The American Diabetes Association (ADA) has just released its new Standards of Medical Care in Diabetes (2020) [1] which once again includes a low carbohydrate diet.  The section on Medical Nutrition Therapy begins by referring to the ADA’s April 2019 Consensus Report[2] which emphasized that there is no ”one-size-fits-all” eating pattern for the prevention or management of diabetes (more in this article).

In the section on Medical Nutrition Therapy (MNT), the new Standards of Medical Care 2020 underscores that for many people with diabetes, the most challenging part about treatment is determining what to eat — and for this reason the ADA emphasizes that meal planning needs to be individualized.

The ADA also states that all people diagnosed with diabetes should be referred to an a Registered Dietitian (RD/RDN) who is “knowledgeable and skilled in providing diabetes-specific MNT at diagnosis and as needed throughout the life span”[1] and that research indicates that Medical Nutrition Therapy delivered by an RD/RDN is associated with decrease in HbA1C of between 0.3 and 2.0% for people with type 2 diabetes [3].

In the section on Eating Patterns, Macronutrient Distribution and Meal Planning, the new Standards of Medical Care in Diabetes re-iterated what the Consensus Report stated, that evidence suggests that;

“there is not an ideal percentage of calories from carbohydrate, protein, and fat for people with diabetes. Therefore, macronutrient distribution should be based on an individualized assessment of current eating patterns, preferences, and metabolic goals.”

As well, the new Standards of Medical Care re-iterates that a low carbohydrate eating pattern is an example of one that is both healthful and helpful in controlling blood glucose;

“The Mediterranean-style ([4-5], low-carbohydrate* [6-8] and vegetarian or plant-based [9-10] eating patterns are all examples of healthful eating patterns that have shown positive results in research, but individualized meal planning should focus on personal preferences, needs, and goals. “

*In the  Consensus Report referred to in this section, a low carbohydrate eating pattern was defined as 26-45% of total calories from carbohydrate and a very low carbohydrate eating pattern (ketogenic) was defined as 20-50 g of non-fiber carbohydrate per day.

The new Standards of Medical Care encourages healthcare practitioners to not only consider a person’s metabolic goals, but also their personal preferences, including tradition, culture, religion, health beliefs, goals, and economic situation in helping them choose a suitable eating patterns.

It encourages each member of the healthcare team;

“to be knowledgeable about nutrition therapy principles for people with all types of diabetes and be supportive of their implementation.”

Given that a low carbohydrate diet is one of the eating patterns that the ADA considers both healthful and helpful in the management of diabetes, healthcare professionals ought to be prepared to be supportive of a person seeking to implement this approach.

The Standards of Medical Care states that until there is stronger evidence surrounding comparative benefits of different eating patterns in specific individuals, “healthcare providers should focus on the key factors that are common among the patterns:

1) emphasize non-starchy vegetables
2) minimize added sugars and refined grains
and
3) choose whole foods over highly processed foods to the extent possible”[2].

Similar to what was stated in the Consensus Report, the Standards of Medical Care reiterates that “research studies on some low-carbohydrate eating plans generally indicate challenges with long-term sustainability, it is important to reassess and individualize meal plan guidance regularly for those interested in this approach”. Given the wide range of “low carbohydrate” diets people may be following, it makes good sense to ensure a person is following one that is evidence-based and appropriate for them.

The Standards of Medical Care restates that  at this time a low carbohydrate eating pattern is not recommended for women who are pregnant or lactating, people with or at risk for disordered eating, or people who have renal disease, and should be used with caution in patients taking sodium—glucose cotransporter 2 inhibitors due to the potential risk of ketoacidosis [11-12]. (Note: This caution regarding those taking certain medication is covered in this previous article).

Carbohydrates

The section of the Standards of Medical Care in Diabetes on Carbohydrates re-emphasizes the benefits to blood sugar (glycemic) control of a low carbohydrate eating patterns that was previously outlined in the Consensus Report, namely;

“For people with type 2 diabetes or prediabetes, low-carbohydrate eating plans show potential to improve glycemia and lipid outcomes for up to 1 year [6, 8, 13, 14-17]

The new Standards re-iterates that “part of the challenge in interpreting low-carbohydrate research has been due to the wide range of definitions for a low-carbohydrate eating plan [8, 18]”.

Final Thoughts…

There is nothing really “new” in the section on Medical Nutrition Therapy in the new Standards of Medical Care as it pertains to the safety and efficacy of low carbohydrate eating patterns, or in their ability to help improve blood sugar control. This, in and by itself is very encouraging because it means that the ADA has considers a well-designed low carbohydrate diet to be both healthful and helpful in the management of diabetes for the second year in a row.

When will Diabetes Canada complete their review of the current literature,  including that cited by the ADA in the Consensus Report and their new Standards of Medical Care in Diabetes 2020 and update their position on the use of low carbohydrate diets in those with diabetes in Canada?

More Info

If you would like more information about the services I provide and how I can design a Meal Plan for you based on your needs, please have a look under the Services tab, or in the Shop. If you have questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

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
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 LCHF-RD (a division of BetterByDesign Nutrition Ltd.)

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

References

1. American Diabetes Association, Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes—2020
   American, Diabetes Care Jan 2020, 43 (Supplement 1) S48-S65; DOI: 10.2337/dc20-S005
2. Evert AB, Dennison M, Gardner CD, et al. Nutrition therapy for adults with diabetes or prediabetes: a consensus report. Diabetes Care 2019;42:731—754
3. Franz MJ, MacLeod J, Evert A, et al. Academy of Nutrition and Dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process. J Acad Nutr Diet 2017;117:1659—167
4. Esposito K, Maiorino MI, Ciotola M, et al. Effects of a Mediterranean-style diet on the need for antihyperglycemic drug therapy in patients with newly diagnosed type 2 diabetes: a randomized trial. Ann Intern Med 2009;151:306—314
5. Boucher JL. Mediterranean eating pattern. Diabetes Spectr 2017;30:72—76
6. Sainsbury E, Kizirian NV, Partridge SR, Gill T, Colagiuri S, Gibson AA. Effect of dietary carbohydrate restriction on glycemic control in adults with diabetes: a systematic review and meta-analysis. Diabetes Res Clin Pract 2018;139:239—252
7. van Zuuren EJ, Fedorowicz Z, Kuijpers T, Pijl H. Effects of low-carbohydrate- compared with low-fat-diet interventions on metabolic control in people with type 2 diabetes: a systematic review including GRADE assessments. Am J Clin Nutr 2018;108:300—331
8. Snorgaard O, Poulsen GM, Andersen HK, Astrup A. Systematic review and meta-analysis of dietary carbohydrate restriction in patients with type 2 diabetes. BMJ Open Diabetes Res Care 2017;5:e000354
9. Rinaldi S, Campbell EE, Fournier J, O’Connor C, Madill J. A comprehensive review of the literature supporting recommendations from the Canadian Diabetes Association for the use of a plant-based diet for management of
10. Pawlak R. Vegetarian diets in the prevention and management of diabetes and its complications. Diabetes Spectr 2017;30:82—88
11. U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections. Accessed 1 November 2019. Available from http://www.fda.gov/Drugs/DrugSafety/ucm475463.htm
12. Blau JE, Tella SH, Taylor SI, Rother KI. Ketoacidosis associated with SGLT2 inhibitor treatment: analysis of FAERS data. Diabetes Metab Res Rev 2017;33:e2924
13. Saslow LR, Daubenmier JJ, Moskowitz JT, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutr Diabetes 2017;7:304
14. Hallberg SJ, McKenzie AL, Williams PT, 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 2018;9:583—612
15. van Wyk HJ, Davis RE, Davies JS. A critical review of low-carbohydrate diets in people with type 2 diabetes. Diabet Med 2016;33:148—157
16. Meng Y, Bai H, Wang S, Li Z, Wang Q, Chen L. Efficacy of low carbohydrate diet for type 2 diabetes mellitus management: a systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2017;131:124—131
17. Tay J, Luscombe-Marsh ND, Thompson CH, et al. Comparison of low- and high-carbohydrate diets for type 2 diabetes management: a randomized trial. Am J Clin Nutr 2015;102:780—790
18. Thomas D, Elliott EJ. Low glycaemic index, or low glycaemic load, diets for diabetes mellitus. Cochrane Database Syst Rev 2009;1:CD006296

Many people say they plan to lose weight, lower their blood sugar, pressure or cholesterol in the New Year, but the difference between a “wish” and a “resolution” is having a plan in place to actually do it.

Wish or Resolution?

A “wish” is really just a hope that something will occur — an “it would be nice” type of thought, whereas a “resolution” is a firm decision to do something and is associated with specific qualities that will make it a reality.  A resolution is a SMART goal; one which is specific,  measurable,  achievable, realistic and timely.

A goal to lose weight or eat healthier isn’t specific — it’s just a wish. A resolution to stop eating foods with added sugar is specific, so is a goal to eat whole, real foods that are low in refined carbohydrate.  These are specific.

A resolution isl measurable. It decides what success looks like. For someone to say they want to lose 25 pounds is very different than to say they plan to lose a pound a week so that in 6 months they’ve lost 25 pounds.

But is that goal achievable?  If someone is significantly overweight, it is achievable to set a goal of losing 25 pounds in 6 months. 

What if someone wants to incorporate long periods of intermittent fasting into their lifestyle, but also eat all of their meals with their family? This isn’t realistic —  but they can choose to have shorter ‘eating windows’ (such as 18:6), intermittently fast each day and still eat dinner each night with their family. That’s entirely realistic. 

For a goal to be timely (or time-bound) means that it will also be achieved in a specific amount of time. So, for example, the resolution to lose 25 pounds in 6 months, is time-bound.

So, while there are lots of people saying they’d like to lose weight, eat healthier, exercise more or have better blood sugar, blood pressure or cholesterol in the New Year, to be successful one needs a go about putting a SMART plan in place now in order to achieve it.

Without such a plan, January will arrive and a week into the New Year, 50% of people will have already given up on their goal [1] and by the end of the month, 83% will have quit [1].  Those are pretty discouraging statistics!

Why is that?

Because it takes ~66 days (more than 2 months) for a habit to become ingrained [2], so having professional support during that critical time is important!

I can help you get off to a good start in achieving your New Year’s resolution, but the best time to put a plan in place is now — before all the festivities begin.

Why not make this the year you actually achieve your health and weight-loss goals?

If you would like more information about the services I provide and how I can design a Meal Plan for you based on your needs, please have a look under the Services tab, or in the Shop. If you have questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

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
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 LCHF-RD (a division of BetterByDesign Nutrition Ltd.)

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

References

1. Norcross, JC et al, Auld lang syne: success predictors, change processes, and self-reported outcomes of New Year’s resolvers and nonresolvers. J Clin Psychol. 2002 Apr;58(4):397-405
2. Lally, P., van Jaarsveld, C. H. M., Potts, H. W. W. and Wardle, J. (2010), How are habits formed: Modelling habit formation in the real world. Eur. J. Soc. Psychol., 40: 998—1009.

The whole matter of ‘when we eat’ meals and ‘when we don’t eat’ was historically a non-issue; we ate when it was daylight and we had food available, and we didn’t eat when it was dark or had no food. With the creation of indoor lighting and electricity, “day” lasted as long as we keep the lights on and for most of us, food is available in our fridges around the clock. Before elaborating on the current science surrounding when to eat meals and to not eat, let’s look at a short history of the origins of eating 3 meals per day, and when the idea of ‘snacks’ became prominent.

Timing of Meals

According to food historian Ivan Day[1], during the Middle Ages, availability of daylight shaped meal times, as there was no electricity. People got up and began to work in the fields at first daylight and by mid-day they were hungry after working for 6 hours or so and lunch was the first and main meal of the day. As there was no artificial lighting, cooking large meals in the evening simply wasn’t possible, so dinner was really a smaller meal, such as bread and cheese.

Breakfast became popular during the mid-19th century when labourers needed an early meal to sustain them at work. It became widely popularized in the early 20th century when John Harvey Kellogg invented the first breakfast cereal. Dinner became the main meal of the day with the creation of artificial (gas) lighting, and by the early 1900s, people were eating 3 meals per day, with the last meal occurring after work. Gas lighting was expensive to run, so after dinner was eaten and cleaned up from, bedtime was shortly after.

Snacks

“Snacks” were frowned upon by the middle class during Victorian era because they did not require use of “proper” utensils (cutlery, plates), were seen as unhygienic and were associated with the lower class [2].

Snacks as we know them took root in the 1950s due to the manufacturing industry’s drive to sell new products in a growing economy after the end of WWII, along with an ability to create inexpensive disposable packaging and unique labelling to market these products. Sale of snack foods escalated in the late 1970s [2], and between 1977 and 2006, Americans were eating approximately 570 calories more per day, much of it as snacks rather than during meals [3].

Historic Dietary Treatment of Diabetes

Before the discovery of insulin, successful management of diabetes involved restricting carbohydrates eaten at meals.

In his text book titled “The Principles and Practice of Medicine” (1892), Dr. William Osler recommended a diet of 65% fat, 32% protein, and 3% carbohydrate, as well as abstaining from ”all fruits and garden stuff.” [4] — not dissimilar to some of the high-fat “keto” diets available today. 

In the early 1900s, Bernard Naunyn encouraged a strict carbohydrate-free diet [5], with energy being provided as fat and protein.

In 1914, Dr. Frederick M. Allen treated people for several days with a period of fasting to clear the excess blood sugar via the urine, and then followed that with a diet that was mostly fat and protein, with a small amount of carbohydrates, mostly as vegetables ⁠[6].

Dr. Elliot P. Joslin was the first doctor in the United States to specialize in treating diabetes, and in 1916 adopted the same low-carbohydrate approach as Fredrick Allen [7].

Medications as Treatment in Diabetes

Type 1 Diabetes

The discovery of insulin by Dr. Fredrick Banting and Dr. Charles Best in 1921 provided life-saving therapy for those with type 1 diabetes (which results from failure of the insulin-producing  β-cells of the pancreas). The insulin was initially isolated from the pancreases of beef and pigs, but “human insulin” became possible in the 1980s due to recombinant DNA technology which enabled the development of both basal insulin, as well as rapid acting insulin. This was life-changing and life-saving to those with type 1 diabetes.

Type 2 Diabetes

Metformin initially became available as a first-line treatment for type 2 diabetes in the late 1990s, and enabled those with type 2 to better control their blood sugar levels along with dietary changes — but when people were unable, or unwilling to adequately limit carbohydrate intake, insulin was prescribed.

Insulin went from being a life-saving therapy for those with type 1 diabetes to  also being a ‘treatment’ for people with type 2 diabetes who ate what they wanted at meals and snacks and “covered it with insulin“. The problem is that this type of “liberalization” of the diet creates a “vicious cycle” for those with type 2 diabetes, described as follows in a new study published ahead of print in September 2019, and to appear in the December 2019 journal, Diabetes Care[8];

“Dietary intervention is usually accompanied by sequential addition of several anti-hyperglycemic agents, including glucagon-like peptide 1 (GLP-1) analogs and sodium—glucose cotransporter 2 (SGLT2) inhibitors. Despite this medical treatment, many patients require insulin therapy, which is gradually augmented according to the glucose target-driven strategy. However, this progressive increase in insulin dose often leads to weight gain, which may increase insulin resistance, leading to a vicious cycle further increasing insulin doses, continued weight gain, decreased likelihood of achieving glycemic targets, a high risk for diabetes complications and increased insulin dose-dependent cardiovascular risk and mortality. It is, therefore, important to prevent the weight gain when insulin treatment is required.”

Of course, medications such as biguanides, sulfonylureas, SLP-1 analogues and SGLT2 inhibitors are very important tools for doctors to add in helping manage blood sugar levels, but too often they are used instead of / in the absence of carbohydrate reducing dietary changes and this results diabetes becomes “a chronic, progressive disease“. It need not be so if people are willing to reduce their carbohydrate intake and time when they do eat some carbohydrate-containing food, in accordance with when their body handles them best.

Dietary Recommendations – meals and snacks

Since 2009, people with type 2 diabetes have been advised to eat 3 meals per day plus several snacks per day ⁠— with carbohydrates evenly distributed across the meals and snacks, in order to achieve the best weight management and blood sugar control [9-11].  They’ve been told to aim for between 45-60 grams of carbohydrate at each meal, and 15-20 grams of carbohydrate for each of 3 daily snacks (between breakfast and lunch, between lunch and dinner, and before bed). Surprisingly, the new study referred to above that will appear in the December 2019 issue of Diabetes Care states that there were no research studies to support these practices [8].

The 45-60 g of carbs for each of 3 meals per day and 15-20 g per snack distribution is still being recommended as goals to those with type 2 diabetes — resulting in between 190 -240 g of carbohydrate being eaten each day. That is a lot of carbohydrate for people who’s bodies can no longer handle that much. Presumably the snacks are to lower the risk of hypoglycemia (low blood sugar) that can result from the anti-hyperglycemic medications that have become necessary to prescribe because these people do not restrict carbohydrate and as a result have blood sugar levels that are too high.

Most concerning is that recent studies have found that snacks consumed later in the day have been associated with an increased risk of obesity and type 2 diabetes, with higher overall blood sugar and higher glycated hemoglobin (HbA1C) [12-13]. These are some of the “costs” of people being told to eat an afternoon and evening snack in order to avoid low blood sugar that can result from taking medication to lower blood glucose, and in an absence of being willing to reduce carbohydrate intake.

Would it not make far more sense to encourage people with type 2 diabetes to eat less carbs and eat less often — along with doctors de-prescribing anti-hyperglycemic medication, including insulin? That way, no snacks are needed to keep them from having low blood sugar and their average blood sugar levels can fall.

In fact, a soon-to-be-published pilot study [8] found that those with type 2 diabetes who ate the same calories each day as 3-meals per day, rather than as 6 meals per day [i.e. 3 meals and 3 snacks] reduced body weight, blood glucose, and insulin doses! Without even changing how many carbs they ate or how many calories they ate, in just 12 weeks, the subjects in the 3 meal per day group, lost on average 12 pounds (5.4 kg) more than those in the 6 meal per day group, had 1.2% lower HbA1C than the 6 meal per day group and their total daily insulin dose was reduced by 26 units ± 7 (with no reduction in the 6 meal per day group). On top of this, this study found that “there was a significant decrease in hunger and cravings only in the 3 meal per day group“. This makes sense of course, because they were able to lower their injected insulin, which drives hunger and fat storage, leading to weight gain. The mechanism was thought to be an up-regulation in the clock genes of those that ate 3 meals per day, which contributed to the improved glucose metabolism.

Note: it’s important to keep in mind that it is the eating of carbohydrate-containing food that triggers the release of insulin from our pancreas, so even in healthy people i.e. those who are not diabetic, eating the same amount of food as 3 meals per day with no snacks (versus 3 meals plus 3 snacks) will result in less insulin being released. Less insulin means less hunger and less fat storage — whether it is the natural insulin from our own pancreas or it is injected insulin. If our goal is weight management, eating the same amount of food as 3 meals, rather than as meals and snacks makes sense.

This study verified that when we eat and when we don’t eat matters a great deal because our body has evolved over hundreds of thousands of years to function in response to light and day cycles, called circadian rhythms.

When We Eat – especially which meals to eat carbs

Chronobiology is the study of the effect of time of day on living systems and is emerging as an important player in human health.

We now know that the body’s processes involved in the maintaining of blood sugar control such as β-cell function, glucose uptake by the muscles, and glucose production by the liver, are all under the control of circadian rhythms. The body’s “master clock” which controls these circadian rhythms is found in a part of the hypothalamus of our brain, called the suprachiasmatic nucleus (SCN) and is “set” by exposure to light.

Note: Historically, the only light that set the SCN was sunlight, but our increasing exposure to bright lights emanating from office- and store- lights, TVs, computers and smart phones has disrupted this once tightly regulated system. 

Similar “peripheral clocks” are found in our body’s tissues, including muscle cells, liver cells, β-cells of our pancreas which produce and release insulin, and fat cells (adipose), and these are controlled by the “master clock” in our SCN, and by when we eat [14,15]. 

As it turns out, our circadian rhythms are optimized for us to eat during periods of light (daytime), and to fast and sleep in periods of dark (night time) [16,17] — so fasting after supper and overnight is consistent with our body’s built-in circadian rhythms.

In addition, blood sugar control is not the same at all times of the day, but fluctuates according to our body’s circadian rhythms. It has been shown in both healthy individuals and those with type 2 diabetes that identical foods eaten in the afternoon and evening cause much higher elevations in blood sugar, compared with the same foods eaten in the morning [18-20] . Based on this, it makes the most sense for any major carbohydrate sources (milk, fruit, root vegetables etc.) that are going to be eaten during the day to be consumed at breakfast, rather than evenly distributed across the whole day and evening.

When We Don’t Eat – intermittent fasting

It has been shown for those with type 2 diabetes that fasting until noon time actually results in much higher after-meal blood sugar levels (postprandial hyperglycemia), as well as an impaired insulin response after lunch and dinner [21], so while it is currently popular for people to chose their “eating windows” based on a wide range of popular protocols, it seems to me that choosing them in a way that is consistent with our circadian rhythms makes the most sense — especially if the goal is weight loss, appetite control and blood sugar regulation.

More Info

If you would like more information about having me design a Meal Plan for you that arranges your eating times and non-eating times around your schedule and in accordance with your natural circadian rhythms, please have a look under the Services tab or in the Shop. If you have service-related questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

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
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 LCHF-RD (a division of BetterByDesign Nutrition Ltd.)

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

References

1. BBD News Magazine, Winterman, Denise, Breakfast, lunch and dinner; Have we always eaten them? Nov 15 2012, https://www.bbc.com/news/magazine-20243692
2. Carroll, Abigail (30 August 2013). “How Snacking Became Respectable”. Wall Street Journal. August 30, 2013, https://www.wsj.com/articles/how-snacking-became-respectable-1377906874
3. Duffey KJ, Popkin BM, Energy Density, Portion Size, and Eating Occasions: Contributions to Increased Energy Intake in the United States, 1977—2006, June 28, 2011, https://doi.org/10.1371/journal.pmed.100105
4. Osler W. The Principles and Practice of Medicine. New York, D. Appleton and Company, 1892
5. Woodyatt RT, Bernhard Naunyn. Diabetes 1952;1:240—241, pmid:1493683
6. Allen FM, Studies concerning diabetes. JAMA 1914;63:939—94
7. Joslin EP, Treatment of Diabetes Mellitus. 2nd ed. Philadelphia, Lea & Febiger, 1917, p. 409
8. Jakubowicz D, Landau Z, Tsameret S et al, Reduction in Glycated Hemoglobin and Daily Insulin Dose Alongside Circadian Clock Upregulation in Patients With Type 2 Diabetes Consuming a Three-Meal Diet: A Randomized Clinical Trial, Diabetes Care 2019 Dec; 42(12): 2171-180.https://doi.org/10.2337/dc19-1142
9. Seagle HM, Strain GW, Makris A, Reeves RS; American Dietetic Association. Position of the American Dietetic Association: weight management. J Am Diet Assoc 2009;109:330—346
10. Beyond the Basics: Meal Planning for Healthy Eating, Diabetes Prevention and Management. Canadian Diabetes Association, 2014.
11. Arnold L,MannJI, Ball MJ. Metabolic effects of alterations in meal frequency in type 2 diabetes. Diabetes Care 1997;20:1651—1654
12. Mekary RA, Giovannucci E, Willett WC, van Dam RM, Hu FB. Eating patterns and type 2 diabetes risk in men: breakfast omission, eating frequency, and snacking. Am J Clin Nutr 2012;95:1182—1189
13. Gouda M, Matsukawa M, Iijima H. Associations between eating habits and glycemic control and obesity in Japanese workers with type 2 diabetes mellitus. Diabetes Metab Syndr Obes 2018;11:647—658
14. Dyar KA, Ciciliot S, Wright LE, et al. Muscle insulin sensitivity and glucose metabolism are controlled by the intrinsic muscle clock. Mol Metab 2013;3:29—41
15. Sadacca LA, Lamia KA, deLemos AS, Blum B, Weitz CJ. An intrinsic circadian clock of the pancreas is required for normal insulin release and glucose homeostasis in mice. Diabetologia 2011;54:120—124
16. Poggiogalle E, Jamshed H, Peterson CM. Circadian regulation of glucose, lipid, and energy metabolisminhumans. Metabolism2018;84:11—27
17. Saad A, Dalla Man C, Nandy DK, et al. Diurnal pattern to insulin secretion and insulin action in healthy individuals. Diabetes 2012;61:2691—2700
18. Bo S, Fadda M, Castiglione A, et al. Is the timing of caloric intake associated with variation in diet-induced thermogenesis and in the metabolic
    pattern? A randomized cross-over study. Int J Obes 2015;39:1689—1695
19. Jakubowicz D, BarneaM, Wainstein J, Froy O. High caloric intake at breakfast vs. dinner differentially influences weight loss of overweight and obese women. Obesity (Silver Spring) 2013; 21:2504—2512
20. Morgan LM, Shi JW, Hampton SM, Frost G. Effect of meal timing and glycaemic index on glucose control and insulin secretion in healthy volunteers. Br J Nutr 2012;108:1286—1291
21. Jakubowicz D, Wainstein J, Ahren B, Landau Z, Bar-Dayan Y, Froy O. Fasting until noon triggers increased postprandial hyperglycemia and impaired
    insulin response after lunch and dinner in  individuals with type 2 diabetes: a randomized clinical trial. Diabetes Care 2015;38:1820—1826

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Many people think that eating a low carb or ketogenic diet necessitates eating meat — in the same way that many assume that one needs to eat lots of added fat, but neither are true. In a previous article, I addressed the misconception that eating a low carb or keto diet is all about eating lots of extra fat and in this article, I will address the false belief that one has to be a meat-eater to follow a low-carb or ketogenic diet.

Before launching into the article, it’s important to define some terms.

Vegetarian versus Vegan

There is a significant difference between vegetarians and vegans and these two terms seem to get mixed up frequently. Vegans eat no animal products, while vegetarians don’t eat the meat of animals but will eat products that come from animals, such as dairy and eggs.

There are different categories of vegetarians, including ovo-lacto (those who eat eggs and milk-based products), as well as those that only eat one or the other (ovo or lacto). Some classify pescatarians who eat wild fish and seafood as a form of vegetarianism because they don’t eat farmed animals for food but for the purpose of this article I will use the term “vegetarian” to mean ovo-lacto vegetarian, as this is the most common form.

Different Motivations, Same Needs

Religious or cultural vegetarians

People are vegetarian for different reasons; some for religious reasons, including some Hindus, Buddhists, Jains, Sikhs and Seventh Day Adventists. Some people don’t eat meat for cultural reasons.  For example, some people from India may not be religious themselves but don’t eat meat because they were not raised eating it or because others in their social circle don’t eat meat. I refer to these type as being culturally vegetarian. Finally, some don’t eat meat for ethical reasons — believing it is morally wrong to kill an animal to eat it. 

From my perspective as a Dietitian, it is important that people who want to eat a low carb or ketogenic diet for health reasons are able to do even if they are vegetarian.

While type 2 diabetes is on the rise in those of various ethnic backgrounds, people of South Asian descent (those who have their roots in India, Pakistan, Sri Lanka, Bangladesh and Nepal) are thought to be at higher risk, and many people from these regions eat a vegetarian diet for religious or cultural reasons. Given what we now know about the association between a diet high in carbohydrate and both hyperinsulemia and type 2 diabetes (documented in many previous posts), offering people the option of eating a low carb or ketogenic vegetarian diet, enables them to obtain the same health benefit as those that choose to eat meat. And why not?

While many omnivores consider vegetarianism an ‘inferior diet’ it need not be so. A well-designed vegetarian or omnivore diet enables people to access all the essential macronutrients (essential fats and amino acids) from real, whole foods. This article will explains ‘how’, below.

Ethical VEGETARIANS

Oftentimes I find that people that choose vegetarianism for ethical reasons don’t realize that one can purchase ethically-raised meat and poultry. There are butchers in my area that raise their animals out back, where they are humanely treated their entire lives and killed humanely. These are a far cry from the industrial feed-lots that often motivate ethical vegetarians, and for understandable reasons. One place that I shop at has the motto “know your farmer, know your meat“. As well, some of the most ethical meat-eaters I know are hunters that train at the range to make sure that the animal they harvest doesn’t suffer, and they use the whole animal for food; from snout to tail. In fact, one local hunting group I’ve heard of is run in association with a local First Nations band that teach hunters that already have their Federal hunting licence to select animals in accordance with centuries-old First Nations principals for animal stewardship. One does not have to become a vegetarian for ethical reasons, as there are other options.

Defining a Low Carb or Keto Diet

Whether one is a vegetarian or a meat-eater, defining what “low carb” or “keto” is necessary in order to determine how one can eat this way.

As mentioned in a prior article, what makes a diet ”low carb” or ”ketogenic” is how much carbohydrate it has, not how much fat it contains. In the same way, what makes a diet low carb or ketogenic has nothing to do with how much meat one eats, or whether one eats meat at all.

Feinman et al [2] defined three categories of reduced-carbohydrate diets as follows;

(a) very low carbohydrate ketogenic*: carbs limited to 20—50 g per day or < 10% of total energy intake.

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

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

In my clinical practice and in other articles on this web page, I define ”low carb” and ”ketogenic” in the same way — with a low carb diet being one that is < 130 g carbohydrate per day, and a ketogenic diet as one that is 20—50 g of carbohydrate per day. What makes a keto diet ketogenic is that carbohydrate intake is low enough to put an individual into a state of ketosis, which is a normal physiological state that people go into after an overnight fast when they have used up their glycogen stores. When the body is in ketosis, it is burning stored fat for energy and releasing ketones which can be used by the brain and other tissues. In general, men can achieve ketosis eating ⩽ 50 g of carbs per day, but women often need to eat ⩽ 35 g of carbohydrate per day.

Essential Macronutrients

As covered in detail in this previous article, from a dietary perspective only protein and fat are essential in the diet. For a nutrient to be ”essential”, it is required to be eaten because the body can’t manufacture it.

There are 2 essential fats; linoleic acid, an omega 6 fat and alpha-linolenic acid, an omega 3 fat, and there are 9 essential amino acids. Amino acids are  are the building blocks from which proteins are made.

For omnivores, getting all the essential nutrients is fairly straight forward and simply requires eating a wide range of meat and animal products, along with nuts and seeds, but for those who are ovo-lacto vegetarians, one needs to be  more intentional to ensure getting all the essential nutrients. 

The 2 essential fatty acids (linoleic and alpha-linolenic acid) can be easily obtained from eggs, nuts and seeds, but ensuring adequate intake of all 9 of the essential amino acids (histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine from low carb, vegetarian sources can be achieves as follows [3];

• Vegetarians following a low carb or ketogenic diet can obtain histidine from dairy foods such as milk and cheese, as well as from nuts, seeds and eggs.
• Isoleucine can be obtained from eggs and cheese, as well as from seaweed and soy protein, if people wish.
• Rich sources of leucine include milk, cheese and egg, as well as from pumpkin or squash seeds. It can also be obtained from tofu and legumes eaten in daily maximum 1/2 cup quantities (as they are a significant source of carbohydrates).
• Lysine can be found in some cheeses such as Parmesan, eggs and spirulina as well as from tofu, and if needed can be supplemented with whey protein isolate and isolated soy protein.
• Foods high in methionine include dairy of different types, cheese, eggs, and nuts, as well as soy and legumes.
• High phenylalanine foods include cheese, nuts and seeds, eggs and dairy, as well as from soybeans and legumes.
• Foods rich in threonine include cheese, nuts and seeds, and if desired, in soy, and in legumes and lentils (in maximum daily 1/2 cup servings as they are significant sources of carbs)
• Good sources of tryptophan include egg, milk products such as yogurt, nuts and seeds and soy products, if eaten.
• High valine foods include nuts and seeds, mushrooms, and soybeans if eaten, as well as legumes.

Note (Nov 8, 2019 @ 10 am): shortly after publishing this article, the topic of whether vegetarians can obtain sufficient vitamin B12 and the long chain fatty acids, DHA and EPA was raised on social media. While this article is about a vegetarian diet providing all the essential macronutrients, I will add the following information for those who are interested:

Re: vitamin B12: 2 cups of yogurt per day provides 100% DV of B12 and so do 4 eggs (which many low carb omnivores eat in a day). Add to that 3 oz of Swiss cheese which provides 100% DV, or a cup of tofu (which provides more than 100%), getting enough vitamin B12 is not an issue, provided vegetarians are not restrained by a “low fat” paradigm.

Re: the long chain fatty acids DHA and EPA: There is no Dietary Reference Intake (DRI) for EPA or DHA, only for alpha-linolenic acid. In healthy young men, approximately 8% of dietary alpha linolenic acid is converted to EPA and ≤4% alpha-linolenic acid is converted to docosahexaenoic acid (DHA). [Burdge GC, Jones AE, Wootton SA. Eicosapentaenoic and docosapentaenoic acids are the principal products of α-linolenic acid metabolism in young men. Br J Nutr. 2002;88(4):355-364].

In healthy young women, approximately 21% of dietary alpha-linolenic acid is converted to EPA and 9% is converted to DHA. [Burdge GC, Wootton SA. Conversion of α-linolenic acid to eicosapentaenoic, docosapentaenoic and docosahexaenoic acids in young women. Br J Nutr. 2002;88(4):411-420. ].

The better elongation in young women is related to the effects of estrogen. [Burdge G. α-Linolenic acid metabolism in men and women: nutritional and biological implications. Curr Opin Clin Nutr Metab Care. 2004;7(2):137-144, Giltay EJ, Gooren LJ, Toorians AW, Katan MB, Zock PL. Docosahexaenoic acid concentrations are higher in women than in men because of estrogenic effects. Am J Clin Nutr. 2004;80(5):1167-1174.]

For vegetarians, eating seaweed including nori, spirulina and other types of edible seaweed provides a good source of pre-formed DHA & EPA in the diet. These also form the basis for vegetarian-sourced DHA and EPA supplements that can be purchased. 

Low Carb and Ketogenic Diets are Truly Not “One-Sized-Fits-All”

There really isn’t a “one-sized-fits-all” low carb or ketogenic diet!

There are the high fat / moderate protein varieties popularized by Dr. Jason Fung and that are often associated with high consumption of bacon, heavy whipping cream, and fatty meat, and offset by periods of intermittent fasting.

There is the higher protein lower fat approach during weight loss, followed by a moderate protein higher fat diet during weight maintenance of Dr. Stephen Phinney MD, PhD and Dr. Jeff Volek RD, PhD.

You can read more about the above two approaches in this article.

There are the higher lean protein type, with more grams of protein than grams of fat (popularized most recently by Dr. Ted Naiman in his P:E Diet and referred to in the previous article). More than likely, there are different macronutrient combinations than the ones listed here that are popular with others.

I don’t believe that any of the above can serve as a “one-sized-fits-all” approach because everybody’s nutritional needs and health conditions are different.  

Those who are omnivore can choose a meal pattern that includes meat, and for those that are vegetarian (for whatever reason) can still reap the health benefits from eating a well-designed low carbohydrate diet that does not include meat.

Final thoughts…

It is my observation that many people who follow a low carb or ketogenic lifestyle tend to be overly loyal to their particular dietary style, which inadvertently makes people who need to or choose to eat differently feel that the health and metabolic benefits of following a low carb diet is not available to them.

People that don’t eat meat for religious, cultural or ethical reasons need to know there are options available for them to have a well-designed meal plan that includes the animal derived products they do eat, rather than to be told how ‘inadequate’ their diet is compared to those who eat meat. 

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If you would like more information about the services that I provide and how I can help design a Meal Plan based on your needs, please have a look under the Services tab, or in the Shop.

If you have questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

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Copyright ©2019 LCHF-RD (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.

Resources

1. Gujral UP, Pradeepa R, Weber MB, Narayan KM, Mohan V. Type 2 diabetes in South Asians: similarities and differences with white Caucasian and other populations. Ann N Y Acad Sci. 2013;1281(1):51—63. doi:10.1111/j.1749-6632.2012.06838.x
2. 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.
3. USDA Food Composition Databases, https://fdc.nal.usda.gov/

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This article is about which protein foods are best for weight loss on a low carb or ketogenic diet, and builds on the previous article, where I outlined that what makes a diet ”low carb” or ”ketogenic” is how much carbohydrate it has, not how much fat it contains.

I’m not sure where the idea came from that eating a low carb or ketogenic diet for weight loss should include piles of bacon,  bulletproof coffee, fathead pizza and ‘fat bombs’. Perhaps it originated with advocates of eating such a diet which is offset by extended periods of fasting, or by the use of the very term “low carb high fat” / “LCHF“, itself. As explained in the previous article, a low carb diet is higher in fat and protein, because the amount of carbohydrate is reduced — and this is necessary for the the body to be provided with adequate amounts of essential fats and essential amino acids (that make up protein) in order to function properly and make any glucose it needs.

Note: if you haven’t yet read the previous article, I’d highly recommend clicking here and reading it first, as it will help considerably with understanding this one.

As mentioned in the preceding article, some “LCHF” diets that target higher protein may be as high as 50-60% fat — which is considered “high fat” compared to the 30% of calories as fat recommended by previous and current food guides. Other some variations of a low carb diet that target protein may have considerably less fat; depending which protein foods are chosen, and whether fat containing foods that are not rich sources of protein (such as avocado and olives) are also included. In either case, a low carb or ketogenic diet that targets protein will have significantly less than the 75% calories as fat of the high fat versions.  The fat eaten on a low carb or ketogenic diet which targets protein will come from fatty fish such as salmon, tuna, mackerel and sardine, the fat that exists in the lean portions of chicken, pork and steak, in egg and cheese, as well as in nuts and seeds, avocado and olives. What is (pardon the pun) essential is for people to ensure is that they eat foods that contain the two essential fats (linoleic acid, alpha-linolenic acid) and the nine essential amino acids (the building blocks of protein), including histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine that the body can’t manufacture. 

Combined List of Essential Nutrient-Containing Foods

In the previous article, I outlined which foods of animal origin and vegetarian origin are the best sources of each of these essential nutrients and that list should be referred to when selecting specific foods containing these, but combining those into one list, the following taken as a whole are good sources of the essential nutrients for those following a low carb or ketogenic diet:

• pork
• beef
• lamb
• chicken
• turkey
• fish, including tuna
• shellfish
• cheese, including Parmesan
• nuts, including walnuts 
• pumpkin seeds and flax
• eggs
• soy protein
• whey protein isolate
• seaweed
• tofu
• legumes and lentils
• spirulina

For those seeking weight loss, it makes good sense to choose foods with the most amount of protein for the least amount of energy (calories). Up until recently, figuring this out would have required lots of calculations, but Dr. Ted Naiman, a board-certified family medicine physician who practices at the Virginia Mason Medical Center in Seattle, Washington has made this easy. Along with William Shewfelt, Dr. Naiman recently published an online book titled The P:E Diet – Leverage Your Biology to Achieve Optimal Health.

Protein to energy (P:E) Ratio

“P:E” is simply the Protein to Energy ratio of a food and Dr. Naiman who is well known on social media for his excellent infographics makes choosing foods with the most amount of protein for the least amount of energy (calories) easy.

Referring to Dr. Naiman’s P:E ratio enables the sorting of the foods available on a low carb or ketogenic diet and which contain the essential nutrients, into those with the highest protein to energy ratio:

• whey protein isolate
• egg white
• fish, including tuna
• prawns
• chicken breast
• other poultry, including chicken legs, turkey, etc.
• plain non-fat Greek yogurt
• ground beef
• pork
• steak
• whole eggs
• soy protein
• tofu
• processed meat such as bacon
• cheese, including Parmesan
• lentils
• milk
• peanuts
• beans / legumes
• nuts

Calculations will still need to be done for other meats such as lamb and goat,  and other types of seafood, but this list provides a good means to select foods that have the highest protein to energy ratio.

Low Carb and Ketogenic Diets Include a Range of Fat Intake

In the previous article, I mentioned how a well-designed low carb or ketogenic diet may have in the range of 50-60% calories as fat, but selecting foods with a higher protein to energy ratio (such as egg white and non-fat Greek yogurt) will provide less fat and few calories (energy) than choosing whole egg and Greek yogurt that is 5% fat. Doing this consistently will result in a significantly lower amount of fat yet it is still a low carb or ketogenic diet because of the low amount of carbohydrate it contains.

Use of a higher P:E ratio makes sense for those who are seeking to build muscle mass or to follow a protein-sparing modified fast type of diet. For this, there is Dr. Naiman’s book (link in the References and above). For those seeking simple weight loss, eating whole egg and slightly higher fat yogurt may provide more satiety (feeling of fullness), albeit with higher caloric intake. Since each person’s reasons for wanting to follow a low carb or ketogenic meal pattern is different, which specific protein foods are best to choose in what quantities will vary, person to person. There is no one-sized-fits-all low carb or ketogenic diet.

Final Thoughts…

People following a low carb or ketogenic meal pattern for weight loss and preserving muscle mass should target protein foods with an optimal P:E ratio for their needs, which will likely fall somewhere between the highest P:E ratio (5.0) and those in the 1.0-1.5 range.

Regular inclusion of high fat foods with relatively low protein such as bacon, bulletproof coffee, fathead pizza and fat bombs’ is neither required nor ideal if weight loss is being sought.

More Info

If you would like more information about the services that I provide and how I can help design a Meal Plan based on your needs, please have a look under the Services tab, or in the Shop.

If you have questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

To your good health!

Joy

You can follow me on:

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Copyright ©2019 LCHF-RD (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.

Reference

Naiman T, Shewfelt W, The P:E Diet – Leverage Your Biology to Achieve Optimal Health, http://thepediet.com/

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Many people assume that a “low carb” or ketogenic (“keto”) diet for weight management and blood sugar reduction requires them to eat a diet high fat — piles of bacon,  bulletproof coffee, fathead pizza and ‘fat bombs’, but this is not true. Not only is eating that way not ideal for many people seeking weight loss — but some actually end up gaining weight doing so.

In fact, what makes a diet “low carb” or “ketogenic” is how much carbohydrate it has, not how much fat it contains.

Defining Low Carb and Keto Diets

Different people define “low carb” or “keto” level of carbohydrates in different ways, but Feinman et al [1] defined three categories of reduced-carbohydrate diets as follows;

(a) very low carbohydrate ketogenic*: carbs limited to 20—50 g per day or < 10% of total energy intake.

Note: What makes a keto diet ketogenic is that that low carbohydrate intake puts people into a state of ketosis, which is a normal physiological state that people go into after an overnight fast. It is where the body burns stored fat for energy, releasing ketones which can be used by the brain and other tissues.

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

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

In my clinical practice and on other articles on this web page, I define “low carb” and “ketogenic” as Feinman et al did; with a low carb diet being one that is < 130 g per day and a ketogenic diet as one that is 20—50 g per day.

Protein, Fat and Carbohydrate — are all essential?

Many people assume that people need to eat all three macronutrients; protein fat and carbohydrate but from a dietary point of view, only protein (as specific amino acids) and fat are considered “essential” in the diet. For a nutrient to be “essential”,  it is required to be eaten in food because the body can’t manufacture it.

There are two fats that are considered “essential”; linoleic acid (an omega 6 fat) and alpha-linolenic acid (an omega 3 fat). We need to eat meat and eggs and/or nuts and seeds for the major dietary sources of linoleic acid, as well as nuts such as walnuts and seeds such as flax to get rich sources of alpha-linolenic acid, although many people obtain these from eating chicken, cheese and whole milk [2].

Amino acids are the building blocks of protein, and there are nine amino acids that are considered “essential”; histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine.

Below are the best low carb foods for obtaining each of these[3]  are listed below.

• • The best sources of histidine include pork, beef, lamb, chicken, turkey, fish, dairy such as milk and cheese, nuts, seeds, eggs.
  • Best sources of isoleucine are eggs, turkey, chicken, lamb, cheese and fish and for vegetarians, soy protein and seaweed.
  • Rich sources of leucine include chicken, beef, pork, tuna, milk, cheese, and egg and for vegetarians tofu, legumes and pumpkin or squash seeds.
  • The best sources of lysine include red meat such as beef and lamb, pork, poultry,  some cheeses such as Parmesan, certain fish such a cod and sardine, egg and whey protein isolate, and for vegetarians there is tofu, isolated soy protein and spirulina.
  • Foods high in methionine include , beef, lamb, cheese, turkey, pork, fish, shellfish, eggs, dairy and nuts, and for vegetarians, soy and legumes.
  • High phenylalanine foods include cheese, nuts and seeds, beef, lamb, chicken, pork, fish, eggs and dairy, and for vegetarians soybeans and legumes.
  • Foods rich in threonine foods include lean cuts of beef, pork, chicken, liver, cheese, shellfish, nuts, seeds, and for vegetarians, soy, legumes and lentils. 
  • While many people associate turkey as being high in tryptophan, there are other foods as well. Tryptophan is required for the body to make the neurotransmitter serotonin, so getting enough tryptophan is…pardon the pun, essential. Good sources of tryptophan include salmon, all kinds of poultry (including turkey), egg, milk, nuts and seeds and for vegetarians, soy products.
  • High valine foods include cheese, beef, lamb, chicken, pork, nuts and seeds, and fish, and for vegetarians, soybeans, legumes and mushrooms.

Carbohydrate is Not Essential in the Diet

The Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids [4] which sets the standard for macronutrient consumption in both the US and Canada states;

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

In short, there is no essential need for dietary carbohydrate provided that ”adequate amounts of protein and fat are consumed”. The reason carbohydrate is not essential is because the body can make what it needs from dietary protein and fat!

The Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005) goes on to explain the process;

”In the absence of dietary carbohydrate, de novo synthesis of glucose requires amino acids derived from the hydrolysis of endogenous or dietary protein or glycerol derived from fat. Therefore, the marginal amount of carbohydrate required in the diet in an energy-balanced state is conditional and dependent upon the remaining composition of the diet.”

What this means is that the body will synthesize the little bit of glucose needed by the brain and red blood cells, etc from the protein taken in through the diet —provided it is in adequate amounts, or from glycerol which is formed when fat is broken down. 

I encourage people to target protein first, add low carb veggies and fruit (such as lime, lemon, and a few berries), then add a bit of fat to make things taste good and to provide a source of essential fatty acids. Protein and fat both provide satiety (not feeling hungry) but protein has significantly less calories than fat. If one is aiming for weight loss, adding lots of extra dietary fat (in addition to what comes naturally in protein foods) is counter-productive. That doesn’t mean avoid fat, either. Eat the egg with the yolk and marbling in steak is fine and so is using some fat for cooking food or putting on veggies, but for weight loss, it’s best to avoid extra fat that doesn’t come a good source of protein.

Final Thoughts…

What makes a diet low carb or ketogenic is how much carbohydrate it has, not how much fat it contains; with a low carb diet being one that is < 130 g carbohydrate per day and a ketogenic diet as one that is 20—50 g carbohydrate per day. The amount of fat in the diet does not make it low carb or keto!

While a low carb diet is often called a “LCHF diet” i.e. “low carb high fat”, it is really only “high fat” relative to the recommended American or Canadian diet which is supposed to be < 30% fat.  A low carb diet that targets protein may be as high ~50-55% fat or significantly lower if lower fat protein is chosen — but is no where near the 75% fat of a classic ketogenic diet (KD diet) used for those with epilepsy*, or some fat-based variations low carb diets. It is my experience that many people, especially peri-and post menopausal women do much better on the higher protein version. A Low carb or keto diet is not about eating lots of bacon, avocado, heavy whipping cream or ‘fat bombs’ and “bulletproof” coffee. It is about eating less carbs.

*Addendum (Nov 1, 2019 @ 2:35 pm) It was pointed out to me that the Charlie Foundation uses a Low Glycemic Index Treatment Diet for the management of epilepsy that is closer to 60% fat, which allows for less fat than a strict KD diet.

Yes, we need some essential fat in the form of linoleic acid and alpha-linolenic acid which can easily be obtained by eating meat and eggs, and for vegetarians to eat nuts including walnuts and seeds such as flax seed, but for the most part, eating the foods listed above that are rich in the nine essential amino acids will provide all the essential fat we need.

Update (Nov 3, 2019): The following article outlines which protein foods are best for weight loss on a low carb or ketogenic diet.

More Info

If you would like more information about the services that I provide, please have a look under the Services tab, or in the Shop. If you have questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

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
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 LCHF-RD (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.

Resources

1. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1—13.
2. National Cancer Institute, Food sources of alpha-linolenic acid (PFA 18:3), Epidemiology and Genomics Research Program, Table 6, https://epi.grants.cancer.gov/diet/foodsources/fatty_acids/table6.html
3. USDA Food Composition Databases, https://fdc.nal.usda.gov/
4. National Academies of Sciences, Engineering and Medicine, Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids, 2005, https://www.nap.edu/catalog/10490/dietary-reference-intakes-for-energy-carbohydrate-fiber-fat-fatty-acids-cholesterol-protein-and-amino-acids

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INTRO: This article documents the science that supplementing with Vitamin D can help protect us against the flu, recommendations for how much we should be supplementing, as well as excellent low carb dietary sources of this important fat-soluble vitamin. 

The other day I shared an article[1] on social media from a local Canadian news outlet about a 37 year old man from Ontario who decided to forgo his annual flu shot last year and ended up in hospital with pneumonia for two months, after he contracted the flu virus from his daughter. The article indicated that data from Statistics Canada indicates that only 1/3 of Canadians above the age of 12 get the flu shot every year, yet according to deputy chief public health officer for the Public Health Agency of Canada, Dr. Howard Njoo, more than 12,000 Canadians end up hospitalized for flu-related complications each year, and between 3,000-4,000 people die as a result. Dr. Njoo was quoted as saying;

“it makes common sense that you should get your flu shot.”

There was much heated discussion on Facebook whether there is  “proof” that the flu shot prevents people from getting the flu. 

A well-known epidemiologist said that “unlike childhood vaccinations (ie, diphtheria, tetanus, pertussis, polio, measles, mumps, rubella, etc), there is no conclusive proof that flu shots reduce risk of either getting the flu or its complications. There are no large randomized trials, which is the standard for establishing a causal connection. So all we really have are observational studies, which are subject to a lot of confounding“. The epidemiologist noted that there was a meta-analysis of 44 years’ worth of studies that was published in Lancet Infectious Diseases in 2011 which found only “moderate efficacy” of the flu vaccine[2].

In response, a GP referenced a 2012 review of 15 meta-analyses related to the effectiveness of the flu vaccine for adults and the elderly which found they provided what was described as ‘satisfactory immunogenicity’,  but that data on inactivated vaccines for children was scarce[3].

One of the other people that commented about the CTV article brought up studies that I was previously unaware of that indicate that Vitamin D supplementation may reduce the risk of getting the flu  ⁠— especially for those who are low in in this fat-soluble vitamin to begin with. Stats Can data from 2013 indicates that 1/3 of Canadians fall in this category [4]. It was this fact that motivated me to write this article.

Studies Showing that Vitamin D Attenuates the Flu

There are two large-scale meta-analyses — one from 2013 and the other from 2017 that indicate that Vitamin D supplementation can reduce the risk of getting an upper respiratory infection (URI) including influenza (“the flu”).

The first study by Bergman et al [5] analyzed data from 11 placebo controlled trials that involved more than 5,600 subjects and found that those taking a daily dose of Vitamin D had half the risk of developing an upper respiratory infection (URI), including influenza (‘the flu”). This held true even though many of the studies used very low dose of supplementation.

The second of the two large-scale meta-analysis by Martineau et al [6] analyzed the data from 25 randomized controlled trials and involved more than 11,300 subjects. This study found that Vitamin D supplementation reduced the risk of developing an upper respiratory infection (URI), including the flu and those who were the most deficient experienced the most benefit. Even those subjects with very low Vitamin D status had 1/3 the risk when supplementing with Vitamin D, compared to those who did not take any.

Both meta-analysis found that daily dosing with Vitamin D was more effective than taking larger (bolus) doses once a week, or once a month.

There are numerous studies which indicate that people with lower levels of Vitamin D are more likely to get the flu and a 2010 study with healthy adults found that people with lower levels of were twice as likely to get the flu than people with high levels of Vitamin D [7].

Supplementing with Vitamin D to Reduce Risk of Flu

Health Canada’s recommended daily intake (RDAs) for Vitamin D (updated in 2011) are 600 International Units (IUs) for everyone aged one year old to 70 years old and 800 IU for adults over 70 years of age. Health Canada’s safe upper limit (UL) is listed as 4,000 IU per day, however recent scientific publications indicate that there was an error in the calculations used to determine them.

Two researchers from the School of Public Health at the University of Alberta published a paper in October 2014 which indicates that the Institute of Medicine (IOM) that develops the Recommended Dietary Allowances (RDAs) used by both Canadians and Americans made a serious error in their calculations in determining the RDAs for Vitamin D [9] and that rather than 600 IUs being needed to prevent deficiency in 97.5% of individuals, the actual amount is estimated to be 8895 IU of Vitamin D per day — which is above the Health Canada’s tolerable upper intake of 4000 IU per day.

On top of that, researchers from the University of California at San Diego and Creighton University in Omaha, Nebraska published a letter in the same online journal in March 2015 which said that they have confirmed the Institute of Medicine’s miscalculation that was noted by the Canadian investigators [10].

A press release published in Science News on March 17, 201[11] indicated that;

“The recommended intake of vitamin D specified by the IOM is 600 IU/day through age 70 years, and 800 IU/day for older ages. Calculations by us and other researchers have shown that these doses are only about one-tenth those needed to cut incidence of diseases related to vitamin D deficiency.“

How much Vitamin D should we supplement?

The Vitamin D Council (a US-based group) recommends adults take 5,000 to 10,000 IU/day, depending on body weight and recommend people have their levels checked to make sure it is > 40 ng/ml (100 nmol/l) and to maintain serum levels at 50 ng/ml (125 nmol/L). Since Vitamin D toxicity manifests as high levels of calcium in the blood and urine, the Vitamin D Council recommends monitoring via blood tests that serum levels don’t exceed 150 ng/ml (374 mmol/L).

Since Health Canada’s current upper limit is 4,000 IUs per day (which may be based on an error in calculation, as noted above), a prudence dosage for supplementation for a healthy adult would not exceed 4,000 IUs per day.

Note: I also recommend people take 100 mcg of Vitamin K2 (menaquinone-4, or menaquinone-7) as Vitamin K2 plays a synergistic role with Vitamin D which regulates blood levels of calcium. Vitamin K prevents calcium from accumulating in soft tissues, such as the blood vessels (contributing to Coronary Artery Calcification)[12].  Put simply, Vitamin K helps ensure that calcium ends up in bone, not arteries.

NOTE: People taking Warfarin (Coumadin) or other anticoagulant medication should not supplement with Vitamin K2 except under the advice of the physician prescribing Warfarin.

If you are a healthy adult under 50 years old with no family risk of cancer* or osteoporosis, 1000 IU Vitamin D3 per day (plus 100 mcg of Vitamin K2) is probably sufficient. Be sure to choose the D3 form (not D2) as it is more efficient at raising serum levels. For adults under 50 with a family history of cancer or who are at risk for osteoporosis, a dosage of 2000 IU Vitamin D3 per day (plus 100 mcg of Vitamin K2) may be more appropriate.

*there are many studies indicating that supplementing Vitamin D levels for those in northern latitudes (such as Canada and the northern US) lowers the risk of certain types of cancer, especially breast, colon and prostate cancer.

I usually recommend that healthy adults over the age of 50 double the amounts above ⁠— so 2,000 IUs Vitamin D3 per day (plus 100 mcg of Vitamin K2) and for those with a family history of cancer to take 3,000 IUs Vitamin D3 per day (plus 100 mcg of Vitamin K2).

Remember though that Vitamin D is a fat soluble vitamin, so be sure to have your serum levels checked periodically as your body is able to stores for long periods of time. The best indicator of Vitamin D status is a routine blood test called 25-hydroxy vitamin D.

Best Low Carb Sources of Vitamin D to Help Our Bodies Fight the Flu

Fish and Seafood

Below is a list of foods that are naturally high in Vitamin D and that can be included on a low carb or ketogenic diet. The best source of all comes from the sea in the form of fish and seafood.

Wild-caught salmon

Wild-caught salmon has on average almost 1000 IU of Vitamin D (988 IU) vitamin D per 3.5-ounce (100-gram) serving and some studies have found up to 1,300 IU per serving [13].

Herring

Fresh Atlantic herring provides 1,628 IU Vitamin D per 3.5-ounce (100-gram) serving [14]. That’s huge!

Halibut

Halibut is an exquisitely delicious white-fleshed fish that  provides 600 IU Vitamin D per per 3.5-ounce (100-gram) serving [14].

Mackerel

Mackerel is simply delicious grilled on the BBQ and provides 360 IU Vitamin D per 3.5-ounce (100-gram) serving [14].

OYSTERS

Oysters contains 320 IU of Vitamin D in a 3.5-ounce (100-gram) serving [14].

Sardine

Sardine is an inexpensive and pretty good source of vitamin D — with one serving containing 272 IU of Vitamin D [14].

Canned Tuna

Canned tuna is an easy and inexpensive way to incorporate more Vitamin D into the diet and contains 236 IU of Vitamin D in a 3.5-ounce (100-gram) serving [14].

Non-fish Sources of Vitamin D

Fish and seafood are not the only sources of Vitamin D. Whole egg is a  good source, with most of the Vitamin D found in the yolk.

Egg yolk

The average supermarket egg contains only 18—39 IU of vitamin D, but pastured eggs that roam outside and are exposed to sunlight produce eggs with 3 to 4 times that amount [15]!

Mushrooms

With the exception of fortified foods such as dairy, mushrooms are the only plant source of Vitamin D, however mushrooms only produce Vitamin D2, rather than Vitamin D3 which is not as effective at raising blood levels of Vitamin D. Even then, button mushrooms grown outside under sunlight contain as much as 2,300 IU per 3.5-ounce (100-gram) serving [16].

Final thoughts…

There is good evidence that adding Vitamin D3 supplementation to your daily routine may boost your ability to fight of upper respiratory infections, including the flu.

Supplementing your diet with Vitamin D and/or eating plenty of low carb foods rich in Vitamin D3 can help ensure adequate stores of this important nutrient.

More Info

If you would like more information about my services, please have a look under the Services tab or in the Shop and if you have any questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

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
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Copyright ©2019 LCHF-RD (a division of BetterByDesign Nutrition Ltd.)

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

References

1. CTV News, Canadian warns against vaccine apathy after flu sends him to hospital for two months, https://www.ctvnews.ca/health/canadian-warns-against-vaccine-apathy-after-flu-sends-him-to-hospital-for-two-months
2. Osterholm MT, Kelley NS, Sommer A, et al. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Lancet Infect Dis 2011 (published online Oct 25)
3. Manzoli L, Ioannidis JP, Flacco ME, De Vito C, Villari P. Effectiveness and harms of seasonal and pandemic influenza vaccines in children, adults and elderly: a critical review and re-analysis of 15 meta-analyses. Hum Vaccin Immunother. 2012;8(7):851—862. doi:10.4161/hv.19917]
4. Dairy Nutrition, Vitamin D status of Canadians — Results from the Canadian Health Measures Survey, https://www.dairynutrition.ca/nutrients-in-milk-products/vitamin-d/vitamin-d-status-of-canadians-results-from-the-canadian-health-measures-survey
5. Vitamin D Council, Dr. John Cannell, MD, Influenza, https://www.vitamindcouncil.org/health-conditions/influenza/
6. Bergman P, Lindh AU, Bjí¶rkhem-Bergman L et al, Vitamin D and Respiratory Tract Infections: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, PLoS One. 2013 Jun 19;8(6):e65835.
7. Martineau AR, Jolliffe DA, Hooper RL, Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data, BMJ. 2017 Feb 15;356:i6583
8. Sabetta, J.R., DePetrillo, P., Cipriani, R.J., et al., Serum 25-hydroxyvitamin d and the incidence of acute viral respiratory tract infections in healthy adults. PLoS One, 2010. 5(6): p. e11088.
9. Veugelers PJ, Ekwaru JP. A statistical error in the estimation of the recommended dietary allowance for vitamin D. Nutrients. 2014;6(10):4472—4475. Published 2014 Oct 20. doi:10.3390/nu6104472
10. Heaney R, Garland C, Baggerly C, French C, Gorham E. Letter to Veugelers, P.J. and Ekwaru, J.P., A statistical error in the estimation of the recommended dietary allowance for vitamin D. Nutrients 2014, 6, 4472-4475; doi:10.3390/nu6104472. Nutrients. 2015;7(3):1688—1690. Published 2015 Mar 10. doi:10.3390/nu7031688
11. Science News, Recommendation for vitamin D intake was miscalculated, is far too low, experts say, https://www.sciencedaily.com/releases/2015/03/150317122458.htm
12. Theuwissen E, Smit E, Vermeer C, The role of vitamin K in soft-tissue calcification, Adv Nutr. 2012 Mar 1;3(2):166-73.
13. Schmid A, Walther B., Natural vitamin D content in animal products, Adv Nutr. 2013 Jul 1;4(4):453-62
14. USDA, Composition of Foods Raw, Processed, Prepared USDA National Nutrient Database for Standard Reference, Release 27
15. Kí¼hn J, Schutkowski A, Kluge H.,Free-range farming: a natural alternative to produce vitamin D-enriched eggs, Nutrition. 2014 Apr;30(4):481-4.
16. Simona RR, Borzelleca JF, DeLuca HF, Safety assessment of the post-harvest treatment of button mushrooms (Agaricus bisporus) using ultraviolet light, Food and Chemical Toxicology, Volume 56, June 2013, Pages 278-289

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There is much “push back” when it comes to the standard advice to “eat less and exercise more” as a means of losing weight, and for good reason. For one, metabolism will slow as a result of caloric restriction — making it that much more difficult to lose weight when deliberately cutting calories. Another reason is that it is exceedingly difficult for an obese person to exercise. For many, just getting around is a chore. It is for this reason that I focus on helping people be less hungry by eating a different mix of protein, fat and carbohydrate — because a natural byproduct of being less hungry, is eating less. Being active is possible once a person is losing weight and not feeling hungry all the time.  Yes, they are still “eating less and moving more” — but as a result, not as the focus.

Addendum (Sept 10 2019) — Weight loss is not only about what we eat.  It’s also about when we don’t eat; whether it’s having times between meals where we don’t eat, or not eating from the end of supper until the first meal of the following day (whenever that is). Thanks Dr. Andy Phung for the reminder!

A new study published yesterday (September 9, 2019) in the journal Nature Medicine[1] has found that “eating less and exercising more” may actually be good advice as we age — because it turns out that we have decreased fat turnover as we age. If we eat the same amount as we always have and don’t increase the amount we exercise,  we will end up gaining approximately 20% over a 10-15 year period [3].

Until recently little was known about fat turnover [2] — which is the storage and removal of fat from adipocytes (fat cells). A 2011 study showed that  during the average ten-year lifespan of human fat cells, the fat in them (triglycerides) turns over six times, in both men and women [2], and that when people are obese, the fat removal rate decreases and the amount of fat as triglyceride stored each year increases [2]. What we didn’t know until now is what happened to fat turnover as we age.  This follow-up study headed by the same lead researcher as the 2011 study explored this issue, as well as differences in fat turnover after people have bariatric surgery which helps explain why some people regain their weight after weight loss, where as others don’t.

Eating Less Matters as We Age

Fat turnover is a difference between the rate of fat uptake into fat cells and the fat removal rate. High fat storage but low fat removal is what results in the accumulation of fat and in obesity. The “bad news” of this new study is that fat accumulation due to decreased fat turnover is what happens as we age, leading to accumulation of fat. That is, even if we don’t eat more or exercise less than previously, we will store more fat — which can result in as much as a 20% increase in body weight over 13 years [3].

“Those who didn’t compensate for that (i.e. decrease fat turnover) by eating less calories gained weight by an average of 20 percent”[3].

Researchers from the University of Uppsala in Sweden and the University of Lyon in France studied the fat cells of 54 men and women over an average 13 year period [3] and regardless of whether the subjects gained weight or lost weight, they had a decreased fat turnover. 

Since fat turnover is decreased as we age, to prevent weight gain we need to take in less calories than we used to, even if we are just as active.

Why We Regain Weight After Weight Loss

The study also looked at fat turnover in 41 women who underwent bariatric surgery. Results showed that only those who had a low lipid turnover rate before the surgery were able to increase their lipid turnover after surgery and maintain their weight loss 4-7 years after surgery [1]. Researchers think that if people had a high lipid turnover rate before surgery, there is less ‘room’ for them to increase their lipid turnover rate after surgery, which is why they regain the weight. This could explain why so many people who lose incredible amounts of weight following any one of a number of “diets” regain it (and then some) afterwards.

Exercise and Lipid Turnover

Previous studies have reported that fat turnover increases as we exercise [2], so based on this new study, the idea of ‘eating less and exercising more’ actually matters as we age. We can either decrease our intake as we age and/or be a little more active and avoid gaining weight — which is easy enough to do for those who are slim, if they know.

But what about those who are already overweight or obese and now find out they are more prone to storing fat now that they’re older, even though they eat the exact same way and haven’t changed their activity level?

I believe the solution is the same regardless of a person’s age — focusing on the person eating in such a way as to be less hungry, so that in the end they end up eating less. As they lose weight because they’re not hungry all the time, being more active is easier to implement.  The difference between it being “doable” depends on what we focus on. As covered in a previous article, we understand why a person who eats foods that are a combination of fat and carbs together eat more, but my approach is to gradually adjust the amount of carbohydrate in the diet, so that people can eat more protein and healthy fat, and end up feeling less hungry. When they aren’t being driven by the reward system of their brain (see linked article) to want more and more foods with carbs and fat together, it is much easier for them to eat when they are actually hungry. As they do, their weight drops as a result.

In light of this new study, what is important is that as people age, there is a natural tendency to put on weight even if they eat the same and don’t change their activity level. This means older people need to modify the amount of calories they take in and/or expend more energy, the question is how.

If you would like more information about my services, please have a look under the Services tab or in the Shop and if you have any questions, please feel free to send me a note using the Contact Me form above, and I will reply as soon as I can.

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
Fipboard: http://flip.it/ynX-aq

Copyright ©2019 The Low Carb Healthy Fat Dietitian (a division of BetterByDesign Nutrition Ltd.)

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

References

1. Arner P, Bernard S, Appelsved K-Y et al. (2019). “Adipose lipid turnover and long-term changes in body weight.” Nature Medicine 25(9): 1385-1389.
2. Arner, P. et al. Dynamics of human adipose lipid turnover in health and metabolic disease. Nature 478, 110—113 (2011).
3. Karolinska Institutet, New study shows why people gain weight as they get older, Published: 2019-09-09 18:35, https://news.ki.se/new-study-shows-why-people-gain-weight-as-they-get-older

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