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.
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
I've been toying with the idea of writing about protein on low-carb diets for a while but until now have resisted due to all the conflicting information I've found on the subject. I decided to address it because I'm often asked how much protein I recommend, and it's a difficult question to answer. Some of the foremost experts on carbohydrate restriction have very different ideas about the optimal amount of dietary protein to consume.
Dr. Rosedale recommends only 0.8-1.0 grams per kilogram of body weight (He has said he sometimes recommends as little as 0.6 g/kg for people with diabetes). Dr. Bernstein is a bit more liberal, allowing his patients as much protein as they would like per meal while cautioning that too much may increase blood glucose levels and lead to weight gain due to increased gluconeogenesis in people with diabetes (It should be noted that he is a fan of small portions of just about everything, including vegetables). Most low-carb research has been conducted with protein intake of 25-30% of total calories (125-150 grams per day on 2000 calories per day) . Dr. Phinney and Dr. Volek have advised eating around 1.5 grams protein per kilogram of body weight, and up to 2.5 g/kg for athletes. Despite having written a best-selling book called Protein Power, Drs. Mike and Mary Eades set protein requirement at a modest 0.6 grams per pound of lean body mass for a moderately active person (about 70 grams protein per day for someone weighing 157 lbs with 24% body fat).
I've read a lot of research that supports higher protein intake with carbohydrate restriction. It would logically support weight loss/improvement in body composition due to protein's higher thermic effect (the amount of calories burned from its digestion and processing), satiety factor (higher than fat and carbohydrate), and ability to promote increased muscle mass. People attempting to build muscle via resistance training will benefit by increasing protein intake to support anabolism, particularly on a low-carb diet.
The available research indicates moderate to high protein intake may be beneficial for people with diabetes. In a long-term study of T2's, protein intake of 30% on an 1800-calorie diet (about 135 grams a day), resulted in improvements in blood sugar control and weight. However, it is unknown whether this is universal among all T2s, and T1s are a different story altogether. Although a recent study found that significantly higher protein intake at meals does not result in an increase in blood glucose levels in those with T1 diabetes, the anecdotal evidence from many people suggests otherwise. I've had several reports from T1s about blood glucose spikes after zero-carb high-protein meals.
If you're confused after hearing all of these conflicting recommendations, you're in good company. I'm a dietitian, and I struggle with making protein recommendations because the ideal amount seems to be so highly individualized. To me, it seems better to err on the side of getting a little more protein than required versus not enough. My diet contains a moderate amount of animal protein -- probably 60-65 grams a day -- but I do get a fair amount from plants as well. I eat a lot of nuts and nut butters, and the several servings of vegetables I consume contain some protein. When I input an average day's intake into FitDay, my total protein is usually close to 100 grams. That comes out to about 1.75 grams/kilogram based on my weight, which is almost double Dr. Rosedale's recommendation. However, my blood sugars remain stable as long as I keep carbs low, and my weight stays exactly where I want it. Based on everything I've read, I wouldn't recommend less than 1 g/kg or more than 2 g/kg ,* but that's obviously a huge range. Some do better at the lower end, while others thrive at the top depending on their fitness goals and unique physiological makeup. As with everything else, I think self-experimentation (monitoring blood sugar and/or weight, appetite, energy levels, body composition, etc.) is key to finding the optimal protein intake for you.
* protein g/kg based on current weight if at or near ideal weight. If overweight or obese, use g/kg ideal weight. There are many charts online, but I use the Hamwi formula:
Men: 106 lbs plus 6 lbs for every inch over 5 feet (add or subtract 10% for large and small frames, respectively)
Women: 100 lbs plus 5 lbs for every inch over 5 feet (add or subtract 10% for large and small frames, respectively)
1. Gannon M, et al. Effect of a high-protein, low-carbohydrate diet on blood glucose control in people with type 2 diabetes. Diabetes. 2004 Sep;53(9):2375-82
2. Nielsen J, et al. Low-carbohydrate diet in type 2 diabetes: stable improvements of body weight and glycemic control during 44 months follow-up. Nutr Metab (Lond) 2008; 5:14
3. Borie-Swinburn C, et al. Effect of dietary protein on postprandial blood glucose in patients with type 1 diabetes. J Hum Nutr Diet.2013 Mar 22. DOI: 10.1111/jhn.12082
Franziska Spritzler, RD, CDE