I'm very happy to announce that I am writing articles for the Authority Nutrition website. For a while, this will be the extent of my writing, given that I'm already very busy seeing clients and working on other projects.
Although I've already shared these articles on social media, I realize some of my readers aren't on Facebook and Twitter, so I intend to share them on my blog on a monthly basis. Also, not every article will be about low-carbohydrate diets, although my first one happens to be.
I appreciate your support very much and hope you enjoy the articles.
A Guide to Healthy Low Carb Eating with Diabetes
Oxalate (Oxalic Acid): Good or Bad?
Recently, I've been eating breakfast out more often than usual because I was out of town on vacation for a few weeks, and I've also started doing breakfast appointments with a few of my clients at home. I realize that most restaurants cater to the general population rather than people on low-carb diets, but generally speaking there are plenty of great breakfast options at most dining establishments. However, I'm concerned that diners are being led to believe that a breakfast very high in carbs and sugar is the healthiest way to go.
It's not just restaurants who do this, of course. The photo above? That's an image I purchased from Shutterstock entitled "Healthy Breakfast." But people are most likely to encounter this message at their favorite eateries.
You may have never eaten at the restaurants whose menus are listed below, but I'm sure you'll find similar offerings and descriptions at breakfast places in your own city.
"Lighter/Healthy/Smart" Breakfast: Where's the Protein?
Let's look at the third one, "The Health Nut Breakfast" under "Lighter Side," in terms of macronutrient composition. I took a conservative estimate of the amount of oatmeal at one and a half cups, 1 teaspoon of brown sugar, half a cup of low-fat milk, 2 Tablespoons raisins, a 3-ounce bran muffin and an 8-ounce (never-empty?!) glass of orange juice, then entered everything into the My Fitness Pal app. The grand total of carbohydrates for this meal is 129 grams, with 11 grams of fiber, for a net carb count of 118 grams, most of which are rapidly digested and absorbed into the bloodstream. On the other hand, the protein content for this meal is only 15 grams, primarily from grains, which are considered an inferior source of protein compared to the type found in animals, including eggs, dairy, and meat. Compare this to a meal of three pancakes with a quarter cup of syrup, and you'll see that the amount of net carbohydrates and protein is very similar.
In my opinion, advertising the three meals above as being the best choices on the menu for the health conscious is very misleading. If someone wants to have waffles at the Waffle House and eat them with the realization that their meal isn't all that nutritious, I have no problem with that. But I do take issue with restaurants advertising carb-heavy breakfasts with juice as "healthy," because it's the people who have made a conscious decision to eat well that end up ordering them. This often results in similar high-carb meals consumed at home as well, compounding the problem. I can't count the number of people with diabetes or weight issues who have looked at me suspiciously when I've told them that their breakfast of cereal, nonfat milk, banana, and juice is exactly what they should not be starting their day with and that they'd be much better off if eating bacon and eggs instead.
Begin the Day with a High-Protein Meal
There have been several recent studies demonstrating the benefits of a protein-based breakfast with low to moderate carbohydrates. In one study of overweight women, those who consumed 30-40 grams of animal protein (sausage and eggs) and less than 15 grams of carbohydrate at breakfast had better satiety, lower blood glucose and insulin levels, and lower calorie intake at lunch compared to women who ate more carbohydrates and less protein in the morning (1). Studies looking at overweight children and adolescents have had similar findings with respect to high-protein breakfasts (2-3). As I stated in a previous post, getting a minimum of 25 grams of protein at each of three meals is particularly important for preventing loss of muscle mass during weight loss (4) and aging (5-6).
Truly Nourishing Breakfast Options
I personally think breakfast is the easiest meal for remaining low carb when dining out. It's not hard to find delicious, satiating, blood-glucose-stabilizing breakfast options -- even at restaurants whose claim to fame is pancakes or waffles -- as long as you stay away from most of the ones classified as" healthy."
Waffle House, IHOP, Bob Evans, Cracker Barrel, and other restaurants: I had a delicious very-low-carb, high-protein breakfast at the Waffle House when we visited Florida last month: poached eggs, bacon, tomato slices, and coffee with half and half -- around 7 grams of net carb for the meal. My husband tweeted about it and even got a retweet by Waffle House.
Best Bets: Eggs with bacon, sausage, ham, or cottage cheese, with tomato slices on the side; or an omelette with cheese, spinach, mushrooms, chiles, bell peppers, and/or other nonstarchy vegetables. Each option provides about 10 grams digestible carbs or less for the entire breakfast*
*Caution: Be careful of the scrambled eggs and omelettes at IHOP if you're watching your carbs or staying gluten free, because pancake batter is added to make them fluffy. This information is printed on the menu. Other restaurants sometimes add batter to their eggs as well, so be sure to inquire about this before ordering. Some of them may allow you to order eggs freshly made without anything added, if you ask.
If they're available, you can also order a side of avocado or berries, which would further increase your meal's nutritional value yet keep net carbs fairly low.
Fine-dining restaurants typically have fantastic breakfast options, including many entrees that can easily be modified for a low-carb lifestyle. This is a lovely smoked salmon plate I ordered at the Monte Carlo Hotel in Las Vegas: smoked Pacific salmon, herbed cream cheese, capers, sliced red onion, tomatoes, and cucumbers. The only change I had to make was asking for no bagel. Again, there were less than 10 grams of net carbohydrate in the entire meal, and in addition to being delicious it was extremely nutrient dense, with omega-3 fatty acids in the salmon and several types of phytonutrients in the vegetables.
Buffets are one of the easiest and most satisfying ways to dine out for breakfast because there's usually a great variety of healthy choices, and you can control the portion sizes of each item so that you end up with a delicious, high-quality breakfast uniquely tailored to your own tastes and appetite. At left is my well-balanced breakfast from a buffet aboard a recent progressive rock music cruise (no, not the Low Carb Cruise): smoked salmon, herring, eggs with cheese and herbs, pico de gallo, and cucumbers topped with whipped cream cheese. You could also create a more traditional breakfast plate with bacon, sausage, ham, cheese or cottage cheese in place of the fish, of course.
Breakfast: In Favor of Informed Choice
Again, I understand that people aren't always interested in choosing the most nourishing breakfast. Trust me, I've dined with plenty of friends and family members who fall into that camp, at least occasionally. But I object to terms like "healthy" being used to describe meals that don't deliver in terms of satiety, nourishment, or blood glucose control, and their effects on customers who order them under the assumption they're making the "best" choice.
1. Rains TM, et al. A randomized, controlled, crossover trial to assess the acute appetitive and metabolic effects of sausage and egg-based convenience breakfast meals in overweight premenopausal women. Nutr J. 2015;14:17
2. Bauer LB, et al. A pilot study examining the effects of consuming a high-protein vs. normal-protein breakfast on free-living glycemic control in overweight/obese "breakfast skipping" adolescents. Int J Obes.(Lond). 2015 Sep;39(9):1421-4
3. Baum JI, et al. Breakfasts higher in protein increase postprandial energy expenditure, increase fat oxidation, and reduce hunger in overweight children from 8 to 12 years of age. J Nutr. 2015 Oct;145(10):2229-35
4. 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
5. Paddon-Jones D, et al. Protein and healthy aging. Am J Clin Nutr. 2015 Apr 29 [Epub ahead of print]
6. Arentson-Lantz E, et al. Protein: a nutrient in focus. Appl Physiol Nutr Metab.
What names come to mind when you hear the term "Ketogenic Diet Expert"? For me, that list includes researchers Steve Phinney, PhD, Jeff Volek, PhD, RD, Thomas Seyfried, PhD, Adrienne Scheck, MD, Eugene Fine, MD, Dominic D'agostino, PhD, and Colin Champ, MD. There are many others who've conducted studies on ketogenic diets or use them in practice and understand their benefits -- and limitations -- for metabolic and therapeutic purposes.
Although I understand the science, have read much of the work of the people listed above, and have worked with several clients who choose to follow a very-low-carbohydrate ketogenic diet, at this point I wouldn't consider myself an expert in this area. In fact, I've spent the last year or so clarifying that my own approach to diabetes and weight management is low carb but not necessarily ketogenic. I make this distinction because I believe a very-high-fat ketogenic diet isn't necessary and in some cases can be counterproductive for weight loss and blood glucose control if energy/calorie intake from fat is too high. I find that a diet moderately high in protein and fat with limited carbohydrates (25-70 grams digestible or "net" carbs per day, depending on the person) works best for most. It's also the type of diet I've followed for several years, with great results.
"The More Fat You Eat, The More Fat You'll Lose"?
Now, a ketogenic diet containing less than 20 grams of net carb daily can produce weight loss provided energy intake is reduced, which often occurs spontaneously with carb restriction. There's no denying that many people experience dramatic weight loss with minimal carb intake, are able to maintain the loss, and feel great eating this way. But some of the statements I've read about keto being a miracle for dropping unwanted pounds are simply untrue, such as:
Very-low-carb ketogenic diets don't work that way. As just one example, a doctor friend of mine has diabetes, is of normal weight, and has been following a very-low-carb ketogenic diet for several years. He recently experimented with increasing the amount of coconut oil in his already high-fat diet. Although his ketone levels increased to well above 3 mm, he put on several pounds over the course of a few months, which he lost by cutting back on the coconut oil. Adding too much butter, cream, olive oil, or any other fat can have the same effect, as can eating excessive quantities of protein or carbohydrates.
Also, think about the group following a very strict traditional ketogenic diet: children with epilepsy that have failed medication therapy. This diet is about 90% fat, 2-4% carb, and less than 10% protein, which results in a level of ketonemia that in many cases significantly reduces or even eliminates seizures (The Modified Atkins Diet is very low in carbs but does not restrict protein, is much easier to adhere to long term, and has also shown effectiveness for seizure management). Children don't lose weight on the ketogenic diet when calorie intake is adequate, and for that and other reasons, it's very important that specially trained dietitians (true ketogenic diet experts) work closely with patients and their families to ensure energy and nutrient needs are met, which involves weighing food to the gram on a kitchen scale. In fact, in the book "Ketogenic Diets: Treatments for Epilepsy and Other Disorders" by Dr. Eric Kossoff and other specialists, there's a section devoted to potential weight gain -- or weight loss -- that may occur during ketogenic diet therapy.
Therapeutic Applications for Ketogenic Diets
While the results of studies investigating the effects of ketogenic diets (KDs) on performance are impressive (1), what I'm most enthusiastic about is their use as an adjunct to traditional therapy in treating serious, often life-threatening diseases where only mediocre results have been achieved with medication or other non-nutritional therapy alone. There's so much established and emerging evidence on their benefits (2), and it's growing monthly as researchers continue publishing their findings.
One of the best-known applications for KDs is cancer, particularly certain types of brain cancer like glioblastoma (3,4). Cancer is a very complex disease, and there are conflicting opinions as to its primary cause(s). Dr. Thomas Seyfried and others in the field of cancer research believe that it results when cells develop dysfunctional mitochondria that are unable to generate energy the way normal cells do (oxidative phosphorylation) and must instead use a different pathway reliant on large amounts of glucose (anaerobic glycolysis) in order to meet energy demands. (For anyone interested in reading more about the science behind this -- along with potential risk factors and ways to address them -- please check out the excellent cancer series by nutritionist Amy Berger on her blog, Tuit Nutrition.)
Based on several studies, Drs. Seyfried, D'Agostino, Champ, and others believe that increasing serum levels of the ketone beta-hydroxybutyrate via a diet very high in fat and moderate in protein with minimal carbohydrates results in an unfavorable environment for cancer cells. According to these researchers, calories must often be somewhat restricted as well in order to achieve a therapeutic level of ketonemia while simultaneously keeping blood glucose levels low enough to reduce cancer cell growth and inflammation.
For a personal account of what it's like living with brain cancer and using a KD in combination with traditional therapy, I highly encourage you to read the blogs of two insightful and inspirational people I follow online: Alix Hayden in Canada and Andrew Scarborough in the UK. These two are truly experts on what day-to-day management of cancer (and in Andrew's case, epilepsy as well) entails.
There's a growing body of research suggesting that people with with Alzheimer's disease, traumatic brain injury (TBI), ALS (Lou Gehrig's disease), Parkinson's, and other neurological diseases may also benefit from ketogenic diets (5-9). While much of the evidence comes from studies on mice and other animals, the results of human research are also promising (10-12), including the case of a 64-year-old woman who experienced significant regression of an advanced glioblastoma tumor (nearly unheard of in a woman her age) when a calorie-restricted, ketogenic diet was combined with standard therapy (13). Unfortunately, as Dr. Seyfried discusses in his excellent presentation Cancer: A Metabolic Disease with Metabolic Solutions, the tumor came back once she went off the diet and began taking the drug Avastin.
Below is another lecture from radiation oncologist Colin Champ discussing the role ketogenic diets, calorie restriction, and fasting can play in cancer treatment. The presentation isn't overly technical, and Dr. Champ covers a lot here in his typical engaging style.
And if you're interested in learning about the latest research on the wide-reaching effects of ketogenic diets for neurological disorders and certain cancers, check out Dr. Dominic D'Agostino's talk Metabolic Therapies: Therapeutic Implications and Practical Application. Notice that the KD is used in combination with medication or hyperbaric oxygen therapy in order to provide maximum benefit.
I realize that there is still much that is unknown in the field of ketogenic diets, and I don't want to make premature statements about the extent of their ability to prevent or treat disease . For instance, the KD may not be appropriate or effective for all types of cancer, including some brain cancers (14). Anecdotally, some people have experienced great benefit from being in sustained ketosis while others haven't. But what I've read and heard about their potential uses is certainly encouraging.
After I finished my dietetic internship and became a dietitian, I worked at a large Veterans Health Administration hospital for five and a half years. The first two were spent in the Spinal Cord Injury unit and the remainder in outpatient care. During that time I saw hundreds of patients with cancer, TBI,'s ALS, Alzheimer's, Parkinson's, and other debilitating conditions. The main goals for nutrition therapy were to prevent weight/lean mass loss and ensure nutritional adequacy by making appropriate dietary recommendations -- if they were even capable of eating (some required tube feeding). It was heartbreaking to see the devastating effects of disease and treatment on patients and their families, knowing there was little I could do beyond trying to prevent loss of muscle mass and micronutrient deficiencies by prescribing high-protein foods and supplements.
The possibility that ketogenic diets may one day become part of standard therapy for various types of serious illness -- reducing the current reliance on toxic therapies, improving outcomes, and elevating people's quality of life -- makes me eager to continue learning as much as possible about them so I can provide "expert" nutritional guidance that may truly make a difference.
1. Phinney SD. Ketogenic diets and physical performance. Nutr Metab (Lond). 2004;1:2
2.Paoli A, et al. Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate ketogenic diets. Eur J Clin Nutr 2013 Aug;67(8):789-96
3. Seyfried TN, et al. Metabolic therapy: a new paradigm for managing malignant brain cancer. Cancer Lett. 2015 Jan 28;356(2 Pt A):289-300
4. Varshneya K, et al. The Efficacy of Ketogenic Diet and Associated Hypoglycemia as an Adjuvant Therapy for High-Grade Gliomas: A Review of the Literature. Muacevic A, Adler JR, eds. Cureus. 2015;7(2):e251
5. Paoli A, et al. Ketogenic Diet in Neuromuscular and Neurodegenerative Diseases. BioMed Rese Int. 2014;2014:474296
6. Greco T, et al. Ketogenic diet decreases oxidative stress and improves mitochondrial respiratory complex activity. J Cereb Blood Flow Metab. October 2015 (epub ahead of print) DOI: 10.1177/0271678X15610584
7. Seyfried, TN. Ketone strong: emerging evidence for a therapeutic role of ketone bodies in neurological and neurodegenerative diseases. J Lipid Res. 2014 Sep;55(9):1815-7
8. Stafstrom CE, Rho JM. The Ketogenic Diet as a Treatment Paradigm for Diverse Neurological Disorders. Front Pharmacol. 2012;3:59
9. Hartman AL. Neuroprotection in Metabolism-Based Therapy. Epilepsy Res. 2012;100(3):286-294
10. Gasior M, Rogawski MA, Hartman AL. Neuroprotective and disease-modifying effects of the ketogenic diet. Behav pharmacol. 2006;17(5-6):431-439
11. Allen BG, et al. Ketogenic diets as an adjuvant cancer therapy: History and potential mechanism. Redox Biology. 2014;2:963-970
12. Champ CE, et al. Targeting metabolism with a ketogenic diet during the treatment of glioblastoma multiforme. J Neuroncol. 2014 Mar;117(1):125-3
13. Zuccoli G, et al. Metabolic management of glioblastoma multiforme using standard therapy together with a restricted ketogenic diet: Case Report. Nutr Metab (Lond). 2010;7:33
14. Dang MT, et al. The Ketogenic Diet Does Not Affect Growth of Hedgehog Pathway Medulloblastoma in Mice. Xie J, ed. PLoS ONE. 2015;10(7) e0133633
Disclosure: I was contacted by the author, who sent me a review copy of this book free of charge.
The ability to see is something we usually take for granted until we start having problems. Loss of vision due to cataracts, glaucoma, and macular degeneration becomes more common as we age, but eye problems can develop throughout the life cycle. I've had several eye disorders: bilateral strabismus ("lazy eye") requiring surgery when I was seven, medium myopia (nearsightedness) since around that age, and most recently presbyopia ("old eyes" -- farsightedness after the age of 40). I also have a strong family history of glaucoma, so doing whatever i can to preserve the sight I have is extremely important to me.
Dr. Bruce Fife is a naturopath, certified nutritionist, and director of the Coconut Research Center. He's a prolific author, having written 20 books based on his extensive review of the literature on the benefits of coconut oil and its medium-chain triglycerides (MCTs). In his latest book, Stop Vision Loss Now!, he provides evidence that a well-balanced, nutrient-rich, very-low-carbohydrate diet supplemented with coconut oil may help to prevent and even reverse some of the most common eye disorders associated with aging.
The major concept of the book is that the eyes are an extension of the brain, so whatever keeps the brain healthy and well nourished will do the same for the eyes. There's a growing body of research demonstrating that maintaining blood glucose and insulin levels as close to normal as possible can help preserve brain function and reduce the risk for Alzheimer's disease and other forms of dementia. According to Dr. Fife, many researchers now believe that although increased intraocular pressure is involved in glaucoma, its primary cause is that nerve cells within the brain become damaged, similar to what happens in Parkinson's and Alzheimer's disease. He explains that coconut oil increases brain-derived neurotrophic factor (BDNF), a gene that stimulates the growth, maintenance, and repair of these nerve cells.. Dr. Fife suggests that the increase in ketone levels that occurs in response to MCT can protect eye health and improve or potentially reverse degenerative eye disorders as a result of increased BDNF. In addition to age-related conditions like glaucoma, cataracts, macular degeneration, and diabetic retinopathy, coconut oil can also be used for dry eyes, eye infections, and other non-vision-limiting conditions.*
In addition to generous amounts of healthy fats and moderate amounts of protein, Dr. Fife recommends including a wide variety of nonstarchy vegetables and berries to reduce oxidative stress that can lead to eye disease. He advises selecting from three different levels of carbohydrate intake based on blood glucose levels and provides a sample menu for a typical day, along with guidance on meal planning and dining out. Lists of protective low-carbohydrate foods and a comprehensive net carb counter are included. I agree with his suggestion to add coconut oil slowly, one tablespoon per day to start, in order to prevent GI symptoms and determine personal tolerance.
I learned several things I didn't know as a result of reading this book, including:
I found Stop Vision Loss Now! very well-researched, comprehensive, and interesting. Dr. Fife has a gift for making advanced nutrition concepts and physiological processes easy for the average reader with an interest in health to understand. It was truly a pleasure read for me. There are many personal accounts throughout the book, including the author's story of how he reversed his own early-stage glaucoma. Although there isn't a lot of published research on the benefits of coconut oil for eye disorders, he makes a great case for including it as part of a whole-foods-based, low-carbohydrate diet in Stop Vision Loss Now!
*Regardless of whether these changes in diet and lifestyle improve your vision, if you have an eye disorder, you should continue to see your ophthalmologist at least once a year for monitoring.
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 equates to at least 1.75 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 an inevitable loss of lean muscle tissue in addition to fat, regardless of diet and exercise. However, research has shown that increasing protein intake can minimize the amount of muscle lost 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 carb0hydrate-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.
I rarely write book reviews on this blog, but this is the first of several I'll be doing over the next few months. As a dietitian, I'm frequently asked to plug a certain book, product, program, etc., but unless I feel right about it, I decline. The author of the book I'll be discussing today didn't even request that I review it, and rather than receiving a review copy, I purchased the book myself. I decided to write a review on my own because (1) I think it's a wonderful book with valuable information; (2) the author self-published, which takes a lot of time and effort and, compared to going with a publisher, considerable expense; and (3) the author does little self-promotion, so I want to make sure everyone knows about it.
If you're not already familiar with DJ Foodie, he's a formerly obese, self-described foodie who lost 150 pounds by following a low-carb lifestyle. He's also very funny, bright, and an extremely talented chef who trained at The Culinary Institute of North America and worked in the food industry for many years.
Why am I recommending that you buy a cookbook when there are so many low-carb recipes online, including those on DJ Foodie's website? I love recipe sites like his and the ones maintained by other low-carb culinary geniuses who never fail to amaze and delight me with their creations. But I really like having a collection of fantastic recipes in hard-copy form too. Plus I feel it's important to support the efforts of those whose online content and hard work we admire. Also, as fantastic as the recipes in this book are -- and they certainly are -- there is so much more included in Taking Out the Carbage. From the moment you take off the wrapping paper (hint: bacon lovers may want to save it) and open this beautiful 570-page, 6-pound hardback book filled with DJ's signature illustrations and engaging writing style, you're in for a real treat (low carb, of course!)
Here's what I love about Taking Out the Carbage:
Explanation of low-carb diets and the DJ Foodie "Low-Primal" approach DJ succinctly explains why energy/calorie deficit is essential for weight loss and that while people can lose on a variety of diet plans, the insulin-modulating, satiating effects of carbohydrate restriction (around 30 grams of net carb per day) make it the best strategy for sustained weight loss and future maintenance.
Rather than being restrictive, his "Low-Primal" lifestyle allows for a wide variety of animal and plant foods, including some wheat products, sugar substitutes, and peanut products that many people have been led to believe should be avoided. DJ's viewpoint mirrors my own: These foods may not be the epitome of healthful fare, but many people find that including them makes it much easier to follow a low-carb way of eating, particularly in the initial stages. Recipes can work for those who wish to follow a Paleo or ketogenic diet as well, with only a small modification of ingredients.
Aside from providing great information, DJ is an excellent writer, whose witty commentary made the book a pleasure to read. His honest, low-key, non-hype style really resonates with me.
Detailed sections about sugar substitutes ( including recipes to make your own sugar-free blends) and net carbs: There's a very balanced discussion on various sugar substitutes and why "natural" sweeteners aren't always better than "artificial" ones, particularly if you're trying to keep carbs down in order to lose weight or control blood sugar levels. DJ provides a great strategy for calculating net (digestible) carbs: total minus all fiber minus 50% of carbs from sugar alcohols (except erythritol, where all carbs can be subtracted).
"Bag of Tricks": Hidden carbs? Cravings? Weight-loss stalls? Getting organized to cook? DJ's got you covered on some of the most common diet challenges.
Organizational and planning tools: Another helpful section of the book contains 2 weeks of sample meal plans with 30 or fewer grams of net carb per day. DJ also provides detailed recommendations for customizing your own food plan. There are ingredients lists and removable grocery lists with net carbohydrate counts for each food. Everything is color coded and organized for ease of use -- all the information you need is at your fingertips.
Creative, easy, nourishing recipes with gorgeous color photographs and comprehensive nutritional analysis of each recipe: Of course, the highlight of the book is the recipes themselves. DJ made certain that each of the 226 recipes met the following criteria:
2. Easy and cost effective
3. Efficient and time saving
4. Never strays from the diet, while still allowing for some "legal cheats"
Each recipe is accompanied by an enticing large color image. The photography is absolutely stunning throughout! Each recipe lists both imperial and metric measurements. The low carb movement is growing internationally, which is very encouraging. Americans use imperial measurements (ounces, pounds, etc.), but most of the rest of the world is on the metric system (grams, milliliters, etc.), so it's great to see both here.
Some of the recipes are available on the DJ Foodie website, but others are exclusive to the book. And despite its subtitle, "The Big Book of Bacon," there are many tantalizing recipes in "Taking Out the Carbage" that don't include bacon, such as:
Asian Sweet 'n' Spicy Chicken
Torta di Rotello
Sausage, Tomato, and Fresh Mozzarella Tower
Raspberry–Cream Cheese Swirl Frozen Custard
Naturally, there are a number of recipes that do feature bacon, including the sensational grilled shrimp-and-bacon entree I prepared this weekend. Wow, was it delicious and satisfying! Even the pieces that got charred (my fault -- heat was up too high) were really tasty, and my husband asked if I would please make it again very soon.
BBQ'd Bacon-Wrapped Basil Shrimp
1 lb. (454 g) shrimp (16/20), peeled and deveined (I used slightly smaller shrimp, 26/30)
1/4 cup (60 mL) Sweet ‘n’ Tangy BBQ Sauce
6 slices (150 g) raw bacon
18 fresh basil leaves
18 bamboo skewers, soaked in water for 30 minutes (I only used 5 skewers)
salt, pepper, and chili flakes to taste
2 Tbsp (30 mL) coconut oil for grilling
1. Marinate the shrimp in the BBQ sauce for about 20 minutes.
2. Preheat the grill.
3. While the shrimp is marinating, cut each slice of bacon into thirds. This will result in 18 approximately two to three-inch (6 cm) slices of bacon. Squish each slice of bacon with the side of a knife or the bottom of a pan. Don’t tear it up. You want 18 nice thin “sheets” of bacon.
4. Set each sheet of bacon on a cutting board, and place a basil leaf on top of each sheet.
5. Place a marinated shrimp above each basil leaf. Season with a small amount of salt and pepper (add chili flakes for extra heat!)
6. Wrap each slice of bacon around the shrimp, and use a thin, premoistened skewer to hold the bacon in place. You can also put up to 3 per skewer, for a different look. (I put 3-4 on each skewer, since I was using smaller shrimp)
7. Brush the oil on the grill to help prevent sticking. Grill the shrimp over medium-high heat until the bacon is crisp and the shrimp are cooked through.
Nutrition information per serving:
Total Carbohydrates: 3 grams
Fiber: 0.5 grams
Net Carbohydrates: 2.5 grams
Protein: 18.5 grams
Fat: 17 grams
To sum up, Taking Out the Carbage is outstanding on every level and would be a wonderful resource for anyone interested in easy-to-preapre recipes that support a low-carb lifestyle. In all honesty, I can't imagine that you'll be anything but delighted with this book.
Starting today, DJ has arranged a second pre-sale where he's offering the book at the discounted price of $29.99 (regular price will be $49.99 on Amazon): Taking Out the Carbage pre-sale. I think it's an incredible bargain considering the quality of this book. If you already have your own copy, feel free to include your thoughts about it below in comments.
About six weeks ago, I took a hard fall when I tripped on a curb. Initially I couldn't walk without limping, and for several weeks my right hip and upper thigh really hurt, particularly when transferring in and out of bed. I also had extremely limited range of motion; I couldn't lift my leg more than an inch above the ground. An X ray and MRI revealed a hairline fracture of the right hip and adductor (groin) strain. This was my first fracture in 48 years of living. The X ray also indicated that I had arthritis throughout my hip region.
Because the hairline fracture occurred as a result of falling from standing height, the doctor had me undergo a bone mineral density (BMD) scan to rule out potential osteoporosis. The results for all areas (spine and bilateral hips) were consistent with osteopenia, or low bone mass that is not severe enough to meet the criteria for osteoporosis. Since I usually feel very healthy and energetic and am often mistaken for being several years younger than my age, I was surprised and a little unsettled to be diagnosed with osteoarthritis and osteopenia -- diseases that are most often associated with the elderly. We generally pay attention to weight, muscle tone, and other aspects of appearance but don't always consider what's happening on the inside, which is even more important. It's often not apparent that someone has bone or joint problems until disease is fairly advanced. And osteopenia isn't uncommon among women in their 40s and becomes more prevalent with age.
Osteopenia and Osteoporosis Classification and Risk Factors
According to World Health Organization criteria, osteopenia is defined as a BMD hip or spine T-score between -1.0 and -2.5 in postmenopausal women (indicating it is 1 to 2.5 standard deviations below the peak bone mass of a 30-year-old). Anything above -2.5 is considered osteoporosis. Both conditions increase the risk of fracture, poor healing, and immobility. For pre-menopausal women, many doctors prefer to use Z-scores, which report how BMD compares to average women of the same age. With the exception of one spine measurement, my Z-scores were all within the acceptable average range for my age. However, many older, postmenopausal women have better BMD than I do, and mine is obviously lower than I'd like it to be.
Risk factors for low bone density:
I have (or had in the past) most of the risk factors above, with the exception of history of anorexia nervosa, smoking or alcohol consumption, and I'm not sure about family history of osteoporosis. One of the biggest contributors was likely hormonal dysfunction for many years, including two episodes of amenorrhea, culminating in a partial hysterectomy in 1999. I'm sure crash-dieting and constantly fluctuating 30 pounds or so during my teens also played a role.
Peak bone mass is achieved between childhood and about 25-30 years of age. After that time, everyone experiences some bone loss, but the extent to which it happens is highly variable. Unfortunately, many teens and young adults don't eat and exercise in a way that allows them to build a solid amount of bone that can withstand small losses over the subsequent decades. Weight reduction itself typically results in some loss of bone as well as muscle. Researchers report that losing weight results in a loss of 0.5-4% of bone mass, with the greatest percentage occurring in women over 45, those who weigh less than 132 pounds, those who restrict calories to very low levels, and those who lose a large amount of weight in a short period of time (1).
Optimizing Bone Mineral Density as We Age
The loss of estrogen that occurs in the years leading up to menopause can exacerbate bone loss. However, at this point most doctors agree that hormone replacement therapy (HRT) should be initiated at the smallest effective dose when necessary. Every woman is different and should speak to her doctor about whether and when to initiate HRT, bioidentical or otherwise, and weighing the risks vs. benefits.
After talking it over with with my amazing integrative medicine MD, who ran several lab tests to rule out any underlying issues, I've decided to hold off on starting HRT right now while we continue to monitor my lab values and symptoms (although I will likely start in the near future because my estrogen levels have been low for a while). Fortunately, there are things that can be done to slow and possibly even reverse bone loss without initiating HRT prematurely or resorting to bisphosphonate medications such as Boniva, Fosamax, and Actonel.
Carbohydrates: "Low-carb diets are bad for your bones." I've seen this charge expressed more than once, and for the most part, I disagree. Bone density is influenced by many factors -- including overall diet composition (macronutrients, micronutrients, energy content), exercise, and genetic differences -- but doesn't seem related to the amount of carbohydrate consumed. More than a decade ago a paper was published in which the authors stated low-carbohydrate diets may increase the risk for osteoporosis because they're low in calcium, fruits, and vegetables (2). However, this certainly isn't true in my own case (where Greek yogurt, sardines, vegetables, avocado, and berries are staple foods), and for others following a well-balanced, carbohydrate-restricted way of eating. The authors provided no evidence for low-carbohydrate diets having a detrimental effect on BMD, and I haven't been able to find any either.
Protein: In the past, concerns were raised that diets high in protein could have a negative impact on bone health by increasing the amount of calcium released from bone and lost in the urine. However, a review of several studies of high-protein diets demonstrated they don't cause loss of calcium when alkaline foods like fruits and vegetables are included (3), and older women in particular appear to have better bone density at higher intakes of animal protein (4). Research suggests low-protein diets compromise calcium absorption and bone health (5), while diets containing a higher percentage of calories from protein appear to reduce the amount of bone lost during calorie restriction (6).
Collagen Hydrolysate: The primary component of bone is collagen. Collagen hydrolysate (gelatin) is derived from animal bones and has been used for nearly 1000 years as a remedy for joint pain. Most studies have looked at its effects on osteoarthritis, several of which have been favorable (7). However, there may also be potential benefits on bone. A 1996 study found that women given gelatin in addition to calcitonin (a hormone involved in calcium regulation) had a reduction in bone collagen breakdown (8).
Calcium: Calcium is arguably the most important mineral for bone health, and we need to consume it in dietary form on a daily basis to help maintain the stores in our skeleton. There are many factors that affect absorption of dietary calcium, including the amount consumed; at higher intakes, a smaller percentage of calcium is absorbed, yet when small amounts are ingested, the rate of absorption increases. Although high intake of dietary fiber can reduce the amount of calcium the body absorbs, consuming plenty of fat in addition to fiber has been found to improve absorption (9,10). In addition, it appears that the type of fiber is a consideration, with wheat bran binding to calcium and reducing its absorption to a much greater extent than the fiber found in fruits, vegetables, nuts, and seeds (11).
Vitamin D: Serum vitamin D levels greatly affect the calcium absorption, and achieving a level of at least 30 ng/ml (80 mmol/L) is crucial for bone health (12). Some people are able to do this via sun exposure and foods high in vitamin D such as fatty fish, liver, and cheese, but others require supplemental vitamin D3*.
Vitamin K2: There are two forms of vitamin K: vitamin K1 (phylloquinone) and vitamin K2 (menaquinones). Vitamin K1 is found in leafy green produce and is involved with blood clotting. Vitamin K2 helps to maintain BMD by encouraging calcium to remain within the bones and teeth. A small amount can be synthesized by gut bacteria. It's also found in several dietary forms, but the two most common are MK-4 and MK-7. MK-4 exists in small amounts in animal products such as liver, eggs and meat, while fermented foods such as cheese, sauerkraut, and especially a soybean product known as "natto" contain MK-7. Research indicates that the MK-7 form may be preferable for raising serum vitamin K levels (13). In several small clinical trials, researchers reported that supplemental K2 improves spinal bone density and reduces the risk of fractures in postmenopausal women with osteoporosis, and its beneficial effects on bone appear to extend to healthy older women as well (14)*.
Omega-3 Fatty Acids: Higher intake of 0mega-3 polyunsaturated fatty acids (PUFAs) and a lower ratio of omega-6 to omega-3 PUFA has been associated with better BMD in a number of studies (15). Although the long-chain omega-3 fats found in fish (EPA and DHA) have demonstrated beneficial effects on bone health, one randomized clinical trial found that plant sources of dietary omega-3 PUFAs may also help to preserve bone density by decreasing the rate of resorption, the breakdown that occurs when bone is broken down and calcium and other minerals are released into the bloodstream (16).
Fruits and Vegetables: A recent study investigated the effects of various fruits and vegetables on bone health. Subjects were randomized into three groups. Group A consumed several servings of generic fruits, vegetables, and herbs, including apples, bananas, eggplant, cauliflower, and basil. Group B consumed the "Scarborough Fair" diet, which included high amounts of specific produce and herbs containing phytochemicals with known benefits on bone turnover (resorption and new bone formation): Chinese cabbage, bok choy, lettuce, arugula, broccoli, tomatoes, mushrooms, cucumber, leeks, green beans, prunes, citrus fruits, garlic, and -- naturally -- parsley, sage, rosemary, and thyme. Group C subjects served as the controls and continued following their customary diet. While both Group A and Group B experienced a decline in urinary calcium losses, only Group B showed improvement in markers of bone turnover (17). Onion consumption alone is associated with improved bone density in women over 50, with those consuming the highest amounts significantly reducing their risk of hip fracture (18).
Weight Bearing and Resistance Exercise: The 12-month BEST (Bone, Estrogen, Strength Training) study investigated changes in bone mineral density between women who participated in 60-minute sessions focused primarily on weight-bearing and resistance-training exercise and a control group who did not. The researchers found significant gains in muscle strength and BMD for the intervention group and a loss of bone density in the non-exercisers. This was independent of hormone replacement therapy (HRT), which enhanced bone density and muscle strength in both groups (19). The most effective type of exercise for preserving and improving BMD in both pre- and postmenopausal women appears to be a combination of resistance training with weights and weight-bearing exercise like walking, running, or step aerobics (20, 21), tailored to the individual's limitations and abilities. For postmenopausal women, a combination of tai chi and green tea (very high in polyphenols, a type of phytochemical) was found to improve markers of bone turnover and increase muscle strength (22).
Take-Home Points and Resources
1. Make sure you're consuming adequate calories, protein, fats, vitamins, and minerals, particularly during weight loss. No starvation diets or overly-restrictive eating plans.
2. Consume adequate calcium. Excellent low-carb sources include plain Greek yogurt, cheese, broccoli, and leafy greens.
3. Supplement with vitamin D3 and vitamin K2, as needed* .
Dr. Spencer Nadolsky and his brother Dr. Karl Nadolsky of Docs Who Lift have a great new combination supplement in an olive oil base.
4. Eat fatty fish (salmon, herring, sardines) at least three times a week. These fish provide long-chain omega-3 PUFAs, calcium (if the bones are consumed), and vitamin D.
5. Eat several servings of produce and herbs every day, especially those listed in the "Scarborough Fair" diet and other brightly- and deeply-colored vegetables.
6. Gelatin might have a beneficial effect on bones, but there's not a lot of research in this area. It does appear to support joint health, so consider adding a tablespoon to your hot beverage in the morning. You can also get gelatin in bone broth or these low-carb, sugar-free recipes using gelatin:
Healthy Low-Carb Marshmallows from KetoDiet
Strawberry Gelatin Tulsi Bites from Holistically Engineered
Sugar-Free Gummy Bears from Low Carb Yum
7. Lift weights and perform weight-bearing exercise several times a week*.
I advise working with a personal trainer to design the safest, most effective workout. This is something I'm currently exploring.
Recommended reading for strength training with heavy weights: "Training" section in the article Menopause and Fitness, with contributions from Dr. Karl Nadolsky and Dr. Spencer Nadolsky.
Recommended DVDs from Ellen Barrett focusing on weight-bearing exercise, light weights, cardio, and flexibility:
Grace + Gusto
Slim Sculpt (light weights)
Skinny Sculpt (light weights)
Super Fast Body Blast
Sleek Sculpt Express (light weights)
Stretch Sculpt (light weights)
Fat Burning Fusion
While there's nothing we can do to change our genetics or our past eating and exercise history, there are plenty of steps we can take to prevent osteoporosis in the future, and it's never too early or too late to start. I'm committed to doing all of the above in order to improve the health of my bones and reduce the risk of fractures as I age. And, of course, I'm going to be more careful when navigating curbs.
* Check with your doctor before beginning an exercise program or taking any of the supplements listed above, and make sure to have routine monitoring of serum vitamin D levels if you are supplementing.
1. Shapses SA, et al. Bone, Body Weight, and Weight Reduction: What Are the Concerns? J Nutr. 2006;136(6):1453-1456
2. Bilsborough SA, et al. Low-carbohydrate diets: what are the potential short- and long-term health implications? Asia Pac J Clin Nutr. 2003;12(4):396-404
3.Barzel US, et al. Excess dietary protein can adversely affect bone. J Nutr.1988;128:1051–1053
4. Promislow JH, et al. Protein consumption and bone mineral density in the elderly: the Rancho Bernardo Study. Am J Epidemiol. 2002 Apr 1;155(7):636-44
5. Kerstetter JE, et al. Low protein intake: the impact on calcium and bone homeostasis in humans. J Nutr. 2003 Mar;133(3);855S-861S.
6. Sukumar D, et al. Areal and Volumetric Bone Mineral Density and Geometry at Two Levels of Protein Intake During Caloric Restriction: A Randomized, Controlled Trial. J Bone Miner Res. 2011;26(6):1339-1348
7. Moskowitz RW. Role of collagen hydrolysate in bone and joint disease. Semin Arthritis Rheum. 2000 Oct;30(2):87-99
8. Adam M, et al. Postmenopausal osteoporosis. Treatment with calcitonin and a diet rich in cartilage proteins. Cas Le`k ces. 1996;135:74-8
9. Ramsubeik R, et al. Factors Associated with Calcium Absorption in Postmenopausal Women: A Post-Hoc Analysis of Dual Isotope Studies. J Acad Nutr Diet. 114.5 (2014): 761–767
10. Wolf RL, et al. Factors associated with calcium absorption efficiency in pre- and perimenopausal women Am J Clin Nutr 2000 Aug;72(2): 466-71
11. Weaver CM, et al. Wheat bran abolishes the inverse relationship between calcium load size and absorption fraction in women. J Nutr 1996 Jan;126(1):303-7
12. Beto JA. The Role of Calcium in Human Aging. Clin Nutr Res. 2015;4(1):1-8
13. Sato T, et al. Comparison of menaquinone-4 and menaquinone-7 bioavailability in healthy women. Nutr J. 2012;11:93
14. Iwamoto J, et al. Vitamin K2 Therapy for Postmenopausal Osteoporosis. Nutrients. 2014;6(5):1971-1980
15. Molfino A, et al. The role for dietary omega-3 fatty acids supplementation in older adults. Nutrients 2014 Oct 3;6(10):4058-73
16. Griel AE, et al. An increase in dietary n-3 fatty acids decreases a marker of bone resorption in humans. Nutr J. 2007;6:2
17. Gunn CA, et al. Increased Intake of Selected Vegetables, Herbs and Fruit May Reduce Bone Turnover in Post-Menopausal Women. Nutrients 7.4 (2015): 2499–2517
18. Matheson EM, et al. The association between onion consumption and bone density in perimenopausal and postmenopausal non-Hispanic white women 50 years and older. Menopause. 2009 Jul-Aug;16(4):756-9
19.Metcalfe L, et al. Post-menopausal Women and Exercise for Prevention of Osteoporosis. American College of Sports and Medicine Journal May/June 2001
20. Martyn-St James M, et al. Effects of different impact exercise modalities on bone mineral density in premenopausal women: a meta-analysis. J Bone Miner Metab. May 2010;28(3):251-67
21. Moreira LF, et al. Physical exercise and osteoporosis: effects of different types of exercises on bone and physical function of postmenopausal women. Arq Bras Endocrinol Metabol. 2014 58(5): 514-522.
22. Shen CL, et al. Effect of green tea and Tai Chi on bone health in postmenopausal osteopenic women: a 6-month randomized placebo-controlled trial. Osteoporos. 2012;23(5):1541-1552
Dietitian Expelled from Dietitians Association of Australia for Providing Advice "Inconsistent with Evidence-Based Practice"
It's rather ironic that only a few short weeks ago I was happily writing about the AND's turnabout on several nutrition issues while today I'm sharing the case of an Australian dietitian whose governing body, the Dietitians Association of Australia (DAA), has expelled her because she makes recommendations that are "inconsistent with Evidence-Based Practice." And to add insult to injury, her name has been added to their public list of other dietitians who have been expelled or suspended from the organization for "disciplinary reasons."
For those of you who don't know Jennifer Elliott, she is a dietitian and author from New South Wales, Australia, who has been practicing for more than 30 years. For the past ten, she has recommended a moderately low-carbohydrate diet for people with diabetes and insulin resistance, many of whom have experienced significant improvement as a result of following her advice. This approach arose out of her own extensive research into the causes of insulin resistance, along with the overwhelmingly positive impact carbohydrate restriction has had on her middle daughter, who was diagnosed with this condition as a teen (You can read the full story on Jennifer's website, along with her recent blog posts about the expulsion). She is an extremely bright, responsible, well-regarded dietitian who truly cares about her patients and does everything she can to help them. .Jennifer is also my friend and someone I speak with on a frequent basis.
In Australia, Accredited Practicing Dietitians (APD's, similar to Registered Dietitians or RD's in the US) are required to provide nutrition recommendations that adhere to Australia's Dietary Guidelines. Jennifer has been genuinely perplexed as to how the situation has unfolded. Australia looks to the US, specifically the American Diabetes Association (ADA), as a trusted source of evidence-based information on diabetes management, and in the past DAA has stated that they endorse the ADA guidelines for use by dietitians in Australia. Jennifer has stayed up to date with these guidelines and the changes over the years, including their 2013 position paper Nutrition Therapy Recommendations for the Management of Adults with Diabetes, which states:
"Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals….A variety of eating patterns have been shown modestly effective in managing diabetes including Mediterranean-style, Dietary Approaches to Stop Hypertension (DASH) style, plant-based, lower-fat, and lower-carbohydrate patterns."
It is disingenuous of the DAA to find against Jennifer for using a lower-carbohydrate approach for patients with diabetes and insulin resistance, when the ADA states that it is indeed one of several options that may be followed by such patients. In fact, the ADA asked me to write an article about carbohydrate restriction for their journal Diabetes Spectrum nearly three years ago.
I find it very upsetting and extremely unfair that a caring, dedicated dietitian such as Jennifer, who has helped so many patients improve their health and quality of life, is being treated this way. At this point, several like-minded dietitians, doctors, and researchers are working to publicize Jennifer's story and provide her with support in fighting this ruling. We can use help in spreading the word. And please stay tuned for further details as they become available.
"When you believe in something, fight for it. And when you see injustice, fight harder than you've ever fought before." - Brad Meltzer
Very exciting news this past week! The Academy of Nutrition and Dietetics (AND), formerly known as the American Dietetic Association, released surprising yet highly welcome comments regarding The DGA (Dietary Guidelines Advisory Committee) Scientific Report, which include the following statements:
"The Academy supports the decision by the 2015 DGAC not to carry forward previous recommendations that cholesterol intake be limited to no more than 300 mg/day, as 'available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol.'"
Conclusion: No restriction on cholesterol
"In the spirit of the 2015 DGAC's commendable revision of previous DGAC recommendations to limit dietary cholesterol, the Academy suggests that HHS and USDA support a similar revision deemphasizing saturated fat as a nutrient of concern."
Conclusion: Saturated fat no longer a villain
"There is a distinct and growing lack of scientific consensus on making a single sodium consumption recommendation for all Americans, owing to a growing body of research suggesting that the low sodium intake levels recommended by the DGAC are actually associated with increased mortality for healthy individuals."
Conclusion: Restricting sodium can lead to negative health consequences
"Carbohydrate contributes a greater amount to the risk for cardiovascular disease than saturated fat, so the replacement of carbohydrate will necessarily result in a greater improvement in risk."
Conclusion: High intake of carbohydrates is more detrimental to heart health than high intake of saturated fat
While the AND recommends tailoring recommendations to individual needs (for instance, those with congestive heart failure do need to limit sodium intake), it has done a complete about-face in changing its recommendations that people should restrict sodium, saturated fat, and cholesterol in order to improve their health. And frankly, I couldn't be happier or more proud of my organization for reevaluating their position based on a thorough review of the evidence.
When I started this blog and website back in July of 2011, I'd reviewed a lot of research (both current and decades old) indicating low-carbohydrate diets were healthy, despite being significantly higher in fat, saturated fat, and sodium than recommended by major health organizations. I'd also read dozens of accounts by people who'd improved their health by adopting a carbohydrate-restricted diet and, of course, there was my own experience of completely normalizing my postprandial blood glucose levels by doing so. Since early 2011, I've remained a staunch advocate of a low-carb lifestyle, especially for those suffering from diabetes, obesity, insulin resistance, and PCOS. Still, it's been hard explaining to people why my recommendations differ so much from what they've heard from their doctors or other dietitians, as well as what they hear on TV and see on the Nutrition Facts food label (which will need to be revised more than what's been proposed, given the DGAC's findings).
As a registered dietitian, I was well aware that I was taking a risk in speaking out against the AND's recommendations. The topics I cover in this blog are certainly controversial, at least from the point of view of most dietitians and health care providers. However, I've worked hard to make sure that every blog post I write is balanced, well-referenced, and takes all of the available evidence into consideration. I also include a disclaimer on my About Me page that my advice may run counter to recommendations of major health organizations, including the AND -- one that I may be able to remove in the near future.
Still, in the back of my mind, I've always worried about retaliation from dietitians who feel that I may be providing harmful advice to my clients and readers of my blog posts and articles. I know at least two dietitians in other countries are being threatened with discipline for making low-carbohydrate recommendations that include higher amounts of fat and saturated fat than their governing bodies deem healthy. Because these investigations are ongoing, I can't provide specifics about either case at the moment but will definitely do so in the future. In addition, I've received several emails from other dietitians who want to discuss carbohydrate restriction with their overweight and diabetic patients yet feel they can't because it's not accepted practice at the facilities where they work. It's extremely upsetting to me that those of us who give truly beneficial advice are often seen as "rogue" practitioners who reject "evidence-based" guidelines, and that we need to watch our backs.
I sincerely hope that dietetic associations around the world follow the AND's lead in updating their recommendations given the totality of the evidence, rather than maintaining the status quo. Improving the nutritional health of all individuals should be the highest priority of these organizations, and if that means admitting their previous positions were wrong, they should step up to the plate and do so.
Franziska Spritzler, RD, CDE