[Update, November 17, 2025: This article was updated to include several powerful graphics from a 2025 paper about the health implications of maltodextrin as an additive in processed foods]

Introduction

A recently updated article titled Complex Carbohydrates as Long Chains of Sugar Molecules, explained that “complex carbohydrates” are really just long chains of sugar molecules, like pearls on a string, and that how quickly blood sugar rises depends on the specific types of sugars in those chains. 

Monosaccharides (made up of a single sugar molecule) are sugars such as glucose and fructose that break down very quickly and quickly impact blood glucose. 

Disaccharides (made up of two sugar molecules), such as sucrose (table sugar), are made up of glucose and fructose combined, and break down more slowly than monosaccharides like glucose and fructose. As a result, the rise in blood glucose is slightly slower than glucose. 

What if you found out that the worst carbohydrate for blood sugar is one that you’ve probably never heard of?

What if you found out that this carbohydrate is often found in sugar-free foods, but is not considered a sugar under Canadian food labeling regulations? 

That is what this article is about.

Glycemic Index (GI)

The Glycemic Index (GI) is a ranking system for carbohydrate-containing foods based on how quickly they raise blood sugar (blood glucose) levels after they are eaten.

Foods are ranked on a scale of 0 to 100, with pure glucose assigned a value of 100. 

High GI foods (ranked with a GI of 70 or more) are rapidly digested and absorbed, causing a quick and high spike in blood sugar levels.

Medium GI foods (ranked with a GI of 56-69) have a moderate effect on blood sugar levels.

Low GI foods (ranked with a GI of 55 or less) are digested and absorbed slowly, releasing glucose gradually into the bloodstream and causing a slower, smaller rise in blood sugar. 

As mentioned in the previous article, factors such as the amount of fiber in the food, as well as the amount of food processing of that food, including cooking, can affect a food’s GI value. 

The Glycemic Index of pure glucose (also called dextrose) is 100, the highest score.

The Glycemic Index of table sugar (i.e., sucrose) is rated with a GI of 65-80 (depending on the source) [4]. Sucrose is a disaccharide made of a mixture of glucose (which has a GI of 100) and fructose (which has a GI of 25). While its overall impact on blood glucose is significant, it is less than pure glucose, which is a monosaccharide, because sucrose takes longer to digest, and thus to spike blood sugar. 

The carbohydrate that you’ve probably never heard of has a Glycemic Index between 85 and 105 (depending on the source), which is higher than table sugar (sucrose) and higher than pure glucose. 

This carbohydrate is maltodextrin. 

Maltodextrin plays a functional role in food manufacturing, primarily serving as a bulking agent, thickening agent, and stabilizer. Products known to contain some of the highest maltodextrin content include sports and energy drinks.

Maltodextrin is also often found in sugar-free foods, but it is not considered a sugar under Canadian food labeling regulations; rather is classified as a “complex carbohydrate”, a polysaccharide food additive.

Note: The reliability of the Glycemic Index in predicting blood sugar responses in individuals was called into question in research conducted in 2016 and 2019, as outlined in this earlier article. However, it is still used, and for comparative purposes, it is used in this article.

What Is Maltodextrin and What Does It Do to Blood Sugar?

Maltodextrin is a refined carbohydrate made from starch — usually from corn, rice, potato, or wheat. Food manufacturers use it as a thickener, filler,  or stabilizer in a wide range of foods and drinks.

Although maltodextrin doesn’t taste very sweet, the body digests it similarly to pure glucose, so it can raise blood sugar very quickly.

Maltodextrin is created when starch is treated with enzymes to break it down into shorter chains of glucose molecules. Because it’s already partially digested, the body absorbs it quickly, giving it a Glycemic Index (GI) between 85 and 105 (depending on the source), which is significantly higher than regular table sugar (sucrose), which has a GI ≈ of 65 and can even be higher than pure glucose (dextrose). 

While maltodextrin has practical applications in the manufacturing of sports drinks or medical nutrition products where quick energy is needed, it is also found in a wide range of foods, including infant formula, protein supplements, and even sugar-free foods. 

Its presence in sugar-free foods is concerning because it can result in a very significant spike in blood sugar in those who are deliberately trying to avoid sugar.

Sucralose, used in the sugar-free sweetener Splenda®. It is made from sucrose (table sugar), where three hydroxyl groups (-OH) are replaced by chlorine. It is approximately 600 times as sweet as table sugar, so most of a packet of Splenda® is maltodextrin, used as a filler.  A 2008 research study found Splenda® to be 1.1% sucralose, 1.1 % glucose, 4.23% moisture, and >93.59% maltodextrin.

While Splenda® is “sugar-free”, the maltodextrin in it can cause blood glucose to spike significantly higher than table sugar. 

Below is a graph comparing the glucose spike from maltodextrin, glucose, and sucrose (table sugar). Table sugar (sucrose) spiked blood glucose to ~145 mg/dl (8.0 mmol/L) at 30 minutes, and maltodextrin spiked blood glucose to ~165 mg/dl (9.0 mmol/l) at 40 minutes.

Below is a bar chart illustrating the percentage of products containing maltodextrin.

Some of the highest maltodextrins are found in sports and energy drinks (84%); however, protein supplements have the same percentage of maltodextrin (84%), and infant formula has an even higher percentage (89%).

Maltodextrin is also present in a wide range of foods that are marketed as “healthy options”, including protein powders and meal replacement bars. As is the case with sugar-free foods containing maltodextrin, consumers rely on labels on these products to make informed dietary choices, unaware of the impact that maltodextrin can have on their blood sugar.

Why Blood Sugar Spikes Matter

Since maltodextrin digests and absorbs rapidly, it can cause rapid spikes in blood glucose and insulin levels.

Over time, repeated spikes can lead to:

• • Energy crashes or fatigue after meals

  • Increased hunger and sugar cravings

  • Blood sugar instability in people with diabetes, PCOS, or insulin resistance

  • Possible gut microbiome disruption when consumed in large amounts 

Final Thoughts…

Maltodextrin is a common hidden carbohydrate used in processed foods.

While maltodextrin may serve a useful role in the manufacturing of specialized products for athletes or in medical nutrition products, people relying on a  “healthy” protein shake or a meal replacement bar are usually unaware of the effect it can have on their blood sugar.  How much more do those with prediabetes or diabetes (type 1 or type 2) need to know which products, including sugar-free products, contain maltodextrin?

For those needing to control their blood sugar, it is recommended to read labels closely and limit foods containing maltodextrin. Choosing whole-food carbohydrate sources in amounts that can be monitored (“carb counting”) makes controlling blood sugar possible.

To your good health. 

Joy 

You can follow me on:

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

References

1. 1. Brand‑Miller JC, Foster‑Powell K, Atkinson F. The International Tables of Glycemic Index and Glycemic Load Values. Am J Clin Nutr. 2002;76(1):5–56. 2008: DOI 10.2337/dc08-1239) [https://pubmed.ncbi.nlm.nih.gov/18835944/]
   2. U.S. Department of Agriculture (USDA). FoodData Central: Maltodextrin – Ingredient Profile and Energy Content. Washington, DC: USDA; Accessed 2024. URL: https://fdc.nal.usda.gov
   3. U.S. Food and Drug Administration (FDA). Code of Federal Regulations Title 21 – Maltodextrin (21 CFR 184.1444). Silver Spring, MD: FDA. URL: https://www.ecfr.gov/current/title-21/chapter-I/subchapter-B/part-184#p-184.1444
   4. Health Canada. List of Permitted Food Additives with Other Accepted Uses. Ottawa, ON: Health Canada; Updated 2023. URL: https://www.canada.ca/en/health-canada/services/food-nutrition/food-additives/permitted-use-additives.html
   5. Hofman, D. L., van Buul, V. J., & Brouns, F. J. P. H. (2015). Nutrition, Health, and Regulatory Aspects of Digestible Maltodextrins. Critical Reviews in Food Science and Nutrition, 56(12), 2091–2100. https://doi.org/10.1080/10408398.2014.940415
   6. Yarley EJ, Unveiling Hidden Sugars: A Critical Analysis of Maltodextrin as a Polysaccharide Additive in Processed Foods and Its Health Implications, International Journal of Medical Science and Clinical Invention 12(04): 7602-7621, 2025DOI:10.18535/ijmsci/v12i.04.02 https://valleyinternational.net/index.php/ijmsci
   7. Magnuson BA, Roberts A, Nestmann ER, Critical review of the current literature on the safety of sucralose, Food and Chemical Toxicology,
      Volume 106, Part A, 2017, Pages 324-355, https://doi.org/10.1016/j.fct.2017.05.047.
   8. Abou-Donia MB, El-Masry EM, Abdel-Rahman AA, McLendon RE, Schiffman SS. Splenda alters gut microflora and increases intestinal p-glycoprotein and cytochrome p-450 in male rats. J Toxicol Environ Health A. 2008;71(21):1415-29. [http://www.ncbi.nlm.nih.gov/pubmed/18800291]

Copyright ©2025 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.

[This article was written on November 10, 2024, and was updated on October 10, 2025.]

We are finally breaking the stigma and talking about mental health. Men grow moustaches in November to raise awareness about prostate health, so it is time to move past embarrassment and talk about colorectal health. This is my first article in this area and is about ways to reduce the incidence of painful conditions related to hemorrhoids. An article related to alcohol consumption as a risk factor for colon or rectal cancer is next.

What are Hemorrhoids?

The most well-known type of hemorrhoids, sometimes called “piles,” are swollen, inflamed veins (like varicose veins) in the rectum, or on the anus that can be painful, itchy, and may bleed, and are frequently (pardon the pun) the butt of jokes. These are external hemorrhoids that form under the skin around the anus and may resolve with a few days of over-the-counter ointment, but can become enlarged and painful.

Internal hemorrhoids are located on the lining of the rectum above what is called the dentate line (2-4 cm / 3/4 – 1.5 inches from the opening of the anus). These are normal structures that are aligned in three columns in the rectum and function like bubble wrap — cushioning the rectum against irritation from the stool until a bowel movement [1].

Most people are unaware that internal hemorrhoids are there until one becomes irritated and swollen, or worse, prolapses and protrudes from the anus. Internal hemorrhoids may result in chronic, low-grade internal bleeding can indeed lead to iron deficiency or iron-deficient anemia, even when people have no idea they are losing blood.

There are four grades of internal hemorrhoids based on the degree of prolapse. 

Grade 1: Not at all prolapsed.

Grade 2: Prolapses with a bowel movement, but retracts by itself. 

Grade 3: Prolapses with a bowel movement and has to be manually pushed it back in. 

Grade 4: Prolapsed but can’t be pushed back in, or only with a lot of pain.

Since internal hemorrhoids lie above the dentate line, they don’t have nerve endings, and are painless and remain that way until one becomes irritated — or worse, becomes inflamed and protrudes from the rectum like a large, angry grape.

If an inflamed internal hemorrhoid is located on the left lateral side, it may be too painful to sleep on that side, and if it is located on the right posterior side, it may be too painful to sleep on one’s back. Regardless of where it’s located, a Grade 3 or 4 hemorrhoid may make it too uncomfortable to sleep much at all — and since people are generally too embarrassed to talk about hemorrhoids, this pain is largely endured in silence.

Note: external hemorrhoids that lie at the dentate line are internally located but are considered external hemorrhoids because they are at or below the dentate line. These have many nerve endings and, once inflamed, can also prolapse outside the anus. If they don’t resolve with over-the-counter treatment, surgical procedures to remove them are required. 

A blood clot may form within a hemorrhoid, causing it to become thrombosed, and if this causes the blood supply to get cut off, a strangulated hemorrhoid results, which is excruciatingly painful. 

The pain of hemorrhoids ranges considerably. It’s only once an internal hemorrhoid becomes irritated, swollen, and inflamed that it becomes painful. If an internal hemorrhoid or an external hemorrhoid at the dentate line prolapses, the pain can go from a 1-3 on a Likert pain scale of 1- 10 (with 10 being the worst) to an 8 or 9 on 10, and this can occur suddenly, without warning. A person can literally go from having no awareness of having internal hemorrhoids or external hemorrhoids at the dentate line, to having a prolapsed hemorrhoid, and significant pain.

Treatment for Hemorrhoids

Internal hemorrhoids above the dentate line can be treated with rubber band ligation (RBL), which is the most common first-line treatment [2, 3]. This is where a small rubber band is applied to the base of the hemorrhoid and cuts off the blood supply to it. In essence, this is a planned strangulated hemorrhoid. Over a week or two (depending on the hemorrhoid’s size), the walls will thicken, and the overall size of it will shrink. After approximately 10-14 days, the rubber bands fall off the hemorrhoid, leaving an ulcer. The ulcer may bleed slightly with bowel movements over a few days as it heals [4]. Finally, what will remain is a bit of scar tissue on the rectal wall, and that may continue to bleed lightly during bowel movements until it heals completely over the following few weeks. While the banding procedure itself is painless when done properly, and is usually performed without anesthesia, the pain from the hemorrhoid itself can be significant until it finally falls off after ligation, and heals. If banding doesn’t work or if the hemorrhoid becomes inflamed or prolapsed, surgery will likely be required.

In some cases, after hemorrhoid banding, or after an external hemorrhoid at the dentate line gets better on its own, a rectal polyp may form from the ulcer that remains where the hemorrhoid was. In some cases, the polyp can become larger than the original hemorrhoid and may become inflamed and prolapse out of the anus.  Since rectal polyps can form for reasons other than a previously existing hemorrhoid, surgery will be recommended to remove the polyp, and a biopsy will be performed to determine if the polyp is benign (not cancerous) or pre-cancerous.

Causes of Hemorrhoids

Hemorrhoids, both internal and external, were previously thought to be preventable mainly through dietary changes; yet diet is only part of reducing the likelihood of getting hemorrhoids. More than two-thirds of Canadians and Americans engage in a daily habit that significantly increases the risk of developing hemorrhoids, and simple lifestyle changes can help reduce that risk.

Half of adults will have had hemorrhoids by age fifty, yet it’s rare for people to talk about them. Only 4% of people go to their doctor for help because they’re embarrassed, and the last thing they want is to have someone have a look “down there” and poking around. They just want their hemorrhoids to stop hurting and to go away— and the faster, the better. Most people will self-treat with Epsom salt sitz baths and over-the-counter topical creams or wipes, and only seek medical help if the symptoms persist or get worse.

As a Dietitian, I have routinely asked my clients about their bowel function, including how often they poop and its texture — and most are fine with answering these questions because they know this is within my scope of practice. Even though I was taught that part of what can help people avoid hemorrhoids is dietary, until recently, I never asked anyone whether they’ve been experiencing hemorrhoids. This has changed. While getting enough of the right type of fiber and drinking sufficient water are important, two lifestyle factors are thought to contribute to the development of hemorrhoids, and these are the focus of this article. 

The good news is that by adopting a few simple dietary changes and modifying two lifestyle habits, the risk of developing hemorrhoids can be reduced. 

Most people know that avoiding constipation is important to reduce the risk of getting hemorrhoids, and think that drinking enough water and eating lots of “roughage” is the way to accomplish that. What few realize is that some types of fiber can make constipation worse — especially if there is insufficient water intake. But reducing the risk of hemorrhoids involves more than diet. The length of time that we sit on the toilet, as well as the position that we sit on it, both play a significant role in the risk of developing hemorrhoids. 

Squatting versus Sitting Toilet   

In much of Asia, South East Asia, and Africa, the squatting toilet is the norm. The user positions themselves in a squat position over a floor-level porcelain bowl, which results in the colon and rectum being positioned in a straight line. This enables bowel movement to occur significantly faster and without straining than what occurs when using a western-style pedestal toilet. These are more than “holes in the ground” but are real toilets with a flush mechanism that the user engages to empty the bowl — just like on a Western toilet. 

In Europe and most of the West, the pedestal toilet is the norm, which is used in a sitting position. This type of toilet results in a bend in the alignment between the colon and the rectum, causing it to take longer to have a bowel movement, and frequently requiring more than one “visit” to accomplish it. Of importance, the seat design of a pedestal toilet results in increased pressure on the rectum and anus, which significantly increases the risk of developing hemorrhoids.

Middle Eastern and North African countries have both squatting and pedestal toilets, depending on the region. 

There are various types of squatting platforms available for purchase that can be placed over a standard Western pedestal toilet, converting it into a squatting toilet. These are popular with people who have emigrated from countries where squatting toilets are the norm. 

Also available online are various types of squatting footstools that are placed in front of a standard Western pedestal toilet and enable the user to sit in a semi-squatting position. These squatting stools allow for better alignment of the colon and the rectum, and are frequently recommended to people recovering from hemorrhoids, hemorrhoid ligation (banding), and hemorrhoid surgery. These squatting stools allow for less pressure on the anus and pelvic floor, and as a result, may help reduce the development of hemorrhoids or deterioration of unknown internal hemorrhoids. 

The Length of Time Sitting on a Pedestal Toilet 

Due to the shape of the seat on a Western-style pedestal toilet, the length of time that one sits on it increases the risk of developing hemorrhoids. This is due to the increased pressure on the pelvic floor, lower rectum, and anus resulting from the seat’s shape. 

Think of a single-hole paper punch. 

The pressure exerted over a small hole is what makes a one-hole paper punch so effective. Good for paper,  not good for rectums.

To limit pressure on the rectum and anus, it is recommended to limit “seat time” to 3-5 minutes at a time, 10 minutes maximum in 24 hours [1]. 

Washrooms as Phonebooths

In the early 1950s, most houses only had one washroom or bathroom, so multiple members of the same household had to do what they needed to in a limited time and get out. It was rare to have the luxury of being able to sit on the toilet for an extended period of time, reading the newspaper. Now, 97% of new home construction has more than one washroom or bathroom [5] — most often having two full washrooms, plus an additional 1/2 bathroom containing a toilet and a sink. 

With three toilets per house for an average family size of three in Canada [6] means that each member of the average household has access to a toilet on demand, and can — and does spend inordinate amounts of time sitting on it.

A recent study found that 2/3 of Canadians and even more Americans are on their smartphones while sitting on the toilet [6]. The washroom is the new phone booth. It is one of the only places in the house where some can have time alone, and all this increased sitting on the toilet scrolling on the phone is thought to be related to the increased rates of hemorrhoids seen in younger and younger adults. 

Final Thoughts

There are simple things we can do to lower the risk of developing hemorrhoids.

We can drink more water and eat enough of the right types of fiber.

A squatting stool can help align our colon, making defecation time shorter, while reducing the amount of pressure on our rectum.

It is recommended to limit “seat time” to 3-5 minutes. Not scrolling on the phone while sitting on the toilet will make it possible to do what is needed in the recommended amount of time, significantly reducing the risk of developing hemorrhoids.

Remembering how a one-hole punch works may be a helpful reminder. 

For those who have never experienced the pain of a large, prolapsed hemorrhoid, implementing these changes may help avoid the experience. For those who have, I hope that learning how to minimize the risk of another will be welcomed news. 

To your good health. 

Joy 

You can follow me on:

Twitter: https://twitter.com/jyerdile

Facebook: https://www.facebook.com/BetterByDesignNutrition/

References 

1. UT Southwestern Medical Centre, Treating hemorrhoidal disease: Conservative vs. surgical approaches, April 14, https://utswmed.org/medblog/best-ways-to-treat-hemorrhoids/ 
2. Zagriadskiĭ EA, Bogomazov AM, Golovko EB. Conservative Treatment of Hemorrhoids: Results of an Observational Multicenter Study. Adv Ther. 2018 Nov;35(11):1979-1992. doi: 10.1007/s12325-018-0794-x. Epub 2018 Oct 1. Erratum in: Adv Ther. 2018 Nov;35(11):1993. doi: 10.1007/s12325-018-0817-7. PMID: 30276625; PMCID: PMC6223991. [https://pmc.ncbi.nlm.nih.gov/articles/PMC6223991/]
3. McKeown DG, Goldstein S. Hemorrhoid Banding. [Updated 2024 Feb 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558967/
4. Hawkins AT, Davis BR, Bhama AR, Fang SH, Dawes AJ, Feingold DL, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024 May 1. 67 (5):614-623. [https://pubmed.ncbi.nlm.nih.gov/38294832/]
5. Eye on Housing, Number of Bathrooms in New Homes in 2021, November 3, 2022, https://eyeonhousing.org/2022/11/number-of-bathrooms-in-new-homes-in-2021/
6. Statistics Canada, Average Family Size in Canada, 2021 https://www.statista.com/statistics/478948/average-family-size-in-canada/
7. Toronto Sun, Two-thirds of Canadians take smart phones into the bathroom: Survey, May 16, 2022, https://torontosun.com/news/national/survey-65-of-canadians-take-their-smart-phones-into-the-bathroom

Copyright ©2025 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 Western culture, the main focus as we age is to keep ourselves “looking young,” usually pursued by buying special skin and hair-care products. In Japan, avoiding “kareishu”, or “old people smell,” is a significant focus in aging. There are special soaps and washing products promoted to meet this need, as well as research into foods that can neutralize it.

What is “Old People Smell”?

“Old people smell” is the characteristic ‘greasy, grassy odor’ most noticeable in nursing homes and long-term care facilities, beyond the smells of urine, feces, and spilled food. Many independent-living older adults also have it, though they may have become desensitized to it. Children and grandchildren are often more aware of it.

Body odor can be influenced by eating foods such as onions, garlic, ginger, and certain spices, as well as by medications. However, “old people smell” mainly comes from 2-nonenal, a volatile compound formed by the oxidative breakdown of palmitoleic acid and vaccenic acid, which are two omega-7 unsaturated fatty acids that increase on the skin from about age 40 onwards [1].

Compared to adults under 40, 2-nonenal can increase by up to 6-fold, though the exact reason is unclear [1]. More omega-7 fatty acids or lipid peroxides on the skin correlate with higher 2-nonenal levels [1]. Like other unsaturated fats, omega-7s are prone to oxidation.

Limiting the oxidation of omega-7 fats, as well as keeping skin, bedding, and clothing clean, can significantly reduce “old people smell.” Because 2-nonenal is fat-soluble, ordinary water-based soaps may not be effective in removing it. Polyphenol-containing soaps have been shown to reduce 2-nonenal on the skin [2].

Targeting “Old People Smell” — Lifestyle and Dietary Changes

Lifestyle Changes

Recommended lifestyle measures include wearing natural fibers such as cotton, linen, or silk to allow fatty acid compounds to transfer to the clothing, which can then be easily washed. Washing bedding and clothes in enzyme-activated detergents can break down odor-causing fatty acids. Soaps containing polyphenols, such as concentrated Japanese persimmon extracts, have been demonstrated to reduce 2-nonenal on the skin [2]. Note: Regular persimmon juice or leaves are not equivalent to concentrated tannin extracts used in studies.

Dietary Changes

Since higher levels of palmitoleic acid and vaccenic acid on the skin increase 2-nonenal, dietary strategies include reducing intake of these fats and increasing dietary intake of antioxidants.

Reducing Intake of Palmitoleic Acid and Vaccenic Acid

Foods rich in palmitoleic acid include macadamia nuts, macadamia oil, avocado, avocado oil, olive oil, and sea buckthorn oil [3]. Vaccenic acid is found in ruminant fats, including beef, lamb, and dairy products [3]. Reducing these foods may decrease 2-nonenal formation. Omega-7 fats are non-essential, as the body can synthesize them via de novo lipogenesis [3]. 

Increasing Intake of Dietary Antioxidants

Certain antioxidants and polyphenols may help reduce lipid oxidation and 2-nonenal formation:

Green tea catechins have antioxidant activity that may help reduce oxidative odor precursors [4].

Champignon (white button mushroom) extract was shown in a 4-week trial to reduce body odor in adults, although the study is limited in sample size [5].

Eggplant phenolamides have demonstrated 2-nonenal scavenging activity in vitro and in animal models, suggesting potential reduction in odor [6].

Blackcurrant powder rich in anthocyanins reduced 2-nonenal skin emission in middle-aged adults [7]. Other anthocyanin-rich foods, such as elderberries, blackberries, blueberries, raspberries, acai, and pomegranate, may have similar effects [8]. 

Final Thoughts

As the saying goes, “beauty is more than skin deep“, and just as young skin and hair aren’t achieved by applying cosmetics and hair dyes, “smelling young” isn’t achieved only by using special soaps.

While cosmetics, special soaps, and detergents can certainly help, the essence of looking young and smelling young is primarily achieved by eating real, whole food rich in natural antioxidants and nourishing oneself from the inside out.

Unfortunately, to limit costs, public long-term care centers rarely provide their residents with the types of antioxidant-rich foods known to minimize the characteristic ‘greasy, grassy odor’ found in these residences. They don’t have to smell like that.

When we become parents, we learn how to feed our infants and children — but who teaches us how to feed ourselves as we age, or our aging parents? Eating well at any age doesn’t just happen by chance. 

Enabling seniors to remain independent into their advanced years begins with dietary and lifestyle changes in middle age (or sooner) — including eating sufficient amounts of the right types of protein to maintain muscle and bone mass, and eating real, whole food rich in antioxidants. 

More Info?

I help adults to be the best they can be at any age, offering services such as the Healthy Aging Package to meet this need. Visit the Services tab to learn more.

To your good health!

Joy

You can follow me on:

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

References

1. Haze S, Gozu Y, Nakamura S, Kohno Y, Sawano K, Ohta H, Yamazaki K. 2-Nonenal newly found in human body odor tends to increase with aging. J Invest Dermatol. 2001 Apr;116(4):520‑524. doi:10.1046/j.0022-202X.2001.01287.x https://pubmed.ncbi.nlm.nih.gov/11286617/]

2. Tatsuguchi I, Matsuoka T, Izumi R, Ijichi S, Shibata H. Preventive effect against the aged men’s body odor by the soap containing polyphenol. Jpn Assoc Odor Environ. 2012;43(5):362–366 [https://www.jstage.jst.go.jp/article/jao/43/5/43_362/_article/-char/en]

3. Venn-Watson E. Fatty 15, Omega 7: What To Know About This Fatty Acid. https://fatty15.com/blogs/news/what-is-omega-7

4. Cabrera C, Artacho R, Giménez R. Beneficial effects of green tea — a review. J Am Coll Nutr. 2006 Apr;25(2):79‑99. doi:10.1080/07315724.2006.10719518 [https://pubmed.ncbi.nlm.nih.gov/16582024/]

5. Nishihira J, Nishimura M, Tanaka A, Yamaguchi A, Taira T. Effects of 4‑week continuous ingestion of champignon extract on halitosis and body and fecal odor. J Tradit Complement Med. 2015 Dec 11;7(1):110‑116. doi:10.1016/j.jtcme.2015.11.002 [https://pmc.ncbi.nlm.nih.gov/articles/PMC5198824/]

6. Kim HM, Kim JH, Jeon JS, Kim CY. Eggplant Phenolamides: 2‑Nonenal Scavenging and Skin Protection Against Aging Odor. Molecules. 2025 May 12;30(10):2129. doi:10.3390/molecules30102129 [https://pmc.ncbi.nlm.nih.gov/articles/PMC12114487/]

7. Willems M, Todaka M, Banic M, Cook M, Sekine Y. Effect of New Zealand Blackcurrant Powder on Skin Emission of Volatile Organic Compounds in Middle‑Aged and Older Adults. Curr Dev Nutr. 2019;3(Suppl 1):nzz031.P06‑092-19. doi:10.1093/cdn/nzz031.P06‑092-19 [https://pmc.ncbi.nlm.nih.gov/articles/PMC6576077/]

8. Lakshmikanthan M, Muthu S, et al. A comprehensive review on anthocyanin-rich foods: Insights into extraction, medicinal potential, and sustainable applications. J Agric Food Res. 2024;17:101245. doi:10.1016/j.jafr.2024.101245 [https://www.sciencedirect.com/science/article/pii/S2666154324002825]

Copyright ©2025 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 have heard about the benefits of intermittent fasting and time-restricted eating; however, the duration and timing of fasting are important considerations. 

Intermittent fasting refers to specific times for ‘eating’ and ‘not eating’ (fasting) on a set schedule. There are two main types, which are (1) partial fasting or alternate-day fasting, and (2) time-restricted feeding (TRF).

Two Main Types of Intermittent Fasting

Partial Fasting or Alternate Day Fasting is a type of intermittent fasting where fasting days are set to a specific number of days out of the week and may include one day out of seven, or ‘alternate day fasting’ — where the usual amount of food is consumed every other day.

Time-Restricted Eating (TRE), also called time-restricted feeding (TRF), is a type of intermittent fasting where eating occurs during a specific period each day, and ‘not eating’ (fasting) occurs the remainder of the time.

The “5:2 diet” is a type of time-restricted eating that has people eating 25% of their normal caloric intake on two non-consecutive days per week (i.e., ~400-500 calories per day for women and ~500-600 calories for men), and consuming normal intake on the other five days. Since the focus is on restricted caloric intake and not intermittent eating, it has not been elaborated on in this article.

A common TRE schedule is 16:8, and is where all eating occurs during 8 hours, and the remaining 16 hours per day is a period of fasting. This is often done by people skipping breakfast and eating from midday until ~8 PM. 

Periods of Fasting of 24 hours or more

Except as required for specific clinical or religious reasons, I do not recommend that people engage in periods of fasting of 24 hours or more based on the effect of fasting on lean body mass (muscle). For this, I refer to the work of medical doctor Dr. Stephen Phinney, MD, PhD, and Registered Dietitian Dr. Jeff Volek, RD, PhD.

Phinney and Volek have documented that, in periods of prolonged fasting (1-42 days), nitrogen loss, which is a marker of protein loss, begins on day 1 and reaches a maximum on day 3, then gradually declines[1].

“Net protein breakdown begins within the first day of fasting, reaches its maximum rate within 2-3 days – typically a pound of lean tissue lost per day.[1]”

While the human body has fat stores that can easily sustain us during extended periods where we don’t eat, the body does not have reserve protein stores to sustain us over long periods of fasting. All the protein in the body — whether as muscle, red blood cells, antibodies, or neurotransmitters is functional, so “whenever the body loses protein, it loses some of its functional reserve[1].” 

Time Restricted Eating 

Time-restricted eating (TRE), also called time-restricted feeding (TRF), is, for most people, the easiest form of intermittent fasting to do because the period of not eating only occurs for part of the day.

An early pilot study from 2019 in adults with metabolic syndrome which includes high blood pressure, elevated blood sugar, excess fat around the abdomen, and abnormal cholesterol levels found that limiting eating to only 10 hours per day (i.e. a 10 hour “eating window”) promoted weight loss, reduced abdominal fat, and led to more stable blood sugar and insulin levels in those taking standard medication to lower cholesterol and blood pressure [2].  

The researchers from the Salk Institute, including circadian biologist Dr. Satchidananda Panda, concluded that the 10-hour time-restricted eating schedule supported an individual’s circadian rhythms, which results in health benefits evidenced by previous and subsequent mouse studies published by the Salk team[3].

Circadian rhythms are the regular 24-hour cycles of biological processes that affect nearly every cell in the body. 

“Eating and drinking everything (except water) within a consistent 10-hour window allows your body to rest and restore for 14 hours at night. Your body can also anticipate when you will eat, so it can prepare to optimize metabolism.[3]”

A follow-up study from the researchers at Salk Institute that was published in 2024, found that people who ate within a consistent eight-to-ten-hour window each day for three months saw improvements in several markers of blood sugar and metabolic function, compared to those who received standard treatment [4].

Given that more than 1/3 of adults in the US [4], and more than 19% — or 1 in 5 adults in Canada have metabolic syndrome[5] which rises to ~40% in adults over the age of 65, the implication that simply changing the amount of time each day in which eating occurs can significantly improve markers or metabolic syndrome, is significant. 

Erratic Eating Patterns in Adults

A landmark study from 2015 by circadian biologist Dr. Satchidananda Panda of Salk Institute had healthy, normal-weight adults who did not perform shift work track everything they ate each day for 21 days (3 weeks) by taking pictures of it using a smartphone app. The time-stamp on each photo enabled analyses of the time at which eating occurred. Participants were recruited through a newspaper advertisement, paper flyers, and online advertisements, and inclusion and exclusion criteria were determined by an online questionnaire and in-person interview.

In contrast to the popular belief that most people eat three meals per day within a 12-hour interval, this study found that eating patterns are much more erratic and differ between weekdays and weekends.

The amount of time spent eating each day (95% interval) approached 15 hours per day for half the people in the study, and the only time they were not eating was when they were sleeping.

In addition, less than 25% of calories were eaten before noon, and more than 35% of calories were eaten after 6 PM.

While the sample set in this study was small, my clinical experience has found that at least half of adults eat this way. 

Supporting Time-Restricted Eating 

It’s important to keep in mind that for some people, the idea of eating actual meals over a 10-hour period without eating snacks IS intermittent fasting when compared to the way that they usually eat. 

For those accustomed to eating meals and snacks or grazing over 15 hours, the idea of eating meals with nothing between over 10 hours can seem daunting. Many are concerned they will be hungry, and others that their blood sugar will drop, making them feel lightheaded or dizzy. By ensuring that meals are made up of sufficient amounts of highly bioavailable protein and healthy fats, both of these concerns are easily addressed. 

Studies support that eating and sleeping according to one’s natural circadian rhythms will, in and of itself, improve many health markers, and when one’s Meal Plan is designed to factor in desired fat loss and/or muscle gain, the benefits are additive.

Implementing a 16:8 Time Restricted Eating Schedule

As mentioned above, a common time-restricted eating schedule is 16:8, where eating occurs during an 8-hour eating window, and the remaining 16 hours per day are fasting. Most people skip breakfast and begin eating from 11 AM or noon until ~7 or 8 PM. This is called a late time-restricted eating window (TRE_L). That, however, is not the only way to eat within a 16:8 window,

Some will eat breakfast at ¬7 or 8 AM and finish eating at 3 or 4 PM (with one or no meals in between), and this is called an early time-restricted eating window (TRE_E).

Does it matter whether someone does an early or a late 16:8 time-restricted eating window? Chrononutrition studies seem to indicate that it can.

Chrononutrition 

Chrononutrition is a field of study that examines the complex relationship between when eating occurs relative to normal human circadian rhythms and metabolic health, and studies indicate that the timing of eating matters — both the timing of the first eating occasion, and how late the last meal occurs. 

Circadian rhythms are regular fluctuations of physiological processes over 24 hours and include the production of hormones such as cortisol, insulin, and melatonin, as well as certain enzymes used in digestion.

Studies have shown that glucose tolerance as well as insulin sensitivity are at their peak in the morning and decrease significantly later in the day. As a result, when meals are eaten late in the evening, when insulin production is at its lowest, there is an increase in blood glucose, insulin release, appetite, and the risk of obesity [8,9].

When We Eat Matters

In the 16-year prospective Health Professionals Follow-up Study, which had almost 27,000 middle-aged male subjects, men who skipped breakfast had a 27% higher risk of coronary heart disease found to be mediated by higher BMI, high blood pressure, diabetes, and high cholesterol [10]. In other studies, breakfast skipping has been linked to greater type 2 diabetes risk, higher total and LDL cholesterol levels, body weight, fat mass, and abdominal adiposity, and lower HDL cholesterol [11,12]. In the same study, there was a 55% higher coronary heart disease risk in men who ate late at night [11]. 

In a 2014 study from Japan, breakfast skipping was associated with 28% and 57% higher odds of developing metabolic syndrome and obesity, but only when it was in combination with eating late-night dinners within 2 hours of bedtime [13]. While it is hard to tease out whether the issue is skipping breakfast or eating late into the evening, an earlier fasting window TRE_E solves both issues.

In the 2019 national Korean dataset, night eating, which was defined as eating after 9 PM, was associated with 48% higher odds of metabolic syndrome in men but not women, suggesting that there may be sex differences in these associations [14]. In ~900 middle-aged to older adults in the same Korean data set, a higher percentage of daily energy eaten within 2 hours of bedtime was associated with 82% higher odds of being overweight and obese, whereas a higher percent of of daily energy intake consumed during the morning window, within 2 hours of waking up was associated with 47% lower odds of being overweight and obese [15].

Early or Late Time-Restricted Eating – Some Considerations

To a large extent, for most adults, deciding to adopt either an early or late time-restricted eating schedule comes down to a matter of personal preference and convenience.

For older adults, however, the need to prioritize protein and the amino acid leucine first thing in the morning favours an early time-restricted eating window, but that will be a topic of an upcoming post. 

Adults who need to eat their dinner with other family members will often adopt a late time-restricted eating window (TRE_L). They will feed their family breakfast, but not begin to eat themselves until 11 AM or noon. They will eat their second meal with their family around 5-6 PM, then eat their final meal of the day at ¬8 or 9 PM.  A drawback to this is that eating this late can delay sleep onset because one of the signals required for the body to release melatonin from the brain is a drop in core body temperature. Since digestion of food produces a lot of heat, late consumption of food delays the release of melatonin and, subsequently, delays sleep. As well, eating within 2 – 3 hours of bedtime may be associated with some of the metabolic drawbacks observed in studies — especially for those who already have abnormal blood sugar, blood pressure, cholesterol, or weight.

Those who adopt an early time-restricted eating window (TRE_E) will usually have their breakfast at ¬7 AM, lunch at around 11:00 AM, and their last meal of the day around 4 PM. By having sufficient highly bioavailable protein at each of the three meals along with sufficient amounts of healthy fats, hunger is a non-issue, and blood glucose is well controlled because eating occurs when the body is the most insulin sensitive.

Final Thoughts…

For those who are used to eating or grazing over 15 hours, having a Meal Plan that distributes meals over a 10-hour eating window may be the best place to start. This will allow for improvements in metabolic markers, fat loss, and muscle gain, while being able to eat their meals with family members.

Those who need to eat dinner with other family members may find adopting a late time-restricted eating window (TRE_L) the most convenient because it lets them feed their family breakfast while beginning to eat themselves closer to 11 AM, eat their second meal with their family around 5-6 PM, and eat their final meal of the day at ¬8 PM. While it can have an impact on sleep onset and be less than optimal in terms of metabolic improvements, it will likely be a significant improvement to how they were eating before.

Finally, those who can adopt an early time-restricted eating window (TRE_E) often enjoy having breakfast at ¬7 or 8 AM, lunch, if they eat it at around 11:00 AM, and eat their last meal of the day around 4 PM. Those who are responsible for making meals for their families do very well following this eating window by eating their dinner early, then sitting with their family while they eat dinner.  This way, they don’t miss out on this important time of connecting with the families.

As in other areas, there is no one-size-fits-all approach.

More Info?

If you would like to learn about how I can help support you with a style of time-restricted eating that best suits your lifestyle, please visit the landing page to learn about the services that I provide.

To your good health!

Joy

You can follow me on:

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

References

1. 1. Virta Health, Phinney S., Volek J., To Fast or Not to Fast: What are the Risks of Fasting, December 5, 2017, https://www.virtahealth.com/blog/science-of-intermittent-fasting
   2. Wilkinson MJ, Manoogian EN, et al Ten-Hour Time-Restricted Eating Reduces Weight, Blood Pressure, and Atherogenic Lipids in Patients with Metabolic Syndrome, Cell Metabolism, Volume 31, Issue 1, 92 – 104.e5, doi: 10.1016/j.cmet.2019.11.004 [https://pubmed.ncbi.nlm.nih.gov/31813824/]
   3. Salk News, December 5, 2019, Clinical Study Finds Eating Within a 10-hour Window May Stave Off Diabetes, Heart Disease, https://www.salk.edu/news-release/clinical-study-finds-eating-within-10-hour-window-may-help-stave-off-diabetes-heart-disease/
   4. Manoogian ENC, Wilkinson MJ, et al. Time-Restricted Eating in Adults With Metabolic Syndrome: A Randomized Controlled Trial. Ann Intern Med.2024;177:1462-1470. doi:10.7326/M24-0859 [https://pubmed.ncbi.nlm.nih.gov/39348690/]
   5. Rao DP, Dai S, et al, (2014) Metabolic syndrome and chronic disease, Chronic Diseases and Injuries in Canada (CDIC), Vol. 34, No. 1, https://doi.org/10.24095/hpcdp.34.1.06
   6. Gill, S., and Panda, S. (2015). A Smartphone App Reveals Erratic Diurnal Eating Patterns in Humans that Can Be Modulated for Health Benefits. Cell Metabolism. 22. 10.1016/j.cmet.2015.09.005. [https://pmc.ncbi.nlm.nih.gov/articles/PMC4635036/]
   7. Raji OE, Kyeremah EB, Sears DD, St-Onge MP, Makarem N. Chrononutrition and Cardiometabolic Health: An Overview of Epidemiological Evidence and Key Future Research Directions. Nutrients. 2024 Jul 19;16(14):2332. doi: 10.3390/nu16142332. PMID: 39064774; PMCID: PMC11280377. [https://pubmed.ncbi.nlm.nih.gov/39064774/]
   8. Poggiogalle E, Jamshed H, Peterson CM. Circadian regulation of glucose, lipid, and energy metabolism in humans. Metabolism. 2018 Jul;84:11-27. doi: 10.1016/j.metabol.2017.11.017. Epub 2018 Jan 9. PMID: 29195759; PMCID: PMC5995632. [https://pubmed.ncbi.nlm.nih.gov/29195759/]
   9. Saad A, Man, CD et al, Diurnal Pattern to Insulin Secretion and Insulin Action in Healthy Individuals. Diabetes 1 November 2012; 61 (11): 2691–2700. https://doi.org/10.2337/db11-1478
   10. Cahill L.E., Chiuve S.E., Mekary R.A., Jensen M.K., Flint A.J., Hu F.B., Rimm E.B. Prospective Study of Breakfast Eating and Incident Coronary Heart Disease in a Cohort of Male US Health Professionals. Circulation. 2013;128:337–343. doi: 10.1161/CIRCULATIONAHA.113.001474. [https://pubmed.ncbi.nlm.nih.gov/23877060/]
   11. Paoli A., Tinsley G., Bianco A., Moro T. The Influence of Meal Frequency and Timing on Health in Humans: The Role of Fasting. Nutrients. 2019;11:719. doi: 10.3390/nu11040719. [https://pubmed.ncbi.nlm.nih.gov/30925707/]
   12. Witbracht M., Keim N.L., Forester S., Widaman A., Laugero K. Female Breakfast Skippers Display a Disrupted Cortisol Rhythm and Elevated Blood Pressure. Physiol. Behav. 2015;140:215–221. doi: 10.1016/j.physbeh.2014.12.044. [https://pubmed.ncbi.nlm.nih.gov/25545767/]
   13. Kutsuma A., Nakajima K., Suwa K. Potential Association between Breakfast Skipping and Concomitant Late-Night-Dinner Eating with Metabolic Syndrome and Proteinuria in the Japanese Population. Scientifica. 2014;2014:253581. doi: 10.1155/2014/253581 [https://pubmed.ncbi.nlm.nih.gov/24982814/]
   14. Ha K., Song Y. Associations of Meal Timing and Frequency with Obesity and Metabolic Syndrome among Korean Adults. Nutrients. 2019;11:2437. doi: 10.3390/nu11102437. [https://pubmed.ncbi.nlm.nih.gov/31614924/]
   15. Xiao Q., Garaulet M., Scheer F.A.J.L. Meal Timing and Obesity: Interactions with Macronutrient Intake and Chronotype. Int. J. Obes. 2019;43:1701–1711. doi: 10.1038/s41366-018-0284-x. [https://pubmed.ncbi.nlm.nih.gov/30705391/]

Copyright ©2025 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.

Functional Dyspepsia is a disorder similar to Irritable Bowel Syndrome (IBS) which affects the stomach rather than the bowel and just like IBS, it is diagnosed after ruling out underlying structural, or biochemical causes such as peptic ulcers, gastritis, or Gastro-Esophageal Reflux Disorder (GERD).

Symptoms of Functional Dyspepsia may include pain or burning called epigastric pain syndrome (EPS), getting full quickly when eating and/or feeling excessively full after eating called postprandial distress syndrome (PDS), feeling bloated, or experiencing reflux. Significantly, not all individuals have the same symptoms.

Functional Dyspepsia and IBS Surge After the Pandemic

A recent study[1] of over 4000 adults in both the US and UK that was done in two stages (a) in 2017 before the pandemic then (b) again in 2023, after the pandemic found that Functional Dyspepsia rose almost 44% (from 8% to 12%), and IBS increased 28% (from 5% to 6%) after the pandemic.

It was also found that Functional Dyspepsia and IBS were often associated with people experiencing long-COVID, or diagnosed with anxiety disorder, or depression.

The Role of the Gut-Brain Axis

Functional Dyspepsia is sometimes referred to as having a “nervous stomach” because of the known interaction between the gut and the brain, along what is called the “gut-brain axis”. The gut-brain axis involves the vagus nerve, which is the longest nerve in the human body and which connects the brain to the organs, including the stomach, intestines,  heart and lungs.

Since symptoms of Functional Dyspepsia and some cases of IBS are more pronounced when the individuals are under stress, interventions may not only include dietary modifications, but may also include behavior interventions that can help relax the gut by affecting the vagus nerve.

Symptoms Vary Between Individuals 

Individuals with Functional Dyspepsia may experience some symptoms, but not others, so dietary treatment must be individualized for each person, and some of the interventions used may be similar to those used for other functional disorders, such as IBS, or for digestive disorders such as Gastro-Esophageal Reflux Disorder (GERD), hiatus hernia, or Small Intestinal Bacterial Overgrowth (SIBO), or interventions that are unique to Functional Dyspepsia. 

For example, addressing the symptom of bloating may involve use of a low-FODMAP diet implemented over three stages which is also used in some individuals with Irritable Bowel Syndrome (IBS), depending on which foods are causing the symptoms.

If acid reflux is one of the symptoms that people are experiencing, dietary interventions and lifestyle interventions may be similar to those used in Gastro-Esophageal Reflux Disorder (GERD), or to help decrease stomach pain, dietary recommendations may involve reducing irritants such as spices, alcohol, coffee and caffeine. 

Some dietary inventions are specific to those with Functional Dyspepsia, such as when people are experiencing feeling “overfull” after eating, even when the meals are small.

Dietary interventions for Functional Dyspepsia are definitely not “one-sized-fits-all”, and as it is with Irritable Bowel Syndrome, dietary treatment must be individualized to each person’s symptoms.

Role of Behaviour Interventions in Functional Dyspepsia 

Since Functional Dyspepsia (and sometimes IBS, as well) involve gut-brain interaction, there are some behavioral interventions that often used such as specific types of breathing exercises that affect the vagus nerve, help relax the gut, thus minimizing symptoms. 

Some Final Thoughts

Functional disorders like Functional Dyspepsia or IBS are diagnosed based on symptoms, rather than lab tests because they don’t involve a structural or biological abnormality. As with IBS, a diagnosis of Functional Dyspepsia is made by a doctor after ruling out disease states, or biological causes.

Just as the diagnosis of Functional Dyspepsia is made based on symptoms, so too is which dietary modifications will be most appropriate. Choosing which approaches to use and the order in which to implement those dietary modifications can significantly shorten the length of time it takes until someone begins to feel better, and this is where the help of a Dietitian experienced in both digestive disorders and functional disorders comes in.

More Info?

If you would like to learn about how I can help support you with dietary changes related to Functional Dyspepsia or IBS, please visit the landing page to learn about the services that I provide.

To your good health!

Joy

You can follow me on:

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

Reference

1. Palsson, Olafur et al. The Prevalence and Burden of Disorders of Gut-Brain Interaction (DGBI) before versus after the COVID-19 Pandemic, Clinical Gastroenterology and Hepatology, Volume 0, Issue 0, DOI: 10.1016/j.cgh.2025.07.012

Copyright ©2025 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 study published in the Annals of Neurology on February 10, 2025, suggests that levels of vitamin B12 considered within lab-normal values may be too low to prevent cognitive decline in healthy older adults [1].

What is Vitamin B12?

Vitamin B12, also known as cobalamin, is a water-soluble vitamin found in foods of animal origin, including fish, meat, poultry, eggs, and dairy products. It is essential for the proper functioning of the central nervous system, as well as for the formation of healthy red blood cells, and the synthesis of DNA.

Vitamin B12 is absorbed in the gastrointestinal (GI) tract, however, a deficiency may result due to inadequate dietary intake in those following a vegan or vegetarian diet, and from conditions which impair its absorption in the GI tract, including decreased intrinsic factor (IF). IF is a protein secreted in the stomach that enables vitamin B12 to be absorbed from food, and which generally decreases with age due to lower amounts of stomach acid production [2].

Vitamin B12 Deficiency Symptoms

If left untreated, vitamin B12 deficiency can lead to health complications, including megaloblastic anemia (where red blood cells are too large), fatigue, muscle weakness, gastrointestinal problems, nerve damage, and mood disturbances. It can also cause neurological issues, including peripheral neuropathy, cognitive decline, and gait (walking) abnormalities [1].

Findings of the Study

The study was led by researchers at the University of California, San Francisco (UCSF) who investigated whether vitamin B12 levels, despite falling within the lab normal range, might still be associated with neurological damage or impaired function in healthy older adults [1].

The study included 231 healthy individuals, all without dementia or mild cognitive impairment, who were recruited from the Brain Aging Network for Cognitive Health (BrANCH) at UCSF. Participants had an average age of 71, with a median blood vitamin B12 concentration of approximately 414.8 pmol/L.

To assess neurological status, researchers used multifocal visual evoked potential testing, cognitive processing speed evaluations, and magnetic resonance imaging (MRI) and measured serum biomarkers associated with neuroaxonal injury, astrocyte activity, and amyloid pathology. To accurately estimate the body’s capacity to utilize vitamin B12, variables such as age, sex, education level, and cardiovascular risk factors were factored in.

Cognitive testing revealed that individuals with lower levels of active vitamin B12 exhibited slower processing speeds, indicating subtle cognitive decline, an effect more pronounced with advancing age. Older participants also showed significant delays in responding to visual stimuli, suggesting slower visual processing and reduced overall brain conductivity.

MRI results showed that individuals with lower levels of transcobalamin (Holo-TC), the active form of vitamin B12, had greater volumes of white matter hyperintensities—an indicator of brain damage. Additionally, researchers found that elevated levels of the inactive form of B12 were associated with increased concentrations of T-Tau protein in the blood, a biomarker linked to neurodegeneration.

Findings of the Study

The findings of this study suggest that the current recommended levels of vitamin B12 may be insufficient to protect against neurological decline, especially in older adults.

Final Thoughts…

Ensuring sufficient B12 intake can be difficult for older adults who consume less food overall, eat fewer animal-based foods, or have reduced levels of intrinsic factor due to aging. 

While taking a supplement may seem like a relatively straightforward solution to ensure adequate vitamin B12 levels, most B12 supplements available on the market contain types of cobalamin that are not able to be used by people who have the relatively common MTHFR genetic variation which affects their ability to convert folate (vitamin B9) and other B vitamins, including B12 into their active form.  

Another factor that needs to be considered is that long-term use of Metformin to manage blood sugar is, by itself, significantly associated with low vitamin B12  levels [4]. Since many older adults are prescribed this medication, and vitamin B12 levels may already be set too low for healthy older adults not taking any medication, the need for assessing and monitoring vitamin B12 status in older adults is essential.

Further complicating the issue, low iron levels lead to smaller-than-normal red blood cells, while low B12 levels cause them to become larger. When both deficiencies are present, which is not uncommon in individuals with low intake of animal-based foods, they can offset each other, causing red blood cells to appear normal in size and potentially masking the underlying problem. A dietary assessment can help identify these risks, while blood tests can determine the extent to which these nutrients may be sub-optimal, guiding appropriate dietary changes and supplementation.

More Info?

If you’re interested in how I support dietary intake in older adults, please visit the landing page to learn about the services that I provide.

To your good health!

Joy

You can follow me on:

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

References

1. 1. Beaudry-Richard, A., Abdelhak, A., Saloner, R., et al (2025), Vitamin B12 Levels Association with Functional and Structural Biomarkers of Central Nervous System Injury in Older Adults. Ann Neurol. https://doi.org/10.1002/ana.27200
   2. National Institutes of Health (NIH) Office of Dietary Supplements, B12, https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/
   3. Vitamin B12-Associated Neurological Diseases. Medscape. News release. Updated February 4, 2025. Accessed April 1, 2025. https://emedicine.medscape.com/article/1152670-overview
   4. Atkinson M, Gharti P, Min T. Metformin Use and Vitamin B12 Deficiency in People with Type 2 Diabetes. What Are the Risk Factors? A Mini-systematic Review. touchREV Endocrinol. 2024 Oct;20(2):42-53. doi: 10.17925/EE.2024.20.2.7. Epub 2024 Jul 12. PMID: 39526048; PMCID: PMC11548349.

Copyright ©2025 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.

Ehlers-Danlos syndrome (EDS) is a group of genetic connective-tissue disorders that often present as symptoms of joint hypermobility (joints that bend in unusual ways), joint instability, stretchy, fragile skin, with accompanying gastrointestinal symptoms.

There are approximately 13 subtypes of Ehlers-Danlos syndrome, with the most common type and the one that I support being Hypermobile Ehlers-Danlos syndrome (hEDS). There is a 50% chance that hEDS will be inherited by children of a parent with the condition [1]. 

It is not uncommon for people with Hypermobile Ehlers-Danlos syndrome to also have symptoms of Mast Cell Activation Disorder (MCAD) (also known as Mast Cell Activation Syndrome /MCAS), which is a reactivity to histamine as well as other bioactive amines [2], previously written about here, which means that it’s nessessary to address the symptoms of both, together. In some cases, Postural Orthostatic Tachycardia Syndrome (POTS) is often involved, too. 

While many of the symptoms of Ehlers-Danlos Syndrome (EDS) are gastrointestinal (GI) and food-reactive in nature, there is no single EDS Diet, but rather general dietary principles on which specific individual recommendations that factor in co-presenting MCAD and POTS can be layered. This includes addressing some associated nutrient deficiencies, as well as dietary interventions to help minimize GI symptoms.

Gastrointestinal (GI) Concerns in EDS

1. 1. Abnormal connective tissue structure, growth, maintenance, or function in EDS may make the GI tract structurally abnormal, sluggish, painful, inflamed, and/or “leaky”.

(i) Functional Gastrointestinal Disorders (e.g., Irritable Bowel Syndrome, chronic constipation)

Dietary approaches to functional GI symptoms are similar to those utilized in Irritable Bowel Syndrome (IBS), and these can be addressed using the following approaches:

(a) Use of a Time Food Time Symptom Journal to determine which foods or food components trigger adverse symptoms

(b) Trialing a low FODMAP diet introduced in three progressive stages

(ii) Dysmotility (e.g., esophageal dysmotility, gastroparesis, slow colonic transit)

This requires medical diagnosis and treatment first, with dietary support.

2. Autonomic nervous system abnormalities (dysautonomia) common in EDS may cause additional GI symptoms or complications (i.e. fight or flight versus rest and digest).

Functional Dyspepsia affects the upper gastrointestinal tract (stomach), and symptoms include nausea, feeling bloated, and stomach pain. It is sometimes referred to as having a “nervous stomach.”

Some people think that Functional Dyspepsia is caused by food sitting too long in the stomach, or food not moving properly through the upper gastrointestinal tract, both of which may be related to the function of the vagus nerve.

Understanding the role of the Vagus Nerve in Functional Dyspepsia and learning some simple techniques to calm the vagus nerve can be helpful to those with GI symptoms related to dysautonomia.

1. 3. Dysbiosis and dysregulation of gut-related immune function common in EDS may cause further inflammation, food intolerances, true food allergies (IgE mediated), local or systemic autoimmune conditions, as well as GI or systemic issues.

Dietary support may include

• • IgE-mediated food allergy including avoiding cross-reactants (e.g., latex cross-reactivity manifesting as intolerance to avocado, banana…)
  • other types of antigen-induced immune reactions (e.g. Food Protein-Induced Enterocolitis Syndrome, FPIES) – a delayed, non-IgE mediated food sensitivity to cow’s milk, soy, rice, oats
  • auto-immune targeting of the body’s own tissue (celiac disease, Hashimoto’s)
  • dietary support for cell-mediated reactions (e.g. Mast Cell Activation Disorder, MCAD)
  • determining whether there is food intolerance using a Time Food Time Symptom Journal so that foods that trigger symptoms can be avoided or reduced (e.g. nightshade intolerance)

Eating a less inflammatory diet, avoiding gluten-based foods, artificial sugar substitutes, processed foods, and foods high in simple carbohydrates, and non-cultured dairy can be helpful – while learning to eat a nutritionally adequate diet without these foods. In some people, avoiding corn and eggs can also be helpful.

If Mast Cell Activation Disorder (MCAD) is also diagnosed, then along with over-the-counter H1 and H2 antihistamines, and mast cell stabilizing prescription medication, learning how to reduce the amount of histamine and other bioactive amines in the diet can be very helpful in managing symptoms, with the first step being learning which specific foods trigger a reaction. 

How to Encourage Normal Gut Biosis

A diet rich in prebiotics such as Jerusalem artichoke, dandelion greens, garlic, leeks, onion, and asparagus, as well as probiotics such as fermented dairy and vegetables including kefir, yogurt, kimchi, sauerkraut, and salt-cured pickles, can support encouraging a normal gut microbiome.

Eating a diet rich in leafy greens and other non-starchy vegetables, as well as specific types of fruit can provide ample amounts of antioxidants and soluble fiber to support a healthy microbiome.

Vitamin and Mineral Deficiency Common in Ehlers-Danlos Syndrome

There are several micronutrient deficiencies (i.e. vitamins and minerals) that are often present in people with Ehlers-Danlos Syndrome, including vitamin B6 and B12, magnesium, vitamin D, and vitamin C.

Sometimes, nutrient deficiency is present for some other reason other than Ehlers-Danlos Syndrome, such as due to one of the MTHFR polymorphisms, in which case supplementation with the bioavailable form of folate or vitamin B12, is required.

Since deficiencies in these nutrients can make the symptoms of EDS worse, it is important to have lab tests to assess levels of these nutrients in the body, so that appropriate supplementation can occur – and to understand that in some nutrients such as magnesium, routine lab tests may be inadequate to be able to assess low nutrient status.

Whenever possible, it is best to get these vitamins and minerals from food, rather than supplements but that said, some supplements are used in specific situations, such as quercetin in Mast Cell Activation Disorder, or methylated B-vitamins when someone has one of the MTHFR polymorphisms.

Having a Meal Plan designed to support your specific diagnoses (i.e. Ehlers-Danlos Syndrome (EDS), Mast Cell Activation Disorder (MCAD), and/or Postural Orthostatic Tachycardia Syndrome (POTS) is important.

Specific Dietary Recommendations

While there is no specific diet for Ehlers-Danlos Syndrome, following the general recommendations below can be a helpful place to start, before seeking the support of a knowledgeable Dietitian.

• • Avoid refined carbohydrates
  • Limit daily intake of fructose to less than 25g/day, and limit natural sugar substitutes (e.g., stevia, agave)
  • Eliminate sugar substitutes: sugar alcohols (e.g., xylitol, sorbitol), natural sugar substitutes (e.g., stevia, agave), artificial sweeteners (e.g., aspartame)
  • Eliminate artificial colors/flavors, preservatives, stabilizers, and emulsifiers (gums)
  • Eliminate or minimize casein (especially A-1 beta-casein), gluten, and corn (which contains the storage protein zein)
  • Limit cured meat
  • Limit alcohol consumption

More Info?

If you have been diagnosed with Hypermobile Ehlers-Danlos Syndrome (hEDS), Mast Cell Activation Disorder (MCAD) with or without Postural Orthostatic Tachycardia Syndrome (POTS), I can help you minimize your symptoms.

Please visit the landing page to learn about the therapeutic dietary services I offer.

To your good health!

Joy

You can follow me on:

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

References

1. 1. Hakim A. Hypermobile Ehlers-Danlos Syndrome. 2004 Oct 22 [Updated 2024 Feb 22]. In: Adam MP, Feldman J, Mirzaa GM, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2025.
   2. Hakim AJ, Tinkle BT, Francomano CA. Ehlers-Danlos syndromes, hypermobility spectrum disorders, and associated co-morbidities: Reports from EDS ECHO. Am J Med Genet C Semin Med Genet. 2021;187:413-5.

   3. Dr. Heidi Collins MD, Nutritional Approaches to Treating GI Concerns in Persons with Ehlers-Danlos Syndrome, The Ehlers-Danlos Syndrome Society, 2020 Virtual Summer Conference

Copyright ©2025 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.

Approximately 90% of Canadians (87%) have extended health benefit plans; 64% of people have them through their employer, another 14 % access them  through another type of group plan, and 9% of people buy private health insurance [1] and most major insurers (7 out of 10) cover Registered Dietitian services in their standard plan [2]. 

While all Canadian insurers provide coverage for Registered Dietitian services [3], each individual company chooses to purchase (or not) different amounts of coverage for their employees. As a result, insurance coverage varies significantly company to company, even with the same insurer, so it’s important to check with your insurer, or group benefits representative to determine what your yearly limits are for coverage for a Registered Dietitian, as well as how much they cover per visit.

Yearly Limits

Yearly limits for Registered Dietitian services on extended benefits plans frequently range from $500/year to $1500/year however this is only one aspect of what determines the amount that each insurer will reimburse.

Reasonable and Customary Fees

In addition to yearly limits, each plan sets how much they will cover per visit.

Some benefit plans set out how much they will cover for the initial assessment visit and how much they will cover for each subsequent visit. Other plans reimburse the same amount per visit, regardless if it is the initial assessment visit or not — up to the maximum of the yearly limit.

The insurer uses what is called “reasonable and customary fees” to determine the basis for pricing their benefit plans, as well as the basis for reimbursing claims, and these limits are based on the usual cost for a service in each province.

Multi-Province Dietetic Registration

Since the “reasonable and customary fee” is based on the usual cost for the service in each province, my clients in British Columbia, Alberta and Ontario (the three provinces that I am licensed in) have different reasonable and customary amounts related to my services.

Below are the reasonable and customary limits for Dietitian services from five of the major benefit insurers in Canada. As can be seen, the range that the same provider covers in each province for the same service varies widely. 

In pricing my services, I not only take yearly limits into consideration, I also factor in the reasonable and customary fee amounts in each province that I am licensed. 

British Columbia – reasonable and customary limits

For an initial Assessment visit to a Registered Dietitian, benefit plans in British Columbia reimburse from $200/hour, to $180/hour, to $170/hour, to $150/ hour.

For subsequent visits to a Registered Dietitian, benefit plans in British Columbia will reimburse from $170/hour, to $155/hour, to $150/ hour, to $120/hour.

Alberta – reasonable and customary limits

For an initial assessment visit to a Registered Dietitian, benefit plans in Alberta will reimburse from $210/hour, to $195/hour, to $180/hour.

For subsequent visits to a Registered Dietitian, benefit plans in Alberta will reimburse from $190/hour,  to $180/hour, to $165/hour, to $150/ hour, to $127/hour.

Ontario – reasonable and customary limits

For an initial assessment visit to a Registered Dietitian, benefit plans in Ontario will reimburse from $215/hour, to $195/hour, to $150/ hour, to $145/hour.

For subsequent visits to a Registered Dietitian, benefit plans in Ontario will reimburse for from $155/hour,  to $145/hour, to $140/ hour, to $122/hour.

Pricing Based on Inter-Provincial Reasonable and Customary Fee Limits

When planning to go to any paramedical practitioner, including Registered Dietitians, it is important that people keep in mind that because of these reasonable and customary fee limits, how receipts are issued determines how much reimbursement they will get.  Packages must broken down into the individual services that make up the package, and each service must have the date and time it was provided, and the individual cost for that service. 

I ensure that the receipts provided contain all the information that a client’s benefits plan requires, so that reimbursement is maximized, and occurs quickly. Since many extended benefits plans reimburse per visit, all the packages that I offer are broken down into their respective services, beginning with the Initial Assessment visit, and each subsequent visit. The date and time of each service is listed, and the cost of each service.

Below is an example of a receipt for the Comprehensive Dietary Package, but all packages are broken down similarly to maximize refunds and to make reimbursement easy.

I have been in private practice since 2008, and I have always charged $150/hour for an Initial Assessment visit, and $100/hour for all subsequent visits in a package. That’s a long time. 

I recently found out that in 2024, the minimum amount covered for subsequent visits from the above five major insurers in the provinces to which I provide services was $127/hour.  I have been billing $100 since 2008.

Beginning January 1, 2025, the costs of subsequent visits will increase to $120/hour — and even with the increase, the new price will remain lower than the Reasonable and Customary Fees for each province to which I provide services. Prices for the Initial Assessment visit will remain $150/hour — the same price it has been since 2008.

Final Thoughts…

The amount that each extended benefits plan reimburses for visits to a Registered Dietitian is based on the reasonable and customary fees in each province.

Beginning on January 1, 2025, the cost of subsequent visits will change to $120/hour, and this is still lower than the Reasonable and Customary Fee limits in each province that I provide services. The cost of an Initial Assessment visit will remain unchanged at $150/hour — the same price it has been since 2008.

If you would like to learn about the many Routine Services, Digestive Health Services, and Therapeutic Diet Services that I provide please have a look the Services tab and to learn about pricing, payment options, and clinical hours, please visit the Book an Appointment tab.  

If you want to maximize your extended benefits for this year, please keep in mind that October, November and December are my busiest months, so I recommend not waiting too long.

I am currently booking ~2-3 weeks ahead, but I do have a cancellation list.

Please check your with your plan provider or company benefits representative to find out what your specific extended benefit plan covers.  

To your good health,

Joy

You can follow me on:

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

References

1. Coletto, David, Abacus Data, “Canadians and Health Care: Workplace and Group Insurance Plans”, April 6, 2023, https://abacusdata.ca/healthcare-canadians-clhia-workplace-and-group-insurance-plans/
2. Dietitians of Canada, “Dietitians are the Best Choice for Employee Benefit Plans”, https://www.dietitians.ca/Advocacy/Priority-Issues-(1)/Dietitian-coverage-on-employee-benefits-plans
3. Dietitians of Canada, “Providing access to nutrition services in employee health benefits plans”, https://www.dietitians.ca/Advocacy/Priority-Issues-(1)/Dietitian-coverage-on-employee-benefits-plans/Nutrition-Services-(Test)

Copyright ©2024 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.

Therapeutic Ketogenic Diets

Therapeutic ketogenic diets have been used for more than 100 years in the treatment of epilepsy and diabetes, and more recently as adjunct treatment in some types of cancer and in mental health.

These diets are very high in fat, from 65–72% (2:1) up to 90% (4:1). [1] Protein, fat, and carbohydrate are strictly controlled, so ingredients are weighed. Blood glucose and ketone levels are monitored to reach the desired Glucose to Ketone Index (GKI). [1]

Three Types of Therapeutic Ketogenic Diets 

The Popularized “Keto Diet”

A Well-Formulated Ketogenic Diet

Final Thoughts…

Both therapeutic ketogenic diets and keto diets limit carbohydrates, but therapeutic diets also tightly control protein. Therapeutic ketogenic diets also require precise weighing and tracking of glucose and ketones, as these diets are dietary prescriptions.

References

Copyright ©2024 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.

International Diabetes Federation has just released a new Position Statement that indicates that an oral glucose tolerance test performed at 1-hour after a glucose load is more effective in screening at-risk individuals for prediabetes and type 2 diabetes than a 2-hour Oral Glucose Tolerance Test (OGTT). 

The International Diabetes Federation is a non-profit umbrella organization of more than 240 national diabetes associations from 161 countries including the United States (represented by the American Diabetes Association), Canada, Australia, as well as many countries in Europe, Asia and Africa. This global reach means that the IDF’s reports and recommendations have significant international implications.

This international Position Statement provides the evidence to support the practice of requisitioning a 1-hour post load glucose test in place of 2 hour Oral Glucose Tolerance Test to diagnose prediabetes and type 2 diabetes in at-risk individuals.

For physicians who prefer to choose to continue to order a 2-hour Oral Glucose Tolerance Test, this new Position Statement provides support for adding an additional extra assessor at 1-hour, something I have asked for over the last several years based on existing evidence. 

Prediction of Risk of Type 2 Diabetes

The new Position Statement highlights that a 1-hour post-load plasma glucose level of 8.6 mmol/L (155 mg/dL) or higher during in people with normal glucose tolerance strongly predicts the development of type 2 diabetes as well as various complications such as micro- and macrovascular issues, obstructive sleep apnea, metabolic dysfunction-associated fatty liver disease, and death in individuals with risk factors. The recommendations are for  individuals with 1-hour plasma glucose of 8.6 mmol/L (155 mg/dL) or higher to be prescribed lifestyle intervention and referred to a diabetes prevention program.

Diagnosis of Type 2 Diabetes

The Position Statement indicates that a  1-hour post-load plasma glucose level of 11.6 mmol/L (209 mg/dL) or higher confirms a diagnosis of type 2 diabetes and recommends that a repeat test be conducted to confirm the diagnosis of type 2 diabetes and once confirmed, to refer the individual for treatment.

Benefits of the 1-hour Post-Load Glucose Test

The Position Statement indicates that the 1-hour post glucose load test;

1. 1. shows glucose dysregulation earlier than the 2-hour post glucose load test
   2. provides an opportunity to avoid misclassification of glucose status if fasting blood glucose or HbA1c are used alone.
   3. predicts diabetes and associated complications including death in populations of different ethnicity, sex and age
   4. allows for early detection in high-risk individuals which enables the ability to provide intervention to prevent a progression to type 2 diabetes.

Conclusion

The conclusion of the International Diabetes Federation Position Statement is that there is strong evidence to support redefining current diagnostic criteria for prediabetes and type 2 diabetes to include testing at 1-hour post glucose during an Oral Glucose Tolerance Test.

Final Thoughts

There is strong evidence for the use of a 1-hour post glucose load test to diagnose or rule out prediabetes or type 2 diabetes in at-risk individuals.

Most significantly, use of the 1-hour post glucose load test allows for early detection and provision of dietary and lifestyle intervention support to prevent the progression to type 2 diabetes. 

To your good health,

Joy

You can follow me on:

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

Reference

1. Bergman M,  Manco M., Satman I., et al, International Diabetes Federation Position Statement on the 1-hour post-load plasma glucose for the diagnosis of intermediate hyperglycaemia and type 2 diabetes, Diabetes Research and Clinical Practice, Vol. 209, 111589, March 6, 2024 https://doi.org/10.1016/j.diabres.2024.111589

Copyright ©2024 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.

If you are considering having a DEXA bone density scan to assess your risk of osteoporosis, where you have it done will significantly impact the accuracy of the results, and whether they will provide you with the information you want.

While dual-energy X-ray absorptiometry (DEXA) bone density scans are considered the gold standard for assessing bone mineral density (BMD), it is important to note that there is a large difference in the accuracy of DEXA scans obtained from non-accredited imaging centers offering bone density scans as a service, and facilities specializing in bone densitometry (the clinical assessment of bone density). An accurate scan enables doctors to rule out or establish a diagnosis and provides opportunity for timely treatment recommendations, including dietary and lifestyle modifications.

To illustrate the difference, the first part of the article will explain the standards for accredited facilities, and then contrast them to non-accredited imaging centers. This comparison will underscore the differences between the two.

Accredited Facilities for DEXA Bone Density Scans

For bone density scan data to be reliable in ruling out or diagnosing osteopenia or osteoporosis, it’s important that the scans are conducted by a trained bone densitometry technologist, in a facility that adheres to accreditation standards established by the International Society for Clinical Densitometry (ISCD), and in Canada, by the local College of Physicians and Surgeons of the province. Finally, the scans must be reviewed by a Radiologist, a doctor who specializes in medical imaging before a report is generated.

In British Columbia, the accreditation of bone densitometry facilities as well ensuring that bone densitometry technologists have the appropriate training is overseen by the College of Physicians and Surgeons of British Columbia (CPSBC). They operate the Diagnostic Accreditation Program (DAP), which ensures the quality and safety of a range of diagnostic services, including DEXA bone density scans. The DAP not only verifies that a facility meets the necessary quality standards but ensures that they consistently maintain those standards.

Accredited facilities must adhere to the Accreditation Standards for Diagnostic Imaging from the College of Physicians and Surgeons(1). This comprehensive 312 page document contains imaging standards for x-rays, mammograms, ultrasounds, MRIs , with the standards for bone densitometry beginning on page 274. These standards ensure the quality and safety of bone density scanning procedures.

These standards also outline that bone densitometry facilities must have a Medical Director overseeing operations, and that bone densitometry technologists performing scans must either be certified with the International Society for Clinical Densitometry (ISCD), or have obtained 12 Continuing Medical Education (CME) credits in bone densitometry. Additionally, technologists in accredited facilities are mandated to regularly update their knowledge by acquiring 24 CME credits in bone densitometry every three years.

Summary of the Accreditation Standards for Diagnostic Imaging for Bone Densitometry

The bone densitometry section of the Accreditation Standards for Diagnostic Imaging (1) consists of ten pages of standards, including;

• • patient preparation for the exam
  • standard imaging procedure protocols to ensure that the examination is appropriate for its intended use in clinical decision making
  • ensuring that current and accurate medical records are kept for each person
  • that diagnostic reports are in a standardized format and provide comprehensive and necessary information for clinical decision making / interpretation 
  • safe operation and maintenance of equipment
  • acceptance testing for equipment to ensure it is tested prior to use, and quality assurance programs to ensure that the required quality is attained

These standards provide additional mandatory requirements and best practices that supplement the accreditation standards established by the International Society for Clinical Densitometry (ISCD) (2).

Below is the first of the ten pages of standards (this page is on patient preparation).

These standards require that the following information be collected before a bone density scan takes place.

(1) taking clinically relevant medical history, including family history, prior fractures, bone trauma, surgery, chronic illness, and any relevant medication that may affect bone density such as corticosteroids, or thyroid medications. 

(2) ensuring that the person has not had any procedures such as a barium x-ray or radionucleotide study that can affect the results,

(3) assessing whether the person has arthritis, deformity or other degenerative changes that can affect measurement,

(4) ensuring the person hasn’t had any implants in the area being assessed, such as a hip replacement,

(5) that a qualified physician is involved in assessing any interference or contraindications,

(6) review of previous bone density scans to determine if a specific site should be excluded from the current scan,

(7) patient height and weight are accurately measured at the time of examination.

None of this, or any of the other 9 pages of standards are required to be followed in an imaging center that provides bone density scans as a service. 

Imaging Center Providing DEXA bone density scans

Imaging centers that provide DEXA bone density scans as a service are businesses, and as such are not clinically regulated.  There are no physicians or radiologists involved. These businesses are not required to meet the international standards of the International Society for Clinical Densitometry (ISCD), or local clinical standards outlined above.

For example, these centres may assess the person’s height using a tape measure or meter stick attached to a wall, rather than a stadiometer. Weight may not even be measured — or even asked, but calculated from the results of a whole body composition scan performed at the same time. Estimating height and weight does not provide the quality data required to interpret the results of the Dexa scan. In addition, questions about personal medical history, family medical history, risk factors, medications or procedures that could affect results are limited, or non-existent.

Image Quality

In accredited facilities, rigorous standards are in place to ensure high image quality, as all scans undergo review by a radiologist prior to report generation.

Images are required to be clear and well defined, such as the top pair of images from HealthLink BC (3). 

Images from imaging centers, such as the pair of images on the bottom often lack the contrast and definition which limits their usefulness.

Measurement Accuracy – hips

For hip scans to be useful in diagnosing osteoporosis, it is essential that the neck of the femur (hip bone) is measured at the narrowest part (4), such as the image on the far right (4).

The image on the left from an imaging center does not measure the neck of the femur at the narrowest part, and as illustrated in the middle image, the narrowest part is to the right of where it was measured.

Measurement Accuracy – spine

Spinal images from accredited facilities (left photo from (4)) are clear, and show equal amounts of soft tissue on either side of the spine. In addition, the height of each vertebrae is roughly the same height, with markers in the disk space (4).

The image on the right from an imaging center is not clear and has little contrast. It does not show equal amounts of soft tissue on either side of the spine, and the height of each vertebrae varies considerably.

Finding an Accredited Facility

In British Columbia, a full list of accredited diagnostic imaging facilities in the province is available on the College of Physicians and Surgeons web site (5).

The International Society for Clinical Densitometry (ISCD) has a searchable list of accredited facilities by country, as well as US states and Canadian provinces.

The College of Physicians and Surgeons in your province or state may also have a list.

Final Thoughts…

For data from a DEXA bone density scan to be reliable and useful for ruling out or diagnosing osteopenia or osteoporosis, it needs to be performed at an accredited facility.

This can be compared to the difference between home lab test testing and lab tests. While at-home blood testing kits are available to screen for different conditions, diagnoses of a medical condition requires blood tests from an accredited laboratory that are reviewed and assessed by a physician.

If you want to have a DEXA bone density scan to assess your risk of osteoporosis, then speak with your doctor to get a referral to an accredited facility.

How I Can Help

If you have been diagnosed as being at risk for osteoporosis, or have been diagnosed with osteopenia or osteoporosis, implementing appropriate dietary and lifestyle changes can be beneficial.  Please let me know if you would like some support.

DEXA Bone Density Scans are the gold standard for assessing the quality of the inside of bone, and determining whether a person has osteopenia or osteoporosis. More on those scans, soon.

A DEXA Body Composition Scan is designed for assessing the amount of body fat and the distribution of that fat, yet often come with a report that includes “bone mineral density” information. It is essential to understand that “bone mineral density” on a DEXA Body Composition Scan is estimated, not measured. 

This article is about the DEXA Body Composition Scan and what information it reliably provides.

NOTE: (February 14, 2024) If you are thinking of having a DEXA Body Composition Scan, be sure the facility you choose is accredited by the College of Physicians and Surgeons in your area.  More on this in the next article!

DEXA Body Composition Scan

The DEXA Body Composition Scan measures

(a) total amount of fat mass in grams, and

(2) total amount of Lean Body Mass plus bone, in grams.

It does not measure bone mass, but adds both lean body mass and bone mass together. This is important because reports that often accompanying DEXA Body Composition Scans include information about “bone mineral density”, but this information is estimated, rather than assessed. 

The DEXA Body Composition Scan reliably indicates how much total fat someone has, and the distribution of that fat over the body. It does not differentiate between sub-cutaneous fat (the fat under the skin) and visceral fat (the fat around the organs) which is associated with increased health risk.

Since fat mass is what is being directly evaluated in a DEXA Body Composition Scan, the total amount of body fat determined by this method is accurate.

DEXA Body Composition Scan Data of Fat and Lean 

Below are two pages from a DEXA Body Composition Scan report. 

This above page from a DEXA Body Composition Scan report is mostly related to what it assesses directly, which is Total Fat Mass in grams, and Lean Body Mass plus bone in grams, and evaluates the distribution of that fat.

While a DEXA Body Composition Scan does not differentiate between subcutaneous fat and visceral fat, the report indicates “Estimated Visceral Adipose Tissue (fat)” in the table of adipose (fat) indices. It is important to note that visceral fat is not assessed, but estimated. 

DEXA scanners (both GE and Hologic brands) have the National Health and Nutrition Examination Survey (NHANES) data integrated into their software, this which enables them to generate Z-scores for total amount of fat in grams, as well as localized Z-scores for fat in arms, legs, and trunk (1).

Z-scores compare the an individual subject’s results to those of an aged-matched population, and since a DEXA Body Composition Scan measures total fat directly, the z-score in this report for adiposity (fat) is valid.

T-scores compare an individual’s results to how many standard deviations it is from the results of a 30-year old young adult, and since a DEXA Body Composition Scan measures total fat directly, the t-score for adiposity (fat) is also valid.

DEXA Body Composition Scan Data on Bone Mineral Density and Bone Mineral Composition

This is where reports that may be provided with a DEXA Body Composition Scan can get really crazy.

A DEXA Body Composition Scan does not differentiate between Lean Body Mass as muscle and bone, so any information about “bone mineral density” and “bone mineral composition” is based on estimations!  

Since there is no measurement of bone mass in grams separate from Lean Body Mass (muscle),  z-scores for “Bone Mass Density” from a Whole Body Composition Scan make no sense.  This is a comparison of estimated bone data to actual data from an aged-matched population! 

Have a look at the table below from a 55 year old woman whose DEXA Body Composition Scan report indicates that she had osteoporosis based on estimated bone density numbers. Without having a DEXA Bone Density Scan, of both hips and lower spine she really doesn’t know if she has osteopenia or osteoporosis or not. A DEXA Body Composition Scan is designed to assess fat mass and the distribution of that fat, not bone.

Final Thoughts…

If you have had a DEXA Body Composition Scan and been told that you have osteopenia or osteoporosis remember that this is based on estimates of total amount of bone, and not actual measurement of bone. In such a case, I would recommend discussing with your doctor having a DEXA Bone Density Scan of both hips and lower spine.

If the DEXA Bone Density Scan indicates that you meet the criteria for osteopenia or osteoporosis, then meet with you doctor to discuss the results and their recommendations. In some cases, a doctor may recommend medication to keep bone from breaking down too quickly, and/or a program designed by a Physical Therapist to enable you to safely exercise and retain as much of bone mass you still have, while minimizing the risk of fractures. 

Take Away Message

Remember, that estimated data of “bone mineral density” from a DEXA Body Composition Scan is not the same as data from a DEXA Bone Mineral Density scan which is based on direct assessments.

Getting accurate information using the right diagnostic tool is essential.

How I Can Help

If you are an older adult who wants to optimize your diet and lifestyle to retain as much bone mass as possible as you age, I can help.

To your good health,

Joy

You can follow me on:

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

Reference

1. Shepherd JA, Ng BK, Sommer MJ, Heymsfield SB. Body composition by DXA. Bone. 2017 Nov;104:101-105. doi: 10.1016/j.bone.2017.06.010. Epub 2017 Jun 16. PMID: 28625918; PMCID: PMC5659281.

Copyright ©2024 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.

Note: This article was originally posted on August 20, 2023, and was revised and reposted on November 2, 2025. It now includes the latest research on protein quality, amino acid bioavailability, and the Digestible Indispensable Amino Acid Score (DIAAS). References and recommendations for both plant and animal proteins have been updated for accuracy.

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 also necessary. Assessing protein quality using the Digestible Indispensable Amino Acid Score (DIAAS) can help identify the best sources of protein for maintaining and building muscle.

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

Amino Acids and Bioavailability

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

Bioavailability refers to the degree to which essential amino acids in food can be used by the body to build its own proteins [2], such as muscle tissue.

Essential amino acids, including leucine, must be consumed in the diet because the body cannot make them. Leucine plays a key role in muscle growth and repair by triggering mTOR signaling in muscle cells, which stimulates protein synthesis [3].

Dietary recommendations for older adults emphasize obtaining about 2.3 g of leucine per meal to support muscle growth [4], and around 3 g per meal to rebuild muscle after exercise [5].

Recent research suggests a practical target range of 2.5–3.0 g of leucine per main meal, roughly equivalent to 25–30 g of high-quality protein. This level best supports muscle protein synthesis in older adults and enhances recovery when paired with light resistance exercise — such as a breakfast of eggs or Greek yogurt.

Plant Protein vs. Animal Protein for Building Muscle

Plant proteins generally contain lower levels of leucine than animal proteins [6]. People choosing a more plant-based diet often rely on legumes like beans or lentils for protein. However, most legumes are incomplete proteins, meaning they lack one or more essential amino acids.

For example:

• Lentils contain about 0.7 g of leucine per half cup.

• Chickpeas contain about 0.42 g of leucine per half cup.

An older adult would need to eat more than 3 cups of lentils or 5½ cups of chickpeas at one meal to reach the 2.3 g leucine threshold needed to trigger muscle protein synthesis.

Is Plant Protein Equivalent to Animal Protein?

A randomized, investigator-blinded, crossover study was conducted with both young and 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 meal. The goal was to determine how efficiently the body uses amino acids from each source.

The Dietary Guidelines for Americans (DGA) defines ounce-equivalents to identify protein foods with similar nutritional content [7]. However, the researchers noted that the assumption of “equivalence” between these sources is questionable.

For instance, one ounce-equivalent of pork loin provides about 7 g of protein, while one ounce-equivalent of almonds provides only 3 g [1]. Beyond quantity, protein quality — the digestibility and bioavailability of essential amino acids — also differs substantially between these sources.

The Bioavailability of Plant Protein – Digestible Indispensable Amino Acid Score (DIAAS)

In 2013, the Food and Agriculture Organization (FAO) introduced the DIAAS method to replace the older PDCAAS system for assessing protein quality [9].

DIAAS measures how well individual essential amino acids are digested and absorbed at the end of the small intestine, giving a clearer picture of how well the protein supports the body’s needs.

High-quality proteins have a DIAAS ≥100, while scores of 75–99 are considered good, and <75 cannot make a quality protein claim [8].

• Most grains and legumes score below 75.

• Pea and soy protein range from 75–100.

• Animal proteins such as beef typically score well above 100 [10].

Although DIAAS provides a more accurate measure of protein quality, it has not yet been adopted for food labeling in Canada or the U.S. Implementation will require regulatory review and harmonized data across food categories. Until then, dietitians and consumers can use academic data to understand the real quality of different protein sources.

Plant Protein versus Animal Protein – What Studies Show

The recent trial found that meals containing animal-based proteins resulted in higher blood levels of essential amino acids compared with meals made from plant-based proteins — in both young and older adults [1].

Additionally, lean pork produced greater amino acid bioavailability than eggs, and no difference was found between black beans and almonds.

Researchers concluded that it is inaccurate to treat different protein sources as equivalent based on ounce-equivalents alone.

Final Thoughts

If you are an active adult wanting to build and repair muscle, or an older adult aiming to maintain strength, it’s essential to choose high-quality proteins that contain all essential amino acids — especially leucine. While the DGA lists one ounce of meat, one egg, 0.25 cups of beans, or 0.5 ounces of nuts as equivalent, this study shows they are not truly equivalent in quality or bioavailability.

If you are exploring a more plant-based lifestyle, understanding the science of protein bioavailability can help you make informed, health-supporting choices.

For those following a vegetarian or vegan diet for ethical or cultural reasons, combining complementary plant proteins and choosing higher-DIAAS options like soy or pea protein can help you meet your needs.

More Info

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

To your good health,

Joy

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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 Acid 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. [https://pubmed.ncbi.nlm.nih.gov/33093304/]

[3] Norton LE, Layman DK. Leucine Regulates Translation Initiation of Protein Synthesis in Skeletal Muscle after Exercise. J Nutr. 2006 Feb; 136(2 Suppl): 533S–537S. doi: 10.1093/jn/136.2.533S. [https://www.sciencedirect.com/science/article/pii/S0022316622080956]

[4] Bauer J, 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. doi: 10.1016/j.jamda.2013.05.021. [https://pubmed.ncbi.nlm.nih.gov/23867520/]

[5] Thomas DT, Erdman KA, Burke LM. American College of Sports Medicine Joint Position Statement: Nutrition and Athletic Performance. Med Sci Sports Exerc. 2016 Mar; 48(3): 543–568. doi: 10.1249/MSS.0000000000000852. Correction in Med Sci Sports Exerc. 2017 Jan; 49(1): 222. [https://pubmed.ncbi.nlm.nih.gov/26891166/]

[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. PMCID: PMC6723444. [https://pubmed.ncbi.nlm.nih.gov/31394788/]

[7] U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025, 9th ed. Washington, DC: U.S. Government Publishing Office; 2020. Available from: https://www.dietaryguidelines.gov

[8] 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(9): 5379–5391. https://doi.org/10.1002/fsn3.1809

[9] Food and Agriculture Organization of the United Nations. Dietary Protein Quality Evaluation in Human Nutrition (FAO Food and Nutrition Paper 92). Rome, Italy: FAO; 2013. Available from: https://www.fao.org/3/i3124e/i3124e.pdf

[10] 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. PMCID: PMC5914309. [https://pubmed.ncbi.nlm.nih.gov/28969364/]

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.

Note: This article was originally posted on August 13, 2023, and was updated and reposted on November 25, 2025

Introduction

In the interest of time, many people throw a cup or more of fruit, some green veggies, and maybe some protein powder into a blender to make a smoothie for breakfast. But most people don’t realize how blending affects their blood sugar, gut microbiome, and how much food they eat.

Making a Smoothie

For people with challenges keeping blood sugar stable, or having pre-diabetes or diabetes, a smoothie made with fruit is something to reconsider. Pureed fruit affects blood sugar very differently from eating the same type and amount of fruit, whole and intact. 

Cellular versus Acellular Carbohydrate

Cellular carbohydrates come from whole, intact foods where the carbohydrate is still inside the cell wall. These foods take longer to digest and to be absorbed into the bloodstream than ground or pureed foods.

Carbohydrates that have been pureed, like fruit in a smoothie, or ground, like flour made from grain, are now outside their cell wall (acellular carbohydrate). As a result, pureed and ground foods are digested more quickly because the fiber that normally slows absorption is disrupted.

A Smoothie as “Pre-Chewed” Food

Most people think digestion begins in the stomach, but it starts in the mouth, when we chew food. As unappealing as it sounds, smoothies are “pre-chewed” food.

Drinking carbohydrates, rather than eating them, can result in spikes in blood sugar, affect gut bacteria, and can even impact how much food we eat due to hunger that follows a quick rise and then fall in blood sugar from the insulin response to quickly digested carbs.

Research shows that when fruit is pureed or juiced, blood glucose rises more rapidly and remains higher than when the same fruit is eaten whole [1]. This occurs because the blender has already broken down the cell walls, doing some of the work that chewing would normally do. For people with higher than ideal blood sugar, or pre-diabetes or diabetes, drinking a morning smoothie instead of eating the same foods intact can lead to a significantly different blood sugar response.

It is important to note that 60 g of whole fruit, 60 g of pureed fruit, and 60 g of juiced fruit all contain the same amount of carbohydrate and have similar Glycemic Index (GI) values. But the GI only tells us how quickly a food raises blood sugar, not how high blood sugar will go. Recent research also emphasizes that food structure, not just carbohydrate content, plays a critical role in blood glucose control [2].

Whole berries or fruit (cellular carbohydrate) are preserved within their cell walls until the digestive juices in the stomach begin to break them down. Once released, the carbohydrate is then absorbed mainly in the large intestine (colon).

Acellular carbohydrates, such as the fruit in smoothies, begin digestion in the small intestine rather than the colon. Early digestion of acellular carbohydrates can alter gut microbial fermentation and is thought to contribute to an imbalance in gut microbes (gut dysbiosis) or leaky gut (increased intestinal permeability) [3].

Drinking carbohydrate-containing foods, rather than eating them, may promote overconsumption and contribute to leptin resistance. Leptin is the hormone that signals us when we are hungry via a negative feedback loop. This feedback loop is thought to become dysregulated when we consume large amounts of acellular carbohydrates, such as pureed fruit. Leptin resistance occurs when the body fails to respond properly to leptin. Some research suggests that acellular carbohydrates alter leptin signaling, increase inflammation, and disturb the gut microbiota, which over time can blunt the body’s feedback loop that signals the brain that we are full [4].

Final Thoughts

Digestion begins in the mouth when we chew food, and there is a big difference between how whole, intact carbohydrates are absorbed and how blended smoothies are absorbed.

Smoothies are “pre-chewed food” that can disrupt blood sugar, alter our gut microbiome, and increase the total amount of food we consume.

Instead of throwing fruit, veggies, and protein powder into a blender, reach for half a cup of berries to put over top a cup of cottage cheese or plain Greek yogourt with a few spoons of hemp hearts, and grab a handful of snap peas or baby carrots. This quick, light meal that has the protein and leucine adults need to preserve their muscle mass — and there is no blender to clean afterwards!

More Info

I understand that not everyone who wants to eat healthy loves to cook. I am experienced at designing Meal Plans using readily available foods that require minimal preparation and little to no cooking. Whether you love to cook or prefer simplicity, I can help. You can learn more under the Services tab. 

To your good health, 

Joy

You can follow me on:

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

References

[1] Haber GB, Heaton KW, Murphy D, Legg NJ. 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. [https://pubmed.ncbi.nlm.nih.gov/71495/]

[2] Forde CG, Frank T, Leong C. Interrelations Between Food Form, Texture, and Matrix. Nutrients. 2022;14(4):731. doi:10.3390/nu14040731 [https://pmc.ncbi.nlm.nih.gov/articles/PMC9174310/]

[3] Stull AJ, Apolzan JW, Thalacker-Mercer AE, Iglay HB, Campbell WW. Liquid and solid meal replacement products differentially affect postprandial appetite and food intake in older adults. J Am Diet Assoc. 2008 Jul;108(7):1226-30. doi: 10.1016/j.jada.2008.04.014. PMID: 18589034; PMCID: PMC2556245. [https://pubmed.ncbi.nlm.nih.gov/18589034/]

[4] 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 Metab Syndr Obes. 2012;5:175-89. doi: 10.2147/DMSO.S33473. Epub 2012 Jul 6. PMID: 22826636; PMCID: PMC3402009. [https://pubmed.ncbi.nlm.nih.gov/22826636/]

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.

Note: this article was originally posted on August 11, 2023, and has been updated and reposted on November 23, 2025.

Understanding Sarcopenia

The inability to retain muscle and strength associated with aging is called sarcopenia. Since adults lose approximately 1% of muscle mass each year after the age of thirty [1], knowing how to retain muscle as an adult is essential, even though the decline in strength normally only becomes noticeable by age fifty [2].

Muscle loss affects 5–13% of adults between sixty and seventy, and up to 50% of adults over eighty years of age have sarcopenia [2].

Not being able to retain muscle mass reduces activity levels, lowers quality of life, increases risk of falls, and worsens metabolic and bone health [3].

Most people have never paid close attention to the amount and quality of protein they eat, often choosing foods based on taste, cost, or ethical or religious reasons. These are important considerations, but they are not the only ones that matter.  As outlined in a previous article on protein for older adults, high-quality protein containing sufficient leucine is necessary for maintaining muscle [4], but not all protein foods are equal.

Amino acids are the building blocks of protein, including muscle. There are twenty amino acids, grouped as essential or non-essential. Essential amino acids, such as leucine, cannot be produced by the body in sufficient amounts and must be obtained through diet [5].

The leucine content of protein is critical because leucine triggers mTOR signaling in muscle, which stimulates muscle protein synthesis. For this reason, proteins consumed by older adults must contain enough leucine to support muscle maintenance and mobility[5].

Plant proteins generally contain lower levels of leucine compared to animal proteins [7]. Grains such as wheat contain less than 7% leucine [6], and even quinoa, considered a “complete protein,” contains only 4.5% leucine [6]. People who want a more plant-based diet may turn to legumes (“beans”), but these are usually incomplete proteins, meaning that they are missing some essential amino acids, and generally low in leucine. Even soybeans, a complete protein, contain only about 8% leucine [6].

Dietary recommendations for older adults emphasize a minimum of 20–30 g of protein per meal, with at least 2.3–3 g of leucine per meal, to effectively stimulate muscle protein synthesis [7][8].

To recover lost muscle mass, the recommended intake is 3 g of leucine at each of three meals, along with 25–30 g of protein per meal [7][8].

Protein Sources to Help Retain Muscle 

Animal proteins are highly bioavailable, complete proteins, and the richest sources of leucine. One cup of low-fat (1%) cottage cheese contains approximately 2.9 g of leucine, enough for a full meal. A cup of plain yogurt contains roughly 1.3 g, and a cup of Greek yogurt provides about 1.2 g. Only 3 oz (85 g) of ground beef or pork contains ~1.8 g, and the same amount of chicken breast provides about 2.25 g — all close to the per-meal leucine target for older adults [9].

Soybeans, a complete plant-based protein, contain only 0.28 g of leucine per half-cup, and firm tofu, a concentrated form of soy protein, provides approximately 0.73 g per 3 oz (85 g). To reach the minimum leucine threshold from firm tofu, an older adult would need to eat about ¾ pound, which may exceed their typical appetite [9].

Incomplete plant proteins, such as lentils, contain 0.7 g of leucine per half-cup, and black beans contain 0.61 g per half-cup. This means an older adult would need to consume more than 3 cups of lentils or black beans, or 5½ cups of chickpeas (0.42 g leucine per half-cup), to meet the minimum leucine requirement per meal [9]

Older adults who want to eat a more plant-based diet need to ensure they consume adequate, highly bioavailable protein rich in leucine to maintain their muscle mass. A practical approach is to “prioritize protein” at each meal [8].

[NOTE: A recent article explains differences in protein bioavailability between plant-based and animal-based sources.]

Prioritize Protein to Retain Muscle 

“Prioritizing protein” means first deciding which protein you will eat at a meal, and then building the rest of the meal around that. For older adults, the protein chosen should provide 25–30 g of highly bioavailable protein and 2.3–3 g of leucine per meal [7].

For breakfast, choosing high-leucine proteins such as 1 cup of cottage cheese or 1 cup of plain Greek yogurt will provide enough protein and leucine to meet the minimum target. In contrast, 2 eggs contain only 12 g of protein and ~1.2 g leucine, which is less than half of the recommended per-meal leucine for older adults [9].

For lunch, 4 oz (113 g) of canned tuna provides about 4 g of leucine and 21 g of protein, and 3 oz (85 g) of cooked chicken breast provides 2.4 g of leucine and 26.5 g of protein. To increase leucine further, you can add 1 oz (28 g) of pumpkin seeds (~0.7 g leucine) or 1 oz (28 g) of sunflower seeds (~0.46 g leucine) to a salad [9].

For dinner, steak is one of the richest sources of leucine, with 4 oz (113 g) providing ~3.4 g, although cost may be a consideration. More budget-friendly options for those who don’t avoid it for religious reasons would be 4 oz (113 g) of pork chops (~27 g protein, 2.5 g leucine) or 4 oz of ground beef (~16 g protein, 2.5 g leucine). If there is a slight shortfall, the protein content of the meal can be boosted by adding a small serving of Greek yogurt [9].

Final Thoughts…

The quality of life and overall health of older adults depend on staying active, which requires adequate muscle mass. Preventing sarcopenia requires consuming sufficient high-quality protein that contains all essential amino acids, including an adequate amount of leucine to stimulate muscle growth.

Since muscle mass is lost at an estimated rate of 1% per year after age thirty, the choice of protein at each meal is crucial for maintaining strength and mobility. 

For those who would like help, we offer the Healthy Aging Package, which helps ensure that middle-aged and older adults eat sufficient protein and leucine at each meal to maintain their muscle and bone mass as they age.

To your good health, 

Joy

You can follow me on:

Twitter: https://twitter.com/jyerdile
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. [https://pmc.ncbi.nlm.nih.gov/articles/PMC3940510/]
2. von Haehling S, Morley JE, Anker SD. An overview of sarcopenia: facts and numbers on prevalence and clinical impact. J Cachexia Sarcopenia Muscle. 2010 Dec;1(2):129–133. doi:10.1007/s13539-010-0014-2. Epub 2010 Dec 17. PMID: 21475695; PMCID: PMC3060646 [https://pmc.ncbi.nlm.nih.gov/articles/PMC3060646/]
3. Fielding RA, Vellas B, Evans WJ, et al. Sarcopenia: an emerging public health problem. StatPearls. 2021. [https://www.ncbi.nlm.nih.gov/books/NBK560813/]
4. Szwiega S, Pencharz PB, Rafii M, et al. Dietary leucine requirement of older men and women is higher than current recommendations. Am J Clin Nutr. 2020;113(2):410–419. doi:10.1093/ajcn/nqaa323 [https://pmc.ncbi.nlm.nih.gov/articles/PMC7851820/]
5. Cruz-Jentoft AJ, Baeyens JP, Bauer JM, et al. Sarcopenia in older people: European consensus on definition and diagnosis. J Gerontol A Biol Sci Med Sci. 2010;65A(3): 101–116. doi:10.1093/gerona/glp018 [https://pubmed.ncbi.nlm.nih.gov/20392703/]
6. Guo Y, Fu X, Hu Q, Chen L, Zuo H. The effect of leucine supplementation on sarcopenia-related measures in older adults: a systematic review and meta-analysis of 17 randomized controlled trials. Front Nutr. 2022;9:929891. doi:10.3389/fnut.2022.929891 [https://www.frontiersin.org/journals/nutrition/articles/10.3389/fnut.2022.929891/]
7. Tanaka T, Simonsick E, Ferrucci L, et al. Leucine intake and risk of impaired physical function and frailty in older adults. J Gerontol A Biol Sci Med Sci. 2022;78(2):241–247. doi:10.1093/gerona/glac219 [https://pubmed.ncbi.nlm.nih.gov/36107140/]
8. MDPI Nutrients. Beneficial effects of leucine supplementation on sarcopenia: a systematic review. Nutrients. 2019;11(10):2504. doi:10.3390/nu11102504 [https://www.mdpi.com/2072-6643/11/10/2504]
9. USDA FoodData Central. Leucine content of common foods. U.S. Department of Agriculture, Agricultural Research Service. https://fdc.nal.usda.gov. Accessed [November 23, 2025].

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.

Introduction

In the last several years, there has been increased interest in the use of a ketogenic diet to support mental health; however, some types of therapeutic ketogenic diets used in mental health conditions, such as bipolar disorder with psychosis, and schizophrenia, can be challenging to follow because they involve eating two to three times more fat than the combined amount of protein and carbohydrates. For example, a Classic Ketogenic Diet (4:1) is 80% fat, and a Modified Ketogenic Diet (3:1) is 75% fat. 

Different Types of Ketogenic Diets

As explained in a previous article called “Use of a Therapeutic Ketogenic Diet in Mental Health,” there are three main types of therapeutic ketogenic diets. The Classic Ketogenic Diet uses a 4:1 ratio of fat to protein plus carbohydrates, the Modified Ketogenic Diet uses a 3:1 ratio, and the Modified Atkins Diet uses a 2:1 ratio.

There have been anecdotal reports of individuals doing very well following a Modified Atkins Diet (2:1) under the supervision of their doctors, and recently, (June 3, 2023), a pre-print pilot study tested this diet in people with bipolar disorder and found it to be successful [2].

It is hoped that a Modified Atkins Diet, which has a 2:1 ratio and is only 60-65% fat, may be useful, along with medication, for reducing symptoms of anxiety, depression, and bipolar disorder without psychosis, where higher levels of ketones produced by 4:1 and 3:1 ketogenic diets may not be required. 

The advantages are that this approach is less time-consuming in terms of the amount of calculations and work needed to design it. It also enables individuals to get into ketosis under medical oversight, then, in consultation with their doctors, decide if the improvements are sufficient to maintain their diet as is, or if gradually increasing fat and reducing protein might work better.

A 2:1 Therapeutic Diet is Not the Same as a “Keto Diet”

Some people mistakenly believe that a 2:1 therapeutic ketogenic diet is the same as the popular “keto” diet used for weight loss and improved metabolic health. While they have some similarities, a therapeutic ketogenic diet is very different. 

In a therapeutic ketogenic diet, the amount of protein, carbohydrates, and fat is carefully weighed at each meal to keep ketone levels steady throughout the day. No weighing of food is required in the popularized “keto diet”. 

Secondly, in a regular keto diet, the goal is simply to get into and stay in ketosis; however, in a therapeutic ketogenic diet, there is a need to monitor both glucose and ketone levels so that a specific therapeutic level called the Glucose to Ketone Index (GKI) is achieved.

Working with Your Doctor to Support Mental Health

If you are thinking about trying a therapeutic ketogenic diet to help support mental health and you are taking medications for depression, anxiety, or bipolar disorder, the first step is to talk with your doctor.

As outlined in the previous article, Harvard Psychiatrist Dr. Palmer recommends that doctors have their patients remain on their medication while trialling a therapeutic ketogenic diet for a period of three months, and be evaluated by their doctor during the stages of ketosis 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 discontinue some medications.  As stated in previous articles, changing dosages of medication is not something people should ever 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 are more reliant on the ketogenic diet to keep symptoms under control. The ketogenic diet is therapeutic; therefore, 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 [ [1]. 

Dr. Palmer recommends the following two steps to doctors who 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.

Dr. Eric Kossoff’s book, Ketogenic Diet Therapies for Epilepsy and Other Conditions, is one that I have referred to often in designing therapeutic ketogenic diets for different physical conditions. 

Steps to Getting Started

If you are thinking of adopting a therapeutic ketogenic diet for improved mental health, then the first step is to reach out to your doctor and discuss it.  

If your doctor is willing to oversee your health and medications while you adopt the diet, then the next step is to have them complete and return a Request for Medical Supervision Form by fax to our office.

More Info

Under the Services tab, you can learn about the 3:1 and 2:1 therapeutic ketogenic diets that I design, and where you will also find the corresponding Request for Medical Supervision Form.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/jyerdile
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 for weight loss and blood sugar control, but a therapeutic ketogenic diet (TKD) is different (read more here). A therapeutic ketogenic diet is a type of medical nutrition therapy used as adjunct treatment for specific physical or mental health conditions that is either prescribed by a Physician (doctor) and implemented by a Dietitian, or implemented by a Dietitian under Physician oversight.

In a therapeutic ketogenic diet, the amount of protein, carbohydrates, and fat is carefully controlled to keep ketone levels steady throughout the day, and both glucose and ketone levels must be monitored so that a specific therapeutic level called the Glucose to Ketone Index (GKI) is achieved. 

Therapeutic ketogenic diets have been used for over 100 years for 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 2022 study in Frontiers in Psychiatry included 31 adults with treatment-resistant depression, bipolar disorder, or schizoaffective disorder in a psychiatric hospital in Toulouse, France. They followed a therapeutic ketogenic diet that restricted carbohydrates to 20g per day. Of the 28 individuals who stayed on the diet for more than two weeks, all showed symptom improvements within three weeks. Forty-three percent achieved full remission, and 64% were discharged on less psychiatric medication [1].

Other pilot studies show similar results in bipolar disorder and schizophrenia [2][3].

“Brain Energy” Book – role of therapeutic ketogenic diets 

The release of the book Brain Energy by Harvard Psychiatrist Dr. Chris Palmer in 2022 brought public attention to the role of therapeutic ketogenic diets in mental health [4], which has led to an increase in inquiries about using them. 

But what is a therapeutic ketogenic diet?

Types of Therapeutic Ketogenic Diets

Therapeutic ketogenic diets are a form of medical nutrition therapy using a specific ratio of fat to protein plus carbohydrate.

Classic Ketogenic Diet (KD)

The Classic Ketogenic Diet has a 4:1 ratio, which means 4g of fat is provided for every 1g of protein plus carbohydrate. This diet is 80% fat 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 is used when the need to achieve and maintain high levels of ketones is necessary.

Modified Ketogenic Diet (MKD)

The Modified Ketogenic Diet (MKD) has a 3:1 ratio, which means 3 parts fat for every 1 part protein and carbohydrate. This diet is 75% of calories from fat, and 25% from a combination of protein and carbohydrate. Protein may be set at 15% of calories, with a maximum of 10% of calories coming from carbohydrate.

Some Psychiatrists will start their patients on a 3:1 therapeutic ketogenic diet. Once their patient is producing significant levels of ketones and is stable with respect to symptoms, they may gradually have them transition to a Modified Atkins Diet (2:1) while monitoring their symptoms, as this can be easier to maintain long-term and is more suitable for those who cannot tolerate very high-fat diets.

Modified Atkins Diet (MAD)

The Modified Atkins Diet has a 2:1 ratio, and is only 60-65% fat, and is used in specific mental health conditions that do not require the higher levels of ketones that can be produced using a Modified Ketogenic Diet (3:1). 

As mentioned above, some Psychiatrists will start their patients on a 3:1 therapeutic ketogenic diet, and once the desired level of ketones has been achieved and the person is stable with respect to symptoms, they may gradually transition them to a Modified Atkins Diet (2:1).

Calculating Ratios Based on a Percentage of Calories

As a Dietitian who designs therapeutic ketogenic diets, the first step is to determine the amount of energy (calories, in kcal) the individual needs. Then, I calculate the percentage of calories that need to come from fat, protein, and carbohydrate based on the specific dietary prescription.

Meals of therapeutic ketogenic diets are much smaller than conventional meals because they are higher in fat. Fat provides the same number of calories for much less mass (weight, in grams), so to get 500 kcals as protein, one would need to eat 125g of protein, but to get the same amount of calories as fat, one would only need to eat 55.5 g of fat. Fat is much more calorically dense, providing 9 kcal/g, whereas protein and carbohydrate have only 4 kcal/g.

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 the 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“, following a ketogenic diet 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 discontinue 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 emphasizes that with the gradual decrease in medications, people are more reliant on the ketogenic diet to keep symptoms under control. The ketogenic diet is therapeutic; therefore, 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 Dietitian 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 I have referred to often in designing therapeutic ketogenic diets for different physical conditions. 

Steps to Getting Started 

If you are thinking of adopting a therapeutic ketogenic diet for improved mental health, then the first step is to reach out to your doctor and discuss it.  

If your doctor is willing to oversee your health and medications while you adopt the diet, then the next step is to have them complete and return a Request for Medical Supervision Form by fax to our office.

More Info

Under the Services tab, you can learn about the 3:1 and 2:1 therapeutic ketogenic diets that I design, and where you will also find the corresponding Request for Medical Supervision Form.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/jyerdile
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, 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.

Androgens are male hormones and as explained below, contribute to hair growth in both men and women. But, androgens also contribute to hair loss, such as in androgenetic alopecia. This is known as the “androgen paradox”.

As explained in the previous article, one of the main contributors to both male pattern baldness and female pattern baldness, also known as androgenetic alopecia, is the hormone dihydrotestosterone (DHT). DHT is a male hormone (androgen) that is a metabolite of testosterone made by the enzyme  5 alpha-reductase (5-AR) acting on testosterone. 

But androgens also play an important role in hair growth.

The Androgen Paradox

Before people go through puberty, most parts of the body (except for the scalp) are covered in thin, fine hair known as vellus hair (“peach fuzz”). Vellus hair is generally lighter and shorter than terminal hair that grows on the scalp, which is longer and thicker [1]. As androgens increase during puberty, vellus hair follicles are change into terminal hair follicles which then produce larger, curlier, and darker hair which appears in the public area, and “arm pits” (axillary area) [1].

During puberty, androgens stimulate beard growth in men [1], but even though androgens such as testosterone, androstenedione, dehydroepiandrosterone (DHEA), and DHEA sulfate (DHEAS) are produced by the ovaries and adrenal glands of healthy women, these are not in large enough quantities to stimulate hair growth on the face. In women with Polycystic Ovarian Syndrome (PCOS) however, hair on the upper lip and chin area (hirsutism) is common and is believed to be due to high levels of male androgens and abnormal levels of luteinizing hormone (LH) from the pituitary interfering with the normal function of the ovaries [2,3].

Paradoxically, androgens also contribute to hair loss in androgenetic alopecia (AGA) [4].  A double blind control study from 1994 of people with androgenetic alopecia found that DHT levels were significantly higher in areas of bald scalp, than in areas of the scalp that contained hair [5]. In 1996, it was determined that the parts of the scalp that show balding in androgenetic alopecia have higher levels of the enzyme 5 alpha-reductase (5-AR) in the hair follicles, than the hair follicles in the parts of the scalp that do not bald [6]. These higher levels of 5-AR in the hair follicles converts testosterone to DHT, and when DHT binds to the receptors in the oil glands of hair follicles, it causes the follicles to shrink, or “miniaturize” until they eventually stop producing hair, resulting in baldness. 

As mentioned in the previous article, 5 alpha-reductase (5-AR) can be inhibited by the drug Finasteride® which lowers levels of DHT in the hair follicle, reducing the attack and slowing, or stopping hair loss.  Finasteride® also reduces the amount of DHT in the blood and scalp [7,8] and slowing androgenic alopecia progression.

As outlined in the first article in the three-part series titled, “Lotions, Potions, and Pills”, there are nutritional supplements available that are documented to restore hair growth and that are supported with the highest-quality evidence. A few of them are 5 alpha-reductase (5-AR) Inhibitors, and function similarly to Finasteride®.

The upcoming second article in the series will outline several oral hair growth supplement mixtures with the best quality scientific evidence to support hair growth — some of which also act as 5 alpha-reductase (5-AR) Inhibitors.

In addition, the third upcoming article in the series will outline evidence-based topical hair supplements that either serve as 5-AR reductase inhibitors to reduce the effect dihydrotestosterone (DHT) on hair follicles, support scalp health through their antibacterial or antimicrobial properties, or stimulate hair growth by increasing blood flow to hair follicles.

Final thoughts…

Androgens can paradoxically stimulate hair growth and cycling and this results in men having more hair on their face, and both men and women having hair in their pubic region and arm pits. Androgens can also contribute to balding on the scalp in the same individual, regardless of gender [9].

The balding effect of dihydrotestosterone (DHT) acting on hair follicles of the scalp can be reduced with use of medication treatment such as Finasteride®, as well as by evidence-based oral nutritional supplements and topical applications of essential oils, botanicals, and herbals.

While  Finasteride® is very effective at treating the hair loss associated with androgenic alopecia (as well as benign prostate hyperplasia (BPH)), its use is not without potential side effects. These can include decreased libido, the inability of men to have or maintain an erection, or problems with ejaculation [10]. 

Use oral nutritional supplements supported by robust scientific studies to promote hair growth and/or the use of topical applications of essential oils, botanicals, or herbals that have been demonstrated to be both safe and effective at reducing or stopping hair loss is also an available option.  Click here to read the first of three articles in a series on this topic.

More Info?

If you would like more information about how I could support you from a nutritional perspective, please send me a note through the Contact Me form at the top of this page.

To your good health!

Joy

You can follow me on:

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

References

1. 1. Inui, S., Itami, S. (2013). Androgen actions on the human hair follicle: perspectives. Exp. Dermatol. 22, 168–171. doi: 10.1111/exd.12024
   2. Barbieri RL, Ehrmann, DA. UpToDate Patient education: Polycystic ovary syndrome (PCOS) (Beyond the Basics), December 20, 2021, https://www.uptodate.com/contents/polycystic-ovary-syndrome-pcos-beyond-the-basics/
   3. Abdelazim IA, Alanwar A, AbuFaza M, et al. Elevated and diagnostic androgens of polycystic ovary syndrome. Prz Menopauzalny. 2020;19(1):1-5. doi:10.5114/pm.2020.95293
   4. Randall, V. A. (2007). Hormonal regulation of hair follicles exhibits a biological paradox. Semin. Cell Dev. Biol. 18, 274. doi: 10.1016/j.semcdb.2007.02.004
   5. Dallob, A. L., Sadick, N. S., Unger, W., Lipert, S., Geissler, L. A., Gregoire, S. L., et al. (1994). The effect of finasteride, a 5 alpha-reductase inhibitor, on scalp skin testosterone and dihydrotestosterone concentrations in patients with male pattern baldness. J. Clin. Endocr. Metab. 79, 703–706. doi: 10.1210/jcem.79.3.8077349
   6. Itami, S., Nakanishi, J., Yoshikawa, K., Takayasu, S. (1996). 21 Expression of androgen receptor, type I and type II 5 α-reductase in human hair follicle cells. J. Dermatol. Sci. 12, 86–86. doi: 10.1016/0923-1811(94)90434-0
   7. Drake, L., Hordinsky, M., Fiedler, V., Swinehart, J., Unger, W. P., Cotterill, P. C., et al. (1999). The effects of finasteride on scalp skin and serum androgen levels in men with androgenetic alopecia. J. Am. Acad. Dermatol. 41, 550–554. doi: 10.1016/s0190-9622(99)80051-6
   8. Price, V. H. (1999). Treatment of hair loss. New Engl. J. Med. 341, 964–973. doi: 10.1056/NEJM199909233411307
   9. Miranda, B. H., Charlesworth, M. R., Tobin, D. J., Sharpe, D. T., Randall, V. A. (2018). Androgens trigger different growth responses in genetically identical human hair follicles in organ culture that reflect their epigenetic diversity in life. FASEB J. 32, 795–806. doi: 10.1096/fj.201700260RR
   10. MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated 2022 Jun 15]. Finasteride, Available from: https://medlineplus.gov/druginfo/meds/a698016.html 

Copyright ©2022 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 identity is tied to their appearance, which makes significant hair loss at any age or gender devastating, but can nutritional supplements help?

Those experiencing different types of hair loss are often desperate to find a solution, and there is no shortage of lotions, potions, and pills promising new hair growth. Are these safe and effective, or are they simply “snake oil”? This article is about evidence-based nutritional supplements that may help restore hair loss, depending on its cause. It’s important to keep in mind that nutrient needs between people differ, so supplementation is not one-size-fits-all.

Androgenic Alopecia

Androgenic alopecia is commonly known as “male pattern baldness” or “female pattern baldness,” and the leading cause of it is an androgenic hormone known as dihydrotestosterone (DHT). DHT binds to the hair follicle, causing it to shrink, and eventually, the hair stops growing entirely. Some nutritional supplements positively affect DHT and help support hair growth, but many “hair growth nutritional supplements” contain ingredients for which evidence of benefit is lacking.

A study at an alopecia clinic [1] found that 81% of the patients were female, and 63% of them used nutritional supplements, compared to the US average of 40% [2]. The most common hair loss supplements used include biotin, vitamin B12, and B-complex multivitamin and while taking these nutritional supplements may seem benign, biotin, for example, is well-known to interfere with diagnostic tests for Thyroid Stimulating Hormone (TSH). The implication of this is that people taking biotin-containing supplements to self-treat hair loss without first being evaluated for a thyroid disorder may result in missing the diagnosis and underlying cause of their hair loss. In addition to interfering with diagnostic tests, some ‘hair loss nutritional supplements’ may be toxic in high doses, while still others may interact with medications, or supplements that people are taking to restore a diagnosed nutrient deficiency [3]. 

A systematic review that was recently published in the Journal of the American Medical Association (JAMA) Dermatology (November 30, 2022) evaluated the effectiveness of nutritional supplements for treating hair loss in people without nutritional deficiency [4]. This first article is based on this current systematic review.

Three Main Types of Hair Loss

There are three main types of hair loss, telogen effluvium, androgenic alopecia (AGA), and alopecia areata (AA).

Telogen effluvium (TE) is the most common form of diffuse hair loss [5] and usually occurs after a profound stress, shock or traumatic event including childbirth,  a thyroid disorder, or rapid weight loss. This type of hair loss was covered in this earlier article. But TE is not the only type of hair loss in hypothyroidism. In a study of more than 1200 people with thyroid disorder, half (50%) of people aged 40 years old and older had either alopecia areata, or androgenetic alopecia [6].

Androgenic alopecia (AGA) affects up to 50% of men and women. In men is called ‘male pattern baldness’ and is mainly seen on the crown of the head and the temples. In women, it is called ‘female pattern baldness’ and is primarily seen at the crown of the head, with a broader center part. Androgenic alopecia is a genetic disorder that involves both maternal (mother’s) and paternal (father’s) genes, with sons being 5-6 times more likely to have it if their fathers were balding [7]. 

Alopecia areata (AA) is an autoimmune disorder where the body’s immune system attacks the follicles. As a result, hair often comes out in clumps, usually the size and shape of a quarter, but it can affect more expansive areas of the scalp [8]. It can occur in those with other autoimmune conditions, including thyroid disease. 

There are medication treatments available for the different types of hair loss, and there is increasing evidence that taking specific nutritional supplements can be helpful in helping restore hair loss.

A systematic review published in JAMA Dermatology [4] published November 30, 2022 — just a month ago, evaluated the effectiveness of nutritional supplements for treating hair loss in people without nutritional deficiency. The dietary supplements with the highest-quality evidence of potential benefit were categorized according to their mechanism of action and are outlined in this article.

Dihydrotestosterone (DHT) as a Main Cause of Hair Loss

One of the main contributors to androgenetic alopecia (AA) is the male hormone (androgen) called dihydrotestosterone (DHT). DHT is made by an enzyme called 5 alpha-reductase (5-AR) acting on testosterone. When DHT binds to the receptors in the oil glands of hair follicles, it causes the follicles to shrink, shortening their life span. Eventually, these follicles shrink so much that they stop producing hair. The end result is baldness. DHT can be suppressed by medications such as Finasteride®, which lowers levels of DHT. This reduces the attack on hair follicles, slowing or stopping hair loss.

(Minoxidil® is a hair loss medication that works by an entirely different mechanism. It acts as a vasodilator, increasing blood flow in the scalp by making blood vessels wider. It is thought that this increased blood flow slows hair loss and encourages hair to regrow.)

[Update, December 29, 2022: While androgens such as DHT contribute to baldness by their detrimental effect on hair follicles in the scalp, androgens like DHT are also a key player in hair growth. This contradictory role of androgens is known as the “androgen paradox”. This short supplemental article explains more. ]

Nutritional Supplements – the role of 5-α reductase (5-AR) inhibitors in restoring hair loss

Pumpkin Seed Oil as a nutritional supplement in hair loss

Pumpkin seed oil is known to be effective in treating benign prostate hyperplasia (BPH) because it acts as a 5AR inhibitor [9,10], so it was an excellent candidate to study for its effect on hair growth. In a 2014 study, 76 male androgenic alopecia (AGA) patients were divided into two groups. For 24 weeks, one group of subjects took a 400 mg capsule of pumpkin seed oil each day, while the other group took a placebo. The group taking the pumpkin seed oil nutritional supplement showed significantly superior hair growth, with a mean hair count increase of 40% in the pumpkin seed oil-treated men compared to 10% in the placebo-treated men. There were no differences in adverse effects between the two groups.

Nutritional Supplements in Hair Loss – Saw Palmetto

In a 2004 pilot study, six of ten subjects (60%) that took an extract made from 200 mg Saw Palmetto extract (Serenoa repens), 50 mg betasitosterol, along with 50 mg lecithin, 100 mg inositol, 25 mg phosphatidyl choline, 15 mg niacin, and 100 μg biotin for 5 months were reported to have improved hair growth compared to the placebo controlled group (11%), however the difference was not statistically significant [11]. Studies with larger groups of both treatment and control groups is needed before conclusions can be made. Most importantly, it is hard to know if the benefits were due to the Saw Palmetto, or some of the other ingredients in the supplement.  For this reason, I think this next study is more helpful.

A two year randomized control study of 100 male patients with mild to moderate androgenic alopecia took either 320 mg of dry Saw Palmetto nutritional supplement extract (Serenoa repens) daily for 24 months, or 1 mg Finasteride daily for the same time period.  While Finasteride was significantly more effective at slowing hair loss, at 24-months the Saw Palmetto extract did stabilize hair loss. [12].

The results of this study suggest that Saw Palmetto can stabilize hair loss over two years, but is less effective than the medication Finasteride.

The Role of Specific Micronutrients in Restoring Hair Loss

Nutritional Supplements for Hair Loss – Vitamin D

Three studies from the last 5-10 years have demonstrated that that lower levels of vitamin D, or vitamin D deficiency have been associated with all three forms of hair loss, including androgenic alopecia [13], alopecia areata [14], and telogen effluvium [15].

A small 2021 study supplemented 40 women with telogen effluvium with very high oral vitamin D3 (200,000 IU every two weeks for six weeks). The study reported that more than 80% had improved results on a hair pull test after six months, with no adverse side effects [16]. However, the limitation of this study was that it was unknown if any of these subjects were deficient in vitamin D before taking the supplements, there was no control group, and telogen effluvium tends to resolve by itself over the same six-month period without treatment.

Before beginning supplementation, it would be prudent to assess vitamin D status and to determine how low or deficient it is, then increase dietary intake of vitamin D, and supplement as necessary to attain and maintain sufficient blood levels of vitamin D.

Foods that are naturally good sources of vitamin D include fatty fish such as salmon, mackerel and tuna.

Nutritional Supplements for Hair Loss – Zinc

A deficiency of zinc is associated with telogen effluvium, and lower zinc levels have been observed in people with alopecia areata (AA) [17-19]. Two small studies of zinc supplementation in patients with alopecia areata both reported benefits. The first study with 38 subjects was from 1981 [20] and supplemented using 220 mg of zinc sulfate per day. The second study from 2012 [21] had 67 subjects supplemented with 5 mg/kg body weight per day of zinc sulfate. Both studies reported benefits at three months; however, larger studies are needed.

It would be best to assess zinc status for those with hair loss (especially alopecia areata) prior to supplementing with zinc.

If zinc status is low, increasing dietary intake of zinc would be a great place to start. Good sources of zinc include red meat, poultry, seafood such as oysters, crab, lobster, and sea urchin (uni, in Japanese), as well as nuts.

If needed to achieve adequate blood levels of zinc, a supplement can be added to attain, and maintain zinc adequacy, but it’s important to ensure there is adequate copper intake as well, as zinc depletes copper. Beef liver is a very good source of dietary copper, but eating 3 or 4 ounces once a week may be enough, as it has 6 times the recommended dietary intake of copper, and high amounts of preformed vitamin A. It is also important not to take zinc supplements within several hours of taking iron supplements, as they complete for binding sites.

Nutritional Supplements for Hair Loss – Vitamin B12

Vitamin B12 is necessary for DNA synthesis and it was proposed in a 2017 report on the role of micronutrients in alopecia areata that vitamin B12 could be helpful in increasing the number of hair follicles [17].

A 2018 study of people with telogen effluvium that included symptoms of itching, pain, soreness, and/or burning were evaluated for symptoms of B12 deficiency. While lab normal values were 200-400 pg/mL, deficiency was evaluated to be <550 pg/ml, a cutoff limit reported to be used in other countries. After four months, 90% of subjects that received either a daily B12 tablet or monthly B12 injection had significant decrease or even an absence of hair shedding [23]. The main shortcoming of this study was the self-resolving nature of telogen effluvium — which means that over the same period of time, doing nothing could have resulted in improvement is hair loss.

The best dietary sources of vitamin B12 are organ meats, including liver and kidney, clams, sardines, and beef, however, some disorders and advanced age can result in reduced dietary absorption of vitamin B12. Testing vitamin B12 status is important especially in older adults who have decreased absorption of B12 due to decreased intrinsic factor, as well as testing B12 status in those taking medication to lower stomach acid. 

Nutritional Supplements – the role of antioxidants in restoring hair loss

Oxidative stress has been thought to play a role in all three types of hair loss [24-26] and antioxidants such as selenium, vitamins A, E and C, and carotenoids (yellow, orange or red coloured fat-soluble pigments found in vegetables, fruit, and some fish. 

A 2015 randomized control study compared the effects of giving a supplement containing omega 3 fat from fish, omega 6 fat from blackcurrant seed oil, as well as the antioxidants lycopene (from tomato), vitamin C, and vitamin E versus giving no supplement to 188 women diagnosed with stage 1 androgenic alopecia [27]. The intervention group had significantly increased hair density and hair thickness at six months.

A 2010 randomized control study compared giving a supplement containing mixed tocotrienol from the vitamin E family versus a placebo to patients with unspecified hair loss. The 50 mg mixed capsules given to the intervention group had 30.8% alpha-tocotrienol, 56.4% gamma-tocotrienol, and 12.8% delta-tocotrienol, as well as 23 IUs alpha-tocopherol). Twenty one subjects were randomly assigned receive 2 x 50 mg (100 mg) of mixed tocotrienols daily, while 17 subjects were assigned to receive an oral placebo capsule. At 8-months, the number of hairs of the subjects in the intervention group increased by 34.5% compared to the placebo group which had a 0.1% decrease [28]. The shortcomings of this study were the small sample size and that the study did not define hair loss in the inclusion criteria of subjects. 

Nutritional Supplements – more is not always better

Caution needs to be taken when choosing types and amounts of antioxidant supplements as excessive use of supplements such as selenium, for example has been tied both to toxic effects and hair loss [29]. Even when getting selenium in the diet by eating Brazil nuts, only 2 is already at the maximum daily amount. Eating 4 or 5 Brazil nuts can exceed the safe upper tolerance of selenium for adults, so more is not better. 

Excess vitamin A intake can result in vitamin A intoxication which can result in seizures or blurred vision, and long term (chronic) over supplementation with vitamin A can result in several symptoms, including muscle and bone pain, high blood lipids and ironically alopecia, or hair loss [30].

The best sources of preformed vitamin A (retinol) are beef liver, fish, and eggs and a delicious and very rich source is Icelandic cod livers.

Cod livers are very high in retinol, and just half a 115g can contains 450% the recommended daily intake for vitamin A. To avoid getting too much preformed vitamin A, it is best not to eat cod livers more than once every week or two, and even further apart if also regularly consuming beef liver which is also high in preformed vitamin A.

Before beginning to take supplements it is important to assess intake form food sources, so as not to take too much as a supplement.

Other Nutritional Supplements – probiotics and growth hormone modulators

Probiotics have been hypothesized to improve blood flow to the scalp and one study from 2020 used a kimchi and fermented soybean paste (cheonggukjang) probiotic product.

Twenty-three men and twenty-three women with androgenic alopecia (AGA) were given the supplement and at four months, 93% showed significant improvement in either hair thickness and/or hair count, with no serious side effects [31]. The limitations of this study were the small sample size and lack of a control group.

Capsaicin, is the chemical that give hot chilis their spiciness and is used as a topical pain reliever. When  applied to the scalp has been found to increase Insulin-like Growth Factor I (IGF-1) which is involved in hair growth [32].

A randomized control study of a capsaicin and isoflavone supplement (6 mg capsaicin, 75 mg isoflavone (from soy) in 48 adults with either androgenic alopecia (AGA) or alopecia areata (AA) compared to controls found significantly more hair growth in the capsaicin and isoflavone group at 5 months, and no adverse effects were reported. The limitations of this study were its small sample size as well as the inclusion of various types of alopecia.

Final Thoughts…

In the United States, dietary supplements are normally considered a food and as such, their safety or effectiveness are not evaluated by the Food and Drug Administration (FDA). It is only if a product is labelled to treat a disease that the product meets the definition of a drug and needs to establish its efficacy [33].

In Canada, however, dietary supplements are considered Natural Health Products (NHP) by Health Canada and are treated as non-prescription drugs which are regulated under the Natural Health Product Regulations. According to Health Canada, in the ten years from 2004 (when the Natural Health Product Regulations came into existence) and 2014, nearly 55,000 licenses for NHPs were issued [34].

The ease by which Canadians can order supplements online from the US essentially bypasses any governmental safeguards put into place by Health Canada so it is important that people in both countries are aware that there is no FDA oversight for safety or efficacy for supplements purchased from the US. For this reason, it is best that before people begin using dietary supplements to self-treat hair loss, that they discuss this with a knowledgeable healthcare professional, such as their doctor or Registered Dietitian. In addition, for those already taking dietary supplements, it is important before going for lab tests to mention to your doctor and Dietitian which supplements you are taking so that they can ensure that you discontinue use of specific supplements for an sufficiently long period of time before the test (such biotin before a Thyroid Stimulating Hormone (TSH) test).

More Info?

Hair loss can be devastating, but before parting with substantial sums for money for lotions, potions, or pills that promise new hair growth, first take the time to find out what you need. 

Consider finding out if your diet or lifestyle may put you at risk for nutrient deficiencies, and if so to have those evaluated. Ask yourself if it is possible you may have a thyroid disorder (this article may help) so that you can have diagnostic tests before taking supplements that can interfere with getting accurate results.

Finally, if blood tests come back indicating that you may have low nutrient status or a deficiency, find out which nutrients can be adequately obtained from food, and which may need to be supplemented.

Nutritional supplements can be very helpful if used correctly, but taken in the wrong dosage, or at the wrong timing, supplements can interfere with the absorption of medications you may take, and/or with other nutrients you are already low on.

If you would like more information on how I can help assess your dietary intake or nutrient status of specific nutrients, please send me a note through the Contact Me form at the top of this page.

To your good health!

Joy

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