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.

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.

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.

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!

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

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.

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).

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

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!

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

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

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.

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!

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.

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, 1999-2018. JAMA, 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.

    

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. 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.

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

1. 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.

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 as “restraining 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.

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. 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.

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. 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. Diabetes Care (2021) https://doi.org/10.2337/dci21-0034
   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.

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 HbA_1c 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 HbA_1c 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. Diabetes Care (2021) https://doi.org/10.2337/dci21-0034
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? Diabetes Care 2009 Nov; 32(11): 2133-2135.https://doi.org/10.2337/dc09-9036
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.

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:

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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.

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.

”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].

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:

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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
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.

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.

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 option. The 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);

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.

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

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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

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