To Hell and Back – recovering from hypothyroidism (a Dietitian’s Journey – Part II)

Last Monday, I went to the lab for updated blood work, including a thyroid hormone panel, additional thyroid antibody tests, and an iron panel. I have moved past the frustration of there being no pricelist available for consumers who are self-paying for lab tests, and am now focusing on the lab test results, and the dietary changes that I need to make in light of those, as I am recovering from hypothyroidism.

The results came back late Monday afternoon and I met with my doctor to discuss them on Thursday, The good news is that based on calculation estimates converting the bovine Natural Desiccated Thyroid (NDT) medication that I had been taking, to a mixture of Synthroid® (a synthetic T4 medication) and Cytomel® (a synthetic T3 medication), my free T4 and free T3 are almost perfect. As my doctor said when we met, “between your research and my experience, we got this“.

This is a beautiful picture.

TSH, fT4 and fT3 levels on T4/T3 thyroid hormone replacement medication

It shows, as my doctor and I had hoped, that my free T3 (the active thyroid hormone) is in the higher part of the reference range (65.5%); a level considered optimal by endocrinologists and thyroidologists who are well-versed in the use of the combination T4/T3 medications that I have been prescribed.

While my free T4 could be in the higher part of the range on the type of medication that I am taking, it may slightly lower because of the feedback from having sufficient free T3. That’s okay! I am feeling so much better, although it will take another year or more until I am really well again.

As expected, my TSH (Thyroid Stimulating Hormone, the pituitary hormone that tells the body how much thyroid hormone to make) is low because the amount of free T3 is optimal. This is a classic feedback loop where free T3 provides feedback on the pituitary gland, indicating that there isn’t a need to make more thyroid hormone. Think of it like a thermostat.  When the room gets warm enough, there is feedback on the thermostat that no additional heat is required, and it turns it off until the room gets cold again.

Of importance, my TSH is not considered “suppressed” (TSH ≤0.03 mU/L) but “low” (TSH = 0.04-0.4 mU/liter) [1], so there is no increased risk of cardiovascular disease or bone fractures. Those with a “high” TSH (>4.0 mU/liter) — which was the level that I was at before being treated, and those with a “suppressed” TSH (≤0.03 mU/L) both have an increased risk of cardiovascular disease, abnormal heart rhythms and bone fractures. Those with “low” TSH (0.04-0.4 mU/liter) like I have, do not [1,2]. So more good news.

I have been diagnosed with Hashimoto’s disease (also known as Hashimoto’s thyroiditis) which is an autoimmune disease and diagnosis is based both on symptoms of hypothyroidism, along with the presence of thyroperoxidase antibodies (TPO-ab) and thyroglobulin antibodies (TG-ab) in the blood [3].

In many cases of hypothyroidism, it is these antibodies that contribute to the gradual disappearance of thyroid cells and the development of hypothyroidism.  In my case, it was the trauma to the thyroid that resulted from surgery that I had 30 years ago to remove a benign tumour that was the major contributor to the eventual decrease in thyroid function.

Prior to being diagnosed, as you can read about here, I had all the classic symptoms of hypothyroidism, including body aches, joint pain, fatigue, feeling chilled, constipation, dry skin, hair loss, being forgetful, and even feeling depressed.

By the point I realized that these symptoms were not consistent with long-Covid (which is what I initially suspected) or aging (which my sons assumed), I had developed some of the symptoms of severe hypothyroidism [3], including difficulty with speech, significant water retention, and peripheral edema (swelling) of the ankles and face [3]. There are more photos of what I looked like when I was very sick here as well as photos from the beginning part of my recovery.


To hell and back – 5 months of recovery from hypothyroidism

The photo on the left, above is what I looked like on June 3, 2022, at my youngest son’s wedding.  I was so sick. I needed help walking on the beach for family photos, getting out of a chair or a car,  I ached all over my body and I was beyond exhausted.  I knew I was ill and had plans to see my doctor when he returned from vacation but in the meantime, I attended my son’s wedding, without talking about how I felt. No one really knew how sick I felt until afterwards and I didn’t know how seriously ill I really was until August.

The middle picture, above was taken on September 3, 2022 after losing half my hair as a result of several nutrient deficiencies related to hypothyroidism that I have been correcting through adding specific foods high in these nutrients into my diet, as well as highly bioavailable supplements.  At the time the middle picture was taken, I had been on Natural Desiccated Thyroid hormones (natural T4/T3 medication) for 6 weeks. While my doctor wanted me to continue on them because I was doing so much better, I wanted to go on synthetic T4 and T3 thyroid replacement hormones as it would be easier to travel across borders with these recognized medications.

The picture on the right, is me today.  I feel as though I have been to “hell and back“.  Last week, my doctor said that it will take another year until I feel really well again, and probably another 6 months on top of that until my hair grows back, but I am so thankful for the difference in how I feel the last 5 months. I get tired easily. Hiking is out, and so are evening activities, but as my nutrient status continues to improve and the thyroid hormones permeate all my body’s tissues, I will gradually feel better and better.


The blood tests confirm that I have both thyroperoxidase antibodies (TPO-Ab) and thyroglobulin antibodies (TG-Ab), which along with my symptoms, confirms my diagnosis of Hashimoto’s disease, but thankfully my blood test results indicate that neither are elevated.

Thyroperoxidase-Ab = 9 (<35 IU/mL)

Thyroglobulin Ab = 14 (<40 IU/mL)

While they are not elevated, they are present. 

Gliadin and Transglutaminase

For many years I avoided gluten containing products because I thought I was gluten intolerant, although not celiac.

A year ago that I stumbled across some novel ingredients and had an idea to create low carb breads to provide dietary options for those with diabetes. My goal was to enable people who would not otherwise consider a low carbohydrate diet to be able to adopt one, for health reasons.   I was mainly thinking of those from bread-centric cultures such as South East Asians (Indian) and Hispanics but in time, I developed many more types of low carb bread. 

I was aware of the connection between high gluten consumption and leaky gut syndrome, but against that I weighed the serious morbidity and mortality linked to uncontrolled diabetes. I had come across many people who would rather stay diabetic, and potentially lose their toes or vision than give up bread and developing these breads seemed like the lesser of two evils. 

Since being diagnosed with hypothyroidism that I had been developing over the previous 9 years (more about that here), I learned that the gliadin fraction of gluten structurally resembles transglutaminase. Transglutaminase is an enzyme that makes chemical bonds in the body, and while present in many organs, there are higher concentrations of transglutaminase in the thyroid.

In leaky gut syndrome, gliadin (and other  substances) result in the gaps in between the cells of the intestinal wall to widen. This results in the immune system of the body reacting to food particles that are inside the intestine, that it normally would not see. It is thought that the immune system reacts to gliadin and creates antibodies to it, seeing it as a foreign invader.  Since gliadin and transglutaminase have very similar structural properties, it is thought that in those with leaky gut syndrome, the immune system begins to attack the transglutaminase in the thyroid, and other tissues, contributing to the development of auto-immune conditions, including hypothyroidism

A-1 Beta Casein and Gluten

A few years ago, I had leaky gut syndrome but it resolved with dietary changes, including avoiding gluten and A-1 beta casein dairy (you can read about what A-1 beta casein dairy is here).  Naturally, as I had been working on recipe development for the low carb bread book, I had been eating gluten as I tested them. I also became more liberal in including dairy products from A1-beta casein cows, when I hadn’t used it in years. That started when there was severe flooding last year in Chilliwack last year due to heavy rains after the summer, and that was where my goat milk came from.  Even once the roads were open again and the highways rebuilt, I never really went back to using goat milk, which is naturally A-2 beta casein. In the interest of an abundance of caution, I will go back to using dairy products from A-2 beta casein cows, or from goat or sheep milk (that are naturally A-2). Humans produce A-2 beta casein protein, and using milk from A-2 beta casein animals does not result in an immune response. It is not seen as “foreign.”

From what I’ve read and in discussing it with my doctor, it is likely that my hypothyroidism has been developing over the last 30 years, related to the surgery I had to remove a benign tumour. Further supporting that me becoming hypothyroid has been a long time in the making, I have had high-normal levels of TSH over the last 9 years — which happens to be a time period over which I was avoiding both gluten and A-1 dairy. Given that, I think it’s logical to conclude that my hypothyroidism is primarily related to the destruction of thyroid tissue in the invasive surgery connected to removal of the tumour. Further supporting this hypothesis, I currently have fairly low levels of TPO and TG antibodies, so I suspect they have begun developing fairly recently. Since a 2018 study reported that  both TPO-antibodies and TG antibodies are decreased in hypothyroid patients following a gluten-free diet [4], it seems wise for me to go back to avoiding gluten, with the goal of lowering my TPO-antibodies and TG-antibodies down to as close to zero, as possible.

Cruciferous Vegetables

Cruciferous vegetables such as Brussels sprouts, broccoli, bok choy, cauliflower, cabbage, kale are known goitrogens. Goitrogens are naturally occurring substances that are thought to inhibit thyroid hormone production. The hydrolysis of a substance known as pro-goitrin that is found in cruciferous vegetables produces a substance known as goitrin, that is thought to interfere with thyroid hormone synthesis [5]. Since cooking cruciferous vegetables limits the effect on the thyroid function, and eating cruciferous vegetables have many health benefits, I will usually eat them cooked, but not in huge quantities. There are studies that found a worsening of hypothyroidism when people ate very large quantities of these (e.g. 1 – 1 ½ kg / day) so it is recommended that intake of these vegetables be kept relatively constant day to day, and limited to no more than 1-2 cup / day. I’ve decided that when I do eat them, to keep intake to the lower end of that range, and eat more non-cruciferous vegetables instead.

Iron Deficiency and Low Stomach Acid (hypochlorhydria)

I now know why I am still so tired. I asked my doctor to run an iron panel and the results show I have low iron. Previous results indicate my vitamin B12 are fine and I continue to supplement methylated folate and B12, so I know those are not a problem.

While my iron stores (ferritin) are okay, they are not optimal i.e., ferritin = 93 (15-247 ug/L) instead of >100ug/L.

My hematology panel is low-normal i.e. hemoglobin = 122 (115-155 g/L), hematocrit = 0.37* (0.35-0.45 L/L), MCV = 88 (82-98 fl), MCH = 29.5 (27.5-33.5 pg), MCHC = 334 (300-370 g/L)

My serum iron and iron saturation are very low i.e., serum iron = 11.9 (10.6-33.8 umol/L), iron saturation = 0.15 (0.13-0.50)

Low iron status is common with hypothyroidism, but it was surprising to me because I eat beef liver, or chicken livers every week, and also take a heme polysaccharide supplement (like Feramax®), so it may be due to an absorption problem.

Low stomach acid (hypochlorhydria) is common in hypothyroidism, and since low pH is needed for iron absorption, I have made dietary changes to improve that.

Final Thoughts…

I am very grateful that my doctor recognizes my knowledge as a clinician and is receptive to me advocating for my health. I am incredibly fortunate that he involves me in decisions regarding blood tests, as well as discussing medication types and dosages.  As for the dietary changes and supplementation, he is content to let me handle that!

I hope that out of my experience that I have called “to hell and back” that I am able to help others better understand hypothyroid symptoms, diagnosis and treatment options so that they can discuss them with their doctor.

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

Articles about Hypothyroidism

References

  1. van Vliet NA, Noordam R, van Klinken JB, et al. Thyroid Stimulating Hormone and Bone Mineral Density: Evidence From a Two-Sample Mendelian Randomization Study and a Candidate Gene Association Study. J Bone Miner Res. 2018;33(7):1318-1325. doi:10.1002/jbmr.3426
  2. Flynn RW, Bonellie SR, Jung RT, MacDonald TM, Morris AD, Leese GP. Serum thyroid-stimulating hormone concentration and morbidity from cardiovascular disease and fractures in patients on long-term thyroxine therapy. J Clin Endocrinol Metab. 2010;95(1):186-193. doi:10.1210/jc.2009-1625
  3. Puszkarz, Irena, Guty, Edyta, Stefaniak, Iwona, & Bonarek, Aleksandra. (2018). Role of food and nutrition in pathogenesis and prevention of Hashimoto’s thyroiditis. https://doi.org/10.5281/zenodo.1320419
  4. Krysiak, R.; Szkróbka, W.; Okopień, B. The Effect of Gluten-Free Diet on Thyroid Autoimmunity in Drug-Naïve Women with Hashimoto’s Thyroiditis: A Pilot Study. Exp. Clin. Endocrinol. Diabetes 2018, 127, 417–422.
  5.  Felker P, Bunch R, Leung AM. Concentrations of thiocyanate and goitrin in human plasma, their precursor concentrations in brassica vegetables, and associated potential risk for hypothyroidism. Nutr Rev. 2016;74(4):248-258.

 

Copyright ©2022 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 to Watch the “Let’s End Diabetes” Sessions for Free

Yesterday (October 22, 2022), I was the Dietitian representing low carb and keto diets in the management of type 2 diabetes at the Diabetes Canada Let’s End Diabetes Virtual Conference. I co-presented with two other Dietitians; Jenna Walsh, RD, CDE who represented intermittent fasting, and Alka Chopra, RD, CDE who represented a plant-based approach.

I had hoped to be able to be able to post a link to the talk so that people could watch it, but that wasn’t possible. It also could not be downloaded and posted, so I made it as easy as possible for those who want to watch the talk to be able to do so.

 

 

Anyone can register for FREE on the Diabetes Canada website and watch any of the sessions (including the one I was in), but since some people had difficulty navigating the site yesterday, I am posting step-by-step directions here, including

(1) registering for the Diabetes Canada “Let’s End Diabetes” Conference for free
(2) finding to the “auditorium”
(3) entering the auditorium, and
(4) selecting the session you would like to watch (with the one I was in, as an example).

To make it easier, you can download a pdf of these same steps, with the links in them — so all you need to do is click on them.

I hope you find this helpful.

How to Register and Watch Diabetes Canada’s “Let’s End Diabetes” Sessions

 

(1) to register for the Diabetes Canada “Let’s End Diabetes” Conference for FREE, click here and select “register”.

(2) once you have completed your registration, find theauditorium” (see Step 2, below) and click on it (you will be brought here).

(3) Once you click on the link, you will be brought into the “auditorium”. On the screen, you will see “click here to view sessions (where circled in red, below).

(4) You will be brought here and see a list of all the sessions available.  To watch “Ask the Dietitian; Demystifying Popular Eating Patterns“, scroll down to the last session and click “play”.

More Info about Me

If you would like more information about how I can support you following a low carbohydrate of very low carbohydrate diet, please have a look under the Services tab, 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 ©2022 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.

Six-Week Follow-Up Doctor Visit – a Dietitian’s Journey

This morning I met with my doctor for my 6-week follow-up appointment to review my ongoing hypothyroid symptoms, current T4 & T3 medication dosages, and to discuss additional blood work to see how my body is responding to medication, as well as nutrient supplementation. I continue to be in awe of how cooperative my doctor is being! I am very well aware how many people with hypothyroidism do NOT get this kind of support from their doctors! I am very thankful.

My doctor agreed to my request for a thyroid panel [TSH, free T4, and free T3] even though I may have to pay for FT3 because of the provincial guidelines.

In British Columbia, free T3 testing is only available for those with suspected hyperthyroidism, not to assess levels of T3 as a result of thyroid hormone replacement medication. I am more than willing to pay for a $9.35 test [1] to have all the data.

I will also be having a full iron panel to see how my body is responding to nutrient supplementation , as iron status tends to be low in those with hypothyroidism. I have already had blood tests for other nutrients of concern in hypothyroidism, as well as for those I have been supplementing.

My doctor even ordered a thyroglobulin antibody (TG-ab) test, even though TPO antibodies for Hashimoto’s were negative. Interestingly, he thinks as do I that it is prudent to assume a Hashimoto’s diagnosis even in the absence of antibodies and act accordingly when it comes to diet and increased risk of other auto-immune disorders.

This coming Monday, I am going for my blood tests and should have the results back in 24-48 hours and am meeting with my doctor again next Thursday to go over the results, and consider medication dosage adjustment.

I am very grateful to be able to work with my doctor to advocate for my health, to be involved in the decision regarding blood tests, as well as discussing together medication adjustment.

I hope that out of my experience navigating my own care related to hypothyroidism, to better be able to help others advocate for themselves in this area.

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

Articles about Hypothyroidism

References

  1. BC Guidelines & Protocols Advisory Committee, Thyroid Function Testing in the Diagnosis and Monitoring of Thyroid Function Disorder, October 24, 2018

 

Copyright ©2022 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.

 

What Does Success Looks Like Now – A Dietitian’s Journey II

This article is the fourth entry in A Dietitian’s Journey Part II, which began with my recent diagnosis of hypothyroidism. This post is about how I will measure success as I recover from hypothyroidism.

NOTE: Articles posted under A Dietitian’s  Journey are separate from referenced clinical articles (categorized as Science Made Simple articles) because these are about what happened to me (i.e., anecdotal) and based on my personal observation.

A Dietitian’s Journey – Part I

What “success” looked like after the first A Dietitian’s Journey

“A Dietitian’s Journey” (Part I) was my personal weight-loss and health-recovery journey that began on March 5, 2017 when I decided to make dietary and lifestyle changes so that I could reclaim my health. At that time, I was obese, had type 2 diabetes for the previous 8 years, and extremely high blood pressure. 

Two years later, on March 5, 2019, I accomplished all but one of my goals, and the last one I achieved three months later. In all, I lost 55 pounds and more than a foot off my waist, and met the criteria for partial remission of type 2 diabetes, and remission of hypertension (high blood pressure).

To get an idea of what I looked like at the beginning and the end of that journey, there are two short videos on my Two Year Anniversary post that tell the story well.  The first video was taken when I started and it is very apparent how obese I was, and how difficult it was for me to walk and talk at the same time. The second clip was taken when I completed my journey, and the difference is unmistakable.  

A Dietitian’s Journey – Part II

Without much difficulty I maintained my health and my weight-loss from March 2019 until August 2020 but then I came down with Covid.  This was at the very beginning of the pandemic and no one really knew what to expect in terms of symptoms. As you can read about in the first post in what has become A Dietitian’s Journey Part II, (When a New Diagnosis is a Long Time Coming ) I had symptoms that both my doctor and I assumed were related to the virus, including muscle aches and joint pain, being exhausted, having ‘brain fog,’ headaches, and having the shivers.

Afterwards, I had to work very hard to regain my mobility. No one knew this wasn’t ‘normal.’

At first, I could barely walk up a flight of stairs. At the time, “success” was being able to walk around the block.  Then I began taking several dietary supplements to help strengthen my immune system and in retrospect, the reason I felt better was likely due to the fact that these were all supplements involved in thyroid support. Success at the time was being able to walk around the man-made lake at the local park, but over the weeks and months of supplementing my diet and walking every weekend, success was being able to complete several medium difficulty hikes in the local mountains. 

Unfortunately, in March of 2022,  I came down with what my doctor assumed was Covid again. At first the symptoms were similar to what I experienced in August 2020, including muscle aches, joint pain, being exhausted, feeling cold all the time, with the only difference being that I didn’t have headaches. The symptoms persisted for several months and I was beginning to think that I had “long-Covid.” As most people did over the pandemic, I put on 20 pounds, but from March to May, I began to look as though I was putting on significant weight, but every time I got on the scale it indicated only a few pounds of difference. I had no idea what was going on.

The next symptom that I became aware of was swelling in my ankles. It wasn’t just a little bit of swelling, but significant enough that I needed to wear compression stockings all day.

At my youngest son’s wedding at the beginning of June, I looked like I did when I was 55 pounds heavier, but I wasn’t.

LEFT: March 5, 2017, RIGHT: June 3, 2022

About three weeks after the wedding, I was diagnosed with hypothyroidism, and started taking desiccated thyroid. At first, I felt significantly better, and within several weeks, the edema in my legs began to subside.

There is still a fair amount of mucin accumulation in my legs, but as of this weekend, I can begin to grab a very small amount of flesh between my fingers. From what I have read it will take at least 6 months for this to resolve. You can read a referenced article about the skin symptoms associated with hypothyroidism here.

It is easy to see from the above photo that in less than 3 months on thyroid medication treatment, my face has lost its puffy, “inflated” look yet amidst the positive improvements of decreased edema and looking more like myself in some respects is the reality that I have lost ~1/2 of my hair due to telogen effluvium that often occurs with sustained hypothyroidism. You can read more different causes for hair loss here.

Loss of half my hair in 3 months due to telogen effluvium.

Even though I have already been on thyroid replacement hormones for several months, it usually takes ~3-6 months for hair loss to stop and another 3-6 months for regrowth to be seen and 12-18 months to complete regrowth [3]For someone like my who has lost half their hair, six months to a year to begin to see hair growth can seem like an eternity.

I recently changed medication forms from desiccated thyroid to a mixture of T4 medication (Synthroid®) and T3 medication (Cytomel®). The overall distribution of T4:T3 is about the same, but it is hoped that this mixture will result in more stable thyroid hormones day-to-day.

In six weeks I will have new blood tests to re-evaluate whether my levels have improved.  At last check, my TSH was still high-normal (3.47 mU/L) when in most patients on thyroid hormone replacement the goal TSH level is between 0.5 to 2.5 mU/L [7]My Free T4 =  14.0 pmol/L which is still in the lower end of the range (10.6-19.7 pmol/L) when it is considered optimal to be in the higher end of the range. 

Metabolic Changes due to Hypothyroidism

It’s well known that people with hypothyroidism experience several clinical changes including different type of anemia, changes in how their heart functions, changes in blood pressure, blood sugar and cholesterol and weight gain due to a slower metabolism. My recent medical work up indicates that I was no different in this regard.

Different Types of Anemia

People with hypothyroidism have a decrease in red blood cells and experience different types of anemia, including the anemia of chronic disease. In addition, 10% of people with hypothyroidism develop pernicious anemia, which is associated with vitamin B12 and folate (folic acid). Iron deficient anemia is also common due to decreased stomach acid that results in decreased absorption of iron.

I was supplementing with B12 and folate and as a result have no signs of pernicious anemia, however my hematology panel indicates that I may have iron deficient anemia. An iron panel would be able to quantify this, however I am already taking heme iron supplements, along with vitamin C to support absorption.

Heart Changes

The slowing of metabolism associated with hypothyroidism also results in a decrease in cardiac (heart) output, which results in both slower heart rate and less ability for the heart to pump blood.  This is what results in the unbearable fatigue.

High Blood Pressure

The decreased ability of the heart to pump leads to increased resistance in the blood vessels, which results in increased blood pressure (hypertension).

In those who had normal blood pressure previous to developing hypothyroidism, blood pressure can rise as high as 150/100 mmHg. Hypothyroidism may increase it further for those previously diagnosed with high blood pressure. While my blood pressure had been normal for more than a year, it gradually started increasing the last year, which in retrospect is the period of time over which I was exhibiting more and more symptoms of hypothyroidism. I have since been put back on medication for hypertension to protect my kidneys, which I hope to be able to get off of again within the next six month to a year, as my thyroid hormones normalize.

Weight Gain

Thyroid hormones act on every organ system in the body, but the thyroid is well-known for its role in energy metabolism. When someone has overt hypothyroidism, there is a slowing of metabolic processes, which results in symptoms such as fatigue, cold intolerance, constipation, and weight gain. 

Weight gain is not only about diet or how much someone eats versus how much they burn off. It is also about the person’s metabolic rate, which can be impacted by several things, including decreased thyroid hormones. I gained 20 pounds over the pandemic (much of which overlaps with the period of time over which I was exhibiting more and more symptoms of hypothyroidism. I also gained 10 pounds from March to June which is mostly water weight, due to the mucin accumulation.

High Cholesterol

It has long been known that those with hypothyroidism have high total cholesterol, high low-density lipoproteins (LDL) [4], and high triglycerides (TG) [5], which results from a decrease in the rate of cholesterol metabolism. My doctor deliberately did not want to check these last time, because he knew they would be abnormal only as a result of the hypothyroidism. He plans to evaluate them once I have been stable on hormone replacement for several months.

So, What Does Success Look Like Now?

Just as I had a clear idea of what success looked like in my first A Dietitian’s Journey, I have a clear idea of what I would like success to look like this time, as I recover from my hypothyroid diagnosis.

Over the next year, this is what I want to accomplish;

    1. weight same as March 5, 2019 (end of A Dietitian’s Journey, part I)
    2. waist circumference same as March 5, 2019 (end of A Dietitian’s Journey, part I)
    3. regrowth of my hair to same thickness as before clinical symptoms of hypothyroidism
    4. restoration of iron deficient anemia:
      (a) normal ferritin 11-307 ug/L
      (b) iron 10.6-33.8 umol/L
      (c) TIBC 45–81 µmol/L
      (d) transferrin  2.00-4.00 g/L
    5. Blood pressure ≤  130/80 mmHg
    6. Blood sugar:
      (a) non-diabetic range fasting blood glucose ≤  5.5 mmol/L
      (b) non-diabetic range HbA1C ≤  5.9 %
    7. Thyroid Hormones:
      (a) optimal TSH= 0.5 to 2.5 mU/L
      (b) optimal Free T4 = 15-18 pmol/L (10.6-19.7 pmol/L)
    8. Cholesterol:
      (a) LDL ≤ 1.5 mmol/L
      (b) TG ≤ 2.21 mmol/L

Final Thoughts…

While I don’t know if it will be possible to achieve all of these within the time frame or within adjustments to medication that my doctor will be willing to make, these are my goals. I believe that most of these are possible, and as far as they are within my control, this is what I would like to accomplish.

I have achieved a lot the last 3 months, but I am not “done.” I want the rest of my life back!

I want to be able to do the things that I enjoy, and to have the freedom to make plans in the evening knowing I will have the energy to follow through.

I think this is reasonable to ask and I will do everything I can to make this a reality.

A Dietitian’s Journey Part II continues…

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. Rotondi M et al. Serum negative autoimmune thyroiditis displays a milder clinical picture compared with classic Hashimoto’s thyroiditis. Eur J Endocrinol 2014;171:31-6. Epub April 17 2014
  2. Croce, L., De Martinis, L., Pinto, S. et al. Compared with classic Hashimoto’s thyroiditis, chronic autoimmune serum-negative thyroiditis requires a lower substitution dose of L-thyroxine to correct hypothyroidism. J Endocrinol Invest 43, 1631–1636 (2020). https://doi.org/10.1007/s40618-020-01249-x
  3. Malkud S. Telogen Effluvium: A Review. J Clin Diagn Res. 2015;9(9):WE01-WE3. doi:10.7860/JCDR/2015/15219.6492
  4. Lithell, H., Boberg, J., Hellsing, K., Ljunghall, S., Lundqvist, G., Vessby, B., & Wide, L. (1981). Serum lipoprotein and apolipoprotein concentrations and tissue lipoprotein-lipase activity in overt and subclinical hypothyroidism: the effect of substitution therapy. European journal of clinical investigation11(1), 3–10. https://doi.org/10.1111/j.1365-2362.1981.tb01758.x
  5. Nikkila E, Kekki M, Plasma triglyceride metabolism in thyroid disease, J Clin Invest. 1973;51:203. 
  6. Iron Disorders Institute, Iron Deficiency, Understanding Iron Deficiency Anemia, http://irondisorders.org/iron-deficiency-anemia/
  7. American Thyroid Association, Is the TSH (thyroid stimulating hormone) a good way to titrate my thyroid hormone therapy? https://www.thyroid.org/patient-thyroid-information/what-are-thyroid-problems/q-and-a-tsh-thyroid-stimulating-hormone/

DISCLAIMER: The information in this post should not be taken as a recommendation to self-diagnose, self-interpret diagnostic tests, or self-treat any suspected disorder. It is essential that people who suspect they may have symptoms of any condition consult with their doctor, as only a medical doctor can diagnose and treat.

 

Copyright ©2022 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.

 

Judging By Appearance – a Dietitian’s Journey

We form an opinion about someone’s appearance when we haven’t seen them in a while, or meet them for the first time. We do so unintentionally, but we judge by appearance. Sometimes the appearance of weight gain is not about diet but a diagnosis. 

DISCLAIMER: (August 28, 2022): This article a personal account posted under A Dietitian’s Journey. The information in this post should in no way be taken as a recommendation to self-diagnose, self-interpret diagnostic tests, or self-treat any suspected disorder. It is essential that people who suspect they may have symptoms of any condition consult with their doctor, as only a medical doctor can diagnose and treat.

The photos below are both of me. On the left is what I looked like when I began my personal weight-loss and health-recovery journey on March 5, 2017. Over the following two years, I lost 55 pounds and 12 ½ inches off my waist following a low carb, and then a ketogenic diet. The process was slow — agonizingly slow and in retrospect, I now know why. The photo on the right is what I looked like two years later, maintaining my weight loss.

LEFT: March 5, 2017 RIGHT: December 2021 – after two years weight maintenance

Almost imperceptibly, my appearance began to change.  I didn’t “see it” at the time, but I was aware that my waist circumference was different and that my clothes felt tighter. What I couldn’t understand was that I had only “gained” approximately five pounds.

The two photos below clearly show the subtle difference.

LEFT: Hiking March 5, 2021, RIGHT: Hiking March 5, 2022

The photo on the left was taken on the two-year anniversary of completion of my weight loss journey which lasted from March 5, 2017-March 5, 2019 (documented under A Dietitian’s Journey). This entry in that journal which is titled From the Mountains Through the Valleys was written for my fifth anniversary, the day before the photo on the right.

The photo on the right was taken this past year in March, exactly one year after the photo on the left.  The comparison is easy because I was wearing the same clothes. While my weight was only approximately five pounds greater than on the left, it is clear to see that my face was puffier, as were my legs.  I remember getting dressed that morning and wondering why all my hiking clothes felt so tight. I also vividly remember how difficult the hike was that day — and it was a simple one with very little elevation. My legs felt heavy, and it was hard to walk up even the gentlest of inclines.

Despite having both vaccines in April 2021 and July 2021, a few days later I came down with what my doctor and I presumed was my second case of Covid-19.

I had Covid the first time in August 2020 and wrote about it in the journey entry titled, To Covid and Back).  In retrospect, I think the ‘post-viral arthritis’ I experienced afterwards may have been linked to my thyroid’s response to the virus (documented in the literature). In that post, I wrote about recovering from Covid the first time;

“By the end of August (after Covid) it was difficult for me to even walk up (or down!) a flight of stairs. This both shocked and scared me.

I began to go for walks — even though it was very hard.  At first they were literally just around the block, but I kept at it.  One of my young adult sons who lives with me kept encouraging me to walk, and would sometimes go with me.  As my legs became stronger, walks turned into short  inadvertent hikes’ and 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 the wood hiking staff that I brought with me when I moved from California and put it into service., invested in some hiking boots and other essentials’. As I said in the previous article, 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.

My first breakthrough was in late November, when I did my 4th real hike which was 12 km around Buntzen Lake — which in terms of a few elevation gains was really beyond my capabilities. With frequent stops and lots of encouragement from my son, I did it.  I had to. He couldn’t exactly carry me back to the car! That day I felt as though I had beaten the post Covid muscle weakness and was on my way back to health.”

When I got Covid again this past March, the symptoms were pretty much the same as in August 2020, muscle aches and joint pain, being exhausted, feeling cold all the time and my lips were frequently blue. The only difference was this time I did not have headaches.  I was loaned an oximeter by a family member who is a nurse and I found it quite strange that my body temperature was always two degrees below normal even though I had fever-like symptoms of being cold and shivering.  The muscle aches were significant, as was the fatigue, but since these are also symptoms of Covid, I didn’t think much of it.  It was only when I began to develop symptoms that were not associated with Covid that I began to become concerned.  

Me at my youngest son’s wedding, June 3, 2022

Fast forward to the beginning of June which was my youngest son’s wedding. I was so very unwell, but avoided talking about it as I did not want to detract from the very special occasion.

I was experiencing joint pain and muscle aches, and chills that would come and go. I would frequently get bluish lips, and continued to have significant non-pitting edema in my legs and ankles, and was wearing compression stockings all the time — even at the wedding. Most pronounced was the debilitating fatigue.

The skin on my cheeks had become flaky and dry and despite trying multiple types of intense moisturizers, nothing helped. My mouth symptoms had progressed to the point that I found it difficult to say certain words when speaking because my tongue seemed too large for my mouth, and the salivary glands underneath my tongue were swollen.

The muscle weakness had progressed to the point where it was difficult for me to get up from a chair, or to get out of my car without pushing myself up with my hands. My eldest son was helping me get to and from the beach for the photos, and out of the car.  He thought it was me aging, and when I recently asked my other two sons, they assumed the same thing.  I was wondering if I had some form of “long-Covid,” but what got me starting to think that my symptoms had something to do with my thyroid was the very noticeable swelling in my face.

At my son’s wedding I looked like I did when I was 55 pounds heavier!

LEFT: March 5, 2017, RIGHT: June 3, 2022 at my youngest son’s wedding.

The photo on the left, above is what I looked like when I began my weight-lost journey on March 5, 2017. The photo on the right is what I looked like June 3, 2022, at my youngest son’s wedding. I look more or less the same in both pictures, but with a fifty pound difference in weight. 

I found out a few weeks later, I had hypothyroidism and was displaying many of the symptoms of myxedema. [I have written an article from a clinical perspective about the symptoms of hypothyroidism, which is posted here.]

While we do it unintentionally, we all judge by appearance, and “weight gain” is no different. If we see someone at one point in time, we form an opinion based on what we see.  If anyone would have bumped into me three months ago, it would have been reasonable for them to assume that I had gained back all the weight I had lost, and then some. But that wasn’t the case. 

But what causes the appearance of “weight gain,” without gaining significant amounts of weight? 

As I explain in this recent clinical post about hypothyroidism, the “puffiness” is due to the accumulation of mucin under the skin. Mucin is a glycoprotein (a protein with a side chain of carbohydrate known as hyaluronic acid) that is naturally produced in the skin. Under normal circumstances, hyaluronic acid binds water to collagen and traps the water under the skin, keeping it looking moist and plump, In fact, hyaluronic acid is injected into the skin by dermatologists to make aging skin appear younger. The problem in hypothyroidism is that an excess of mucin accumulates under the skin, giving it a “tight, waxy” swollen texture. (I would describe it as feeling like an over-inflated balloon). 

Below is a photo showing the change in appearance in my left leg from November 3, 2021 (left), to July 16, 2022 (middle), to August 26, 2022 (right).

The photo on the left was taken by me last November while I was doing some stretches. It was still on my phone in mid-July when I took a picture of the swelling in my lower legs and ankles caused by mucin accumulating in the skin. The photo on the right was taken this morning, and while much of the swelling has been reduced, I am still unable to pinch any skin on my legs due to the remaining mucin. I have read that it can take 6 – 8 months for this to resolve.

I want people to understand that the appearance of “weight gain” and “weight loss” in hypothyroidism is different than weight gain and weight loss due to dietary changes. The difference, however can be very subtle.

In my case, the appearance of “weight gain” occurred very slowly.

My appearance between March 5, 2021 and exactly a year later are almost indistinguishable. It is only in retrospect, that I can see the puffiness in my face and legs. At the time, I was puzzled why my clothes fit tighter when there was only a 5 pound difference in my weight, but beyond that I didn’t give it any thought.

Below is a composite photo to help illustrate how slowly my appearance changed at first, and how quickly it progressed as my thyroid disorder progressed. Look how rapidly my appearance changed in only three months, between March 5, 2022, and my son’s wedding on June 3, 2022! 

[NOTE: As I’ve mentioned in all of my previous articles and posts about hypothyroidism, each person will present with different symptoms, and even those with the same symptoms may have very different appearance because of differences in their thyroid dysfunction.  Keep in mind, these photos describe only my own experience.]

Below is a composite photo to illustrate how quickly the appearance on my my face has resolved after only two months of thyroid treatment.

[NOTE: Again, this is my experience and each person’s will be different, depending on the nature of their thyroid dysfunction, as well as the type, timing and dosage of treatment their doctor prescribes.]

Last two photos are only 2 months after beginning thyroid treatment
I understand “regular” weight gain and the “weight gain” that often goes with hypothyroidism from both sides of the clinical desk.

An Expanded Perspective

My clinical practice changed 5 years ago when I came to understand what hyperinsulinemia was, and how early clinical signs of developing type 2 diabetes are evident as long as 20 years before diagnosis. In a similar way, my clinical practice is changing again now as the result of what I am learning about hypothyroidism.

Understanding the wide range of clinical and subclinical symptoms that people may have leads me to ask additional questions, to look at lab test results differently, and to ask for additional ones if it seems clinical warranted. While it is beyond the scope of practice of a Dietitian to diagnose any disease or to treat hypothyroidism, I am more aware of what to look and this helps me to refer people back to their doctor if I feel there may be a clinical concern.

Final Thoughts…

We form an opinion about someone’s appearance when we haven’t seen them in a while or when we meet them for the first time. While we do so unintentionally, in developing that opinion, we judge by appearance but sometimes the appearance of “weight gain” is not about diet, but about a diagnosis.

If anyone had seen me three months ago after not seeing me in a while, they might have assumed that I had gained back all the weight I had lost.

When we encounter someone who is overweight, we ought to bear in mind that don’t know where they are on their journey. We don’t know if they have metabolic issues related to glucose and insulin metabolism, are struggling with food addiction, or have an endocrine dysfunction, like hypothyroidism, or something else.

photos taken less than 3 months apart

People seeing me now have no idea that less than three months ago I looked as I did on the left, and was very ill.

As much as it is natural for all of us to form an opinion, let’s try not to let that opinion become a judgement.  Listening is a great way to find out 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

 

Copyright ©2022 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.

FREE 27-page Download with Sample Recipe

Finally, there are low-carb breads made without nut flour, cheese, or beaten egg whites, and that contains no psyllium, chia seed, xanthan gum, guar gum, or inulin which cause many people digestive issues. These are “real breads that happen to be low carb.”

Click on the green button below to get a FREE 27-page booklet that explains the essentials about this new category of homemade low-carb breads and includes the “game changer” that led to the development of the others.

FREE 27-PAGE DOWNLOAD

This 27-page
FREE DOWNLOAD
includes the
“game changer” recipe

that led to the development
of all the other recipes.

Click on the free download button to get yours.


Looking for something shorter that you can print out?

FREE 1-PAGE DOWNLOAD

Click on the purple button below to get a FREE 1-page printable download about this new category of low carb breads that are made with NO nut flours, psyllium, chia seed, xanthan or guar gum, or inulin.

 

About My Book – Low Carb Breads of the World

I never planned to write a low carb bread book, but it came about due to both interest and need.  Beginning in September 2021, I began to experiment with low carb breads that were not made from nut flour. By mid-December I was finally successful and posted the recipe for Low Carb High Protein Yeast Bread, and this bread turned out to be a “game changer”.  It was what I called “real bread that happens to be low carb.” But, most impressive were the macros! Each slice of Low Carb High Protein Yeast Bread had only 1.6g net carbs and 11.4 g protein. I knew I was onto something.

The ingredient that made this first ‘real bread’ possible was vital wheat gluten, which is not wheat flour but one of several types of wheat protein isolate. Wheat protein isolate is to wheat, what whey protein isolate is to dairy, and both are proteins that have been used in food production and as a protein supplement. This ingredient gives bread its distinct “pully” texture and makes bread different from cake or pastry. Discovering this and other low-carb ingredients resulted in me re-visiting my old hobby of bread baking – something I did over the previous 35 years before adopting a low carb diet in March 2017.

After posting the recipe for Low Carb High Protein Yeast Bread in mid-December 2021, I began to have people contact me on social media to request that I bake the breads and ship them to them. One person wanted me to courier them several loaves, and I had to explain that I am a Dietitian in full-time private practice and had no time to bake bread as a sideline. A few people tried to convince me to open a low-carb bakery (which I also had no interest in), and then some said I should write a cookbook featuring recipes for these low-carb bread. I mentioned this to one of my young adult sons, who thought I should consider the idea. Without really thinking it through, I created a Twitter poll asking who would be interested in such a book and then asked the same question on Facebook and Instagram. The responses were overwhelmingly in favor, so the following morning, I looked at my young adult son and said, “it looks like I am writing a low-carb bread book.”

And so, it began…

The recipes in this book form a completely different category of low-carb bread. They contain no nut or seed flour, and while cheese and egg may be included as ingredients in a recipe, they do not form the basis of the bread. In addition, these bread contain no psyllium, chia seed, xanthan gum, guar gum, or inulin, as these ingredients often cause digestive issues. As a result, Low Carb Breads of the World may remove unnecessary barriers that people currently have to adopt a low-carb lifestyle. This book makes culturally appropriate and ingredient-appropriate bread available to people from bread-centric cultures with high rates of type 2 diabetes, including Southeast Asian and Hispanic.

Low Carb Breads of the World is more than a cookbook or a collection of recipes. It introduces novel ingredients for baking low-carb bread and explains how to use them successfully in different types of recipes.  The recipes provide an opportunity to utilize the ingredients and the methods to produce a variety of breads of the world. These recipes are not perfect replicas of the high-carb originals but are as close as I was able to get them using readily available low-carb ingredients with minimal allergens or ingredients that cause digestive issues.

I hope that people from a wide range of backgrounds will apply the information in my book to create low-carb versions of bread central to their cultures, thereby making a low-carb diet accessible to those who would not have otherwise considered it.

While I never set out to write a low-carb bread book, I realize that this book will do what I do in my private practice: help people pursue a healthier lifestyle.

You can click on the “free download” button below to get a FREE 27-page booklet that explains the essentials about this new category of homemade low-carb breads and includes the “game changer” that led to the development of the others.

To your good health!

Joy Y. Kiddie MSc, RD

 

FREE DOWNLOAD

 

Includes the “game changer” recipe that led to the development of all the others.

Click on the free download button below to get your FREE 27-page booklet with recipe.

 

Why I Changed My Mind About Low Carb Bread

I have been supporting people in following a low‐carb and keto lifestyle for the past five years, but until recently, I was not in favor of low‐carb bread. The reason was that there were only a few low‐carb or keto bread options, and each had its drawbacks.

Most low‐carb bread is made from nut flours such as almond flour and coconut
flour, with or without adding different types of cheese (such as so‐called
“fathead” pizza).

While these breads work well for some people, the extra energy intake provided by the nuts and cheese often made weight loss more difficult, especially for peri and post‐menopausal women.

While bread made from whipped egg white provides a high protein, low‐fat, low carb bread option, the texture of this protein‐sparing bread is often disliked.

The lack of acceptable low‐carb bread options posed a problem for me as a Dietitian. While some people are fine using lettuce to wrap a burger in, lettuce wraps do not address the needs of people from bread‐centric cultures. People of South Asian (Indian) descent have approximately 6x higher rates of type 2 diabetes than the general population and I came to realize that it was essential
for them to have culturally appropriate low‐carb bread such as chapati/roti,
paratha, and naan.

With rates of type 2 diabetes being almost double in the Hispanic population, low‐carb corn‐style and flour‐style tortillas were also important. While these could be made using nut flours and gums such as xanthan gum, guar gum, or psyllium to make them flexible, these ingredients often cause digestive issues.

In addition to people’s cultural needs, there was also the fact that many people have nut allergies which makes most low‐carb bread options made with almond flour unavailable. A similar issue exists for those allergic to eggs ‐‐ making egg white‐based bread such as ‘cloud bread’ or protein‐sparing bread unavailable as low‐carb options.

In late October 2021, I saw a protein bread imported from Germany that was like the classic Vollkornbrot bread but made from some unique ingredients.

This bread had more than three times the protein of this company’s whole‐meal rye bread and more than 80% fewer carbohydrates, so I bought it to try. It was heavy and dense and tasted good, but at almost 50 cents per slice, I thought, “this can’t be that hard to make.”

I ordered some of the ingredients online and began experimenting with making low carbohydrate, yeast‐risen, high‐protein bread that contained no beaten egg white, no nut flours, and no cheese. It took quite a few attempts until I made a successful bread, but I persisted, and on December 14, 2021, I posted the recipe for Low Carb High Protein Yeast Bread. This bread turned out to be a “gamechanger.” It was “real bread that happened to be low carb.”

Most impressive were the macros! Each slice of Low Carb High Protein Yeast
Bread had only 1.6 g net carbs and 11.4 g protein.

Even with ordering all the ingredients online from Canada, compared to commercial Carbonaught® Multigrain Bread that weighed the same (544 g), it cost 35% less.

Most ingredients are available in regular supermarkets in the US, and no matter where in the world people live, like me, they could order these ingredients online and bake these low‐carb bread themselves. I knew I was onto something.

The ingredient that made this first ‘real bread’ possible was ‘vital wheat gluten,’ which is not wheat flour but one of several types of wheat protein isolate. Wheat protein isolate is to wheat, what whey protein isolate is to dairy, and both are proteins that have been used in food production and as a protein supplement. I later found out that there are several different types of wheat isolates. Vital wheat gluten is a protein isolate of gliadin and glutenin separated from the wheat starch (where all the carbs are) and other grain components. Gliadin and glutenin give bread its distinct “pully” texture and make bread different from cake or pastry. Just as adding vital wheat gluten gives bread its characteristic texture, the inclusion of whey protein gives low carb bread its crisp, brown crust.

Discovering these low‐carb ingredients resulted in me re‐visiting my old hobby of bread baking – something I did over the previous 35 years before adopting a low carb diet in March 2017. Most of my low‐carb breads began as recipes for regular high‐carb bread that are hand‐written on recipe cards and fill one of the multiple recipe boxes.

It was vital wheat gluten that made other breads possible – from crusty sandwich loaves, brioche, buns and rolls to culturally acceptable low‐carb versions of chapati/roti, paratha, naan, and corn‐style and flour‐style tortillas.


As Dietitian it was finally possible to offer those from a South Asian or Hispanic background culturally appropriate low‐carb breads they could make at home, enabling them to adopt a low‐carb diet to help improve their health. In addition, these ingredients meant that those with nut allergies could have low‐carb bread without having to resort to egg‐white bread and since many of these breads do not contain eggs, there are low‐carb bread alternatives for those with egg allergies.

After posting photos of some of these early breads on social media, people kept asking me for the recipes. Some wanted to commission me to make these breads and courier them to them regularly, but I am a Dietitian in full‐time clinical practice with no desire to open a baking business. When someone suggested I write a book, I was initially resistant to the idea; however, it was evident that there was both an interest and a need.

In January 2021, I decided to write Low Carb Breads of the World because it provided a much‐needed dietary option to many people. The breads contain no nut flours. They have no psyllium, xanthan gum, guar gum, or inulin, as these ingredients cause many people digestive issues, and many of the breads in the book are made without eggs or dairy. These breads are not perfect replicas of the original but are as close as possible using low‐carb ingredients that are readily available and with minimal priority allergens. They are real breads that happen to be low carb.

Low Carb Breads of the World is not just a cookbook or a collection of recipes. Instead, it introduces low‐carb ingredients and explains how to use them for baking several different types of low‐carb bread. The recipes in the book provide an opportunity to utilize the ingredients and the methods to produce a variety of breads of the world. By understanding the science behind using these ingredients, people will begin to be able to adapt their traditional bread recipes to be low carb, and that is ultimately the goal of the book.

Like the expression “give a man a fish, you feed him for a day, teach a many to
fish, you feed him for a lifetime,” this book is intended to teach people what is
needed so they can apply that knowledge to make the breads they grew up on
and love, low carb.

For those who can eat and enjoy nut‐flour and egg‐based low carb bread, these are an excellent option, but for those for whom they are not suitable, there is another choice.

To your good health!

Joy

 


Joy Kiddie is a Registered Dietitian with a master’s degree in human nutrition from the University of British Columbia (Canada). She has been providing low‐carb and keto services since 2015 through her long‐standing dietetic practice BetterByDesign Nutrition (www.bbdnutrition.com) and since 2017 has been supporting people through her dedicated low‐carb division, The Low Carb Healthy Fat Dietitian (www.lchf‐rd.com). Joy helps people reduce their hunger and food cravings to achieve their weight loss goals and improve their metabolic health. She is also the author of the upcoming book, Low Carb Breads of the World.

 

You can download a copy of this article here.

ADA Releases a Low and Very Low Carb Guide for Health Care Providers

The American Diabetes Association (ADA) has released a 28-page guide for Health Care providers on implementing low-carbohydrate (LC) and very low-carbohydrate (VLC) eating patterns to improve outcomes in adults with type 2 diabetes. The purpose of the Guide is to assist Health Care Providers, including Physicians, Registered Dietitians, certified diabetes care & education specialists (CDCES), and others, to assess whether these interventions would be appropriate for their patients and if so, how to best implement them.

The Guide is authored by Kelly Siverhus MS, RD, CD, and several advisors. These include three American Diabetes Association Dietitians, five expert advisors including 4 Registered Dietitians and an MD, and a Registered Dietitian primary advisor from Diabetes and Nutrition Consultants. One of the four expert Advisors was Dawn Noe, RD, LD, CDCES, who gave a presentation on Person-Centered Implementation of Low Carbohydrate Eating Plans at the American Association of Diabetes Educators (AADEs) annual conference in Houston, Texas, in August 2019. She graciously shared her slides with me for this article.

This new Guide is the culmination of several American Diabetes Association position statements, a consensus report, and several Standards of Medical Care in Diabetes (2019, 2020) publications which included the use of both a low carbohydrate and very low carbohydrate (ketogenic) diet.

Low Carbohydrate and Very Low Carbohydrate Eating Patterns in Adults with Diabetes: A Guide for Health Care Providers

This 28-page guide includes information on

    • Potential Benefits
    • Indications and Contraindications
    • Determining and Reassessing a Carbohydrate Goal
    • Tools and Strategies for Eating Pattern Education, including what to emphasize
    • A 10-page section (pages 16-26) with Resources for Patient Education, including
      • Food Lists for Low Carbohydrate Meal Planning
      • Getting Started
      • Low Carbohydrate Starch Alternatives
      • Low Carbohydrate Plate Method
      • Sample Meal Plans (Structured)
      • Sample Meal Plans (Build your Own)
    • References

The Guide is an excellent resource for Health Care Providers to help them assess the appropriateness of a low-carbohydrate (LC) or very-low-carbohydrate (VLC) diet for any given patient and provides good explanations of the different approaches that can be taken. In addition, the 10-page Resources for Patient Education provide strategies and sample meal plans for implementing a low carb or very low carb eating pattern, along with the necessary details to assist a wide range of Health Care Providers in supporting their patients in adopting a low carbohydrate or very low carbohydrate diet.

This Guide can be ordered directly from the ADA online shop for $8.95 USD.

Final Thoughts…

While nothing is “new” in this Guide, it is an excellent synthesis of information already contained in the American Diabetes Association’s 2018 Position Statements, 2019 Consensus Report, and Standards of Medical Care in Diabetes (2019, 2020). The Guide provides a convenient, evidence-based tool for US-based Health Care providers to use with their patients.

It is my sincere hope that Diabetes Canada might make something like this available for use by Canadian-based Health Care providers, including Physicians, Registered Dietitians, and certified diabetes care & education specialists.

More Info?

If you would like more information about how I can support you following a low carbohydrate of very low carbohydrate diet, please have a look under the Services tab, 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 ©2022 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.

From the Mountains Through the Valleys – 5 year update

Tomorrow is March 5th and it is five years since I began my personal health and weight recovery journey that I’ve dubbed “A Dietitian’s Journey“.  While it began in 2017, in a way it still continues today and that is the point behind this post. 

March 2017

Five years ago, I was obese, had type 2 diabetes for the previous 8 years, and had developed dangerously high blood pressure. 

This picture is what I looked like then.  There is no mistaking that I was a very sick woman.

You can hear it in my voice in the video below. It is very apparent that I could barely walk and talk at the same time.

A year after I had adopted a low carbohydrate lifestyle (March 5, 2018), I had lost:

  • 32 pounds
  • 8 inches off my waist
  • 2 inches off my chest
  • 3 inches off my neck
  • 1 inch off my arms
  • 1/2 inch off my thighs
  • no longer meet the criteria for type 2 diabetes (achieved without the use of medication)
  • had blood pressure that ranges between normal and pre-hypertension without medication
  • had ideal triglycerides and excellent cholesterol levels achieved without any medication.
April 2017 – April 2019

Two years after beginning my journey I had lost a total of;

  • 55 pounds
  • 12- 1/2 inches off my waist
  • 3 -1/2 inches off my chest
  • 6 -1/2 inches off my neck
  • 4 inches off each arm
  • 2- 1/2 inches off each thigh
  • met the criteria for partial remission of type 2 diabetes
  • blood pressure still ranged between normal and pre-hypertension
  • had ideal triglycerides and excellent cholesterol levels
March 2020

On the third anniversary of beginning my journey, March 5, 2020, I remained at a normal body weight, had an optimal waist circumference (slightly less than half my height), and was still in remission of type two diabetes and high blood pressure.

I had gone from taking 12 different medications three years earlier, to being on one prescription for something non-metabolically related. I felt so good — so happy in my own skin that decided to stop straightening my hair, and began wearing it the way it grows out of my head.

March 5 2021 was 4 years from when I began my journey. Here is a short clip from a podcast I was on around that time. Listen to how different I sounded from the clip above.

Then I took up hiking! 

Four years earlier, I could barely walk and talk at the same time and for six months, I was hiking every week, or two.

This photo was taken last year on March 6, 2021 — the 4th anniversary of beginning my journey.

But like most journeys, this one has had ups and downs. There have been “mountain top experiences,” and “valleys,” and currently I am in a bit of a valley.

About two months ago, I was exposed to the Delta variant of Covid and while I didn’t get more than cold-like symptoms, once again my body responded to the exposure with post viral arthritis that I have had a twice since my late 20s.  The first time was after I contracted rubella as a young adult, and the second time was after having what was presumed to be Covid in August 2020 (covered in previous posts). Despite the overall joint pain, I was not going to let it get me down. I kept pushing myself — working on developing recipes for my upcoming book, Low Carb Breads of the World.

The joint pain has eased up quite a bit over the past few weeks, but there remained increasing discomfort at the base of my thumb on my right hand that kept getting worse. Last week it became unbearable.  I assumed that I had developed arthritis in the CMC joint of my thumb, but I found out this week that it is DeQuervain’s tenosynovitis that developed from the repetitive motion of kneading bread several times a week for long periods of time. This was an unfortunate by-product of working on recipe development for the low carb bread book.

Out of necessity, many of the things I was actively doing suddenly came to a halt. For the next 4-6 weeks I have to wear a brace 24-hour per day that splints my thumb and wrist, and enables it to heal.  It is discouraging, but there isn’t much I can do about it. I apply ice, do my physio, wear the brace and focus on looking ahead.

In a way, tomorrow being the 5th anniversary of my journey encourages me.

While not the “mountain top experience” of a year ago, even in this temporary “valley”, things are SO much better than they were 5 years ago.

While I haven’t managed to lose all the 20 pounds I had put on during Covid as I had planned to do, I also haven’t regained my weight, either. My blood sugars are still good, and so is my blood pressure and that is something I am very thankful for, and to celebrate.

Despite the ups and downs, I am still moving forward. I continue to eat low carb and have no desire to eat any other way. I am metabolically healthy and that is a lot to be thankful for.

While we all go through ups and downs, it is what we do day-to-day that really counts towards putting diseases like type 2 diabetes and hypertension into remission.

People ask me why I “still” eat this way and the answer is easy. If I go back to eating the way I did before, I will become “fat and sick” like I was before, too! No, thanks.

For me, there is no looking back — only forward. From the mountains to the valleys, I choose to remain low carb for my ongoing health. 

I hope my story and persistence encourages you.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/lchfRD/
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Copyright ©2022 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.

Embracing the Unchangeable

With the new Covid-19 variant now in circulation, widespread flooding in the Pacific Northwest and out East, and the resulting supply shortages in many areas affecting food prices, many people feel overwhelmed.  I find that I do best in these situations when I embrace that which is unchangeable, while focusing on changing the things that I can.

I think that circumstances are more about how we look at them and respond, than about the situations themselves, and our reaction to the weather around us exemplifies this. 

Viktor Frankl was an Austrian neurologist, psychiatrist and Holocaust survivor who said that there is a ‘space’ between a stimulus (or an event) and our response, and in that space we have the power to choose our response. This includes our reaction to a new strain of Covid, environmental events such as the weather, and the condition of our own health.

”Between stimulus and response there is a space. In that space is our power to choose our response.” ~Viktor Frankl

When I woke up to the snow this morning, I decided to embrace the unchangeable, and this  short video touches on that.

We have the power to choose how we are going to respond in any situation, and this includes everything from the weather, to our own health.  We can choose to change the things that we can, while embracing the unchangeable.

When I set out to restore my health four years ago, that’s exactly what I did.  Maintaining it simply takes making those same choices, daily.  It really does come down to recognizing that there is a space between the circumstances and our response, where we have the power to choose.

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.

When Meat Prices Go Crazy — best sources of protein on a budget

INTRODUCTION:  Not everyone who eats a “low carb” diet can afford to keep buying meat at the today’s current crazy prices. This article looks at options on the basis of protein to energy, in calories (kcals). Yes, it contains some ‘unconventional’ protein sources, but ones that can still fit within a low carb diet. It provides people with options who may not have a choice.


Meat prices have gone crazy and many people are wondering how to eat well on a budget. Steaks and chops are familiar, but they aren’t the only source of protein — or even the best sources.

A rib steak is only 60% protein but skipjack tuna is 92% protein — which is substantially more, and costs a great deal less. Skinless turkey breast is 86% protein and skinless chicken breast is 75% protein— both higher than a rib steak and both considerably less expensive. While medium-lean ground beef (80% lean) is inexpensive it only has 41% protein, and canned pink salmon, beef- or chicken liver, canned mackerel and sardines all have more protein in them than that!

Note: In this article, protein to energy ratio (P:E in kcals) is protein in calories (kcals) compared to the total amount of calories in one ounce (28g) of the food. This is different than the Ted Naiman’s “P:E ratio“, where energy is “non-fiber carbohydrate + fat”. In this calculation the energy provided by protein is not counted, however not all protein is used for muscle accretion, but in a high protein diet, excess protein is burnt for energy, or stored as fat.

Below are some examples of relatively low-cost animal source foods, sorted from the highest amount of protein to the lowest and as animal products, these are all complete proteins — having all 9 essential amino acids.

Highest protein animal source foods, from highest to lowest

But what to make out of canned pink salmon? “Salmon patties” were a staple in my home growing up. They are made from drained canned pink salmon, mixed with a little chopped celery, minced green onion and egg to bind them (my mom would add breadcrumbs but I omit them and they come out fine!). They are formed into patties and either fried in a bit of fat or cooked in a non-stick skillet. They are an excellent source of highly bioavailable protein, a good source of omega 3 fatty acids, and are inexpensive and delicious! They can be served with homemade cabbage salad (Cole slaw), or a side of cooked vegetables…and yes, frozen vegetables are just as nutritious as fresh, and much less expensive.

Canned tuna is delicious mixed up with a bit of mayonnaise, with or without some minced celery and of course is terrific added to casseroles that for those not following a low carb diet, are made with pasta. I find that chunks of lightly cooked cauliflower stands in well for noodles and these casseroles can be a complete meal with the addition of a few handfuls of fresh or frozen vegetables.  They are also wonderful with a sprinkle of grated cheese on top.  Tuna is a great source of protein as well as omega 3 fat, and is often on sale. Buying a few cans to have on hand makes it easy to reach for at the end of a long day.

Some people don’t like liver because their only experience with it is something akin to shoe leather, but when it is bought fresh and cooked on a barbeque (or broiled in the oven) until “just cooked”, it is delicious. Chicken liver can be cooked that way too, but is also delicious pan fried with onion, mushroom and peppers, or made into a pí¢té.

Spinach soufflé

Eggs can provide the protein in a spinach soufflé which is delicious with or without some grated parmesan or swiss cheese. Adding extra egg white makes it even higher in protein, and makes for an even better soufflé!

shakshuka

Eggs can stand on their own served as shakshuka as the main dish for dinner. A cucumber and tomato salad makes a delicious side dish and all together, this is a very affordable and tasty meal!

What about some non-animal sources ?

Non-Animal Source of Protein

Ma-Po tofu

Tofu is very versatile and to many people’s surprise, contains all 9 essential amino acids.  It comes in so many forms — from firm blocks, to silky and custard-like, and can be cooked into so many wonderful dishes. If you haven’t tried Chinese Ma-Po tofu, you are missing something! It has a delicious sauce made from garlic, green onions and brown bean sauce (and for non-vegetarians includes a small amount of ground meat), and is simply just delicious! Serve it with stir fried broccoli or bok choi and garlic.

fish without bones

Firm tofu, cut in small rectangles, dipped in egg and pan fried with some ginger and green onion and finished by steaming with a bit of broth is just delicious!  The Chinese fondly refer to tofu as “meat without bones” and I call the egg dipped fried with green onion and ginger, as “fish without bones” (because this is often the way the Cantonese prepare fish).

Highest protein non-animal source foods, from highest to lowest

While many people who eat low carb think that legumes such as lentils and chickpeas are “off limits”, 1/2 cup of legumes contain approximately the same amount of carbs as 1/2 cup of yam or squash, but comes with an added bonus of 7g of protein. For those that are concerned about anti-nutrients in pulses, these are reduced with soaking and cooking, and not using the soaking water for cooking them reduces most of the gas that people think of when they think of pulses.

[Note: November 7, 2021 – Best to not purée cooked legumes, as they will raise blood sugar more than if left intact.]

Animal proteins are complete proteins which means they contain all 9 essential amino acids. While lentils and other pulses have a good protein to energy (kcals) ratio, it is important to note that they are missing amino acids. That is why they are considered “incomplete proteins”.  For example, lentils are missing the sulfur-containing amino acids methionine and cysteine, and pinto beans are missing methionine and tryptophan. Since pulses are missing amino acids, it is important for those who are vegetarian to be sure to eat other foods during the day that contain the missing amino acids. It used to be believed they had to be eaten at the same meals, but that is not necessary.

Protein in Some Nuts, Seeds and Grains

Highest protein per kcal foods, from highest to lowest (nuts, seeds and grains)

Nuts and seeds also provide some protein, but are easy to over-eat. Nuts are high in fat and like hard cheese can stall weight loss, if over eaten. Same with nut butters like peanut butter or tahini which is made from ground sesame seeds. It is helpful to think of these as fat sources that have some protein, rather than protein sources. It is best to use them as a decoration to make other foods like salad taste good, rather than as a protein source.

Cottage Cheese – a surprising low carb high protein staple

Have a look at the protein to energy (kcal) ratio of pressed cottage cheese (see photo) in the table, below.  Ounce for ounce, pressed cottage cheese provides way more protein than steak, or ground beef, and even more than turkey or chicken breast!  Who would have thought? Once the bane of calorie counter’s existence, cottage cheese is an excellent protein source for those following a low carb diet, even high than eggs!

Low carb diets — especially the high fat ones always seem to highlight eggs, but eggs are only 33% protein (see table, above) whereas pressed cottage cheese is 84% protein, Greek yogurt is 74% protein, and creamed cottage cheese is 51% protein!

Highest protein per kcal foods, from highest to lowest (dairy source, with eggs)

Different Types of Cottage Cheese Compared [Added November 8, 2021)

I decided to add this  clarification to explain the different types of cottage cheese. 

 

Pressed cottage cheese” is sometimes called baker’s cottage cheese, or “Farmer’s cheese”.

“Dry cottage cheese” is just the curd that is used for making “creamed cottage cheese”, but without the liquid.  In years gone cream was added to the dry curd to make “creamed cottage cheese” hence the name — but now it is a mixture of milk with various gums, such as carrageenan, guar gum and xanthan gum.
As can be seen from the table below, these have very different amounts of protein per ounce.
Difference between dry cottage cheese, pressed cottage cheese and regular (creamed) cottage cheese
But how does one eat pressed cottage cheese? It can be mixed with egg, herbs such as parsley and green onion, formed into patties and fried like the salmon patties mentioned above, or mixed with egg and/or spinach and used as a filling for lasagne or manicotti.
chicken noodle lasagne

Seriously, low carb lasagne is a “thing”! Thin slices of deli chicken make a terrific low-carb substitute for the noodles in lasagne (just choose brands that don’t have added sugar) and the cottage cheese and egg filling can be rolled up in strips of zucchini, like manicotti.

Creamed cottage cheese is an excellent protein source for breakfast or lunch and Greek yogurt is a good source, and delicious with 1/2 cup of berries thrown. Even though Greek yogurt pales in comparison to cottage cheese in terms of its protein to kcal ratio, it still scores higher than steak — and higher than eggs!

low carb manicotti, in process

There are so many good sources of inexpensive protein that can stand on their own, or mixed together to make so many delicious combinations!  Looking to other cultures that use these ingredients is a great way to find out what to do with them. Chinese, Korean and Japanese have wonderful easy recipes for tofu.  Hispanic cultures including Mexican have so many ways to cook pinto beans, kidney beans, and black beans — both with and without meat and for lentils and chickpeas you need not look far. Middle Eastern recipes abound using these, as do South Asian recipes from India, Pakistan and Sri Lanka. And don’t forget the lowly “offal” meats, like liver and heart! These are inexpensive and good sources of complete protein. Finding out how to cook them properly can make all the difference.

Protein is a very important macronutrient needed as a building block for the body. Carbohydrate and fat are the body’s energy sources, but the body can make its own glucose from protein or fat, provided they are supplied in sufficient quantities. Protein is so important that according to the “protein leverage hypothesis“, people will keep eating and eating until their body gets the protein it needs. Targeting protein first is important to keep from overeating foods that are “protein dilute”. And it is not only children and adolescents that need protein, but older people need more protein as they age, to lower the risk of sarcopenia (muscle wasting).

A “low carb” diet need not fit a philosophy, but a definition. What makes a diet low carb is how few carbs it has, not what the source of those carbs are.

Final Thoughts…

Yes, meat prices are crazy these days, but steaks and chops are not the only source of protein and not even the best source!  Salmon, tuna, chicken and turkey breast are all excellent sources and one doesn’t need to eat the expensive variety to benefit.  Frozen pink salmon or canned tuna are fine! And don’t forget cottage cheese!

More Info?

If you would like more information about how I can help you 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

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.

Could Protein be the Appetite’s Control – the Protein Leverage Hypothesis

The idea that there is a specific food that acts as the “off switch” for appetite is very compelling.  Who hasn’t eaten more food than they planned or wanted? Whether it was too much of the same food or too much of a variety of foods, we often eat until we are stuffed. Wouldn’t it be amazing if we could eat something that could satisfy that drive to eat? According to Dr. Stephen Simpson and Dr. David Raubenheimer, that “something” is protein.

In their 2005 paper published in Obesity Reviews, Simpson and Raubenheimer proposed that obesity isn’t primarily caused by eating too much fat, or eating too many ‘carbs’, but by eating food that has too little protein [1]. They called this the “Protein Leverage Hypothesis”.  This states is that humans have a built-in appetite for protein that drives food consumption. When we eat food that contains low amount of protein, we will over-eat until the amount we need is met.  

In paleolithic times, the human diet was ~35% animal protein, 33% fat and the remainder plant protein (which was limited in the diet due to antinutrients such as phytates, oxalates, tannins, trypsin-, amylase-,  and protease inhibitors, and glycosides) [2].  Humans evolved and thrived eating this way. 

In contrast, currently the percentage of protein in diets around the world remains at ~16% of daily calories [3] and Simpson and Raubenheimer believe that it is this ‘protein dilution‘ of the diet that results in us overeating food, to try and obtain sufficient amounts.

In their 2005 paper, they wrote;

”The obesity epidemic is among the greatest public health challenges facing the modern world. Regarding dietary causes most emphasis has been on changing patterns of fat and carbohydrate consumption. In contrast the role of protein has largely been ignored because (i) it typically comprises only approximately 15% of dietary energy and (ii) protein intake has remained near constant within and across populations throughout the development of the obesity epidemic. We show that paradoxically these are precisely the two conditions that potentially provide protein with the leverage both to drive the obesity epidemic through its effects on food intake and perhaps to assuage it. [1]

What this implies is, if we don’t intentionally prioritize protein in the diet, we will overeat fat and carbohydrate to reach the amount we require (or have evolved to eat).

To complicate matters, the food environment is made up of ultra processed foods that are mostly carbohydrate and fat.  Snack and convenience foods were only introduced the early 1970s — which, coincidently was when the obesity epidemic began.

We have known since 2018 that foods high in both carbohydrate and fat result in more dopamine being released from the reward-center in striatum of our brain, than foods with carbohydrate alone, or fat alone [4]. This is why will often overeat French fries, but rarely a baked potato. Perhaps, the fact that snack and convenience foods are so low in protein is a contributing factor to us overeating them.

Current statistics indicate that 55% of calories eaten by adults [5] and 67% of calories eaten by children and teenagers [6] come from ultra-processed foods — high in both carbohydrate and fat, and low in protein.

A 2018 follow-up paper by Simpson and Raubenheimer based on the 2009-2010 National Health and Nutrition Examination Survey (NHANES) found higher consumption of ultra-processed foods was associated with lower protein density [7].

“Consistent with the Protein Leverage Hypothesis, increase in the dietary contribution of ultra processed foods was also associated with a rise in total energy intake, while absolute protein intake remained relatively constant [7].

“The protein-diluting effect of ultra processed foods might be one mechanism accounting for their association with excess energy intake [7].”

Rather than going in circles arguing whether eating too much fat or eating too many carbs resulted in obesity, perhaps it is more productive to focus on ensuring sufficient intake of high quality protein.

But how much is best? It depends for whom.

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. The RDA is not the optimal requirement, but the absolute minimum to prevent deficiency.

The RDA – enough protein to prevent deficiency

The RDA for protein for healthy adults is calculated at 0.8 g protein / kg of body weight [8]. A sedentary 70 kg / 154 pound man needs a minimum of 56 g and a sedentary 60 kg / 132 pound woman needs a minimum of 48 g protein per day.

Protein Needs for Active Healthy Adults

For physically active adults, the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine [9] recommend an intake of 1.2—2.0 g protein / kg of lean body mass (LBM) per day to optimize recovery from training, and to promote the growth and maintenance of lean body mass.

Protein Needs for Older Adults

Several position statements by groups working with an aging population indicate that intake between 1.0 and 1.5 g protein / kg of lean body mass (LBM) per day may best meet the needs of adults during aging [10, 11].

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 written 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 of LBM 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.

Final Thoughts…

We know that the presence of both carbs and fat together in a food has a supra-additive effect on the pleasure center of our brain [4]. This leads to us eating way more of these foods, than foods with just carbs or just fat.  Given this, it would make sense to avoid foods that have high amounts of both carbs and fat which include almost all of our favourite snack and convenience foods.

With the exception of nuts, seeds and milk most real, whole food is high in either carbs or fat, not both.  Aim to eat these foods the most, but not together at the same meal.

Based on the Protein Leverage Hypothesis, aim to eat sufficient high protein foods based on your individual needs.  Reach for foods such as salmon, tuna, skinless chicken and shrimp the most often. These contain 8 grams of protein per ounce (28 g) and 1.5 grams of fat.  Enjoy a good ribeye, some pork or chicken legs that have on average 6.2 grams of protein per ounce (28g), and 6g of fat.

Vegetarian? No problem!

Cottage cheese has 28 g of highly bioavailable protein per cup, and Greek yogurt has 16 grams of protein per cup. Tofu only has ~4.7 grams of protein per ounce (28g), and is a complete protein containing all the essential amino acids.

Think of protein as a control button for appetite and reach for the types of protein that suit your lifestyle best!

More Info?

If you would like more information about how I can help you 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

References

  1. Simpson SJ, Raubenheimer D. Obesity: the protein leverage hypothesis. Obes Rev. 2005 May;6(2):133-42. doi: 10.1111/j.1467-789X.2005.00178.x. PMID: 15836464.
  2. Ben-Dor M, Gopher A, Hershkovitz I, Barkai R (2011) Man the Fat Hunter: The Demise of Homo erectus and the Emergence of a New Hominin Lineage in the Middle Pleistocene (ca. 400 kyr) Levant. PLoS ONE 6(12): e28689. https://doi.org/10.1371/journal.pone.0028689
  3. Lieberman HR, F.V., Agarwal S, et al. , Protein intake is more stable than carbohydrate or fat intake across various US demographic groups and international populations. The American Journal of Clinical Nutrition, 2020. 112(1): p. 180-186.
  4. DiFeliceantonio AG, Coppin G, Rigoux L, et al., Supra-Additive Effects of Combining Fat and Carbohydrate on Food Reward. Cell Metab. 2018 Jul 3;28(1):33-44.e3. doi: 10.1016/j.cmet.2018.05.018. Epub 2018 Jun 14. PMID: 29909968.
  5. Zefeng Zhang, Sandra L Jackson, Euridice Martinez, Cathleen Gillespie, Quanhe Yang, Association between ultraprocessed food intake and cardiovascular health in US adults: a cross-sectional analysis of the NHANES 2011—2016, The American Journal of Clinical Nutrition, Volume 113, Issue 2, February 2021, Pages 428—436, https://doi.org/10.1093/ajcn/nqaa276
  6. Lu Wang, Euridice Martí­nez Steele, Mengxi Du, Jennifer L. Pomeranz, Lauren E. O’Connor, Kirsten A. Herrick, Hanqi Luo, Xuehong Zhang, Dariush Mozaffarian, Fang Fang Zhang. Trends in Consumption of Ultraprocessed Foods Among US Youths Aged 2-19 Years, 1999-2018JAMA, 2021; 326 (6): 519 DOI: 10.1001/jama.2021.10238
  7. Martí­nez Steele E, Raubenheimer D, Simpson SJ, Baraldi LG, Monteiro CA. Ultra-processed foods, protein leverage and energy intake in the USA. Public Health Nutr. 2018 Jan;21(1):114-124. doi: 10.1017/S1368980017001574. Epub 2017 Oct 16. PMID: 29032787.
  8. National Academies Press, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005)
  9. 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
  10. 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
  11. 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

    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.

Do You Identify as a Food Addict?

As a Dietitian who supports people with food addiction, I was recently asked to speak at a food addiction summit.  The evening prior to speaking, I was given a list of the questions I would be asked. The first one was “How has food addiction impacted your life? How old were you”? The opening question at the summit was “do you identify as a food addict”?

I had to really think about how to answer this. I knew there were two specific foods over which I had no “off button”.  If you’ve listened to some of the podcasts I’ve spoken at, you will know that those two foods are hot Montreal-style bagels that are baked in a wood burning oven, and pizza — but only ones baked in a wood-burning oven (or at a very high heat in a pizza oven).  I have NO idea why these are like “kryptonite” to me, and can think of no memory that offers a clue. When I was a kid, there were “Cheezies ®” (a brand of cheese puff snack food from Canada — essentially they are extruded cornmeal covered in powdered cheddar cheese), and as a teenager, there was Nutella®.  I would eat Cheezies or Nutella over a period of a few hours, until the container was empty.

To answer the question, ‘how has food addiction impacted my life‘, I first had to define ‘food addiction‘. Since my post-graduate research was in the area of mental health nutrition, I turned to the Diagnostic and Statistical Manual (DSM-5) which is used to classify mental health disorders for diagnoses, treatment, and research. The DSM-5 was published in 1994 and recognizes substance use disorders [1] resulting from the use of 10 separate classes of drugs:

    1. alcohol;
    2. caffeine;
    3. cannabis;
    4. hallucinogens (such as LSD);
    5. inhalants;
    6. opioids;
    7. sedatives, hypnotics or anxiolytics (anti-anxiety medication);
    8. stimulants (including amphetamine-type substances, cocaine, etc.);
    9. tobacco;
    10. and other or unknown substances

Is food addiction a substance use disorder? I guess it depends who one asks.

On one hand, one’s “kryptonite” foods could fall under “and other or unknown substances,” but as I mentioned in the summit, I don’t think it is the foods themselves that people become addicted to.

I believe that it is the release of dopamine from the pleasure center of the brain that is associated from the release of dopamine from the brain (explained in this article), and supported by endo-cannabinoids and endo-opioids that are also released.

The first question I was asked at the summit was whether I identified as a food addict. 

I referred to the list from the DSM-5 which lists the 11 criteria related to substance use disorder.

Food addiction in terms of the definition of “substance use disorder” (DSM-5)

In preparation for the talk, I had marked a red “x” beside the ones that applied to foods that I consider my “kryptonite”.

    1. Taking the substance in larger amounts or for longer than you’re meant to.
    2. Wanting to cut down or stop using the substance but not managing to.
    3. Spending a lot of time getting, using, or recovering from use of the substance.
    4. Cravings and urges to use the substance.
    5. Not managing to do what you should at work, home, or school because of
      substance use.
    6. Continuing to use, even when it causes problems in relationships.
    7. Giving up important social, occupational, or recreational activities because of substance use.
    8. Using substances again and again, even when it puts you in danger.
    9. Continuing to use, even when you know you have a physical or psychological problem that could have been caused or made worse by the substance.
    10. Needing more of the substance to get the effect you want (tolerance).
    11. Development of withdrawal symptoms, which can be relieved by taking more of the substance.

I could certainly remember eating more hot bagels or pizza than I wanted to, and for longer than I intended, so “yes” to criteria #1.

I certainly wanted to cut down or stop eating hot bagels or pizza, but not managing to, so “yes” to criteria #2.

Criteria #3, was a “no”.  I never spent a lot of time getting, using, or recovering from eating those (or any) foods.

There was no question, criteria #4 was a “yes”. I certainly had cravings and urges to eat these foods that only abated when I went low carb and stopped eating them.

Criteria #5, #6, and #7 and #11 were all “no”. Eating these (or any foods) did not interfere with me doing what I needed to at work, home or school, they didn’t cause problems in relationships and I didn’t give up any important social, occupational, or recreational activities because of them. I didn’t experience withdrawal symptoms when I ate those foods.

The reality of answering criteria #8 and #9 was undeniable.

I ate foods such as bagels and pizza (and foods high in both carbs and fat) again and again — even when it put me in danger.  I continued to eat these foods,  even though I knew (but was in denial!) that I had several physical problems that could have been caused by or made worse by eating these foods.

I was obese, had type 2 diabetes and dangerously high blood pressure — and was a Registered Dietitian with a master’s degree who was in denial as to just how much danger I had put myself in!  If you haven’t heard my story, it is under the Food for Thought tab, and titled A Dietitian’s Journey.

Reading Dr. Vera Tarman’s book, Food Junkies made me come face-to-face with criteria #10. I had given up milk chocolate when I adopted a low carb lifestyle, but reading the book made me realize that I needed more dark chocolate to enjoy it.  This was classic tolerance

As I talk about it the food addiction summit, coming to that realization resulted in me giving up all chocolate for a full year.  At present, I am finding that I can eat small amounts of >78% cocoa without it being problematic, but am doing so cautiously. I will abstain* completely if I am unable to do that.

I met the criteria for ‘substance use disorder’ when I applied the definition of “substance’ to specific foods.

In colloquial terms, I am a food addict, however I don’t say “I am a type 2 diabetic,” because I am in remission. I don’t say “I have hypertension or  obesity”, because I am in remission. So, more accurately, I am a person with food addiction, in remission. 

…and like type 2 obesity, hypertension and obesity, I will remain in remission provided I don’t go back and eat how I used to eat before.

Food addiction in terms of substance use disorder

If food addiction would be classified as a ‘substance use disorder’, then meeting 6 of 11 criteria indicates it would be “severe”. 

But it’s only hot bagels and pizza! Does that make me a “food addict”?

Here is a rhetorical question that may help answer this.

Does it matter if an alcoholic is powerless over only one type of rum and one type of whiskey?

I don’t think so.

One of the other questions I was asked during the summit was to define  “abstinence” and and what an “abstinence food plan” is.

This is how I defined them; 

“For me, abstinence is “the practice of restraining oneself from indulging in something”. There is alcohol-addiction, drug-addiction, gambling-addiction, sex-addiction, and food-addiction — but it is not possible to completely abstain from food, as it is necessary for survival. I define abstinence as “restraining from indulging in foods over which one has no control”.

Alcoholics Anonymous uses the term “powerless” to describe addiction, so I define abstinence asrestraining from foods over which one is powerless to stop eating.”

An “abstinent food plan” is one that does not include foods over which a person is powerless to control the amount they eat.”

Final Thoughts…

The DSM-5 does NOT define “food addiction”.  It defines “substance use disorder”. That said, I think that looking at whether specific foods or categories of food result in these types of symptoms can be helpful to consider.  It can help one decide whether getting support for food addiction may provide a context and structure that they find helpful.

More Info

I design abstinent meal plans for people with food addiction and support the dietary side as people work with either a food addiction- or sugar addiction counsellor, or in a food addiction 12-step program.

If you would like more information please send me a note through the Contact Me form, on the tab above.

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

Hasin DS, O’Brien CP, Auriacombe M, et al. DSM-5 criteria for substance use disorders: recommendations and rationale. Am J Psychiatry. 2013;170(8):834-851. doi:10.1176/appi.ajp.2013.12060782

 

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.

Time to Stop Calling Type 2 Diabetes a “chronic, progressive disease”

For as long as I can remember, type 2 diabetes has been called a chronic, progressive disease and people diagnosed with type 2 diabetes have been  taught that (1) the disease will persist (i.e. is chronic), (2) will only get worse (i.e. is progressive), (3) that medication to manage the disease is inevitable, and (4) that as the disease progresses multiple medications may be required, including insulin.

A newly published consensus report (August 31, 2021) from an expert panel made up of representatives from the American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD) and Diabetes UK states that “diabetes may not always be active and progressive” [1,2,3], and the report highlights that remission is possible, and a person may need ongoing support and regular monitoring to prevent relapse. You can read a summary of the report here.

The website of the American Diabetes Association states [4];

“You might start managing your diabetes with diet and exercise alone, but, over time, will have to progress to medication, and further down the line you might need to take a combination of medications, including insulin.”

While this will be the case if diet and lifestyle are not adequately changed, but it is by no means inevitable!

Diabetes Canada in its patient resources on “the basics” of type 2 diabetes states; ”type 2 diabetes is a progressive, life-long disease” [5].

 

…and in its March 2020 handout on access to diabetes medication states, Diabetes Canada states that; [6];

Diabetes is a chronic, progressive disease that affects the body’s ability to regulate the amount of glucose (sugar) in the blood. It has no cure, but can be managed through education, support, healthy behaviour interventions, and medications.

…and in its advocacy report on bariatric surgery as a type 2 diabetes intervention strategy [7] states;

Diabetes is a chronic, progressive disease affecting more than 3.6 million Canadians; approximately 90 per cent of whom live with type 2 diabetes. Type 2 diabetes is caused by a combination of genetic, lifestyle and environmental factors. It occurs when the body cannot properly regulate the amount of glucose (sugar) in the blood. Insufficient insulin production, insulin resistance, or both, cause hyperglycemia (high blood sugar) which, over time, can damage blood vessels, nerves and organs, and lead to many debilitating and irreversible complications. Type 2 diabetes can be managed with education and support, behaviour interventions (including healthy eating, regular physical activity and stress reduction) and medication.

Why do diabetes associations not explain that there are three documented ways to put type 2 diabetes into remission, two of which are dietary;

    1. a ketogenic diet [8,9]
    2. a low calorie energy deficit diet [10,11,12]
    3. bariatric surgery (especially use of the roux en Y procedure) [13,14]

Why are people diagnosed with type 2 diabetes still told that type 2 diabetes is a chronic, progressive disease — rather than told about the two evidence-based dietary options to achieve remission?

Final Thoughts…

In light of this new consensus report stating that “diabetes may not always be active and progressive” [1,2,3],  it is time to stop referring to diabetes as “a chronic, progressive disease”.

People  need to know that remission is possible, as well as information about the evidence-based dietary options that remission can be achieved.

What We’ve Been Taught and What We Need to Know

More Info?

If you would like more information about how I can support you in seeking remission of type 2 diabetes, please have a look under the Services tab, 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. Riddle MC, Cefalu WT, Evans PH. et al. Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes, The Journal of Clinical Endocrinology & Metabolism, 2021, dgab585,  https://doi.org/10.1210/clinem/dgab585
    2. Riddle MC, Cefalu WT, Evans PH. et al. Consensus report: definition and interpretation of remission in type 2 diabetes. 
    3. Riddle MC, Cefalu WT, Evans PH. et al.  Consensus report: definition and interpretation of remission in type 2 diabetes. Diabetologia (2021). https://doi.org/10.1007/s00125-021-05542-z
    4. American Diabetes Association, How Type 2 Diabetes Progresses, https://www.diabetes.org/diabetes/how-type-2-diabetes-progresses
    5. Diabetes Canada, Type 2 diabetes – the basics, https://guidelines.diabetes.ca/docs/patient-resources/type-2-diabetes-the-basics.pdf
    6. Diabetes Canada, Access to Diabetes Medication, March 2020 https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Advocacy%20Reports/Access-to-Diabetes-Meds_Time-to-Listing_EN.pdf
    7. Diabetes Canada, Bariatric surgery as a type 2 diabetes intervention strategy, https://www.diabetes.ca/advocacy—policies/advocacy-reports/bariatric-surgery-as-a-type-2-diabetes-intervention-strategy
    8. 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
    9. 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.
    10. 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
    11. 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
    12. 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.
    13. Cummings DE, Rubino F (2018) Metabolic surgery for the treatment of type 2 diabetes in obese individuals. Diabetologia 61(2):257—264.
    14. 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.

Type 2 Diabetes Remission – proposed definition from international experts

A new consensus report from an expert panel made up of representatives from the American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD) and Diabetes UK [1,2,3] have proposes a standard definition for remission of type 2 diabetes. This new article outlines the different factors involved in that definition, as well as the proposed cut-offs.


As outlined in a previous article, in 2009 the American Diabetes Association defined  partial remission, complete remission and prolonged remission of type 2 diabetes as follows [4];

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.*

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.

In 2019, the Association of British Clinical Diabetologists and the Primary Care Diabetes Society [5] defined remission of type 2 diabetes as follows;

“Remission of type 2 diabetes can be diagnosed when a person with confirmed type 2 diabetes has achieved all three of the following criteria: (1) weight loss; (2) fasting plasma glucose or HbA1c below the WHO diagnostic threshold (<7 mmol/L or <48 mmol/mol, respectively) on two occasions separated by at least 6 months; (3) the attainment of these glycaemic parameters following the complete cessation of all glucose-lowering therapies.”

I am by no means an expert in diabetes, but in clinical practice I’ve defined remission of type 2 diabetes as blood sugar levels “at or below the cut-offs for diagnosis” (HbA1C & FBG) without the use of medication. 

Choice of the Term “Remission”

The consensus report’s expert panel outlined that while several terms have been proposed to describe those who have become free of a previously diagnosed disease state, including ‘resolution‘, ‘reversal‘, ‘remission‘, and ‘cure‘,  that with respect to type 2 diabetes ‘remission‘ is the most appropriate term [1,2,3]. They chose the term remission as it is used widely used in the field of cancer treatment (oncology) as defined as a decrease in or disappearance of signs and symptoms of cancer [6].

The expert panel believes that the term remission captures that (1) “diabetes may not always be active and progressive“, while also implying that (2) “notable improvement may not be permanent“, and (3) is consistent with the view that a person may need ongoing support and regular monitoring to prevent relapse [1,2,3].

“Remission” Not Equivalent to No Evidence of Disease

The panel highlighted that the tendency to equate remission with “no evidence of disease” is not appropriate with respect to type 2 diabetes because diabetes is defined by hyperglycemia, which exists on a continuum [1,2,3], and noted that any criterion chosen to define remission is somewhat arbitrary, as it represents a point on a continuum of glycemic levels. They also highlighted that remission is not equivalent to “no evidence of disease” because the underlying cause of type 2 diabetes is rarely resolved by dietary or lifestyle changes, or by bariatric surgery — including insufficient release of insulin from βeta-cells and insulin resistance.

Different Levels of Remission

The panel decided against dividing diabetes remission into partial remission and complete remission using different blood glucose thresholds as this could result in challenges with respect to policy decisions related to insurance premiums, and coding for medical visits and that the 5-year threshold previously used by the ADA for defining prolonged remission “did not have an
objective basis”.

Use of Glucose-Lowering Medication in Defining Remission

The issue of whether remission could be diagnosed while a person was receiving ongoing medication support, was also addressed. This is an important consideration, as some studies such as those from Virta Health [7,8] define remission of type 2 diabetes as a HbA1C < 6.5% and fasting blood glucose ≤ 5.5 (100 mg/dl) while taking no other medication except metformin / glucophage.

The panel concluded that since it is not possible to tell if a person has achieved remission due to dietary and lifestyle changes or due to medication that lowers glucose, “a diagnosis of remission can only be made after all glucose-lowering agents have been withheld for an interval that is sufficient both to allow waning of the drug’s effects and to assess the effect of the absence of drugs on HbA1c values“.

The panel concluded the absence of medication includes the use of metformin for weight maintenance, to improve markers of risk for cardiovascular disease or cancer, or prescribed for polycystic ovarian syndrome (PCOS), GLP-1 receptor agonists (such as Ozempic, Victoza / Saxenda and others) which may be used for weight management or to reduce the risk of cardiovascular events, and sodium glucose cotransporter inhibitors (such as Invokana, Jardiance, Synjardy and others) which may be prescribed for heart failure or renal protection.

The panel concludes that if it is not possible to discontinue these drugs for 3 months or longer, then remission cannot be diagnosed even though
normal or near normal blood sugar values are maintained — and that without doing so “
whether true remission has been attained remains unknown”.

Timeline for Determining Remission

Whether the changes made are dietary, lifestyle or surgical (such as gastric bypass), varying amounts of time are required to determine whether remission has been achieved.

Medication Intervention (Pharmacotherapy)

The expert panel determined that when the  intervention has been through medication (pharmacotherapy), there needs to be  a period of at least 3 months after the medication has been completely stopped before tests of HbA1C can reliably evaluate whether remission has been achieved.

Surgical Intervention

In the event of surgical intervention, the panel determined that there needs to be a period of at least 3 months after the surgical procedure and 3 months after the medication has been completely stopped before tests of HbA1C can reliably evaluate whether remission has been achieved.

Lifestyle Changes

When lifestyle changes, including diet and exercise are made, the panel determined that there needs to be a period of at least 6 months after beginning this intervention and 3 months after the medication has been completely stopped before tests of HbA1C can reliably evaluate whether remission has been achieved.

Need for Ongoing Monitoring

As outlined above, since the improvements in blood glucose may not be permanent, a person who has achieved remission from type 2 diabetes as defined above will likely need ongoing support and regular monitoring to prevent relapse as weight gain, stress resulting from other illnesses, and the continued decline of βeta-cell function can all result in recurrence of type 2 diabetes. The panel recommends regular laboratory testing of HbA1c or another measure of blood sugar control should be performed at least once a year.

The panel cautions that since there can still be the “legacy effect” of prior poor blood sugar control in various body tissues that continues after remission of symptoms, there is a need not only for ongoing monitoring of HbA1C, but also regular retinal screening for retinopathy, tests of renal function to rule out nephropathy, foot evaluation to rule out neuropathy, as well as measurement of blood pressure and weight to reduce the risk of cardiovascular disease.

HbA1c as the Defining Measurement of Remission

The expert panel set the cut-off point for defining remission as HbA1c to < 6.5% (<48 mmol/mol) while stating that “the relative effectiveness of using HbA1C of 6.0% (42 mmol/mol), HbA1c of 5.7% (39 mmol/mol), or some other
level in predicting risk of relapse or microvascular or cardiovascular complications should be evaluated“. As noted above, the panel believes that any criterion chosen to define remission is somewhat arbitrary, as it represents a point on a continuum of glycemic levels. 

Conclusions of the Expert Panel

The expert panel concluded that the term “remission” should be used to describe a sustained metabolic improvement in type 2 diabetes to nearly normal levels defined as a return of HbA1c to < 6.5% (<48 mmol/mol) that occurs spontaneously, or following an intervention and that persists for at least 3 months in the absence of usual glucose-lowering medication (pharmacotherapy).

When HbA1c is determined to be an unreliable marker of chronic glycemic control, the panel concluded that a fasting blood glucose (FBG) / fasting plasma glucose (FPG) <126 mg/dL (<7.0 mmol/L) or eA1C <6.5% calculated from continuous glucose monitoring (CGM) values can be used as an alternative.

Final Thoughts…

In addition to the new proposed cut-offs, there are three very important points made in this new consensus report:


NOTE
: Be sure to read the following post about why it is time to stop calling type 2 diabetes
”a chronic, progressive disease”.

More Info?

If you would like more information about how I can support you in seeking remission of type 2 diabetes as defined above, 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: A consensus report is not an American Diabetes Association (ADA) position statement but represents expert opinion of this international expert panel’s collective analysis, evaluation, and opinion.

References

  1. Riddle MC, Cefalu WT, Evans PH. et al. Consensus Report: Definition and Interpretation of Remission in Type 2 Diabetes, The Journal of Clinical Endocrinology & Metabolism, 2021, dgab585,  https://doi.org/10.1210/clinem/dgab585
  2. Riddle MC, Cefalu WT, Evans PH. et al. Consensus report: definition and interpretation of remission in type 2 diabetes.
  3. Riddle MC, Cefalu WT, Evans PH. et al.  Consensus report: definition and interpretation of remission in type 2 diabetes. Diabetologia (2021). https://doi.org/10.1007/s00125-021-05542-z
  4. Buse JB, Caprio S, Cefalu WT, et al. How do we define cure of diabetes?
  5. Nagi D, Hambling C, Taylor R. Remission of type 2 diabetes: a position statement from the Association of British Clinical Diabetologists (ABCD) and the Primary Care Diabetes Society (PCDS). Br J Diabetes 2019, June 2019; 19 (1):73—76. https://doi.org/10.15277/bjd.2019.221
  6. Barnes E. Between remission and cure: patients, practitioners and the transformation of leukaemia in the late twentieth century. Chronic Illness 2008, Jan 2008;3(4):253—264.https://doi.org/10.1177/1742395307085333
  7. McKenzie AL, Hallberg SJ, Creighton BC, Volk BM, Link TM, Abner MK, Glon RM, McCarter JP, Volek JS, Phinney SD, A Novel Intervention Including Individualized Nutritional Recommendations Reduces Hemoglobin A1c Level, Medication Use, and Weight in Type 2 Diabetes, JMIR Diabetes 2017;2(1):e5, URL: http://diabetes.jmir.org/2017/1/e5, DOI: 10.2196/diabetes.6981
  8. Hallberg, S.J., McKenzie, A.L., Williams, P.T. et al. Diabetes Ther (2018). 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.  https://doi.org/10.1007/s13300-018-0373-9

 

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.

High Protein to Energy Matcha Drink – role in abdominal fat loss

INTRODUCTION: Green tea which is high in the catechin EGCG (epigallocatechin gallato) has been associated in two meta-analysis with a reduction in body weight and body fat — especially abdominal fat [1,2] and matcha powder is especially high in EGCG.


Catechins make up ~ 30% of green tea’s dry weight and while ordinary brewed green tea contains ~50—100 mg catechins [3], just 1 gram (~1/3 teaspoon) of matcha powder contains 105 mg of catechins of which 61 mg are EGCs.

A 2009 meta-analysis of 11 green tea catechin studies found that subjects consuming between 270 to 1200 mg green tea catechins / day ( 1 — 4 tsp of matcha powder per day) lost an average of 1.31 kg (~ 3 lbs) over 12 weeks [2], but that the effect of green tea catechins on body composition was significant, even when the weight loss between treated and untreated groups is small (~5 lbs in 12 weeks).

Even with as little as a 3 pound weight loss, the total amount of abdominal fat decreased 25 times more with green tea catechin consumption than without it (−7.7 vs. −0.3%) [2] and the total amount of subcutaneous abdominal fat (fat just below the skin on the abdomen) decreased almost 8 times more with green tea catechin consumption than without it (−6.2 vs. 0.8%) [2].

A 2017 meta-analysis found that consuming as little as 100 and 460 mg/day has shown significant effectiveness on body fat and body weight reduction in intervention periods of 12 weeks or more [1].

How do Green Tea Catechins in Matcha Work?

The mechanisms by which green tea catechins reduce body weight and reduce the amount of total body fat and in particular reduce the amount of abdominal fat are still being investigated but it is thought that green tea catechins increase thermogenesis (increased heat production which would result in increased energy expenditure), increase fat oxidation (using body fat as energy), decrease appetite, result in the down-regulation of enzymes involved in liver fat metabolism, and decrease nutrient absorption [2].

Timing of Matcha Catechin Consumption

Green tea catechins such as EGCG found in matcha are absorbed in the intestine and since the presence of food significantly decreases their absorption, green tea catechins are best consumed 1/2 an hour before meals, or 2 hours after meals.

The timing of green tea catechin intake may also affect the absorption and metabolism of glucose. A study by Park et al [4] found that when green tea catechins were given one hour before to a glucose (sugar) load, glucose uptake was inhibited and was also accompanied by an increase in insulin levels.

Effect of Milk Casein on Catechins

It was previously thought that the protein casein found in milk binds green tea catechins, making them unavailable for absorption in the body, however a recent study found that while the antioxidant activity of polyphenols is lowered from 11-27% by the presence of casein, EGCG which is the catechin in matcha is actually increased by the presence of casein [5].

Final Thoughts…

Consuming between 1 — 4 tsp of matcha powder per day (270 to 1200 mg green tea catechins / day) is sufficient to contribute to weight loss of ~ 3 lbs in 12 weeks (with no other dietary or activity changes) and more significantly decrease body fat composition, especially abdominal fat.

Along with a well-designed meal plan, beverages containing matcha powder may be helpful for those who have already lost significant amounts of weight and who would like to lose remaining fat on their abdomen.

WARNING TO PREGNANT WOMEN

While EGCG has also been found to be similar in its effect to etoposide anddoxorubicin, a potent anti-cancer drug used in chemotherapy [6 al], high intake of polyphenolic compounds during pregnancy is suspected to increase risk of neonatal leukemia. Bioflavonoid supplements (including green tea catechins) should not be used by pregnant women [7].

High Protein to Energy Matcha Drink

This drink is great after a workout, or as a quick high protein, low carb meal replacement when time doesn’t allow for real, whole food. It may be helpful for those who have already lost significant amounts of weight, yet are having difficulty losing residual fat around their abdomen.

Since matcha does contain caffeine, I recommend drinking these before 2 PM in the afternoon so that the caffeine does not interfere with sleep.

Ingredients

1 tsp matcha (green tea) powder  (1 tsp = 2 gm)

1 scoop unflavoured whey isolate powder (25 g protein per scoop)

12 cubes ice cubes

1 cup (250 ml) fat free Fairlife® milk (low carb, high protein) 

Optional: 1.5 tsp monk fruit / erythritol sweetener

Method

  1. Place 1 tsp matcha powder in a small stainless steel sieve and gently press through the sieve into a small bowl with the back of a small spoon
  2. Put the sieved matcha powder into a ceramic or glass bowl (not metal, as the tannins in the tea will react and give the beverage and ”off” metallic taste)
  3. Whisk 3 tbsps. boiled and cooled water into the matcha powder using a bamboo matcha whisk (available at Japanese and Korean grocery stores) until the mixture is smooth and frothy
  4. Add low carb erythritol sweetener, if desired
  5. Add 1 scoop of unflavoured whey isolate powder
  6. Stir in 1 cup Fairlife® (low carb, high protein) milk
  7. Pour mixture over ice cubes

Macros

calculated by Cronometer®

Protein to Energy Ratio = 3.17

protein to energy calculated from ptoe.com

More Info?

I design low carb Meal Plans from a variety of perspectives, including a Low Carb High Protein /  P:E perspective.

If you would like more information, please send me a note using the Contact Me form on the tab above.

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. Vázquez Cisneros LC, López-Uriarte P, López-Espinoza A, et al. Effects of green tea and its epigallocatechin (EGCG) content on body weight and fat mass in humans: a systematic review. Nutr Hosp. 2017 Jun 5;34(3):731-737. Spanish. doi: 10.20960/nh.753. PMID: 28627214.
  2. Hursel R, Viechtbauer W, Westerterp-Plantenga MS. The effects of green tea on weight loss and weight maintenance: a meta-analysis. Int J Obes (Lond). 2009 Sep;33(9):956-61. doi: 10.1038/ijo.2009.135. Epub 2009 Jul 14. PMID: 19597519.
  3. Weiss DJ, Anderton CR, Determination of catechins in matcha green tea by micellar electrokinetic chromatography, Journal of Chromatography A, Vol 1011(1—2):173-180, September 2003
  4. Park JH, Jin JY, Baek WK, Park SH, Sung HY, Kim YK, et al. Ambivalent role of gallated catechins in glucose tolerance in humans: a novel insight into nonabsorbable gallated catechin-derived inhibitors of glucose absorption. J Phyisiol Pharmacol 2009;60:101—9.
  5. Bourassa P, Cote R, Hutchandani S, et al, The effect of milk alpha-casein on the antioxidant activity of tea polyphenols, J Photochem Photobiol 2013;128, 43-49.
  6. Bandele, OJ, Osheroff, N. Epigallocatechin gallate, a major constituent of green tea, poisons human type II topoisomerases”.Chem Res Toxicol 21 (4): 936—43, April 2008.
  7. Paolini, M, Sapone, A, Valgimigli, L, ”Avoidance of bioflavonoid supplements during pregnancy: a pathway to infant leukemia?”. Mutat Res 527 (1—2): 99—101. (Jun 2003)

 

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.

Video Update: Maintaining Weight and Health – Four Years Later

As I was heading out the door early this morning to begin walking again at the local track, I realized it was the same weather as it was more than four years ago, when I made my first video. I decided to wear the same glasses and rain shell that I did in that video and post the side-by-side comparison. This is that video update!

That first video was part of a post called “The Road to Better Health” in what I ended up calling ”A Dietitian’s Journey”, my personal weight-loss and health-recovery story.  In the post which accompanies that video, I mentioned how just three weeks earlier I was faced with two choices; (1) go on medication or (2) change my lifestyle — and on March 5, 2017, I chose the latter.

In retrospect, that video really marked the beginning of my journey, and over time hundreds of people ended up following me on social media in order to watch my progress. I never set out to do that, but I think the novelty of someone posting “before” pictures, before there were “after” photos caused people wanted to see if I would actually be successful.  I was — and I still am.

Here is that first video, which I posted on YouTube.  In it, you can clearly see how I was not only obese, but could barely walk and talk at the same time!

 

Since the weather was almost the same today, I thought it would be a great time to post an update to encourage those who have followed my journey from the beginning.

While it took me two years to attain my weight loss and put my diabetes and high blood pressure into remission, here it is more than 2 years since then and I have maintained remission of type 2 diabetes and hypertension.

Like most people, I gained almost 20 pounds over the past year due to the Covid pandemic, but I have already lost half of that and anticipate losing the rest by the end of the summer.

Everyone’s weight and health-recovery “journey” will be different. This is mine.

I hope this update encourages you that it is both “doable” and “sustainable”.

More Info?

If you’d like to know more about what I do, and how I may be able to help you achieve your own weight-loss and health recovery, please have a look under the Services tab, above. If you have questions, please send me a note using the Contact Me form and I will reply as soon as I am able.

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

Low Carb High Protein Diet is Different Than the P:E Diet

I’ve recently been asked to explain the difference between a Low Carb High Protein (LCHP) diet and the new P:E Diet, and that is the purpose of this article.  While both these diets prioritize protein, the recommended macros are very different.  This article outlines these two approaches and highlights the similarities and difference between the macro recommendations of these two diets.

Defining Terms

In order to describe how these two diets are similar and different, it is necessary to define some terms — specifically

(1) “low carb“, “keto” and “moderate carb

(2)  “low fat

(3) “high protein

Defining Carbohydrate Intake

Feinman et al [1] define very low carbohydrate (”keto”) diet, low carbohydrate diet and moderate carbohydrate diet as follows:

1. very low carbohydrate (keto) diet: 20—50g carbohydrate /day,  < 10% total energy intake

2. low carbohydrate diet: < 130g carbohydrate / day, < 26% of total energy intake

3. moderate carbohydrate diet: 130—225g carbohydrate / day, 26—45% of total energy intake

Since these same cut offs for carbohydrate are used by diabetes associations around the world — including the American Diabetes Association, European Association for the Study of Diabetes (EASD), Diabetes Australia, and Diabetes Canada, I use these established definitions, as well.

Defining “Low Fat”

A low fat diet is defined by the USDA as ”not more than 30% of calories from fat” [2].

Defining “High Protein”

Lower and Higher protein diets were defined in a very recent systematic review and meta-analysis[3] with some overlap;

    • Lower Protein Diets provide 10-23% of calories from protein
    • Higher Protein Diets provide 20-45% of calories from protein

The P:E Diet

P:E Diet -the book

I’ve read the P:E Diet book and find that it provides excellent guidance for healthy individuals who are seeking to build muscle, and lose excess fat. For those seeking to accomplish those goals, the P:E diet is excellent as it encourages people to eat the best quality protein for the least amount of energy (as fat + net carbs).

That said, as I have covered in previous articles and will elaborate on below, I am concerned that the total amount of protein generated in the P:E Macro Generator associated with the P:E Diet (located at the bottom of www.p2eq.com) can get close to the maximum rate at which the kidney can get rid of nitrogen waste from protein in the urine. 

I also have concerns that the P:E Macro Generator associated with the diet provides a carbohydrate intake of >100 g of carbohydrate per day to up to >160 g carbohydrate per day which is fine for healthy individuals, but may be inappropriate for someone who is metabolically unhealthy, especially having difficulty with higher than normal blood sugar levels. There is a clear disclaimer at the beginning of the book that it is not intended for those with health conditions, but none on the P:E Macro Generator.

Recommended Macros for the P:E Diet

The P:E Diet Macro Calculator associated with the P:E Diet is located at the bottom of www.p2eq.com recommends 40% protein and 30% fat and 30% carbohydrate for males or females of different heights. Recommended weight generated by the Macro Calculator is set to Ideal Body Weight (i.e. a BMI of 22) which is halfway through the normal weight category.

Below are some examples of macros from the P:E Macro Generator for different heights for both genders;

Carbohydrate recommendation for a man who is 5’7″ tall are at the low end of the moderate carbohydrate range — providing 131 g of carbs / 30% of total energy intake — where moderate carbohydrate is defined as 130—225g carbohydrate / day, 26—45% of total energy intake.

Fat recommendation of 30% calories as fat is low fat, i.e. ”not more than 30% of calories from fat”.

Protein recommendation of 40% calories as protein is a High Protein Diet i.e. provides 20-45% of calories from protein.

 


Macros for a man who is 5’10” tall are in the moderate carbohydrate range — providing 144 g of carbs / 30% of total energy intake — where moderate carbohydrate is defined as 130—225g carbohydrate / day, 26—45% of total energy intake.

Fat recommendation of 30% calories as fat is low fat, i.e. ”not more than 30% of calories from fat”.

Protein recommendation of 40% calories as protein is a High Protein Diet i.e. provides 20-45% of calories from protein.

 


Macros for a woman who is 5’6″ tall are in the low carbohydrate range — providing 117 g of carbs / 30% of total energy intake — where low carbohydrate is defined as < 130 g carbohydrate / day, < 26% of total energy intake.

Fat recommendation of 30% calories as fat is low fat, i.e. ”not more than 30% of calories from fat”.

Protein recommendation of 40% calories as protein is a High Protein Diet i.e. provides 20-45% of calories from protein.

 


Macros for a man who is 6’2″ tall are in the middle of the moderate carbohydrate range — providing 162 g of carbs / 30% of total energy intake — where moderate carbohydrate is defined as 130—225g carbohydrate / day, 26—45% of total energy intake.

Fat recommendation of 30% calories as fat is low fat, i.e. ”not more than 30% of calories from fat”.

Protein recommendation of 40% calories as protein is a High Protein Diet i.e. provides 20-45% of calories from protein.

 

Summary of P:E Macros

For the most part, carbohydrates in the P:E Diet are in the moderate carbohydrate range, although are on occasion they are in the high end of the low carbohydrate range, or at the low end of the moderate carbohydrate range [1].

The P:E Diet is a Low Fat Diet as it provides ”not more than 30% of calories from fat” [2].

The P:E Diet is a High Protein Diet providing 40% of calories from protein which is in the 20-45% of calories from protein range [3].

Recommended Macros for Low Carb High Protein Diet

As outlined in the previous article, the way I have taught a Low Carb High Protein (LCHP) diet the past 3 years is that protein is set at 25-30% protein (to a maximum of 2.5-3.0 g protein per kg ideal body weight), fat at 65-70% fat and carbohydrate at 10% carbs. This is at the high end of the protein range recommended by Phinney and Volek [7] of 20% to up to 30% of daily calories as protein — and fat is the same as they recommend, at 65-70% fat and 10% carbs.

A Low Carb High Protein diet is always low carb or very low carb;  low carb when it contains <130g carbohydrate per day,  < 26% of total energy intake, and very low carb (‘keto‘) when it contains 20—50g carbohydrate /day,  < 10% total energy intake.

A Low Carb High Protein diet is a High Fat Diet as it provides 65-70% fat, which is ”more than 30% of calories from fat” [2]. Unlike the popularized Low Carb High Fat diet, most of the fat in a Low Carb High Protein Diet comes from the fat inherent in the protein eaten — such as the fat in high fat fish like salmon and tuna, fat in Greek yogurt or the fat that comes in ground beef.  There is very little added fat, since a Low Carb High Protein Diet is often used for weight loss.

A Low Carb High Protein diet is a High Protein Diet providing 25-30% of calories from protein [3] to a maximum of 2.5-3.0 g protein per kg ideal body weight, and which is in the 20-45% of calories from protein range of a High Protein Diet [3].

Important Differences Between Low Carb High Protein and P:E Diet

From my perspective, there are two significant differences between a Low Carb High Protein diet and the P:E Diet.

The first significant difference is that the P:E Diet may be low carb — but for the most part is a moderate carbohydrate diet.  For those who are metabolically healthy, a diet which provides a carbohydrate intake of >100 g of carbohydrate per day to up to >160 g  carbohydrate per day as real, whole (cellular) food is fine. My concern is that for those who already have pre-diabetes or type 2 diabetes, a carbohydrate intake of >100 g carbohydrate per day up to >160 g per day is not the best way to improve blood sugar levels.

As outlined in the American Diabetes Association’s April 2019 Consensus Report a low carb diet has ”demonstrated the most evidence for improving glycemia (blood sugar) for individuals with diabetes”[4].

A Low Carb High Protein diet is, by definition, a low carb diet so it has demonstrated the most evidence for improving blood sugar.

The second significant difference between a Low Carb High Protein Diet and the P:E Diet is that protein in the P:E Diet is set at 40% of daily calories — and as described in this earlier article, for some heights and weights, the P:E Macro Calculator generates protein at the high end of the maximum protein intake of 3.2 g protein per kg ideal body weight.

When protein is eaten, the body must get rid of the nitrogen by-product and the main way the body gets rid of this nitrogen is by turning it into ammonia, and then excreting it as urea in the urine. Since 84% of the nitrogen waste produced from protein intake is excreted as urea in the urine [5], the safe upper limit of protein intake is based on the maximum rate of urea production which is 3.2 g protein per kg body weight [6], described in more detail in this article

Protein needs should always be calculated as grams of protein per kilogram of body weight of the person and not as a percentage of daily calories e.g. 40 % of daily energy as protein. This is to ensure adequacy and avoid the excess. An intake of 40% of daily calories as protein for one person may be below the safe upper limit of 3.2 g protein per kg body weight, but for another 40% of calories as protein put them right at the upper limit (more in this article).

By the P:E Diet Macro Generator setting protein intake at 40% of daily calories without limiting a maximum to below the safe upper limit of 3.2 g protein per kg body weight, the protein recommendations generated may sometimes be at the very upper limit.

The Low Carb High Protein Diet, the way I teach it sets protein at 25-30% of daily calories — with a maximum of 2.5 g protein per kg ideal body weight, which is below the safe maximum intake level.

Different Diets for Different Purposes

The P:E Diet is geared towards healthy people seeking to build muscle and lose fat, and as indicated on page 85;

all bodybuilders are really combining low carb AND low fat AND high protein to the very highest level of success.

That is what the P:E Diet Macro Calculator located at the bottom of www.p2eq.com is set to do!

It generates macros that are 40% protein, 30% fat and 30% carbohydrate.

A diet that is 30% carbohydrate IS “low carb” when compared with the 45-65% carbohydrate range of the US or Canadian dietary guidelines AND low fat (“”not more than 30% of calories from fat” AND high protein (40% of daily calories as protein) and this is by design.

A Low Carb High Protein Diet, the way I teach it (and as conceptualized by Phinney and Volek in their book) is primarily a therapeutic diet aimed at improving metabolic health including high blood sugar, insulin resistance and for weight loss. 

The P:E Diet book is not directed at those who have medical conditions such as pre-diabetes or type 2 diabetes, or for those who have higher than normal blood sugar.  

These are very different diets, for very different purposes.

Final Thoughts…

I think the P:E Diet as outlined in the book provides excellent guidance for healthy individuals seeking to build muscle and lose excess fat and P:E ratio as a concept is excellent — encouraging people to eat the best quality protein for the least amount of energy (as fat + net carbs).

I also find that the tool for looking up the P:E ratio of individual foods (at the same link as the Macro Generator, except at the top of the page) is very helpful and saves people from having to do the math to determine Protein / (Fat + Net Carbs).

That said, I am concerned that total amount of protein in the P:E Macro Generator is not limited to a maximum of 3.0 g protein / kg ideal body weight — to ensure it does not exceed the 3.2 g protein / kg ideal body weight (the rate at which the kidney can get rid of nitrogen in the urine). This could easily be done, given that the weight it generates is already set at Ideal Body Weight.

For those who are metabolically healthy, the P:E Macro Generator which provides a carbohydrate intake of >100 g of carbohydrate per day to up to >160 g  carbohydrate per day as real, whole (cellular) food is fine, but my concern is that this level of carbohydrate intake may be inappropriate for someone who is already metabolically unhealthy — especially for someone with prediabetes or type 2 diabetes or challenges with higher than normal blood sugar.  This could easily be solved by providing a clear disclaimer such as the one that appears in the book.

More Info?

I design low carb Meal Plans from a variety of perspectives, including a Low Carb High Protein and can help individuals decide between different approaches based on their health, goals and nutritional needs.

For those who are metabolically healthy, I also design Meal Plans from a P:E perspective, however I do limit maximum protein intake to a maximum of 2.5 g protein per kg of ideal body weight.

If you would like more information, please send me a note using the Contact Me form on the tab above.

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. 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. Institute of Medicine (US) Committee on Examination of Front-of-Package Nutrition Rating Systems and Symbols; Wartella EA, Lichtenstein AH, Boon CS, editors. Front-of-Package Nutrition Rating Systems and Symbols: Phase I Report. Washington (DC): National Academies Press (US); 2010. Appendix B, FDA Regulatory Requirements for Nutrient Content Claims. Available from: https://www.ncbi.nlm.nih.gov/books/NBK209851/
  3. Vogtschmidt YD, Raben A, Faber I et al, Is Protein the Forgotten Ingredient: Effects of higher compared to lower protein diets on cardiometabolic risk factors: a systematic review and meta-analysis of randomised controlled trials, Atherosclerosis, May 25, 2021, DOI:https://doi.org/10.1016/j.atherosclerosis.2021.05.011
  4. A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
  5. Tomé D, Bos C, Dietary Protein and Nitrogen Utilization, The Journal of Nutrition, Volume 130, Issue 7, July 2000, Pages 1868S—1873S, https://doi.org/10.1093/jn/130.7.1868S
  6. 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
  7. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
  8. Naiman T, Shewfelt W, The P:E Diet – Leverage Your Biology to Achieve Optimal Health, June 10, 2020, 330 pages

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.

There’s More Than One Way to Do a Low Carb or Keto Diet

People still think that a “keto diet” is all about eating loads of fat, and while a Low Carb High Fat (LCHF) diet is certainly one way to do ‘keto’, it is by no means the only way — or is it even a single diet. There are therapeutic ketogenic diets for epilepsy and adjunct treatment (along with chemotherapy and radiation) for certain types of cancer, as well as for seeking to improve quality of life outcomes in certain neurological disorders, such as MS. There are also different types of “low carb” and “keto” diets that are used for weight loss and for improving metabolic heath — that range from ones that prioritize fat, to those that prioritize protein. This article outlines some of the key advantages and disadvantages of different types of low carb* and keto** diets that are used for weight loss and normalizing blood sugar.

As outlined here, *low carb is defined as < 130g carbohydrate / day, < 26% of total energy intake and very low carb / **keto diets are defined as 20—50g carbohydrate /day,  < 10% total energy intake.


Humans can use protein, fat and carbohydrate for fuel, but our two main energy sources are fat and carbohydrate.  While amino acids from the protein we eat can be used to make glucose to maintain blood sugar and to supply red blood cells when there is inadequate food intake, protein’s main role in the diet is NOT as a fuel source, but to provide amino acids (the building blocks of protein) for the body to make its own proteins. Protein is primarily there to provide structure and function, not energy.

Fat and carbohydrate are human’s two primary energy sources — and carbohydrate is entirely optional from a biological perspective.

Even the Dietary Reference Intakes support that carbohydrate in the diet is optional, provided we eat adequate amounts of protein and fat.

Protein and fat are not optional, carbohydrate is.

Page 275 Dietary Reference Intakes for Carbohydrate [1]
Page 275 of the Dietary Reference Intakes states that;

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

Our body has an absolute requirement for specific essential nutrients — and these are called “essential nutrients” because we must take them in through our diet because we can’t synthesize them.

As I wrote about back in 2017, there are 9 essential amino acids that must be supplied in the different kinds of protein that we eat, and include histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, valine and there are 2 essential fatty acids — linoleic (an omega 6 fat) and alpha-linolenic (an omega 3 fat) that also must be provided in the diet because that can’t be synthesized by the body.

There are also 13 essential vitamins (vitamin A, vitamin B1 (thiamine), B2 (riboflavin), B3 (niacin), B5 (pantothenic acid), B6 (pyrodoxine), B12 (cyanocobalamine), biotin, vitamin C (ascorbic acid), choline, vitamin D (cholecalciferol), vitamin E (tocopherol) and  folate), and several essential minerals, including major minerals (calcium, phosphorus, potassium, sodium, chloride and magnesium) and minor minerals (chromium, cobalt, copper, fluorine, iodine, iron, manganese, molybdenum, selenium, silicon, sulfur and zinc).

Of the 3 macronutrients (protein, carbs and fat), protein and fat are not optional because they provide the essential amino acids and essential fats — and with them, many (but not all) of the essential vitamins and essential minerals. The remainder of the essential vitamins and minerals are provided by eating a wide range of vegetables and fruit.

Prioritizing Protein

Whether we eat a Low Carb High Fat (LCHF) diet, or Low Carb High Protein (LCHF) diet, we first need to make sure we are eating adequate amounts of high quality protein for our needs, and with high quality proteins come the essential fats. 

Think of protein as the foundation of a balance scale — providing the body with building blocks for structure and function — and the two arms of a balance scale as the two sources of fuel for energy: carbohydrate and fat.

We need to have enough protein for our needs, but not so much as to exceed the body’s ability to get rid of the excess nitrogen in our urine (more about that here).

Basic protein requirements are set in the Recommended Daily Allowance (RDA) for protein, which is the level that is sufficient to meet the needs of 97-98 % of healthy people and to prevent deficiency. The RDA for protein for healthy adults is calculated at 0.8 g protein / kg of reference body weight (i.e. IBM) [1]. Remember, this is the bare minimum to prevent deficiency in most people.

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 IBW per day to optimize recovery from training, and to promote the growth and maintenance of lean body mass.

Older people also need more protein in order to maintain muscle mass, and prevent sarcopenia (muscle loss associate with aging). 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 IBW per day may best meet the needs of adults during aging [3,4].

The Need to “Trade Off” Protein for Ketones

If we need to supply our body with lots of ketones for therapeutic reasons — such as the management of seizure disorder, or as an adjunct treatment for certain types of cancer or neurological disorders, then there is the need to “trade off” supplying the body anything more than the bare minimum of protein, in order to provide it with the very high levels of fat needed to make high levels of ketones.

The classic Ketogenic Diet (KD) has a 4:1 ratio i.e. 4 parts of fat for every 1 part protein and carbs and the Modified Ketogenic Diet (MKD) has a 3:1 ratio i.e. 3 parts fat for every 1-part protein, but unless a person has a therapeutic need for high levels of ketones, then why eat super high levels of fat

Higher Fat than Carbs – two very different approaches

As outlined in the American Diabetes Association’s April 2019 Consensus Report, a low carb diet has “demonstrated the most evidence for improving glycemia (blood sugar) for individuals with diabetes“[6], so either a Low Carb High Fat diet or a Low Carb High Protein diet are excellent approaches for those with prediabetes or type 2 diabetes seeking to significantly improve their blood sugar, or to put type 2 diabetes into remission.

Popularized “Keto” Diet

When most people think of a Low Carb High Fat (LCHF) diet, they think of the standard “keto diet” of 75% fat, 15% protein and 10% carbs, which is the popularized high fat approach of Dr. Jason Fung and the Diet Doctor website recommend. As will be outlined below, there are other Low Carb High Fat approaches.

If the goal is to lose weight however, it really doesn’t make a lot of sense to eat tons of fat which provides almost twice as much energy, as either protein or carbs — unless also doing regular periods of intermittent and extended fasting. While people do have success with this type of low carb high fat diet when used this way, this approach has drawbacks for some people.

Intermittent fasting for less than 24 hours has many benefits, but the problem with extended fasting for periods longer than 24 hours is there is a loss of lean body mass (muscle) that goes along with it — which is more of a concern for older adults who are already losing lean body mass, than for younger people.

According to a 1979 research article published in the American Journal of Clinical Nutrition [7], 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 [9,10].

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

This graph from Virta Health [10] based on the same research [7] 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 [9] 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 [9].

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 [10]”.

This time frame is consistent with the research above [9,10] showing that the slowing of muscle loss only occurs after 10 days of fasting, when ketones become the preferred fuel.

It is for this reason that I do not recommend fasting longer than 24 hours for older adults — especially post-menopausal women who are already at risk of sarcopenia (muscle loss), but daily periods of intermittent fasting (from the end of dinner until the first meal of the day, the following day) is recommended to help normalize blood sugar and circulating levels of insulin.

Another shortcoming with the popularized “keto” macros is that 15% protein may be insufficient for an older adult or for someone to sustain regular physical activity (more here).

For younger adults and those who are not trying to build muscle, this approach can be very helpful for losing weight and controlling blood sugar levels.

A “Well-Formulated” Ketogenic Diet

Another approach which falls in the Low Carb High Fat (LCHF) category are the recommendations of Dr. Stephen Phinney and Dr. Jeff Volek from their book The Art and Science of Low Carbohydrate Living — which recommends ~60-70% fat, 20%-up to 30% protein, and 10% carbohydrate [11].

This style of low carb high fat diet provides up to 30% protein, which is almost twice as much protein as the popularized keto’ diet, which is only 15% protein — and as outlined in an earlier article is insufficient for older adults, as well as people sustaining regular physical activity.

Low Carb High Protein

In a sense, a Low Carb High Protein (LCHP) diet which provides ~25-30% protein really falls at the higher end of the range of Dr. Stephen Phinney and Dr. Jeff Volek’s approach of 20% — up to 30% protein and provides a similar fat range of 65-70% fat, and 10% carbs.

As a “low carb diet” it offers all the benefits for lowering blood sugar, and as such is ideal for those seeking to put pre-diabetes or type 2 diabetes into remission.

It is also ideal for those seeking weight loss without periods of extended fating, as it does not have excessive fat, and provides sufficient protein for older adults and those who participate in regular physical activity.

Final Thoughts…

Both a Low Carb High Fat diet and Low Carb High Protein diet are low carb — so both are great for controlling blood sugar.

A Low Carb High Protein diet has almost twice the protein as a Low Carb High Fat diet — so, great for older adults and those who exercise regularly.

Protein provides satiety (feeling full) for almost half the calories as fat –so, great for weight loss.

If there is no need for a person to have very high levels of ketones, than a person should select which low carb or keto diet they follow on the basis of first meeting their protein needs. Then they can select the amount of carbohydrate that best meets their blood glucose goals. Finally, they can add a little fat to make things taste good as their essential fats come with their protein.

More Info?

If you are interested in learning more about my services, please have a look at the Services tab.  At the top are services provided as a Registered Dietitian to those in Canada, and at the bottom are Nutrition Education services provided to those outside of Canada.

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
  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. Kossoff EH, Doward JL. The Modified Atkins Diet. Epilepsia 2008; 49 (Suppl8): 37-41
  6. 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
  7. 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
  8. 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.
  9. 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
  10. Cahill GF Jr. President’s address. Starvation. Trans Am Clin Climatol Assoc. 1983;94:1-21.
  11. 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.

 

Three Ways to Balance Carbohydrate and Fat as Fuel

The human body is able to use carbohydrate, fat or protein to generate energy, however only carbohydrate and fat are major fuel sources.  Protein’s role in the diet is mainly to provide amino acids needed by the body to make its own proteins, for structure and function.

During digestion, carbohydrate, fat and protein from food are broken down into their basic components — carbohydrates are broken into simple sugar and turned into glucose, proteins are broken down into amino acids, and fat is broken down into fatty acids and glycerol.

Figure 16.4.4 : The Effect of Exercise Intensity on Fuel Sources (from [1]
Protein is not usually used for energy, although small amounts of amino acids from broken down protein are used by the body when we’re resting, and even smaller amounts are used when we’re doing moderate-intensity exercise[1].

During moderate-intensity exercise, our body will use half fatty acids as fuel and half glucose. During high-intensity exercise our body will rely on glucose as fuel — both from the carbohydrates we ate, as well as generated by breaking down fat stores. It is only if we are not getting enough calories in our food or from our fat stores that protein will be used for energy[2] and burned as fuel. If more protein is eaten than is needed by the body, the excess will be broken down and stored as fat [2].

Determining Individual Macros

In determining the amount of protein, fat and carbohydrate that each individual needs (i.e. “macros”), choosing the amount of protein we require comes first. The amount of carbohydrate and fat is chosen after that — based on the needs of the individual for blood sugar control and their metabolic health.

Since it is not a primary fuel source for the body, think of protein as the base of a balance scale — providing the body with building blocks for structure and function. The two arms of the balance are the two sources of fuel for energy: carbohydrate and fat

How do we choose the amount of protein we need?

We need to have enough protein for our needs, but not so much as to either store the excess as fat — or worse, to exceed the ability of our body to get rid of the excess nitrogen-by-product in the urine. Since 84% of the nitrogen waste produced from protein intake is excreted as urea in the urine[3], the safe upper limit of protein intake is based on the maximum rate of urea production which is 3.2 g protein per kg of ideal body weight [4] i.e. lean body mass.

NOTE: this calculation is based on lean body mass (also known as Ideal Body Weight or Ideal Body Mass (IBW), 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.

Basic protein requirements are set in the Recommended Daily Allowance (RDA) for protein, which is the level that is sufficient to meet the needs of 97-98 % of healthy people and to prevent deficiency. The RDA for protein for healthy adults is calculated at 0.8 g protein / kg of reference body weight (i.e. IBM) [5]. Remember, this is the bare minimum to prevent deficiency in most people.

For those who are physically active, the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine[6] recommend a protein intake of 1.2—2.0 g protein / kg IBW per day to optimize recovery from training, and to promote the growth and maintenance of lean body mass.

Older people also need more protein in order to maintain muscle mass, and prevent sarcopenia (muscle loss associate with aging). 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 IBW per day may best meet the needs of adults during aging [7,8].

Balancing Carbohydrate and Fat as Fuel

There are 3 ways that carbohydrate and fat as fuel can be balanced — and which one is best for a specific individual depends on their protein needs (outlined above), as well as their metabolic health.

Higher Carbohydrate than Fat

The standard American (and Canadian) diet recommended by national dietary guidelines aims for the majority of fuel (energy intake) to come from carbohydrate.

These diets are High Carb, Low Fat (HCLF) diets.

They are high carb” because they provide >225g – 300 g carbohydrate / day, 45-65% of total energy intake.

They are “low fat” as they provide “not more than 30% of calories from fat [9].

For those who are metabolically healthy, a high carbohydrate diet where carbohydrate sources are unrefined whole grains (include the husk and the bran), as well as unprocessed starchy vegetables such as yam, peas and winter squash is certainly one optionThe problem is that 88% of Americans are already metabolically unwell [10], with presumably a large percentage of Canadians as well (more about that here).

People who are already showing indications that they are not tolerating carbohydrate well; manifest either as high HOMA-IR, pre-diabetes or type 2 diabetes might do better to select another option for their main fuel source  — especially given that the American Diabetes Association (ADA) consensus report on Diabetes and pre-diabetes published on April 2019 indicated that;

”Reducing overall carbohydrate intake for individuals with diabetes has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual needs and preferences[11].”

Higher Fat than Carbohydrate

Low Carb, High Fat (LCHF) diets are one type of diet that provides more fuel (energy) from fat, than from carbohydrate. There is another type, outlined below.

These range from the popularized “keto diet” of Dr. Jason Fung and the Diet Doctor website which typically provide ~75% fat, 15% protein, ~10% carbohydrate — to the recommendations of Dr. Stephen Phinney and Dr. Jeff Volek from their book The Art and Science of Low Carbohydrate Living which recommends ~60-70% fat, 20%-up to 30% protein, and 10% carbohydrate [12].

These are considered “low carb” diets when they provide < 130g carbohydrate / day, < 26% of total energy intake and “very low carb” (ketogenic) diets when they provide 20—50g carbohydrate / day, < 10% total energy intake — based on the definition from Feinman et al [13] which defines very low carbohydrate, low carbohydrate, and moderate carbohydrate diets as follows:

1. very low carbohydrate diet: 20—50g carbohydrate /day, < 10% total energy intake

2. low carbohydrate diet: < 130g carbohydrate / day, < 26% of total energy intake

3. moderate carbohydrate diet: 130—225g carbohydrate / day, 26—45% of total energy intake

The same definitions of “low carbohydrate” and “very low carbohydrate” are also used in the clinical guidelines of the American Diabetes Association [11], as well as Diabetes Canada [15] where these are meal pattern options for those with diabetes and pre-diabetes to control blood sugar.

Balanced Fat and Carbs

This type of diet is a High Protein, Low Fat (HPLF) diet and the best-known is the P:E Diet of Dr. Ted Naiman.

The P:E Diet is “high protein” diet – recommending 40% protein with equal amounts of fat (30%) and carbohydrate (30%) — as generated by the P:E ratio Macro Calculator  (located at the bottom of www.p2eq.com);

Macros as generated by the P:E ratio Macro Calculator  (located at the bottom of www.p2eq.com).

 

The P:E diet is “low fat” as it provides “not more than 30% of calories from fat [9].

For the most part, the P:E diet is moderate carb” — providing ~130—225g carbohydrate per day — although for some weights and heights, the carbohydrate content is slightly below the 130 g carbs / day cut-off for “low carb” (see examples from the P to E Macro Calculator, above).

While a high protein intake makes sense for those seeking to build and sculpt muscle, as outlined in this previous article setting the recommendation for protein at 40% of dietary intake (instead of as “g protein per kg body weight) results in protein sometimes coming close to exceeding the excretion rate for urea of 3.2 g protein per kg reference body weight. 

This could be avoided if the P:E Macro Calculator was set a maximum limit of protein of 3.0 g protein / per kg body weight.

Low Carbohydrate High Protein

A Low Carb High Protein (LCHP) diet provides ~25-30% protein, which is significantly higher than the 10-20% protein of the standard American (or Canadian diet), yet without the possibility of exceeding the urea excretion capacity of the kidney as protein intake is set to up to 2.5 grams protein per kg body weight (which is well below the maximum of 3.2 g protein / kg ideal body weight).

Having high protein, it offers more satiety at less than half the calories of fat [16] — which makes much more sense for someone seeking weight loss.

Like the Low Carb, High Fat diets of Dr. Jason Fung and Diet Doctor (~75% fat, 15% protein, ~10% carbohydrate) this diet is “high fat“, and provides 65-70% fat. In a sense, a Low Carb High Protein meal pattern reflects the higher end of the range of Dr. Stephen Phinney and Dr. Jeff Volek’s approach of ~60-70% fat, 20%-up to 30% protein, and 10% carbohydrate.

This meal patterns provides a wide range of fats from olive oil and avocado oil to (depending on the lipid profile of the person) butter and coconut oil. Most of the fat provided in the diet is not from added fat, but from fat that comes along with protein — such as the fat in meat, cheese, nuts or yogurt.

Most significantly, this meal pattern is “low carb” (< 130g carbohydrate / day) or “very low carb” / ketogenic — providing ~20—50g carbohydrate / day and as a low carb diet “has demonstrated the most evidence for improving glycemia” [11].

For those seeking fat loss but already having difficulty handling carbohydrate, a Low Carb High Protein (LCHP) meal pattern offers the “best of both worlds”.

It offers the benefits of being able to build new muscle, as well as lower the risk of muscle loss.

It also offers the higher satiety of high protein — without the possibility of exceeding the body’s ability to excrete ammonia in the urine.

…and it is “low carb” — providing the improved blood sugar control that “low carb” is known for.

Final Thoughts…

Humans only have two primary fuel sources, so meal patterns such as Low Carb High Fat, Low Carb High Protein and P:E (High Protein Low Fat) always come down to a choice between “low carb” or “low fat“.*

*theoretically, one could set all 3 macros at 33% each — making the meal pattern neither low fat or low carb — but to what end?

Whether low carb or low fat is the most suitable for someone depends on their protein needs and metabolic health.

Comes down to a choice between “low carb” and “low fat”

I started out 5 years ago teaching low carb from a Low Carb High Fat (LCHF) perspective, and for the last 3 years have also provided a Low Carb High Protein (LCHP) meal pattern.

For those seeking to improve blood sugar or put type 2 diabetes into remission, either one of the low carb options work, however it has been my experience that peri- and post-menopausal women often do much better on the higher protein version of a low carb diet when it comes to weight loss. 

Over the last few months, I have also been asked to provide metabolically healthy people with a P:E / HPLF Meal Plan — which I do, although I set an upper limit on protein intake to a maximum of 2.0 g protein per kg ideal body weight.

Different people have different goals and health needs, which is why I offer more than one type of meal pattern. While a P:E diet is just on the edge of “low carb” — it is very much “low carb” when compared with the Standard American (and Canadian) diet.

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

More Info?

If you are interested in having me design a Meal Plan for you, then please have a look at the Complete Assessment Package under the Services tab (for those in Canada).

If you are outside of Canada and would like me to provide you with Nutrition Education for either low carb high fat or low carb high protein, then please have a look the Meal Plan Package under the Services tab.

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. Fuel Sources. (2020, August 13). Retrieved May 24, 2021, from https://med.libretexts.org/@go/page/7071
  2. Youdim A, Merck Manual, Carbohydrates, Proteins and Fats, https://www.merckmanuals.com/en-ca/home/disorders-of-nutrition/overview-of-nutrition/carbohydrates-proteins-and-fats
  3. Tomé D, Bos C, Dietary Protein and Nitrogen Utilization, The Journal of Nutrition, Volume 130, Issue 7, July 2000, Pages 1868S—1873S, https://doi.org/10.1093/jn/130.7.1868S
  4. 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
  5. National Academies Press, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005)
  6. 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
  7. 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
  8. 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
  9. Institute of Medicine (US) Committee on Examination of Front-of-Package Nutrition Rating Systems and Symbols; Wartella EA, Lichtenstein AH, Boon CS, editors. Front-of-Package Nutrition Rating Systems and Symbols: Phase I Report. Washington (DC): National Academies Press (US); 2010. Appendix B, FDA Regulatory Requirements for Nutrient Content Claims. Available from: https://www.ncbi.nlm.nih.gov/books/NBK209851/
  10. Araíºjo 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
  11. 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
  12. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
  13. 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
  14. 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
  15. 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

 

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 Standard Definition for “Low Carbohydrate” is Needed

I was surprised to read a discussion on social media today which said that the Diet Doctor website recommended that low carbohydrate meal plans be up to 100g of carbohydrate per day, rather than using the generally accepted definition from Feinman et al [1] which defines low carbohydrate < 130g carbohydrate / day.

Feinman et al [1] define very low carbohydrate (“keto”) diet, low carbohydrate diet and moderate carbohydrate diet as follows:

1. very low carbohydrate (keto) diet: 20—50g carbohydrate /day,  < 10% total energy intake

2. low carbohydrate diet: < 130g carbohydrate / day, < 26% of total energy intake

3. moderate carbohydrate diet: 130—225g carbohydrate / day, 26—45% of total energy intake

The above definitions have been used by Diabetes Associations around the world, including the American Diabetes Association, the European Association for the Study of Diabetes (EASD), Diabetes Australia, and Diabetes Canada.

The American Diabetes Association in conjunction with the European Association for the Study of Diabetes (EASD) used the above definition of a low carbohydrate diet and very low carbohydrate diet in their joint 2019 Consensus Report [2] and the American Diabetes Association used the same definition in their 2020 Standards of Medical Care in Diabetes [3].

The same definition for a low carbohydrate diet and moderate carbohydrate diet were also used by Diabetes Australia in their 2018 Position Statement on Low Carbohydrate Eating for People with Diabetes [4].

Diabetes Canada in their 2020 Position Statement on Low Carbohydrate Diets for Adults with Diabetes also defined a very low carbohydrate diets as < 50 g of carbohydrate per day and a low carbohydrate diet as 51 – 130 g of carbohydrate per day [5].

Given that the definitions for low carbohydrate and very low carbohydrate (“keto”) are widely accepted, why define a low carbohydrate meal plan as “up to 100 grams of carbs per day”?

Why does it matter?

Why a Standard Definition of a “Low Carbohydrate” Diet Matters

It matters whether there is a standard definition because otherwise there is no standard in the marketplace or in research for what “low carbohydrate” is.

Product Labelling

There are hundreds, if not thousands of “low carb” products available on the market and none of these are held to any standard as to what makes them suitable for individuals following a low carbohydrate or very low carbohydrate (“keto”) diets. The terms “low carb” or “keto” on product labels are meaningless! Without a standard definition, it is up to each consumer to read the label and try to determine if these products are suitable. 

A Nutrient Content Claim characterizes the level of a nutrient in a food, so terms like “low-fat” have specific nutritional thresholds and nutrition content claims made on labels are regulated by law. At present, there are no nutrient thresholds for carbohydrate content — and these are needed.

Adopting Feinman et al’s widely used definitions makes sense and will make it possible to for the consume to be provided with meaningful labels, enabling the average consumer to know if a product is suitable for their needs, or not.

Scientific Research Requires a Standard Definition for “Low Carbohydrate”

Without a standard definition for “low carbohydrate < 130g carbohydrate / day”, research studies can define “low carbohydrate” anyway they want — which also means that conclusions of studies can state that “a low carbohydrate diet is associated with increased mortality (death)” when the diet used in the study was well over 130 g of carbohydrate per day”.

In fact, this is exactly what has been occurring.

Dr. Sarah Hallberg, Medical Director at Virta Health said it best on Twitter April 20, 2021;

“Honest representation of evidence is important. How many people have heard someone say that a low carb diet is associated with increased mortality? There is no evidence for this. Here are all the studies that make that claim. None were actually low carb. Much closer to SAD [Standard American Diet].

Let’s have a closer look at the studies Dr. Hallberg cited.

The above 10 studies were said to associate “low carbohydrate diets” with increased mortality, however none of the studies were actually “low carbohydrate”, as defined by Feinman et al [1].

The average carbohydrate intake in these studies were 41.34%not a low carbohydrate diet which is < 26% of total energy intake [1]. These studies were moderate carbohydrate diet, using Feinman et al’s definition.

The range of carbohydrate intake in these studies was 36.2 % – 51.5 % /day — which means even the study with the lowest carbohydrate intake exceeded the cut-off of a low carbohydrate diet of < 26% of total energy intake, defined by Feinman et al [1].

Final Thoughts…

When the media circulates reports that “a low carb diet is associated with increased mortality” it is imperative that “low carb” is defined as <130 g carbohydrate per day. Otherwise what the message that the public receives is that these diets are dangerous, when the diet used in the study wasn’t a low carbohydrate diet at all!

We need to get our terms straight.

We need to be consistent.

Feinman et al’s definition of “low carbohydrate” and “very low carbohydrate” / “keto” have already been adopted by Diabetes Associations around the world, including the American Diabetes Association, the European Association for the Study of Diabetes (EASD), Diabetes Australia, and Diabetes Canada.

Let’s use them.

Let’s lobby our governments to require them to be used on product labels to provide honesty and accuracy in labelling.

Let’s push for academic institutions and scientific publications to adopt these definitions as standard, so that research has meaning — and conclusions to not mislead people to believing something is dangerous, when the thing that was studies was something different.

More Info?

If you would like to know more about the low carbohydrate (<130g carbs / day) and very low carbohydrate (“keto”) services I provide (< 50 g carbs / day), please have a look under the Services tab, above.

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: This article was inspired by important discussion on Twitter between Antonio Martinez II and Nina Teicholz, which included the post above from Dr. Sarah Hallberg.

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. A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
  3. American Diabetes Association, Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes—2020
    American, 
  4. Diabetes Australia, Position Statement – Low Carbohydrate Eating for People with Diabetes, August 2018, https://www.diabetesaustralia.com.au/wp-content/uploads/Diabetes-Australia-Position-Statement-Low-Carb-Eating.pdf
  5. 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.

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.

The Problem with Excess Fat or Protein — when more is not better

Therapeutic ketogenic diets such as the classic Ketogenic Diet (KD) or the Modified Ketogenic Diet (MKD) are used in the management of epilepsy or seizure disorder or as adjunct therapy in the treatment of glioblastoma and these diets have a purpose; to produce very high levels of ketones that are used by the body to minimize seizures, or to lower glucose availability to cancer cells.  If one does not have a therapeutic need for very high levels of ketones, why eat a very high fat diet that produces lots of them? Why add lots of added fat to diet that is already high in fat?  Likewise, if one is eating a high protein low fat diet like P:E in order to build muscle and lose body fat, what is the benefit to eating even more protein? Are there any risks or possible downsides to eating more protein in a high protein low fat diet, or more fat in a low carb high fat diet? How can a low carb high protein diet avoid the problem of excess fat or excess protein?

Eat Fat to Lose Fat?

Some people have come to believe that they need to eat more dietary fat in order to burn body fat, so they add copious amounts of fat to food in the form of heavy whipping cream, butter, fatty meats and to make sure, they supplement with “fat bombs”. If one is trying to lose body fat, then it makes no sense to add tons of dietary fat that will be used by the body for energy before using their own body fat stores. A very high fat version of a LCHF diet may have a role at the very beginning in order to help people make the transition from being predominantly glucose-burning to being fat-burning (referred to as becoming “fat adapted“), but there is no need to keep eating a very high fat diet (75% of energy as fat) once that has occurred. In fact, for many people, continuing to eat 75% fat “keto” diet after the initial adoption often (but not always) results in a stall in weight loss, and in some cases in weight gain — especially when not also doing extended periods of fasting.  Fat is two and a half times as energy-dense as protein and carbohydrate, so unless one needs very high levels of ketones for therapeutic purposes and is not concerned about losing muscle mass from extended periods of fasting (more about that here), it makes no sense to keep eating lots of fat.

High Fat Diet Needed for Satiety?

Some people believe that eating high dietary fat on a low carbohydrate diet is needed to keep them from feeling hungry— and that it is this which results in them eating less. While fat does keep people from feeling hungry (i.e. produces increased ‘satiety’), it is not the best source of satiety. Protein 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 [1];

”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.”

Since protein produces more satiety than fat and has less than half the calories, it makes much more sense for someone seeking weight loss to eat more protein in the diet, and not add excess dietary fat.

Impact of High Fat on Blood Glucose Control

For blood glucose improvements, dietary fat has no impact on the body’s (endogenous) insulin levels, so adding dietary fat does not help lower circulating levels of insulin or blood glucose (blood sugar). It is only the “low carbohydrate” part of a low carb high fat (LCHF) diet that helps improve insulin levels, and in turn glucose levels and it is for this reason that a low carbohydrate diet (defined as <130 g of carbs per day) has been approved by the American Diabetes Association for both improved blood sugar control and weight loss [2] and is why the American Diabetes Association’s Consensus report of April 2019 also includes use of a very low carb (keto) diet of 20-50 g carbs per day [3]. for blood sugar management. Since it is only the low carbohydrate part of a low carb high fat (LCHF) diet that is important for glucose control, keeping carbohydrate low is the goal (not keeping fats high). 

For people with pre-diabetes, type 2 diabetes or for those at increased risk due to past medical history or family risk factors, selecting the level of carbohydrate intake that is most appropriate for blood glucose control around prioritizing protein intake based on physiological need, is the first step and the remainder of the diet will be made up of various types of dietary fat. Since the level of fat intake will be above the “not more than 30% of calories from fat” that the USDA defines as a “low fat diet” [4], this diet pattern will still be considered ahigh fat diet“.

Depending on whether fat or protein is higher, this type of meal pattern will be either a low carb high fat (LCHF) diet or a low carb high protein (LCHP) diet. More on this second one, below.

Determining Protein Needs without Exceeding the Safe Upper Limit

Protein needs are always calculated as grams of protein per kilogram of body weight of the person and not as a percentage of daily calories e.g. X % of daily energy as protein. This is to ensure adequacy and avoid the d excess.

When protein is eaten, the body must get rid of the nitrogen by-product which is toxic to the body. As can be seen from the table below, the main way the body gets rid of this toxic nitrogen by-product is by turning it into ammonia, and then excreting it as urea in the urine.

Distribution of Nitrogen Losses from the body in humans (from [5])
Since 84% of the toxic nitrogen waste produced from protein intake is excreted as urea in the urine[5], the safe upper limit of protein intake is based on the maximum rate of urea production which is 3.2 g protein per kg body weight [6], described in more detail in this article.  Only 12.7% of nitrogen-waste is lost in the feces, but much of that is from breakdown of endogenous proteins of the intestine [5]. 

Protein intake in high protein diets should not be set as a percentage of daily calories, but as a maximum of 3.2 g protein per kg body weight. This is because an intake of 40% of daily calories as protein for one person may be below the safe upper limit of 3.2 g protein per kg body weight, but for another 40% of calories as protein put them right at the upper limit (more in this article). 

How Much Protein is Best?

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 wanting to prevent protein 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.

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 [7]. 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[8] 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 [9,10].

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.

At present, there is very little data for defining the upper limit of protein beyond the urea cycle, which has been established to be safe at 3.0 g protein / kg body weight (tied to the maximum rate of urea production which is 3.2 g protein per kg body weight [6]), so the range of safe intake is defined as  >0.8 g protein body/ kg body weight to >2.5 g protein/ kg body weight.

Recommended Daily Allowance (RDA) for Protein [slide from Dr. Donald Layman, PhD — The Evolving Role of Dietary Protein in Adult Health]
This does not mean that it is automatically “unsafe” for healthy people to eat more protein than that (e.g. 2.8 g protein / kg body weight or 3.0 g protein / kg body weight), but in the absence of clinical data showing otherwise, protein intake should not exceed 3.0 g protein / kg body weight so as not to exceed the body’s capacity to excrete the nitrogen by-product.*

*in clinical practice, I have set a maximum of 2.5 g protein / kg IBW but in practice, Meal Plans have routinely been below 2.0 g protein / kg IBW.

Is “More” Better

There is a tendency for people to think that because a high fat diet is “good” — or a high protein diet is “good”, that “more is better”. This is a bit like thinking that since a certain amount of laundry detergent is “good”, that “more detergent is better”, but before adding “more”, a few questions need to be asked. For example, will the clothes come out any cleaner, or is there a possibility that “more” may cause the suds to overflow the machine? There is a benefit / risk to “more” that first needs to be considered.

Considering the benefit / risk of more also needs to be considered when contemplating adding “more fat” in a low carb high fat (LCHF) diet (e.g. 75% fat, 15% protein, 10% carbs).

If one needs high ketones for therapeutic reasons, then “more fat” has a benefit — but if weight loss is the goal, then “more fat” may result in a weight stall, or possibly a weight gain. That isn’t a “risk” as one normally thinks of it, but it certainly isn’t a benefit.

“More” may be better, but not always.

One also needs to consider the benefit / risk of adding “more protein” to a high protein, low fat (HPLF) diet, such as P:E (e.g. 40% protein, 30% carbs, 30% fat).

If one is eating a diet that provides 2.5 g protein / kg body weight is “good” in order to build up muscle or be a swimsuit model, one has to consider if it is really “better” to eat 3.3 g – 4.4 g protein per kg body weight (1.5 or 2 grams protein per pound). 

Just because some “do” does not make it “better”. It has to also be safe.

One has to ask if there are clinical studies that indicate that eating this high amount of protein intake long term is safe, but at present there are not.  All we have at present is the safe upper limit based on the rate of urea excretion of 3.2 g protein per kg body weight, so until it is known that “more” is better AND “safe”, staying within this safe upper limit is what is recommended.

Some will argue that since our ancient ancestors ate a largely meat diet that there is no limit on the amount of protein we can eat, however not all “meat” is protein, some is fat. In addition, it is known that our ancient ancestors also had carbohydrate in the diet as berries, above ground vegetables and tubers and recently it was discovered that~ 6,000 years ago, our ancient ancestors from present-day Kenya and Sudan were also eating milk products, which contains carbohydrate.

Dr. Loren Cordain, Professor from the Department of Health and Exercise Science at Colorado State University who is renowned for his work over the last two decades on the evolutionary and anthropological basis for diet estimates the protein intake of our ancient ancestors at 35% of total caloric intake [11].

A Low Carb High Protein (LCHP) Diet

A low carb high protein (LCHP) diet can be either low carbohydrate (<130g of carbs) or very low carbohydrate / ketogenic (20-50 g of carbs) and a low carbohydrate diet, is suitable for people with pre-diabetes or type 2 diabetes for improved glucose control and weight loss. low carb high protein diet avoids the problem of excess fat or excess protein by prioritizing protein around individual need (outlined above), then limiting carbs to the level most suited to the individual for glycemic (blood sugar) control. The remainder of dietary intake is just enough fat to make everything taste good, and to provide essential fatty acids. The situation of either excess fat or excess protein is avoided. 

A high protein low fat (HPLF) diet such as the P:E Diet (40% protein, 30% carbs, 30% fat) is very different. It is a moderate carbohydrate diet of ~130—177 g carbohydrate per day, and is not the most suitable for those already not tolerating higher amounts of carbohydrate intake, such as those with pre-diabetes or type 2 diabetes. It’s good for healthy individuals seeking to build muscle mass; provided dietary intake of protein does not exceed the maximum level of urea excretion.

Final Thoughts…

For those seeking to lose weight or normalize blood glucose levels, a low carbohydrate diet is accepted by both the American Diabetes Association and Diabetes Canada and considered both safe and effective, so either a low carb high fat or low carb high protein diet would be suitable. In either, the percentage of fat is considered “high”, because a “low fat diet” is anything at or below 30% of calories[4]. By definition, since either diet provides more than 30% of energy as fat , they are both considered “high fat” diets.

I think it is more reasonable to consider diets with fat intakes of 30-45% of daily calories as fat as moderate fat diets, and those above that level as “high fat” diets, but this is only my opinion.

Whether one sets fat intake at 50% or 75% of calories depends on an individual’s goals. If a person needs low levels of ketones for therapeutic reasons, or are engaging in regular periods of extended fasting and can handle the extra energy intake of a high fat diet, then for weight loss or blood sugar control, a low carb high fat diet might be a good choice.

For those who don’t have any specific need for ketones, or who  practice only daily periods of intermittent fasting (12-16 hours), then for blood sugar control and weight loss, a low carb high protein diet may be a better option.

I have been providing a low carb high fat (LCHF) Meal Plans for the last 5 years and low carb high protein (LCHP) Meal Plans for the last 3 years and design Meal Plans for either.

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

More Info?

If you are interested in having me design a Meal Plan for you, then please have a look at the Complete Assessment Package under the Services tab (for those in Canada).

If you are outside of Canada and would like me to provide you with Nutrition Education for either low carb high fat or low carb high protein, then please have a look the Meal Plan Package under the Services tab.

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. 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
  2. American Diabetes Association, Lifestyle Management Standards of Medical Care in Diabetes — 2019. Available at: http://care.diabetesjournals.org/content/42/Supplement_1. Accessed: Dec. 17, 2018.
  3. 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
  4. Institute of Medicine (US) Committee on Examination of Front-of-Package Nutrition Rating Systems and Symbols; Wartella EA, Lichtenstein AH, Boon CS, editors. Front-of-Package Nutrition Rating Systems and Symbols: Phase I Report. Washington (DC): National Academies Press (US); 2010. Appendix B, FDA Regulatory Requirements for Nutrient Content Claims. Available from: https://www.ncbi.nlm.nih.gov/books/NBK209851/
  5. Tomé D, Bos C, Dietary Protein and Nitrogen Utilization, The Journal of Nutrition, Volume 130, Issue 7, July 2000, Pages 1868S—1873S, https://doi.org/10.1093/jn/130.7.1868S
  6. 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
  7. National Academies Press, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005)
  8. 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
  9. 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
  10. 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
  11. Cordain L, Miller JB, Eaton SB, Mann N, Holt SH, et al. (2000) Plant-animal subsistence ratios and macronutrient energy estimations in worldwide hunter-
    gatherer diets. The American Journal of Clinical Nutrition 71(3): 682—692
  12. Bleasdale, M., Richter, K.K., Janzen, A. et al. Ancient proteins provide evidence of dairy consumption in eastern Africa. Nat Commun 12, 632 (2021). https://doi.org/10.1038/s41467-020-20682-3

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 Low Carb High Protein Diet is STILL a viable option!

At the beginning of 2018, there were basically three types of low carb diets; the popularized low carb, high fat diet of Dr. Jason Fung and Diet Doctor, the low carb, higher protein, moderate fat diet of Dr. Stephen Phinney and Dr. Jeff Volek, and the (then) new low carb, high protein diet of Dr. Ted Naiman. 

In 2018, Dr. Ted Naiman was promoting a diet which aimed to “target protein, limit carbs and balance fat” and was recommending ~120 gm of protein (based on 1 g protein per pound of ideal body weight),  <50 gm of net carbs, and ~120 gm of whole food fats’ (fat found naturally in food) and ~30 gm of added fat (such as on top of vegetables, salads and cooking), but last year (2020), he came out with his “P:E Diet” associated with his P:E ratio Macro Calculator (bottom of www.p2eq.com) which is a very high protein (40%), moderate  carbohydrate (>100g carbohydrate / day) and low fat diet.

The low carb high protein diet was abandoned* by Dr. Naiman in favour of a high protein low fat approach — but since his audience is primarily those who are seeking to build and sculpt their muscles, a high Protein to Energy (P:E) ratio does make sense, provided amounts do not exceed the urea excretion capacity of the kidney.  As I outlined in this previous article, it can come close to exceeding that safe level in some cases.

* [UPDATE – May 17, 2021] – I misspoke myself above and am adding a correction. 

Dr. Naiman has not “abandoned” a low carb high protein approach. As indicated below, for some weights and heights Dr. Naiman’s P:E Macro Calculator (p2eq.com) does generate carbohydrate recommendations that are below the low carb cut-off of <130g carbs per day [1], but for the most part a P:E diet is moderate carbohydrate (130-225g), based on the definition of Feinman et al (Nutrition. 2015;31(1):1—13) and is low fat, based on the USDA definition of less than or equal to 30% of daily energy as fat. 

Low Carb High Fat Moderate Protein

In 2018, both Dr. Jason Fung and the Diet Doctor website were promoting a low carb high fat (LCHF) diet of ~75% fat, 15% protein and 10% carbohydrate, but since that time, Dr. Fung has increasingly focussed on the role of regular intermittent- and long term fasting for weight loss and diabetes remission, while continuing to encourage the same distribution of macros.

From High Fat to High Fat and Low Fat

To many people’s shock and surprise, recently the Diet Doctor website announced that they would not only be supporting the popular low carb high fat diet but also the high protein approach of Dr. Naiman — even bringing him on staff to head it up. The backlash on social media was so strong that it resulted in a clarifying post this week from Dr. Bret Scher.

“Some feel we have gone too far and are now ”fat bashing” or promoting ”fat-phobia.” We regret that our message hasn’t been clear on this subject. But that is not our intent. someone may lose weight and feel great on a 20% protein, 5% carb, and 75% fat diet. Someone else may do the same with a 30% protein, 10% carb, and 60% fat diet. The latter is a low-carb, higher protein diet, but by no means is it a low-fat diet.”

Based on the macros generated by the p2eq.com calculator (see macros above), Dr. Naiman’s current approach is 40% protein, 30% carb and 30% fat — and not a 30% protein, 10% carb and 60% fat diet. Whether the Diet Doctor website will choose a middle ground has yet to be seen.

The Role for Low Carb High Protein

It has been my clinical experience since 2018 that a low carb higher protein diet is an excellent option for those seeking weight loss and remission of type 2 diabetes — especially those who do not do well on a very high fat diet, or for whom regular intermittent or extended fasting is not optimal due to the increased risk of sarcopenia (muscle loss). 

This approach is safe, provided an individual is able to handle intakes of 1.5 – 2.5 grams protein per kg ideal body weight. This enables carbohydrate content of the diet to be kept low — which it is very effective for lowering blood sugar levels for those who have pre-diabetes or diabetes, or at risk of those and provides room for a wide range of healthy fats — from fish and meat, dairy foods, as well as nuts and seeds.

Those following most low carb or ketogenic diets choose the number of grams of carbs they want to limit the diet to, then they establish the amount of protein, then the rest is fat. A low carb high protein diet prioritizes protein based on individual. need*, then sets the upper limit of carbohydrate based on blood glucose control, then the remainder is added fat, based on weight goals. 

*But how much protein is best? That depends for whom.

As outlined in an earlier article, 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. 

Dr. Naiman’s P:E database of foods has made it very easy to choose foods with the highest amount of protein for energy*. Setting carbohydrate levels low and adding a bit of fat for taste works incredibly well for those whose goals are blood sugar control and weight loss. This is the basis of a low carb high protein approach. 

*An oversimplification of Dr. Naiman’s P:E ratio is used in the above graphic for illustrative purposes. 

Final Thoughts…

The P:E Diet was supposed to “end diet wars” but when one increases protein, by necessity one has to either decrease carbohydrate or fat, and the P:E diet chooses to decrease fat. Again, this makes perfect sense for those who are seeking to build muscle, but not so much for those with pre-diabetes and diabetes who don’t tolerate even moderate amounts of carbohydrate, regardless of glycemic index. Different people have different nutritional needs. 

I truly believe there is “no one-sized-fits-all low carb or keto diet” and that there is a room for a low carb higher protein diet among the options.

More Info?

If you are interested in having me design a low carb higher protein Meal Plan for you, please have a look at the Complete Assessment Package under the Services tab or send me a note through the Contact Me form on the tab above.

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

Resources

  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. Institute of Medicine (US) Committee on Examination of Front-of-Package Nutrition Rating Systems and Symbols; Wartella EA, Lichtenstein AH, Boon CS, editors. Front-of-Package Nutrition Rating Systems and Symbols: Phase I Report. Washington (DC): National Academies Press (US); 2010. Appendix B, FDA Regulatory Requirements for Nutrient Content Claims. Available from: https://www.ncbi.nlm.nih.gov/books/NBK209851/

 

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.

 

 

 

 

 

 

Another Client Journey — freedom from food addiction

After reading the journey of one of my clients, “J” asked if she could tell her story. I thought it would be good for others to hear of her past struggles with disordered eating and how she came to realize she was a food addict. This is “J”, in her own words.


“I could not stop eating. I ate in secret and until I was ill. I repeated this behaviour over and over again, despite the negative consequences. For 20 years of my life, from the age of 9 to the age of 29, I struggled with food addiction, disordered eating, obesity, and yo-yo dieting. My mind was incessantly focused on one of three things:

      • what I was going to eat
      • how I was going to keep myself from eating, or
      • how to compensate for what I had eaten

In addition to disordered eating and food addiction, I faced severe depression and ADHD.  I isolated myself, struggled with exhaustion, and was unable to focus on my work. I frequently wished I had not been born, or that my life would end.  I attempted numerous diets and attended eating disorder treatment programs, but was unable to stop my binge eating and associated compensatory behaviours for any significant amount of time. Twice, I successfully lost approximately 70 pounds but on both occasions, I gained back all of the weight back, and more.

Approximately two years ago, I reached my highest weight of 250 pounds and decided to make one more attempt to lose weight, and began researching low-carbohydrate and ketogenic diets. Through this research, I discovered books, articles, and podcasts about food addiction. As I read and listened, I became certain that I qualified as a food- and sugar addict. I learned that sugar and flour are addictive substances and decided to remove them from my diet. I searched the internet for a dietitian who could help me to formulate a meal plan that eliminated the foods that I found addictive. I discovered The Low Carb Healthy Fat Dietitian’s website and contacted Joy Kiddie to schedule a Complete Assessment Package. Joy developed a meal plan for me that excluded the foods that were addictive for me and which allowed me to feel satisfied and energized, while losing weight. For the first time, weight loss did not feel like work.

I have so many reasons to recommend Joy as a dietitian. She supports me in my health, weight loss, weight maintenance, and sugar addiction recovery goals while also understanding and taking into consideration my history of disordered eating. She provides me with much-needed accountability. I am able to troubleshoot any challenges I am having with my health or weight loss, and she helps me adjust my meal plan to address these issues. Joy is incredibly knowledgeable about food and nutrition, and is a dependable support in my life.

I have lost well over a 100 pounds, and am a normal body weight and a waist circumference. I am so thankful for my weight loss, and my improved physical health. Even more importantly however, my depression has been significantly better, and I am truly enjoying life. In addition, my ADHD symptoms have greatly decreased, and my mental capacity has significantly improved. For the first time in my life, I can complete my work with little procrastinating.

I have been profoundly blessed and am so thankful for the role that Joy has played in my healing journey. I know there are many others who struggle with food addiction, and I hope my story provides some hope.”

 


og:imageI feel it is important to add that as a Dietitian, I do not specialize in food addiction or disordered eating — but I do help with the “eating end” of things for those who are getting support for these issues through other means.

Some people with food addiction find a 12-step group helpful, while others prefer individual counselling with a trained food-addiction counsellor. Many do both.  Whatever works best for them is fine with me. I am only a part of their recovery process.

While it is a sensitive topic, I am mindful that for some with a background of disordered eating, a “keto” diet can sometimes be another form of food restriction. When it makes sense to achieve clinical outcomes, I may choose to use a low carb diet, rather than a keto diet if I am concerned that food restriction may be an issue.

I do not encourage food restriction except when it comes to person’s specific “trigger foods” that have been identified in their process of their recovery, and for those with a disordered eating past, this sometimes takes some negotiation.  While weighing and measuring food is not what I want for the majority of my clients, many food-addiction counsellors do recommend this and  I am happy to support my clients in this way.  

NOTE: Just like I am in remission of T2D and HTN, I believe that people like “J”  are in remission of food addiction and disordered eating. We aren’t “cured”.  It is my belief that for both of us to remain in remission requires us to keep walking in what enabled us to get there in the first place, one day at a time.

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

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.