Year: 2021

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

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

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

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

Does this amount meet people’s needs? 

For the 100 kg man;

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

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

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

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

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

For the 60 kg woman;

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

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

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

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

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

B – The Higher Protein, Lower Fat Ketogenic Dietary approach

This approach used for weight loss by Drs. Phinney and Volek in their book The Art and Science of Low Carbohydrate Living works out to approximately 60-70% fat, 20% up to 30% protein and 10% carbohydrate (Nutritional Ketogenic), but the macros are determined based on ideal body weight, which is estimated by lean body mass.

From page 210 of their book [6];

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

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

A man who is 5’9″³ (1.75 m) tall and weighs 100 kg ( 220 pounds) has an IBW (lean body mass) of 155 pounds (70 kg), so protein intake should be 105 g – 175.0 g protein.

A woman who is 5″² 4 “³(1.63 m) tall and weighs 60 kg (132 pounds) has an IBW (lean body mass) of 127 pounds (55 kg), so protein intake according to Phinney and Volek should be between 82.5 g – 137.5 g protein.

For the 100 kg man;

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

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

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

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

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

For the 60 kg woman;

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

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

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

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

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

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

By definition, the P:E ratio diet (40% protein, 30% carbs, 30% fat) is a High Protein Low Fat diet, as fat is at or below the USDA low fat cutoff of 30% — based on the P:E ratio calculator located at www.p2eq.com.

It is largely a moderate carbohydrate approach (130-225g carbs per day), but for some weights and heights generates carbs of just under 130g / day, the cutoff for low carb.

Based on that calculator:

A man who is 5’9″³ (1.75 m) tall should weigh 155 pounds (70 kg). According to this calculator and assuming this man is metabolically healthy, he should should eat 1,860 kcals as 186 g protein (2.66 g pro/kg IBW), 62 g of fat and 140 g of total carbs.

A woman who is 5″² 4″³ (1.63 m) should weigh 120 pounds (55 kg). According to this calculator and assuming she is metabolically healthy, this hypothetical woman should eat 1,440 kcals per day as 144 g protein (2.67 g protein /kg IBW), 48 g of fat and 108 g of total carbs.

For the 100 kg man;

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

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

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

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

√ Does protein exceed the maximum level of amount of protein based on the disposal of ammonia in urea in the urine? According to the online calculator, a man who is 5’9″³ (1.75 m) tall should weigh 155 pounds (70 kg), and eat 1,860 kcals as 186 g protein but in this case, he weighs 100 kg (220 pounds) and has 30% body fat. Safe intake is based on his LBM so the fact that he is overweight makes no difference.  Based on the maximum amount of ammonia disposal of 3.21 g of protein / kg of lean body mass his maximum amount of protein would be 225 g / day, so 186 g protein is safe.

For the 60 kg woman;

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

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

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

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

√ / X? Does protein exceed the maximum level of amount of protein based on the disposal of ammonia in urea in the urine? According to the online calculator, a woman who is 5″² 4″³ (1.63 m) should weigh 120 pounds (55 kg). should eat 1,440 kcals per day as 144 g protein (576 kcal / 1440 kcals = 40% protein). Based on the maximum amount of ammonia disposal of 3.21 g of protein / kg of lean body mass [5], her maximum amount of protein is 144 g / day, so she is at the very high end of the safe range. 

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

Final Thoughts…

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

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

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References

1. National Academies Press, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005)
2. Thomas DT, Erdman KA, Burke LM. American College of Sports Medicine Joint Position Statement. Nutrition and Athletic Performance [published correction appears in Med Sci Sports Exerc. 2017 Jan;49(1):222]. Med Sci Sports Exerc. 2016;48(3):543-568. doi:10.1249/MSS.0000000000000852
3. Fielding RA, Vellas B, Evans WJ, Bhasin S, et al, Sarcopenia: an undiagnosed condition in older adults. Current consensus definition: prevalence, etiology, and consequences. International working group on sarcopenia. J Am Med Dir Assoc. 2011 May;12(4):249-56
4. Bauer J1, Biolo G, Cederholm T, Cesari M, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013 Aug;14(8):542-59
5. Rudman D, DiFulco TJ, Galambos JT, Smith RB 3rd, Salam AA, Warren WD. Maximal rates of excretion and synthesis of urea in normal and cirrhotic subjects. J Clin Invest. 1973;52(9):2241-2249. doi:10.1172/JCI107410
6. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
7. Phinney SD, Volek JS, Volk B, How Much Protein Do You Need In Nutritional Ketosis? February 21, 2018, Virta Health, https://www.virtahealth.com/blog/how-much-protein-on-keto

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.

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

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

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

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

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

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

Protein Needs for Active Healthy Adults

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

Protein Needs for Older Adults

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

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

Range of Safe Intake

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

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

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

Maximum Amount of Protein the Body can Safely Process

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

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

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

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

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

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

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

Here are some examples of calculations;

More Info?

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

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

To your good health!

Joy

You can follow me on:

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

References

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

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

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

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

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

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

Wilder’s First Use of a Ketogenic Diet in Diabetes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Final Thoughts…

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

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

More Info?

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

To your good health!

Joy

You can follow me on:

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

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

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

References

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

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

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

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

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

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

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

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

Calories Don’t Count When Eating “Keto” 

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

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

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

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

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

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

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

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

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

Frequent and/or Extended Fasting

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

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

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

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

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

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

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

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

Dietary Fat or Dietary Protein as the Source of Satiety

Proponents of the high fat ‘keto’ diet say that it is the high dietary fat that makes them so much less hungry, which makes them able to fast frequently and for extended period of time, and which results in them eating less over all.  I don’t doubt this, but fat is not the only — or even the best source of 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 [3];

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

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

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

But how much protein?

Protein Intake in a Ketogenic Diet

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

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

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

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

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

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

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

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

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

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

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

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

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

Protein to Energy (P:E) Ratio

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

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

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

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

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

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

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

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

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

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

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

NOTE (February 23, 2021): 

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

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

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

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

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

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

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

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

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

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

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

These are each valid goals.

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

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

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

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

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

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

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

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

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

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

Please let me know if I can help.

To your good health!

Joy

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