For quite a while, whenever I've said I eat a low-carb, high-fat diet, I've felt a little conflicted. Certainly the highest proportion of my calories comes from fat, but "high fat" is a relative term. Unlike many people in the very-low-carb community who consume a diet containing 65-85% fat, mine is around 50%. The truth is, I eat a lot more protein than is currently in vogue: generally 100 grams or more per day, which is about 1.8 to 2 grams per kg of total body weight. And after recently watching this 2013 lecture by one of the leading experts on protein, Dr. Donald Layman, and doing a lot of reading on the subject, I'm more convinced than ever that a high-protein version of carbohydrate restriction is best for me and most others.
"High protein" is a relative term as well, and Dr. Layman believes that truly high protein intake is over 170 grams per day. Now, I'm not suggesting that people eat more than 170 grams of protein on a regular basis unless they're very muscular and lift heavy weights several times a week. But I think my diet would qualify as relatively high in protein by many people's standards.
If you don't have time to watch the excellent video above, here are some key points made by Dr. Layman:
There's plenty of research in favor of moderately high protein consumption, including a study Dr. Layman published earlier this year expanding on many of the concepts above, such as the amount and type of protein required at mealtimes to optimize leucine's effects on MPS: 3 grams of leucine per meal, or a minimum of ~25 grams of protein per meal (1).
Also, while insulin is viewed by many in the low-carb community as a "storage" hormone, it's actually also an anabolic hormone that promotes growth in children and increased muscle mass in adults. Chronically high levels of fasting and postmeal insulin are indeed unhealthy, but along with leucine, a small rise in this hormone after meals is vital for MPS. Also, research suggests that much like insulin resistance, aging may produce "leucine resistance," which requires additional amino acids in order to promote MPS signaling (1).
Muscle protein breakdown (MPD) and MPS occur in everyone and should be in balance in order to maintain muscle mass. If your goal is to increase muscle size, the ratio of MPS to MPD must be increased through strength training as well as sufficient protein intake. Loss of lean muscle due to inadequate amino acid intake is one of the major drawbacks of fasting, which results in an extended period of MPD, and "fat fasts," where a 1000-calorie, 90% fat diet is consumed for several days to break out of a weight loss plateau.
Weight loss: There's been much talk lately about striving for nutritional ketosis in order to lose weight. I've seen people encouraged to keep protein "moderate" (i.e., 1 gram per kilogram lean body mass) and increase fat intake in order to drive up serum ketone levels. But all the studies on low-carbohydrate diets supporting weight loss have used high protein intakes, whether ad libitum or prescribed (2-6), including the ones described as "very-low-carbohydrate ketogenic diets," whether urinary ketone levels were measured and reported or not. And for the record, I don't believe ketogenic diets promote weight loss any better than low-carbohydrate diets do and can in fact be counterproductive for weight loss at low protein and energy intakes.
Protein has the highest thermic effect of food (TEF) of the three macronutrients, meaning its digestion and absorption cause metabolic rate to increase significantly more than with carbohydrates or fat. An older study linked this effect to protein's high satiety value (7), and many studies have confirmed that with higher protein intake, people end up eating less as a result of feeling full and satisfied (8-10).
Retention of muscle mass: During weight loss, there's a risk of losing lean muscle tissue in addition to fat. However, research has shown that increasing protein intake can protect against muscle loss during the process of losing weight (11). Higher protein intake can also decrease sarcopenia, or the loss of lean mass that occurs as a natural part of the aging process, estimated at 3-8% per decade after the age of 30 (12), and it's particularly effective when combined with resistance exercise. Dr. Bill Lagakos of Calories Proper wrote a great blog post demonstrating that nutritional ketosis in the absence of adequate protein (~100 grams per day for most) does not prevent a decline in muscle mass during weight loss. Bill has written many other excellent articles on protein and other topics, so please check out his blog if you haven't already.
Over the past few years, I've seen a disturbing trend in people who are trying to lose weight limiting protein to 50-60 grams per day in an attempt to achieve beta-hydroxybutyrate values over 1.5 mmol/L. (Fasting, of course, limits protein to zero grams for the duration of the fast). For therapeutic purposes such as epilepsy, brain cancer, neurological or mood disorders, this may be warranted. But I strongly disagree with this tactic for weight loss or diabetes management, the population group I primarily work with.
Protein is a satiating, self-limiting nutrient that increases metabolic rate, increases satiety, and helps maintain muscle health. So my question is why would we want to intentionally limit it if the goal is fat loss?
What about kidney health, bone health, and blood glucose levels?
There's a misconception that high protein intake is bad for the kidneys, but this seems to be based on the results of an older study on individuals who already had renal disease (13). Subsequent studies have demonstrated that high protein consumption (more than 1.5 grams per kg body weight) doesn't adversely affect the health of kidneys in people without preexisting renal disease (14). In fact, recent research suggests that even individuals with renal disease may not need to limit protein as previously believed, depending on the stage of disease. In 2013, researchers looked at the effect of a "moderate" protein diet (90-120 grams) vs. a "standard" protein diet (55-70 grams) in overweight and obese men with type 2 diabetes and impaired kidney function (15). This was a long-term study lasting two years, and in addition to weight loss and better blood glucose control, both groups saw an improvement in renal function.
I've written about the effects of high protein diets on bone health recently. It's a very long blog post, but if you skip to the "Protein" section at about the halfway point, you'll see that high-protein intake is actually beneficial rather than harmful for bone density, provided intake of minerals such as calcium are optimized and alkaline foods like vegetables are included in the diet.
And what about the effect of high protein intake on blood glucose levels in people with diabetes and prediabetes? Like the studies on weight loss discussed above, all of the carbohydrate-restricted research verifying its benefits on glycemic control have been high in protein (often ad libitum amounts of meat, poultry, and eggs) (16-19), including one coauthored by Dr. Eric Westman in which 17 out of 21 subjects were able to eliminate or reduce dosage of insulin and/or oral diabetes medications over the course of the 16-week study(20). Although the amounts of food consumed weren't listed, most if not all of these participants were likely eating at least 100 grams of protein daily, given that their carbohydrate intake was less than 20 grams and portion sizes of protein foods weren't limited.
When the term "very-low-carbohydrate, ketogenic diet is used" in weight loss and diabetes research, it's referring to carbohydrate restriction -- not extremely high fat intake and definitely not protein restriction.
In 2004, Mary Gannon and Frank Nuttall studied 8 men with type 2 diabetes who followed a moderately low-carbohydrate (~100 grams net carbohydrate), high-fiber (~36 grams), very-high-protein (~200 grams) diet. After 5 weeks, fasting and postprandial blood glucose levels, insulin levels, and HbA1c had significantly improved (21). Of course, this was a very small study, but the results are pretty encouraging, given that dietary protein intake was roughly twice the amount consumed by most people.
Going with Science
When I say I'm in favor of high-protein, low-carbohydrate diets, I'm not recommending that most people eat anywhere close to the amount of protein consumed in the Gannon study. In fact, I don't think most of us could eat that much and feel well. Protein needs vary from person to person based on size, age, activity, and certain medical conditions. But I think we need to base low-carbohydrate recommendations on what the science shows, which is moderately high protein intake -- particularly during weight loss and aging -- on an ad libitum basis for most people.
1. Layman, DK. Defining meal requirements for protein to optimize metabolic roles of amino aids. Am J Clin Nutr. 2015 Appr 29. poi:ajcn084053. [epub ahead of print]
2. Brehm BJ, et al. A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women. J Clin Endocrinol Metab. 2003 Apr; 88(4):1617-23
3. Foster GD, et al. Weight and Metabolic Outcomes After 2 Years on a Low-Carbohydrate vs. Low-Fat Diet: A Randomized Trial. Ann Intern Med. 2010;153(3):147-157
4. Brinkworth GD, et al. Long-term effects of a very-low-carbohydrate weight loss diet compared with an isocaloric low-fat diet after 12 months. Am J Clin Nutr. 2009 Jul;90(1):23-32
5. Volek JS, et al. Carbohydrate restriction has a more favorable impact on the metabolic syndrome than a low fat diet. Lipids. 2009 Apr;44(4):297-309
6. Ebbeling CB et al. Effects of Dietary Composition on Energy Expenditure During Weight-Loss Maintenance. JAMA. 2012;307(24):2627l-2634
7. Crovetti R, et al. The influence of thermic effect of food on satiety. Eur J Clin Nutr. 1998 Jul;52(7):482-8
8. Anderson GA, et al. Dietary proteins in the regulation of food intake and body weight in humans. J Nutr. 134:974S-979S
9. Rolls BJ, et al. The specificity of satiety: the influence of foods of different macronutrient content on the development of satiety. Physiol Behav. 1988;43(2):145-53
10. Halton TL, et al. The effects of high protein diets on thermogenesis, satiety, and weight loss: a critical review. J Am Coll Nutr. 2004 Oct;23(5):373-85
11. Soenen S, et al. Normal protein intake is required for body weight loss and weight maintenance, and elevated protein intake for additional preservation of resting energy expenditure and fat free mass. J Nutr. 2013 May;143(5):591-6
12. Arentson-Lantz E, et al. Protein: a nutrient in focus. Appl Physiol Nutr Metab.
13. Brenner BM, et al. Dietary protein intake and the progressive nature of kidney disease: the role of hemodynamically mediated glomerular injury in the pathogenesis of progressive glomerular sclerosis in aging, renal ablation, and intrinsic renal disease. N Engl J Med. 1982; 307:652-659
14. Martin WF, et al. Dietary protein intake and renal function. Nutr Metab (Lond). 2005;2:25
15. Jesudason DR, et al. Weight-loss diets in people with type 2 diabetes and renal disease: a randomized controlled trial of the effect of different dietary protein amounts. Am J Clin Nutr. 2013 Aug;98(2):494-501
16. Nielsen JV, et al. Low-carbohydrate diet in type 2 diabetes: stable improvement of bodyweight and glycemic control during 44 months follow-up. Nutr Metab. 2006 Jun 14;3:22
17. Yamada Y, et al. A non-calorie-restricted low-carbohydrate diet is effective as an alternative therapy for patients with type 2 diabetes. Intern Med. 2014;53(1):13-9
18. Unwin D, Unwin J. Low carbohydrate diet to achieve weight loss and improve HbA1c in type 2 diabetes and pre-diabetes: experience from one general practice. Practical Diabetes 2014, 31: 76–79
19. Tay J, et al. Comparison of low- and high-carbohydrate diets for type 2 diabetes management: a randomized trial. Am J Clin Nutr. 2015 Jul 29pii: ajcn112581.[epub ahead of print]
20. Yancy WS, Westman EC, et al. A low-carbohydrate, ketogenic diet to treat type 2 diabetes. Nutr Metab. 2005 2:34
21. Gannon MC, Nuttall FQ: Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes. Diabetes. 2004 53:2375–2382
Could returning to the foods our paleolithic ancestors consumed (or modern versions thereof) tens of thousands of years ago be used to treat diseases that are all too common today, particularly diabetes and prediabetes?
In Paleobetic Diet: Defeat Diabetes and Prediabetes with Paleolithic Eating, Dr. Steve Parker and Sunny Parker provide compelling evidence that it very well could. I'm a big fan of Dr. Parker's previous book, Conquer Diabetes and Prediabetes: The Diabetic Mediterranean Diet, as well as his website, Diabetic Mediterranean Diet. He's an expert on the Mediterranean Diet and one of a small but growing number of physicians who recommend a low-carbohydrate diet based on whole foods for people with diabetes and prediabetes. A few years ago he created another website, Paleo Diabetic, covering the beneficial aspects of a carbohydrate-restricted based on paleolithic food principles. Paleobetic Diet is an extension of that website. It's a very well-written, informative book that's easy to understand, even for those unfamiliar with paleolithic nutrition or carbohydrate restriction. Dr. Parker's writing style is professional, low key, and subtly humorous. He's also very up front about saying "I don't know" rather than engaging in conjecture or hype, which I really appreciate. His wife Sunny "served primarily as the editor, food maven, recipe mastermind, and Steve's muse."
Here are several topics addressed in Paleobetic Diet:
What did people actually eat during the paleolithic era? After introducing us to the modern "Paleo Diet" and a number of people (including doctors and other health professionals with both type 1 and type 2 diabetes) who have experienced health improvements as a result of following it, Dr. Parker discuses the foods that our ancestors subsisted on from roughly 2.5 million to 10,000 years ago, prior to the Agricultural Revolution. During this time the food of our hunter-gatherer ancestors was primarily meat, fish, nuts, roots, grasses, and berries. The omega 3 to omega 6 ratio of polyunsaturated fatty acids was about 1:1 or 1:2 versus 1:10, which is a conservative estimate of what most people currently consume. While the total carbohydrate content was low-moderate (roughly 30-40%, although some sources argue it was somewhat higher), digestible carbohydrate would have been considerably lower given the amount of fiber contained in the plant foods -- 70 or more grams, in sharp contrast to our average modern-day consumption of 20 grams or less of total fiber.
Diabetes: There's an excellent section on the root cause of diabetes and the many complications that can result from long-term uncontrolled blood glucose levels. Dr. Parker stresses that of the three macronutrients (protein, carbohydrates, and fat), carbohydrates have by far the largest impact on blood sugar and insulin levels, and that his own experience with patients who adopt a low-carb diet is congruent with studies demonstrating its effectiveness for diabetes management.
Paleobetic Diet: Dr. Parker's Paleobetic Diet is based on low-carb ancestral foods like meat (including organ meat), fish, vegetables (primarily nonstarchy), fruit, nuts, and oils. No processed foods, dairy, or artificial sweeteners are allowed. The recommended daily carbohydrate range is 40 to 80 grams of net carbohydrates (total carbohydrates minus all fiber), with advice to aim for a lower carbohydrate amount at breakfast, when insulin resistance is typically the most severe.
There's a one-week sample meal plan to be used as a guide, along with recipes for each meal that include both imperial and metric measurements. Comprehensive nutritional information is included. The recipes are quick, simple and tasty -- much like the kind I prepare on a daily basis. Some of my favorites are the Brian Burger with Bacon, Brussels Sprouts, Tomato, and Pistachios; the Turkey Tomato Bowl; and the Mexican Eggs and Avocado Slices pictured below with accompanying recipe.
Mexican Eggs and Avocado Slices
3 large eggs
2 oz (60 g) fresh tomato
3/4 oz (20 g) fresh onion (I used about 1/4 oz)
1/4 jalapeño pepper (I used 1 Tbsp chopped green chiles)
3-4 sprigs fresh cilantro, chopped (I used 1 sprig)
2 tsp olive oil
1 medium California avocado
salt and pepper, to taste
Make the pico de gallo first: Finely chop and mix together the tomato, onion, jalapeño pepper, cilantro, salt, and pepper.
Peel and slice the avocado. Add salt and pepper, to taste.
Fry the eggs in a pan coated with olive oil. Salt and pepper as desired. When done, transfer to a plate and spoon the pico de gallo onto the eggs. Enjoy with avocado slices on the side.
20.5 grams carbohydrate
13 grams fiber
7.5 grams digestible carbohydrate
47 grams fat
22 grams protein
810 mg sodium (assuming 1/4 teaspoon total is used)
1235 mg potassium
Diabetes Medications: One of Dr. Parker's goals is to help reduce the amount of medication needed to achieve optimal blood sugar control. In addition to a detailed plan for successful implementation of the Paleobetic Diet, he provides a section about all 12 classes of diabetes medications that includes their benefits, risks, and whether they have potential to cause hypoglycemia. He stresses the importance of speaking with a healthcare provider (doctor, nurse practitioner, or diabetes educator) prior to making dietary changes for those currently taking insulin or oral diabetes medications.
Paleo Eating Tips: I really enjoyed the "Daily Life with Paleo Eating" chapter, which contains guidance on shopping, cooking, cravings for sweets and other high-carbohydrate foods, and weight loss. There's also a substantial list of online resources for low-carb Paleo recipes, nutrition analysis, and support. Despite the overall simplicity that characterizes a Paleo way of eating, there are still adjustments that will likely need to be made, based on each person's particular circumstances, and this chapter is very helpful in that regard.
Exercise: Dr. Parker did a great job on the exercise section, including a subtitle declaring "Exercise Is Not Fun." (Did I mention how much I appreciate his wry sense of humor?) He gives practical tips for choosing activities that you'll stick with that provide health-related benefits. Again, he stresses consulting with your physician to obtain medical clearance before engaging in an exercise program.
Research: Here he explains that while there isn't a great deal of research on the paleolithic diet, what exists is quite promising for those looking to lose weight and improve blood glucose control and overall health. In addition to citing references, he provides detailed analyses of several studies, along with his own commentary on the results and suggestions for further research. In the final chapter, Dr. Parker discusses new theories about the cause of type 2 diabetes, which I found very interesting. There's considerable disagreement among the experts on this topic, and I appreciate the opportunity to hear from all sides.
Paleobetic Diet provides a great framework for people with diabetes and prediabetes interested in a paleolithic-inspired way of eating. While my own diet is much closer to the one Dr. Parker recommends in The Diabetic Mediterranean Diet (for one thing, I enjoy at least one serving of dairy every day, often more), I understand the potential benefits for people with autoimmune disease or food intolerances. I like his guideline of aiming for 15-20 grams of net carbohydrate per meal, and using a glucometer to assess whether further reduction in carbs is necessary to optimize blood sugar control. He's done a wonderful job summarizing the research on paleolithic diets and constructing his own plan to help people achieve a healthier lifestyle with a decreased risk for complications.
While much of the information contained in the book is available on the Paleo Diabetic website (in fact, the book has links to certain documents that can be downloaded directly from the site at no charge), I highly recommend purchasing the print or Kindle version of Paleobetic Diet for the additional material covered. I'd also encourage you to support the efforts of this low-carbohydrate MD who provides free, high-quality, well-researched informative content on his websites.
Franziska Spritzler, RD, CDE