Some people are considering going “plant-based” for perceived health reasons, or for ethical considerations and while these are important, evaluating plant protein quality is a necessary consideration. Evaluating protein quality using the Digestible Indispensable Amino Acid Score [DIAAS] can help.

A recent study found that essential amino acids from animal protein are more bioavailable than from plant protein [1], and these findings are especially important for older adults who need to preserve muscle mass, and for active adults wanting to build muscle. 

Amino Acids and Bioavailability

Amino acids are the building blocks of protein, including muscle. There are twenty amino acids categorized into two groups: essential amino acids (EAA) and non-essential amino acids.

Bioavailability means the degree to which the essential amino acids in a food can be used by the body to make its own proteins [2] such as muscle.

Essential amino acids, including leucine, which is required for muscle growth and repair, must be eating in protein foods in the diet. This is why they are called “essential” amino acids. The leucine content of a protein is vital because leucine is what triggers mTOR signaling in muscle, which stimulates muscle growth[3]. Dietary Recommendations for older adults emphasize obtaining 2.3 g leucine at each of 3 meals to ensure the building of new muscle protein [4], and 3g leucine per meals [5] to rebuild muscle. Protein recommendations for older adults range from between 20g per meal [3] to 25-30g protein per meal [5] for those recovering muscle mass. For physically active adults, the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine recommend a protein intake of 1.2—2.0 g protein / kg per day to optimize recovery from training, and to promote the growth and maintenance of lean body mass [6].

Plant Protein vs Animal Protein for Building Muscle 

Plant protein generally contains lower levels of the essential amino acid leucine than animal proteins[7] but those seeking to eat a more plant-based diet often turn to legumes (“beans”) for protein. Most legumes are incomplete proteins – meaning they are missing essential amino acids. For example, lentils have only 0.7g of leucine per half cup and chickpeas contain only 0.42g of leucine per half cup.  This means that so for an older adult to get the minimum amount of leucine at a meal (2.3 g leucine) they would have to eat more than 3 cups of lentils, or 5 ½ cups of chickpeas at a meal.

But what about the protein content of foods? Are plant-based proteins equivalent to animal-based proteins?

Is Plant Protein Equivalent to Animal Protein?

A newly randomized, investigator-blinded, crossover study was first performed with a group of young adults, and then in a group of older adults [1]. Researchers compared ounce-equivalents (oz-eq) of animal-based protein (lean pork or whole eggs) with plant-based protein (black beans or sliced almonds) in a mixed whole foods meal. The goal was to see how well the body can use essential amino acids from each type of protein to make body protein. To determine essential amino acid bioavailability, as well as blood sugar and insulin levels, blood samples were taken before they ate the meal, and at 30, 60, 120, 180, 240, and 300 minutes after eating.

Researchers chose the measure of ounce-equivalent (oz-eq) because the Dietary Guidelines for Americans (DGA) uses ounce-equivalent to “identify the amount of (protein group) foods with similar nutritional content” [1, 8]. For example, the DGA indicates that one ounce-equivalent equals one ounce of meat, or one whole egg, or 0.25 cups of beans, or 0.5 ounces of nuts but the authors of the study note that the ‘basis for stating these protein foods are “equivalent” and have “similar nutritional content” is unclear’ [1].

 

As pointed out by the authors, protein foods differ in energy content and macronutrient contents, including both protein quantity, and protein quality. With regards to protein quantity, one ounce-equivalent of pork loin contains ~7 g of total protein, and one ounce-equivalent of almonds contains only ~3 g of total protein [1]. 

With regards to protein quality, the authors define this ‘as the ability of a dietary protein source to provide adequate amounts and proportions of essential amino acids (EAA) that are digestible and as a result are bioavailable for use in the body for stimulating protein synthesis, and maintaining or growing body tissues’. 

The Bioavailability of Plant Protein – Digestible Indispensable Amino Acid Score

The bioavailability of amino acids in different types of proteins have been determined and is available in the The Digestible Indispensable Amino Acid Score [DIAAS]. In 2013, the DIAAS was recommended by the Food and Drug Administration to replace their previous method called the Protein Digestibility Corrected Amino Acid Score (PDCAAS) [9]. In the DIAAS system, each essential amino acid is recognized as an individual nutrient, rather than lumping all amino acids together and this is very important because the bioavailability of a protein source must to be taken into account when determining if a diet is adequate in protein, and in specific essential amino acids such as leucine.

High quality proteins are those with a DIAAS score ≥100, and are considered excellent quality proteins. DIAAS scores of 75–99 are considered high-quality proteins, and those with scores of <75 are considered to be able to make no quality protein claim [8]. Based on this recent research, plant protein from most grains and legumes (“beans”) are <75 on the DIAAS score, with pea and soy falling between 75 and 100.  Animal protein such as pork consistently score over 100 on the DIAAS [10].

If regulatory guidelines such as the Dietary Guidelines for Americans and Canada’s Food Guide for Health Eating used the protein values generated by the Digestible Indispensable Amino Acid Score, rather than the PDCAAS, consumers would easily be able to see that a 4oz plant-based patty is not equivalent in protein quantity of quality as a 4oz beef patty, and 20g of vegan protein powder is not equivalent to 20g of whey protein powder. Use of the DIAAS in both countries would more accurately reflect protein quality [11] and enable consumers to make better choices.  

Plant Protein versus Animal Proteins – conclusions of the study

The study found that consuming meals with equivalent amounts of animal-based proteins versus plant-based proteins resulted in more essential amino acids in the blood compared with meals containing animal-based proteins in both young and older adults, separately and combined.

Also found was that there was greater essential amino acid bioavailability in lean pork, than in eggs in both young adults and older adults, separately or combined, and there as no difference in essential amino acid bioavailability between black beans and almonds.

The researchers concluded that it is inappropriate to say that different protein sources on an ounce-equivalent basis are “equivalent” .

Final Thoughts…

If you are an active adult seeking to build and repair muscle, then knowing which is better (plant protein vs animal protein for building muscle) is important. If you are an older adult wanting to retain muscle mass, eating high quality protein that contains all the essential amino acids including leucine is essential. While the US Dietary Guidelines states that one ounce of meat or one whole egg or 0.25 cups of beans or 0.5 ounce of nuts are equivalent, this recent study finds that the protein in beans and nuts is not equivalent to that in meat and eggs. 

If you are toying with the idea of becoming more plant-based, be sure that you understand the science of protein bioavailability so you can make a sound decision. 

For those who already eat a vegetarian diet for religious or ethical reasons, ensuring that your meals contain the most bioavailable plant-based proteins at each meal requires knowledge and effort.

More Info

If you would like support ensuring that you or someone you love eats sufficient high-quality protein at each meal needed to trigger muscle synthesis, please reach out to me through the Contact Me form, above.

To your good health, 

Joy

You can follow me on:

 

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/

 

References

1. Connolly G, Hudson JL, Bergia RE, Davis EM, Hartman AS, Zhu W, Carroll CC, Campbell WW. Effects of Consuming Ounce-Equivalent Portions of Animal- vs. Plant-Based Protein Foods, as Defined by the Dietary Guidelines for Americans on Essential Amino Acids Bioavailability in Young and Older Adults: Two Cross-Over Randomized Controlled Trials. Nutrients. 2023; 15(13):2870. https://doi.org/10.3390/nu15132870
2. Gaudichon C, Calvez J. Determinants of amino acid bioavailability from ingested protein in relation to gut health. Curr Opin Clin Nutr Metab Care. 2021 Jan;24(1):55-61. doi: 10.1097/MCO.0000000000000708. PMID: 33093304; PMCID: PMC7752214.
3. Layne E Norton, Donald K Layman, Leucine Regulates Translation Initiation of Protein Synthesis in Skeletal Muscle after Exercise12, The Journal of Nutrition,
   Volume 136, Issue 2, 2006, Pg 533S-537S, doi.org/10.1093
   (https://www.sciencedirect.com/science/article/pii/S0022316622080956)
4. Bauer JI, Biolo G, Cederholm T, Cesari M, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013 Aug;14(8):542-59
5. Nutrition Heart Beat, Leucine: perform better and maximize your muscle through diet, https://nutritionheartbeat.com/sports-nutrition/leucine-diet-muscle
6. Thomas DT, Erdman KA, Burke LM. American College of Sports Medicine Joint Position Statement. Nutrition and Athletic Performance [published correction appears in Med Sci Sports Exerc. 2017 Jan;49(1):222]. Med Sci Sports Exerc. 2016;48(3):543-568. doi:10.1249/MSS.0000000000000852
7. Berrazaga I, Micard V, Gueugneau M, Walrand S. The Role of the Anabolic Properties of Plant- versus Animal-Based Protein Sources in Supporting Muscle Mass Maintenance: A Critical Review. Nutrients. 2019 Aug 7;11(8):1825. doi: 10.3390/nu11081825. PMID: 31394788; PMCID: PMC6723444.
8. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025, 9th ed.; U.S. Department of Agriculture and U.S. Department of Health and Human Services: Washington, DC, USA, 2020. Available online: DietaryGuidelines.gov
9. Herreman, L, Nommensen, P, Pennings, B, Laus, MC. Comprehensive overview of the quality of plant- And animal-sourced proteins based on the digestible indispensable amino acid score. Food Sci Nutr. 2020; 8: 5379–5391. https://doi.org/10.1002/fsn3.1809
10. Food and Agriculture Organization of the United Nations. Dietary Protein Quality Evaluation in Human Nutrition: Paper 92. Rome, Italy: Food and Agriculture Organization of the United Nations; 2013.
11. Marinangeli CPF, House JD. Potential impact of the digestible indispensable amino acid score as a measure of protein quality on dietary regulations and health. Nutr Rev. 2017 Aug 1;75(8):658-667. doi: 10.1093/nutrit/nux025. Erratum in: Nutr Rev. 2017 Aug 1;75(8):671. PMID: 28969364; PMCID: PMC5914309.

 

Copyright ©2023 BetterByDesign Nutrition Ltd.

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

 

 

In the interest of time, many people will throw a cup or more of fruit, some green veggies and maybe some protein powder into a blender to make a smoothie for breakfast without realizing the effect that blending has on their blood sugar, gut microbiome, and even the overall amount of food they eat.

Making a Smoothie 

Cellular versus Acellular Carbohydrate

Cellular carbohydrates come from whole, intact food that remains in the cell wall. These take longer to be digested and absorbed into our bloodstream than carbohydrates that have been ground or pureed. As well, cellular carbohydrates have a lower “carbohydrate density” than processed carbohydrate, where the carbohydrate density are the grams of carbohydrate in a food, minus  the grams of fiber, based on the total gram weight of the food [1].

Acellular carbohydrates are no longer are contained within their cell wall, because they have been pureed (like fruit in a smoothie), or ground, such as flour, from grain. As a result, these foods have a much higher “carbohydrate density” because the fiber is no longer contained in the cell wall, along with the carbohydrate.

A Smoothie as “Pre-Chewed” Food

Most people think digestion begins in the stomach, but it doesn’t. It starts in the mouth when we chew food. As unpalatable as it sounds, smoothies are really “pre-chewed” food, and consuming carbs this way can disrupt our blood sugar, gut microbiota, and even affect the amount of food we consume.

1. A 1977 study published in the journal Lancet demonstrated that when fruit is pureed fruit or juiced and then eaten, the glucose response 90 minutes later is significantly higher than if the fruit were eaten whole [2]. This is because the blender or juicer has made the carbohydrate acellular, by doing some of the work that chewing does. In this way, carbohydrate-containing smoothies are essentially “pre-chewed”. For those with pre-diabetes or diabetes, having a morning smoothie instead of eating the same foods intact has a very different effect on blood glucose. Keep in mind, that while 60g of a whole fruit, 60g of pureed fruit, and 60g of fruit that has been juiced have the same amount of carbohydrate and similar Glycemic Index (GI), the GI only indicates how quickly a food or drink will increase blood sugar, not how much higher blood sugar will go.  The two-part article, titled The Perils of Food Processing explains in scientific terms the effect of food processing on blood sugar.
2. Carbohydrates that remain with their cell structure such as whole berries or fruit (i.e. cellular carbohydrates) have their carbohydrate density preserved until the digestive juices in the stomach begin to break down the cell wall of the fruit. Once free from the cell wall, the carbohydrate is absorbed in the large intestine, or colon. Acellular carbohydrates, on the other hand such as fruit-containing smoothies begin to be digested in the small intestine, instead of the colon (where cellular carbohydrates are digested). It is thought that this early fermentation may raise the risk of gut dysbiosis and leaky gut syndrome [1].
3. Finally, the processing of acellular carbohydrates in a blender so we can drink our food, as opposed to eating it makes it too easy to have more than one would if eating the same amount of the intact food. Since acellular carbohydrates are higher in carbohydrate density than the diets made of intact, whole food, it is thought that this may raise the risk for obesity, and leptin resistance [1]. Leptin is the hormone that tells us when we are hungry, and it is thought that this negative feedback loop becomes dysregulated when we consume large amounts of acellular carbohydrates, including pureed fruit, flour-based baked goods, and refined grains.
4.  

Final Thoughts…

It is important to keep in mind that digestion begins in the mouth when we chew food and how we absorb the carbohydrate contained in those foods is very different when we eat whole, intact food, as opposed to pureeing them into a smoothie. Smoothies are really “pre-chewed” food that can disrupt our blood sugar, gut microbiota, and affect the overall amount of food we consume.

Instead of throwing some fruit, veggies and protein powder into a blender, why not eat a half cup of berries, with a cup of cottage cheese or plain Greek yogourt, and grab a handful of snap peas for the low carb veggies, instead? This is a quick, light meal that has all the protein and leucine required for adults to preserve their muscle mass — and there is no blender to clean, afterwards!

How I Can Help

I understand that not everyone who wants to eat healthy loves to cook. I often design Meal Plans for people based on easy-to-obtain foods that require minimum preparation and little to no cooking. Whether you love to cook or can’t be bothered, I can help.

For more information, please look under the Service tab or contact me through the Contact Me form above.

To your good health, 

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/

 

References

1. Spreadbury, I., Comparison with ancestral diets suggests dense acellular carbohydrates promote an inflammatory microbiota and may be the primary dietary cause of leptin resistance and obesity. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy. 2012:5 175-189.
2. Haber GB, Heaton KW, Murphy D, Burroughs LF. Depletion and disruption of dietary fibre. Effects on satiety, plasma-glucose, and serum-insulin. Lancet. 1977 Oct 1;2(8040):679-82. doi: 10.1016/s0140-6736(77)90494-9. PMID: 71495

Copyright ©2023 BetterByDesign Nutrition Ltd.

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

 

The inability to retain muscle and strength associated with aging is called sarcopenia, and it is not only a concern for older adults. Loss of muscle mass begins to occur after the age of thirty at the rate of 1% per year [1], and the gradual inability to retain muscle mass and strength generally begins occurring by age fifty [2]. Muscle loss affects 5-13% of adults between the ages of sixty to seventy, and up to half of adults older than eighty years of age have sarcopenia [3].

Not being able to retain muscle mass results in older adults no longer being able to remain active, a reduced quality of life, osteoporosis, increased risk of falls, and a worsening of metabolic health [4].

Most people have never paid attention to the amount and quality of the protein they eat – choosing instead to select protein foods based on taste preference, economics, or ethical or religious reasons. These are all important considerations; however, they are not the only ones. As outlined in a previous article about the role of protein in the diet of older adults, high biological value protein that contain sufficient amounts of the amino acid leucine are necessary for the health of muscle [5], but in this regard not all protein foods are equal.

Amino acids are the building blocks of protein, including muscle, and there are twenty amino acids categorized into two groups: essential and non-essential amino acids. Essential amino acids, including leucine which is required for muscle growth and repair are not produced by the body in sufficient amounts. Leucine must be obtained through diet, which is what makes it an “essential” amino acid.

The leucine content of proteins is critical because leucine is what triggers mTOR signaling in muscle that stimulates muscle growth. For this reason, the proteins people need to contain sufficient leucine – especially older adults who want to retain muscle mass, and mobility.

Plant proteins generally contain lower levels of leucine compared to animal proteins [6]. Grains such as wheat contain less than 7% leucine [7] and even quinoa which is considered a “complete protein” because it has all essential amino acids only contain only 4.5% leucine [8]. People who want to eat a more plant-based diet to retain muscle may turn to legumes (“beans”) for protein, but they are usually incomplete proteins – meaning they are missing essential amino acids, and are generally poor sources of leucine. Even soybeans, which are complete proteins, contain only 8% leucine [9].

Dietary Recommendations for older adults emphasize a minimum of 20g of protein per meal, with more than 2.3 g leucine at each of 3 meals to ensure the building of new muscle protein [10].

Furthermore, to retain muscle and to recover the loss of muscle mass in older adults, the recommended intake of leucine is 3g per at each of 3 meals, along with 25-30g of protein [11].

Protein Sources to Help Retain Muscle 

Animal proteins are highly bioavailable complete proteins and the richest sources of leucine.  Only 1 cup of 1% fat cottage cheese contains 2.9g of leucine per cup – the amount needed for an entire meal! A cup of plain yogurt contains 1.3g of leucine, and a cup of Greek yogurt contains 1.2 g of leucine. Only 3 oz. of ground beef or pork contains 1.8g of leucine and the same amount of chicken breast contains 2.25g – all the leucine that is needed in a meal [11]. These are excellent protein and leucine containing food to help retain muscle. 

Soybeans which are a complete plant-based protein contain only 0.28g leucine per half cup, and firm tofu which is a concentrated form of soy protein has between 0.73g of leucine for three ounces, so to get sufficient leucine from firm tofu would require an older adult to eat ¾ of a pound – well beyond the appetite of many older adults. Incomplete proteins such as lentils have only 0.7g of leucine per half cup, and black beans only 0.61g leucine per half cup – so for an older adult to get the minimum amount of leucine at a meal (2.3 g leucine) from either of these, they would have to eat more than 3 cups at a meal, or 5 ½ cups of chickpeas (0.42g of leucine per half cup). 

For older adults who want to eat a more plant-based diet, ensuring adequate highly bioavailable protein that are also rich sources of leucine is essential to retain muscle – so I recommend “prioritizing protein” along with eating plenty of non-starchy vegetables, like broccoli, green beans, and leafy greens.

[NOTE: This recent article explains the difference in bioavailability between plant-based protein and animal based protein.]

Prioritize Protein to Retain Muscle 

“Prioritizing protein” means to first decide what protein you are going to eat at a meal, and then build the rest of the meal around that.  For older adults, the protein should have between 25-30g of highly bioavailable protein, and 2.3-3g of leucine.

For breakfast, choosing high leucine proteins such as a cup of cottage cheese, or a cup of plain Greek yogurt will provide the needed minimum amount of highly bioavailable protein, as well as sufficient leucine. On the other hand, 2 eggs only contain 12 g of highly bioavailable protein, and 1.2g leucine less than half the recommended amount for older adults.

Choosing 4 oz (113g) of canned tuna for lunch will provide 4g of leucine and 21g of protein, and 3 oz of chicken breast (113g) will provide 2.4g of leucine and 26.5g of protein. To top up the leucine contents, you can serve that with some salad greens sprinkled with an ounce (28g) of pumpkin seeds that contains 0.7g of leucine or an ounce (28g) of sunflower seeds that contains 0.46g of leucine.

In terms of dinner options, while steak is one of the richest sources of leucine – having 3.4 g leucine per 4 oz (113g), cost is a factor. More cost-effective options for those that eat it are 4 oz. (113g) of pork chops which contains 27g of protein, and 2.5 g of leucine. Four ounces of ground beef contains only 16 g of protein but has 2.5 g of leucine, so boosting the protein content of the meal can be as simple as adding some Greek yogurt for dessert.

UPDATE (August 20, 2023) – Be sure to read the new article “Is Plant Protein and Animal Protein Equivalent” based on a recently published study.

Final Thoughts…

The quality of life of older adults and their health depends on remaining active, which requires adequate muscle mass, and preventing sarcopenia requires sufficient protein with all the essential amino acids, as well as enough of the amino acid leucine.

Given that we lose muscle mass at the rate of 1% per year after the age of thirty, which proteins we choose to eat at each of our meals is essential.

If you would like support ensuring you or a loved one eats sufficient high quality protein and leucine as well as other nutrients of concern, please reach out to me through the Contact Me form, above.

To your good health, 

Joy

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/

 

References

1. Keller K, Engelhardt M. Strength and muscle mass loss with aging process. Age and strength loss. Muscles, Ligaments and Tendons Journal. 2013;3(4):346-350.
2. Lexell J. Human aging, muscle mass, and fiber type composition. Journals of Gerontology Series A: Biological and Medical Sciences. 1995;50:11–16
3. Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyère O, Cederholm T, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. (2019) 48:16–31. 10.1093/ageing/afy169
4. Hunter GR, Singh H, Carter SJ, Bryan DR, Fisher G. Sarcopenia and Its Implications for Metabolic Health. J Obes. 2019 Mar 6;2019:8031705. doi: 10.1155/2019/8031705. PMID: 30956817; PMCID: PMC6431367.
5. Tessier AJ, Chevalier S. An update on protein, leucine, omega-3 fatty acids, and vitamin d in the prevention and treatment of sarcopenia and functional decline. Nutrients. (2018) 10:1099. 10.3390/nu10081099
6. Berrazaga I, Micard V, Gueugneau M, Walrand S. The Role of the Anabolic Properties of Plant- versus Animal-Based Protein Sources in Supporting Muscle Mass Maintenance: A Critical Review. Nutrients. 2019 Aug 7;11(8):1825. doi: 10.3390/nu11081825. PMID: 31394788; PMCID: PMC6723444.
7. Norton, L.E., Wilson, G.J., Layman, D.K. et al. Leucine content of dietary proteins is a determinant of postprandial skeletal muscle protein synthesis in adult rats. Nutr Metab (Lond) 9, 67 (2012). https://doi.org/10.1186/1743-7075-9-67
8. El-Sohaimy, Sobhy & Mehany, Taha. (2015). Physicochemical and functional properties of quinoa protein isolate. Annals of Agricultural Sciences. 60. 10.1016/j.aoas.2015.10.007.
9. Amino Acid Analysis of Soybean, https://www.drugfuture.com/chemdata/Soybean.html
10. Bauer JI, Biolo G, Cederholm T, Cesari M, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013 Aug;14(8):542-59
11. Nutrition Heart Beat, Leucine: perform better and maximize your muscle through diet, https://nutritionheartbeat.com/sports-nutrition/leucine-diet-muscle
12. Rondanelli M, Nichetti M, Peroni G, Faliva MA, Naso M, Gasparri C, Perna S, Oberto L, Di Paolo E, Riva A, Petrangolini G, Guerreschi G, Tartara A. Where to Find Leucine in Food and How to Feed Elderly With Sarcopenia in Order to Counteract Loss of Muscle Mass: Practical Advice. Front Nutr. 2021 Jan 26;7:622391. doi: 10.3389/fnut.2020.622391. PMID: 33585538; PMCID: PMC7874106.

 

 

Copyright ©2023 BetterByDesign Nutrition Ltd.

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

 

 

 

 

People’s interest in following a ketogenic diet for improved mental health has significantly increased over the past year. Emerging evidence suggests that this diet may be helpful as an adjunct treatment, along with medication, for improving mental health symptoms of anxiety, depression, and some types of bipolar disorder. However, not everyone is prepared for the demands of adopting a diet that contains twice (2:1) or three times (3:1) the amount of fat compared to protein and carbohydrates combined.

Some people assume that a 2:1 therapeutic ketogenic diet is the same as the popularized “keto” diet used for weight loss and improved metabolic health. While there are similarities, the 2:1 diet is therapeutic in its design, and the popularized “keto diet” is used therapeutically to improve weight and metabolic health. You can read more about his here.

In a 2:1 therapeutic ketogenic diet, the amount of protein, carbs and fat are regulated at each meal so that ketone levels are consistent through the day. In the popularized “keto diet” the goal is to be in ketosis with little to no regard to the level of ketosis, or the relationship between glucose levels and ketone levels.

Different Types of Ketogenic Diets

As outlined in a previous article titled “Use of a Therapeutic Ketogenic Diet in Mental Health,” there are three basic types of therapeutic ketogenic diets; a Classic Ketogenic Diet that uses a 4:1 ratio of fat to protein plus carbs, a Modified Ketogenic Diet that uses a 3:1 ratio, and a Modified Atkins Diet that uses a 3:1 ratio.

There are anecdotal reports of individuals doing very well following a Modified Atkins Diet (2:1) under the supervision of their doctors, and very recently (June 3, 2023) a pre-print pilot study came out where this approach was successfully trialed in people with bipolar disorder [2].

This alternative approach is much less time consuming in terms of the amount of calculations and work need to design, so the benefit to the individual is that it is less costly. It enables people to get into ketosis under medical oversight to see if they feel, then in consultation with their doctors can decide if the improvements are sufficient to maintain their diet as is, or whether it may be worth seeing if a gradual increase in fat, and decrease in protein may work better.

Working with Your Doctor to Support Mental Health

As mentioned in the previous article, Dr. Palmer recommends that Psychiatrists first determine if trialing a ketogenic diet is appropriate for a specific patient. For people considering using a ketogenic diet as an adjunct treatment for mental health, the first place to start is by having this discussion with your doctor — especially if taking any medications for depression, anxiety disorder, or bipolar disorder or for metabolic conditions such as high blood pressure or to control blood sugar.

Dr. Palmer also recommends that doctors have their patients remain on their medication while trialing the diet for a period of three months, during which they are evaluated to see if there has been any significant change in symptoms [1]. If the doctor finds that the diet is helping, they may begin to gradually deprescribe some medications. As I’ve said in many other articles, changing dosages of medication is not something people should do on their own. 

There is an important point that Dr. Palmer makes that should not be overlooked. With the gradual decrease in medications, people must realize that they are more reliant on the ketogenic diet to keep symptoms under control. Since the diet is therapeutic, taking “cheat days” may result in it taking several days to get back into ketosis — during which symptoms can dramatically reappear [1]. I do not recommend “cheat days” when following a ketogenic diet for therapeutic purposes.  While a 2:1 diet is much easier to maintain long term than a 3:1, consistently maintaining the correct ratio of fat to protein and carbohydrate is essential.

Dr. Palmer recommends the following two steps to doctors that want to use ketogenic diets with their patients [1]; 

1. Find a licensed Dietitian knowledgeable in therapeutic ketogenic diets and partner with them. 

2. Read the book “Ketogenic Therapies” by Dr. Eric Kossoff [3]

Dr. Eric Kossoff’s book, Ketogenic Diet Therapies for Epilepsy and Other Conditions is one that have referred to often over the last 5 years of designing therapeutic ketogenic diets for other conditions.

Steps to Getting Started

If you are thinking of adopting a ketogenic for improved mental health, then the first step is to reach out to your doctor.  To assist you in having this type of discussion, please feel free to download this letter. 

If your have already discussed this and your doctor is willing to oversee your health and medications while you adopt the diet, I can provide you with a Request for Medical Supervision Form. 

More Info

If you would like more information about having a therapeutic ketogenic diet designed for you, please visit the Services tab and scroll down to Therapeutic Diets. 

To your good health!

Joy

 

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

1. Dr. David Puder, MD, Psychiatry Podcast, Episode 163, Dr. Chris Palmer: Ketogenic Diet for Mental Health, M=November 15, 2022, https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/163-treating-mental-health-disorders-with-a-ketogenic-diet
2. Needham Nicole, Campbell Ian, Grossi Helen et al, Pilot Study of a Ketogenic Diet in Bipolar Disorder, June 3, 2023, doi.org/10.1101/2023.05.28.23290595, https://www.medrxiv.org/content/10.1101/2023.05.28.23290595v1
3. Kossoff, Eric & Turner, Zahava & Cervenka, Mackenzie & Barron, Bobbie. (2020). Ketogenic Diet Therapies For Epilepsy and Other Conditions. 10.1891/9780826149596.

 

 

Copyright ©2023 BetterByDesign Nutrition Ltd.

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

 

A recent social media post about a Canadian woman living in the United States who discovered that the ingredients in a major brand of ketchup manufactured in Canada and the United States were different caused quite a stir.  Online discussion centered around whether the inclusion of high fructose corn syrup (HFCS) in the US product posed an increased risk of fatty liver disease.

The ingredients listed in the US and Canadian products were as follows;

Heinz Tomato Ketchup (America): Tomato concentrate from red ripe tomatoes, distilled vinegar, high fructose corn syrup, corn syrup, salt, spice, onion powder, natural flavoring.

Heinz Tomato Ketchup (Canada): Tomato paste (from fresh, ripe tomatoes), sugar, vinegar, salt, spices

One Difference Between the US and Canadian Ketchup 

The significant difference between the two ingredient lists was that the US-manufactured ketchup used high fructose corn syrup (HFCS) and corn syrup to sweeten the product, whereas the Canadian ketchup was sweetened using sugar (sucrose). 

High Intakes of Fructose and Non-Alcoholic Fatty Liver Disease

There have been a few research articles over the last several years which seemed to indicate that large intakes of fructose may be linked to non-alcoholic fatty liver disease (NAFLD) but I had not yet written anything about it, largely due to a lack of time. This recent social media post going viral made me want to write a brief post pointing to some recent evidence that large intakes of fructose, including high fructose corn syrup (HFCS) may pose a risk of NAFLD.

What is fructose?

Fructose is a natural occurring sugar that is present in fruit, some vegetables and honey and which is used as a component in the manufacture of high-fructose corn syrup (HFCS) which is used as a sweetener in soda (soft drinks, pop), in candies, and in condiments such as ketchup.

Approximately a quarter (24%) of US adults have non-alcoholic fatty liver disease (NAFLD) which results in the excess build-up of fat in the liver that is unrelated to heavy alcohol use [1]. NAFLD is a serious condition that can progress to chronic liver damage, and lead to death [1].

An expert talk given this time last year at Endo 2022, the annual meeting of the Endocrine Society which took place from June 11-14, 2022, in Atlanta, Georgia, titled Fructose Consumption and NAFLD in US Adult Population presented evidence that non-alcoholic fatty liver disease (NAFLD) is associated with high intakes of fructose.

The researchers analyzed data from the 3,292 US adults enrolled in the National Health and Nutrition Examination Survey (NHANES) from 2017-2018 and found that those who consumed the greatest amount of fructose were Mexican Americans (48%), non-Hispanic Blacks (44%), with a lower percentage of fructose consumption amongst non-Hispanic whites (33%).

The researchers found the highest prevalence of non-alcoholic fatty liver disease (NAFLD) amongst Mexican Americans who consumed the highest amount of fructose (70%) which was significantly different than the prevalence of NAFLD in Mexican Americans that consumed the lowest amount of fructose (52%) [2]. When researchers adjusted for body composition and laboratory variables, they found that high fructose consumption was related to a higher risk of NAFLD in the total population, not only in Mexican Americans [2].

The researchers concluded that “there is an association between fructose consumption and the odds of developing non-alcoholic fatty liver disease (NAFLD)” and that “interventions should aim to decrease consumption of fructose overall” [1,2].

The researchers recommended that health care providers encourage people to consume less food and beverages with high-fructose corn syrup to prevent the development of NAFLD [1].

Final Thoughts…

Consuming small amounts of ketchup sweetened with high-fructose corn syrup in and by itself does not pose a risk of developing non-alcoholic fatty liver disease.

Where the risk lies is for people who are consuming fruit juice, soda pop, candy and condiments including ketchup that contain high-fructose corn syrup.

The recommendation of the Endocrinologists above is to encourage people to consume less of these foods and beverages to prevent the development of non-alcoholic fatty liver disease.

To your good health!

Joy

 

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

 

1. Williams, Colleen, Reports and Proceedings of the Endocrine Society, News Release June 12, 2022, People who consume too much high fructose corn syrup could be at risk for NAFLD, https://www.eurekalert.org/news-releases/955131
2. Kermah D, Najjar S, Puri V, Schrode K, Shaheen M, Zarrinpar A, Friedman T. OR10-5 Fructose Consumption and NAFLD in US Adult Population of NHANES 17-18. J Endocr Soc. 2022 Nov 1;6(Suppl 1):A17. doi: 10.1210/jendso/bvac150.035. PMCID: PMC9625025.

 

Copyright ©2023 BetterByDesign Nutrition Ltd.

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

Most people have heard of the high fat, low carb “keto” diet that is often followed for weight loss and for improving blood sugar, but a  therapeutic ketogenic diet is very different. Therapeutic ketogenic diets have been used for more than 100 years in the treatment of epilepsy and diabetes and more recently, in the treatment of various mental health disorders, including depression, bipolar disorder, and schizophrenia.

Therapeutic Ketogenic Diet for Mental Health 

A research article published on July 6, 2022 in Frontiers of Psychiatry was my first exposure to the use of a therapeutic ketogenic diet in the treatment of mental health disorders. This was of great interest to me because my graduate research was in the area of mental health nutrition, and for the last 5 years I have supported people following therapeutic ketogenic diets for seizure disorder, and as adjunct treatment in specific forms of cancer. The use of a therapeutic ketogenic diet in mental health brings these two formerly separate areas of my experience together. 

In this pilot study, thirty one adults in a psychiatric hospital in Toulouse, France who had treatment-resistant depression, bipolar disorder, and schizoaffective disorder were placed on a therapeutic ketogenic diet that restricted their carbohydrate intake to 20g per day. Of the 28 patients that followed the diet for longer than two weeks, symptoms of depression and psychosis improved in all 28 patients, with improvements becoming noticeable within three weeks or less. Most impressive was that 43% of patients achieved clinical remission of symptoms, and 64% were discharged from the hospital on less psychiatric medication [1].  There have also been other pilot studies [2,3] using a therapeutic ketogenic diet in both bipolar disease, and schizophrenia.

“Brain Energy” Book – role for therapeutic ketogenic diet 

The release of the best-selling book Brain Energy in mid-November 2022, written by Harvard psychiatrist Dr. Chris Palmer, one of the pioneers in the use of a therapeutic ketogenic diet in treating psychiatric disorders [4], brought the use of this type of diet in mental health to public awareness. As a result of the book, I have had many more individuals contact me about designing such a diet to see if it would improve their mental health.  

But what is a therapeutic ketogenic diet?

Types of Therapeutic Ketogenic Diets

There are several types of therapeutic ketogenic diets, each designed according to a specific “ketogenic ratio” which specifies the amount of fat in the diet compared to the total amount of protein plus carbohydrate.

Classic Ketogenic Diet (KD)

The Classic Ketogenic Diet uses a 4:1 ratio which means it is made up of 4 grams of fat for every 1 gram of protein plus carbohydrate. That is, for every 5 grams of food eaten, there are 4 grams of fat and 1 gram of protein and/or carbohydrate. A 4:1 ketogenic diet contains 80% fat (4÷5=80%) and 20% protein plus carbohydrate (1÷5=20%), and protein may be set at 15% of calories with a maximum of 5% of calories coming from carbohydrate, or protein may be set lower at 10%, and carbohydrate as high as 10%. This type of diet may be used when the need to achieve and maintain high levels of ketones is necessary.

It is important to note that the ketogenic ratio compares the amount of fat, protein, and carbohydrates in grams, which is a measure of weight. The diet is calculated in grams, since food is measured by weight, in grams.

As you will see below, the amount of fat, protein and carbohydrate in the diet can also be calculated as a percentage of calories.

Modified Ketogenic Diet (MKD)

The Modified Ketogenic Diet uses a 3:1 ratio which means it is made up of 3 grams of fat for every 1 gram of protein plus carbohydrate. For every 4 grams of food eaten, there are 3 grams of fat and 1 gram of protein and carbohydrate. A 3:1 ketogenic diet contains 75% fat (3÷4=75%) and 25% protein plus carbohydrate (1÷4=25%). Some psychiatrists will start their patients on a 3:1 therapeutic ketogenic diet and once their patient is producing significant levels of ketones and is stable with respect to symptoms, may gradually have them transition over to a Modified Atkins Diet (see below) while monitoring their symptoms.

Modified Atkins Diet (MAD)

The Modified Atkins Diet uses a 2:1 ratio and is often used when people are taking a break from a 4:1 or 3:1 therapeutic ketogenic diet, and is also used as a therapeutic diet in mental health as it is the easiest for people to sustain long term. As mentioned above, some psychiatrists will start their patients on a 3:1 ketogenic diet to generate higher levels of ketones and then gradually have their clients transition over to a Modified Atkins Diet as it is more sustainable long term. This diet is also very helpful for those who do not tolerate the very high fat content of a 4:1 or 3:1 diet. In a Modified Atkins Diet, for every 3 grams of food eaten, there are 2 grams of fat and 1 gram of protein and carbohydrate. A 2:1 ketogenic diet contains 67% fat (2÷3=67%) and 33% protein plus carbohydrate (1÷3=25%).

Calculating Ratios Based on a Percentage of Calories

The first step for me, as a Dietitian in designing a therapeutic ketogenic diet is to determine the amount of calories (kcals) a person requires. This is routine work in designing any Meal Plan.

The next step is unique to the design of therapeutic ketogenic diets and that is calculating the specific percent of calories that needs to come from fat, protein and carbohydrate.

It is important to note that calculating the ratio provided from fat, protein and carbohydrate based on calories arrives at a different percentage than when calculating the ratio based on grams of food. This is because fat provides more calories per gram (9 kcal/g) than protein and carbohydrates (4 kcal/g).

To get 500 calories as protein, one would need to eat 125g of protein (500÷4=125), but to get the same 500 calories as fat, one would only need to eat 55.5 g of fat (500÷=55.5), because fat is much more calorically dense. Therapeutic ketogenic diets have much smaller meals because fat provides the same number of calories, for much less mass (weight, in grams).

Classic Ketogenic Diet – 90% fat as a percentage of calories

On a 4:1 ketogenic diet, 90% of the calories in the diet comes from fat when measuring by calories (80% fat if you are measuring by weight, in grams). This can be confusing, but remember that a 4:1 ketogenic ratio represents 4 grams of fat for every 1 gram of carbohydrate plus protein.

• • Four grams of fat (which provides 9 calories per gram) provides a total of 36 calories (4 x 9 = 36).
  • One gram of protein or carbohydrate (which provides 4 calories per gram) provides a total of 4 calories (1 x 4 = 4). 

That is, the ratio of calories from fat to calories from protein plus carbohydrate is 36:4. This means that for every 40 calories consumed, 36 calories come from fat and 4 calories come from protein and/or carbohydrate. Thus, 90% of the calories comes from fat (36÷40=90%), and 10% comes from protein and carbohydrate (4÷40=10%) [5]. 

Modified Ketogenic Diet (MKD) – 87% fat as a percentage of calories

On a 3:1 ketogenic diet, about 87% of the calories comes from fat, and 13% comes from protein plus carbohydrate. 

• Three grams of fat (which provides 9 calories per gram) provides a total of 36 calories (3 x 9 = 27).
  • One gram of protein or carbohydrate (which provides 4 calories per gram) provides a total of 4 calories (1 x 4 = 4) [5]. 

On a Modified Ketogenic diet, the ratio of calories from fat to calories from protein plus carbohydrate is 27:4. This means that for every 31 calories consumed, 27 calories come from fat and 4 calories come from protein and/or carbohydrate. Thus, 90% of the calories comes from fat (27÷31=87%), and 13% comes from protein and carbohydrate (4÷31=13%) [8]. 

A Dietitian’s Role in Therapeutic Ketogenic Diets

In a recent Psychiatry and Psychotherapy podcast where Dr. Chris Palmer was interviewed, he talks about how Psychiatrists can incorporate use of a therapeutic ketogenic diet in their practice [8].  The first thing he said was that there was a need for the physician to determine if this approach is appropriate for a specific patient.

 

As outlined in a 2018 article titled “Don’t Try This at Home – when medical supervision is needed“, beginning a ketogenic diet is something that needs to be done with the knowledge and oversight of one’s doctor — especially when taking specific types of medication such as;

1. 1. insulin (or insulin analogues)
   2. medication to lower blood glucose such as sodium glucose co-transporter 2 (SGLT2) medication including Invokana, Forxiga, Xigduo, Jardiance, etc.,
   3. medication to control blood pressure such as Ramipril, Lasix (furosemide), Lisinopril / ACE inhibitors, Atenolol / βeta receptor antagonists, etc.,
   4. mental health medications such as antidepressants, medication for anxiety disorder, bipolar disorder (such as Lithium), and schizophrenia

Dr. Palmer recommends that doctors have their patients remain on their medication while starting a therapeutic ketogenic diet, and be evaluated during the stages of ketosis to see if there has been any significant change in symptoms [6]. 

[People who follow a therapeutic ketogenic diet for medical reasons are often asked to track their Glucose-Ketone Index (GKI) so their doctors can monitor the benefit of the diet. I teach people how to do that.]

Dr. Palmer suggests that individuals should trial a therapeutic ketogenic diet for a period of three months [4], and if the doctor finds that the diet is helping, they may begin to gradually deprescribe some medications. As mentioned in the “Don’t Try This at Home” article, changing dosages of medication is not something people should do on their own. 

In the podcast, Dr. Palmer makes an important point. With the gradual decrease in medications, people must realize that they are more reliant on the ketogenic diet to keep symptoms under control. Since the ketogenic diet is therapeutic, taking “cheat days” is not an option. Dr. Palmer notes that it takes several days to get back into ketosis after breaking the diet and during this time, symptoms can dramatically reappear [8].

Dr. Palmer says that if a Psychiatrist is interested in beginning to use a therapeutic ketogenic diet in their clinical practice, they must be “well-informed on the science behind a therapeutic ketogenic diet, as well as metabolic functioning as a whole”.

Dr. Palmer recommends that doctors begin with the following first two steps [6]:

1. 1. Find a licensed dietician knowledgeable in therapeutic ketogenic diets and partner with them. 

   2. Read the book “Ketogenic Therapies” by Dr. Eric Kossoff

Dr. Eric Kossoff’s book, Ketogenic Diet Therapies for Epilepsy and Other Conditions is one that have referred to often over the last 5 years of designing therapeutic ketogenic diets in different applications. 

Steps to Getting Started 

If you are thinking of adopting a ketogenic for improved mental health, then the first step is to reach out to your doctor.  To assist you in having this type of discussion, please feel free to download this letter. 

If your have already discussed this and your doctor is willing to oversee your health and medications while you adopt the diet, I can provide you with a Request for Medical Supervision Form. 

[UPDATE (June 21, 2023): There is emerging evidence from a June 3, 2023 pre-publication paper that the easier-to-follow 2:1 ketogenic diet may work well as an adjunct treatment in mental health disorders, such as bipolar disorder. You can read more about that in this more recent article.

More Info

If you would like more information about having a therapeutic ketogenic diet designed for you, please send me a note using the Contact Me form at the top of this page.

To your good health!

Joy

 

You can follow me on:

Twitter: https://twitter.com/lchfRD
Facebook: https://www.facebook.com/BetterByDesignNutrition/

 

References

1. Danan A, Westman EC, Saslow LR, Ede G. The Ketogenic Diet for Refractory Mental Illness: A Retrospective Analysis of 31 Inpatients. Frontiers in Psychiatry, 06 July 2022. https://doi.org/10.3389/fpsyt.2022.951376 
   
2. Sethi S, Wakeham D, Ketter T, Hooshmand F, Bjornstad J, Richards B, et al. Ketogenic Diet Intervention on Metabolic and Psychiatric Health in Bipolar and Schizophrenia: A Pilot Trial. Psychiatry Research,  2024 May 1,
   https://www.sciencedirect.com/science/article/pii/S0165178124001513
3. Campbell IH, Needham N, Grossi H, Kamenska I, Luz S, Sheehan S, et al. A Pilot Study of a Ketogenic Diet in Bipolar Disorder: Clinical, Metabolomic and Magnetic Resonance Spectroscopy Outcomes,  Oct 2023,
   https://www.medrxiv.org/content/10.1101/2023.10.23.23297391v1
4. Palmer, C.M., J. Gilbert-Jaramillo, E.C. Westman. “The Ketogenic Diet and Remission of Psychotic Symptoms in Schizophrenia: Two Case Studies.” Schizophrenia Research. 2019 June; 208: 439-440, ISSN 0920-9964. https://doi.org/10.1016/j.schres.2019.03.019
5. Sarnyai, Z, Palmer, C.M.,Ketogenic Therapy in Serious Mental Illness: Emerging Evidence, International Journal of Neuropsychopharmacology, Volume 23, Issue 7, July 2020, Pages 434–439, https://doi.org/10.1093/ijnp/pyaa036
6. Norwitz, N., G.A. Dalai, S. Sethi; C. Palmer. “Ketogenic diet as a metabolic treatment for mental illness.” Current Opinion in Endocrinology & Diabetes and Obesity: 2020 Oct: 27(5): 269-274.
7. Eastman, M., KetoConnect, The Ketogenic Ratio Explained, September 16, 2014, https://www.myketocal.com/blog/the-ketogenic-ratio-explained/
8. Dr. David Puder, MD, Psychiatry Podcast, Episode 163, Dr. Chris Palmer: Ketogenic Diet for Mental Health, M=November 15, 2022, https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/163-treating-mental-health-disorders-with-a-ketogenic-diet

 

Copyright ©2023 BetterByDesign Nutrition Ltd.

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