A Low Carb, High Fat Food Revolution [10] — both of whom write extensively on the Diet Doctor website.

Defining “High Fat”

In the US, the recommendation has been to limit calories from fat to no more than 30% of daily calories, of which no more than 1/3 comes from saturated fat and in Canada, to limit fat to 20-35% of daily calories as fat, with no more than 1/3 from saturated fat.  By definition, diets higher than 30% fat (US) or 35% fat (Canada) are considered “high fat”.

A “keto” diet which is only 40% fat would be considered “high fat” by the USDA and Health Canada, as would a “keto” diet that is 75% fat.  

But is a diet that is 40% fat really “high fat”?

From 1949 until 1977, dietary intake in Canada was at ~40-50% of daily calories as fat,  ~20-30% of daily calories as protein, and only 20-30% as carbohydrate. Was this the original “low carb high fat” diet?

Clarifying Definitions

In anything, it is important to define terms.

A “low carb” or “keto” diet is ONLY about how little carbohydrate it has (<130 g carbohydrate per day, 20-50 g of carbohydrate per day) and has absolutely nothing to do with how much fat it has.

Or how much protein in has, for that matter.

Contrary to what some on social media want to know, there is no “protein starting point” for a low carb or “keto” diet.  Each individual’s macro needs (energy, protein, fat and carbohydrate) are different, and vary depending on a person’s age, gender, stage of life,  health conditions, and activity for example.

There is no one-sized-fits-all low carb or “keto” diet with a set amount of fat, and set amount of protein. It depends what one is seeking to accomplish. Based on the definition, a low carb or “keto” diet for weight loss could range from 40% fat to 75% fat — and up to 90% for those following a therapeutic ketogenic diet for seizure disorder or glioblastoma.

People are always looking for the “formula for success” when it comes to weight loss but there isn’t one, except the one that works best for them.

More Info?

If you would like more information about my services then please have a look under the tab of that name or send me a note through the Contact Me form.

To your good health!

Joy

 

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
Instagram: https://www.instagram.com/lchf_rd

 

Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

References

  1. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1–13
  2. Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
  3. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
    Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
  4. National Academies of Sciences, Engineering and Medicine, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids, 2005, https://www.nap.edu/catalog/10490/dietary-reference-intakes-for-energy-carbohydrate-fiber-fat-fatty-acids-cholesterol-protein-and-amino-acids
  5. Eades M, Dan Eades M (1997), Protein Power: The High-Protein/Low-Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health–in Just Weeks! Bantam; New edition edition (1 December 1997)
  6. Westman E, Phinney SD, Volek J, (2010) The New Atkins for a New You – the Ultimate Diet for Shedding Weight and Feeling Great, Atria Books February 17, 2010)
  7. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
  8. Noakes T, Creed S-A, Proudfoot J, et al, (2013)The Meal Real Revolution, Quivertree Publications
  9. Fung J (2016) Obesity Code, Greystone Books, Vancouver
  10. Fung J, Moore J (2016), The complete guide to fasting : heal your body through intermittent, alternate-day, and extended fasting, Victory Belt Publishing
  11. Eenfeldt A, Low Carb, High Fat Food Revolution: Advice and Recipes to Improve Your Health and Reduce Your Weight (2017), Skyhorse Publishers

One Client Journey – down over 200 pounds

Introduction: It’s been almost three years since I started working with my client Karen D. in February of 2018 and in that time she has lost over 200 pounds. Yes, two hundred pounds!

When she came to see me the first time, I was only one year into my own weight-loss and health-recovery “journey”,  and was still very much overweight and metabolically unwell, but had come to understand from the scientific literature that a well-designed low carbohydrate diet was both safe and effective for weight loss, as well as for helping put some metabolic conditions into remission.  

In April 2019, Karen private messaged me on social media and sent me a photo of herself, after she had lost 150 pounds. It was both delightful and very rewarding to receive this from a client and to see that she had continued to apply what she had learned, and was doing exactly what she set out to do. She gave me permission to share it on social media with only her first name and initial of her last name, which I did. All people knew is that this was what one client had accomplished in a year.

Last week instead of private messaging me an update,  Karen decided to post a compilation photo of herself under one I had posted of myself on Facebook.  Even though I had not spoken to her in over a year, there was her picture for everyone, including me, to see! Wow!! Karen had lost more than 200 pounds, and had every reason to be proud of her accomplishment! 

In response to her initiative to share her progress publicly on Facebook, I ask Karen if she would be willing to tell her story in her own words from a client perspective and she agreed — and her reason for doing so is this;

“I don’t want others living the same life I was stuck in”.

So, if you think you can’t “do it” and that your weight loss goals are “impossible”, this post is for you.

This is one client story. This is Karen’s journey.


Karen D. – January 2018, 440 pounds

“I started keto on my own in January 2018, but it really stressed me out. There is so much information ‘out there’, and everything contradicted itself. It didn’t make sense to me. Macros, IF, fat bombs…..even in my coffee. Seriously, don’t mess with my coffee.

I needed help!

In one way I felt ‘lost’, but I did know that not eating lots of “complex carbohydrates” was right for me. I knew that keto was the right option, but this high fat thing scared me, largely because of my history of having had eating disorders since I was 12 years old.

There was something about this way of eating that made me feel like I had control over food for a change, instead of food having control over me but I didn’t feel like I grasped it enough to be successful.

I researched dietitians that specialized in low carb eating, as I’d seen dietitians before that just pulled out the Canadian Food Guide and told me to eat oatmeal for breakfast. I came across Joy.  Boy did I get excited! You see, I have severe anxiety and always feel like I’m doing something wrong. When I tried to do keto on my own, it was hard to know if it was wrong, or I just felt it was. I needed clear answers and directions.  And I was desperate. I had to loose weight.

I started at over 440lbs, last time a scale was able to weigh me. I’d been successful at loosing some weight on my own since January but I was on a mission. I was going to do it this time. For me, for my kids, for everything I had. The prospect of working with Joy meant clear answers to my questions, directions on how to really achieve my goals, and SUPPORT! I was going to have help, and not have to try to figure this out myself!

How I felt leading up to seeing Joy (from my Facebook)

Leading up the appointment was nerve racking for me. As a morbidly obese person, you get used to being told how far gone you are and how your health is at jeopardy.  Just asking for help sometimes is scary as you don’t know how judged you are going to be. I had so many questions that I wanted to ask, and was just hoping I’d really be “heard”.

My biggest question as a client was “why do I have to eat so much fat?” Is that really necessary?

And my second big question as a client was “do I really need to track my macros?” because that flares up my eating disorders.  I end up punishing myself if I see how much I’ve actually eaten.

It was the day of my appointment and I arrived at Joy’s office. She greeted me so warmly. Off to a good start. Honestly, the first bit is a bit of a blur as my anxiety was pretty high. I remember us talking about my health,  my back, my fibromyalgia, my families health diseases.  But I also remember how encouraging Joy was about the success I had already accomplished on my own. She was excited for me. I was freely able to talk about my eating disorders and we were able to come up with solutions with my meal plan to help me, not freak out over the calories and macros! And we discussed ‘fat’. Enough fat for flavor,  enjoy your food, have that piece of avocado, but I had enough fat on me that my body will take that for fuel. It was not necessary to eat high fat.

[more info about that here]

Joy put together a meal plan for me that made sense and that eased my fears as her client. She explained to me what my body needed, and I needed her explanation. It gave me ‘permission’ not to have to eat all that fat, and I was able to get my head to wrap around this way of eating. Now it made sense. I had the tools and I had the backup!

When I started seeing and feeling the results, it created the motivation to continue. 

This is me after I lost the first 50 pounds.

June 1, 2018, down 50 pounds

 

 

 

 

 

 

 

 

And this is what I wrote on my Facebook:

Eating low carb is a very anti-inflammatory way of eating, so my body just started to feel so much better without all the sugar.  I was starting to see huge changes in the way my body moved and looked. I was experiencing amazing non-scale victories that just kept me driven to keep going and wanting more.

January 1, 2019, down 100 pounds

It wasn’t always easy. Sure, there where set backs and temptations. It took a great mind-change to see things differently.

 

 

Karen D. down 150 pounds January 2018 – April 25, 2019

I didn’t make alternative foods. Didn’t try to find alternative to chips and rice and pasta. I just didn’t eat them anymore.

If I accidentally ate an ingredient that wasn’t keto friendly, that didn’t mean I ruined my whole day and should start over tomorrow. It just meant one bad thing went in my mouth.

Same as if I gave into temptation.  “Give yourself a break“, I would say to myself. “We aren’t perfect,  don’t make your success suffer because of one small stumble. Why start over tomorrow when you can continue today?”

This is me today.

I’m passionate about this because I’m working on my journey, and it has changed my life.

I went from being bed-bound for sometimes weeks at a time, to living a full life now.

I’m working hard to regain my life to the fullest and know that it is something that is possible for anyone who wants to do it.

I still have a bit to go before I’m at my ideal weight, but I can see the finish line. I’m going to be there soon.”

~ Karen D, January 3, 2021

A picture tells a thousand words (January 2018 – January 2021)

More Info?

If you would like more information about my services, please have a look on the tab above, or send me a note through the Contact Me form.

To your good health!

Joy

 

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Copyright ©2021 The LCHF Dietitian (a division of BetterByDesign Nutrition Ltd.)

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the “content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.