Month: February 2021

I often hear the question, “how much protein is best?” but that depends for whom. Different people have a different protein needs. A healthy man or woman seeking to build muscle has a different protein need than an older adult wanting to reduce the risk of sarcopenia (muscle loss) or someone simply wanting to prevent deficiency. The amount of protein someone needs depends on many factors, including whether a person is growing, pregnant or lactating (breastfeeding), or has been sick or just had surgery. Even for those who aren’t in these special circumstances, protein needs may be calculated to prevent deficiency, to sustain exercise or to preserve muscle mass in older adults, and each of these calculations are different.

Protein needs are calculated as grams of protein per kilogram of body weight of the person, and not as a percentage of daily calories (energy). As explained below, 40% of calories as protein may be safe for one person and be in excess for someone else. For this reason, protein must to be calculated as grams of protein per kilogram of body weight.

Basic Needs – the Recommended Daily Allowance (RDA) for Protein

The Recommended Daily Allowance (RDA) for any nutrient is the average  daily dietary intake level that is sufficient to meet the needs of 97-98 % of healthy people. It is important to keep in mind that the RDA is not the optimal requirement, but the absolute minimum to prevent deficiency.

The RDA for protein for healthy adults is calculated at 0.8 g protein / kg of body weight [1]. A sedentary 70 kg / 154 pound man needs a minimum of 56 g of protein and a sedentary 60 kg / 132 pound woman needs a minimum of 48 g protein per day.

Protein Needs for Active Healthy Adults

For those who are physically active, the Academy of Nutrition and Dietetics, Dietitians of Canada, and the American College of Sports Medicine[2] recommend a protein intake of 1.2—2.0 g protein / kg per day to optimize recovery from training, and to promote the growth and maintenance of lean body mass.

Protein Needs for Older Adults

There have been several position statements issued by those that work with an aging population indicating that protein intake between 1.0 and 1.5 g protein / kg per day may best meet the needs of adults during aging [3,4].

For the average, healthy 70 kg / 154 pound sedentary man this would be daily protein intake of 70 -105 g per day and for the average, healthy 60 kg / 132 pound sedentary woman this would be a protein intake of 60-90 g protein per day.

[UPDATE (August 15, 2023): Protein needs for older adults are now established at above 90g per day, with the optimal amount of 30g highly bioavailable protein over each of 3 meals, along with sufficient amounts of the amino acid leucine, which is needed to trigger muscle protein synthesis.  This updated article explains.

Range of Safe Intake

As I wrote about in an earlier article, according to Dr. Donald Layman, PhD, Professor Emeritus, of Nutrition from the University of Illinois, the highest end of the range of safe intake of protein is 2.5 g protein/ kg per day.

For the average 70 kg / 154 pound sedentary man this would be a maximum daily protein intake of 175 g per day and for the average 60 kg / 132 pound sedentary woman, this would be a maximum protein intake of 150 g/ day.

Someone eating on occasion above their safe range is a different scenario than someone eating above or at the very high end of that range on a regular basis. The body has a flexible capacity to tolerate higher protein intake on occasion, but regularly eating too much protein can result in protein toxicity.

Maximum Amount of Protein the Body can Safely Process

[Special thanks to Richard Morris, research biochemist from Canberra, Australian for the information contained in this section.]

When protein is eaten, the body needs to get rid of the ammonia that results and this is done by turning the ammonia into urea and excreting it in the urine.

The disposal rate of ammonia isn’t able to be calculated because ammonia is literally given off by the lungs and skin, and tracer studies suggest that the disposal rate is higher than the rate that urea appears in urine. This means that there are probably several reservoirs for ammonia (such as urea building up in circulation before filtration in the kidneys) and this ‘elastic’ or flexible capacity for ammonia enables us to survive high protein days interspersed with low protein days.

The rate limit for maximal disposal of urea through urine is 0.53 g of N per kilo of 3/4 body weight[4], as a proxy for lean body mass. The ratio of molecular weights between a nitrogen atom and the average molecular weight of amino acids is a factor of 6.05x, so the effective rate limit for maximal disposal of urea through urine is .53 x 6.05 = 3.21 g of protein/kg lean body mass. If someone were to eat above that amount of protein for too long, they will have filled their ‘elastic’ (flexible) reservoirs with urea, and would then be at risk of ammonia intoxication.

This calculation for determining the maximum amount of protein based on urea clearance requires know a person’s energy consumption (in kcals / calories), as well as lean body mass (LBM).  Note that this is lean body mass, not total body weight. Lean body mass is essentially one’s total body weight minus the amount of fat they have.

Lean body mass can be assessed using a DEXA scan, or estimated by using relative fat mass (RFM). The amount of fat someone has can be estimated from total body weight (taken on a scale), minus their estimated RFM as described in this article. 

Once we know a person’s lean body mass, we can use the equation (3.21 g of protein / kg lean body mass) to determine the maximum amount of protein they can eat on an ongoing basis while being able to safely dispose of the ammonia via urea through urine.

Here are some examples of calculations;

Note: This article was originally posted on February 16, 2021, and has been updated and reposted on November 10, 2025.

Introduction

More than a hundred years ago, Dr. Russell M. Wilder and two Dietitians from the Mayo Clinic wrote a 69-page book titled A Primer for Diabetic Patients – A Brief Outline of the Principles of Diabetic Treatment, Sample Menus and Food Tables [1]. It described how diabetes was managed before the discovery of insulin, using several levels of low-carbohydrate and very low-carbohydrate (ketogenic) diets and short fasting periods. The approach is very similar to current low-carbohydrate and very low-carbohydrate (keto) diets used by those who want to improve or achieve remission of the symptoms of type 2 diabetes using a diet-first approach.

Wilder’s Early Work and the Ketogenic Diet

The name Dr. Russell Wilder is best known for his 1921 paper “The effect of ketonemia on the course of epilepsy” [2]. In it, Wilder proposed a very high-fat, low-carbohydrate diet to mimic the benefits of fasting for people with epilepsy.

Wilder is the one who coined the term “ketogenic diet,” and his classic 4:1 ketogenic diet, where 4g of fat is provided for every 1g of protein plus carbohydrate, is still used today to manage epilepsy and seizure disorder, and as an adjunct in treatment for glioblastoma, an aggressive form of brain cancer.

While Dr. Russell Wilder’s name is tied to the use of a ketogenic diet in the treatment of epilepsy, his prior work used low-carbohydrate and very low-carbohydrate (ketogenic) diets in the treatment of diabetes. But how could he be so well known for using a ketogenic diet in epilepsy, yet be almost unknown for his earlier use of low-carbohydrate and ketogenic diets for diabetes?

The answer lies in timing.

Just a year after Wilder began using low-carbohydrate and very low-carbohydrate (ketogenic) diets in the treatment of diabetes, Dr. Frederick Banting and Charles Best discovered insulin [3], and the Eli Lily company soon began manufacturing it.

The discovery of insulin quickly pushed Wilder’s low-carbohydrate dietary treatment for diabetes into the pages of history.

Insulin was life-saving for people with type 1 diabetes, whose pancreas made little or no insulin of its own. Its use by those with type 1 diabetes was necessary.

It is harder to understand why Wilder’s dietary approach did not continue for those with type 2 diabetes, where the body still makes insulin but cannot use it properly. It is possible that since type 1 and type 2 diabetes were not clearly differentiated until 1936, when Harold Himsworth made the distinction, the use of insulin had already become the standard therapy for treating (all types) of “diabetes”.

Determining Carbohydrate Tolerance

Wilder’s approach to treating those with diabetes was to view it as “carbohydrate intolerance” (which is what it is).

Wilder defined carbohydrate tolerance as “the amount of sugar-forming foods which a person can eat in twenty-four hours without causing sugar in the urine.”

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Below is a description of how Wilder determined a person’s carbohydrate tolerance.

“The tolerance of a given patient is ascertained by feeding foods of known composition in weighed and gradually increasing amounts.”

“The actual procedure will vary with different patients, but, in general, foods of known composition in weighted amounts are fed, the total intake of carbohydrate, protein, and fat being increased very gradually as high as possible without the return of sugar in the urine.”

“Some patients will be found to have low tolerance, others may stand 100 gm. of carbohydrate. Every patient should be treated as an individual case, but for convenience in prescribing diets, the following arbitrary grouping is made:

• Group A: had carbohydrate tolerance below 40 g of carbohydrate

• Group B: had carbohydrate tolerance between 40–60 g of carbohydrate

• Group C: had carbohydrate tolerance between 60–100 g of carbohydrate

• Group D: had carbohydrate tolerance above 100 g of carbohydrate.”

   

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Different Daily Macros

Different amounts of carbohydrate, protein, and fat (i.e., “macros”) were prescribed to each group, based on their carbohydrate tolerance.

• Group A (carbohydrate tolerance <40 g carb): were instructed to eat 20 grams of carbohydrate, 70 grams of protein, and 100 grams of fat at each of 3 meals. [1]

• Group B (carbohydrate tolerance between 40–60 g): were instructed to eat 40 g carbohydrate, 70 g protein, 100 g fat at each of 3 meals. [1]

• Group C (carbohydrate tolerance between 60–100 g): were instructed to eat 60 g carbohydrate, 70 g protein, 100 g fat at each of 3 meals. [1]

• Group D (carbohydrate tolerance > 100 g): were instructed to eat 100 g carbohydrate, 70 g protein, 140 g fat at each of 3 meals. [1]

These diets provided adequate protein for satiety and exceeded today’s DRI levels for most adults. 

Fat came mainly from butter, cream, cheese, eggs, and animal protein.

Carbohydrates were mainly from low-carb baked items made with “Hepco flour” or “Cellu-flour,” (low-carbohydrate flours high in cellulose, a fiber that is not digestible), low-carb vegetables, and small amounts of fruit or root vegetables.

Use of Fasting and Protein-Sparing Fasts

Wilder also utilized short fasts of 12–24 hours to improve blood sugar control.

Those in Group A who had a tolerance < 40 g of carbohydrate were advised to take a weekly “fast day” with liquids such as broth, coffee, or tea.

Those in Group B  who had a tolerance of 40-60 g of carbohydrate followed a “half-fast day” once per week, eating approximately 20 g carbohydrate, 12 g protein, and 12 g fat.

There was no fasting protocol for those in Group C whose carbohydrate tolerance was between 60 and 100 grams.

If sugar persisted in the urine, Wilder prescribed what we would now call a protein-sparing modified fast:

“If sugar persists, the patient should return to one-half of his diet, continue on this for a week, and then again try the effect of a fast day. After the urine is again sugar-free, he can return gradually to his previous diet.””

Wilder cautioned that longer fasts should never be attempted outside of an institution, possibly because at this time, no distinction had been made between type 1 and type 2 diabetes.

As mentioned above, only a year after Wilder began using low-carbohydrate and very low-carbohydrate diets in the treatment of diabetes, Banting and Best discovered insulin [3], and the Eli Lilly company started manufacturing it and began distributing it without cost (free) to those with diabetes (both type 1 and type 2).  Wilder’s low-carbohydrate dietary treatment for those with type 2 diabetes was no longer seen as needed, because people could eat wherever they wanted and “cover it with insulin”. 

From Insulin to Oral Medications

Oral diabetes medications only became available in the mid-1950s.

Tolbutamide, the first sulfonylurea, was introduced around 1956, and Metformin was first reported for use in people with diabetes in 1957 [6][7]. Before the 1950s, insulin was the main treatment for all types of diabetes.

A 1958 paper by Wilder [5] helps explain how the discovery of insulin and its subsequent free distribution by the Eli Lilly company led to the decline of low-carbohydrate and very low-carbohydrate (ketogenic) diets for diabetes.

Wilder noted:

“Insulin at that time cost five cents a unit in the market. However, the patients in our early cases received theirs gratis for a period of several years, thanks to the Eli Lilly Company.” (p. 247–248 [5])

In Wilder’s book, Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919–50., Wilder described how A Primer for Diabetic Patients evolved between 1921 and 1950.

The first edition followed Dr. Frederick Allen’s approach from the Rockefeller Institute, which used fasting and strict carbohydrate restriction.

The second edition (1923) added insulin and permitted a higher amount of fat.

Over the years, as insulin became less expensive and widely available, diets that focused on reducing carbohydrate intake were abandoned, and diets became increasingly liberalized. By 1950, recommended diets for those with diabetes looked like those of people without diabetes [5].

In the 1958 edition, Wilder describes how diabetes treatment evolved from a diet-first approach before the discovery of insulin, to a diet that was indistinguishable from the carbohydrate and protein-rich diet of those without diabetes due to the use of insulin [5].

What Was Lost

Perhaps the reason that diabetes has been considered a “chronic and progressive disease” is that dietary treatment had been all but forgotten after the discovery of insulin.

In 1921, Wilder wrote that:

“Diabetes is a disease which is manifested by excretion of sugar in the urine. This sugar comes from the foods which the patient eats, but which his body, owing to the disease, is unable to utilize.”

Wilder’s dietary recommendations were simple:

“Suit the diet to the condition of the patient and feed no more sugar-forming foods than the patient’s body is able to use. [1]”

Before the discovery of insulin, diet was the only treatment, and its discovery was lifesaving for those with type 1 diabetes. Unfortunately, it also resulted in those with type 2 diabetes forgetting that they could manage their blood sugar with diet.

Today, people with type 2 diabetes can still follow a carbohydrate-reduced diet while their doctors gradually decrease their diabetes medication. In many cases, diabetes medications are eventually discontinued entirely. Given these diets have been established as both safe and effective, why isn’t a carbohydrate-reduced diet regularly recommended as a viable diet-first approach to treating type 2 diabetes? 

Revisiting Dietary Treatment

The safety and effectiveness of a ketogenic diet for epilepsy are well-established [2].

So too is the safety and efficacy of a low-carbohydrate and very low-carbohydrate (keto) diet for the treatment of diabetes.

• In 2019 [8], the American Diabetes Association released its Standards of Care, which included the use of a low-carbohydrate diet.
• This was followed in 2020 [9] by Diabetes Canada releasing its Position Statement, acknowledging that a low-carb and very low-carb (keto) diet is both safe and effective for adults with diabetes.
• In 2021, Diabetes Australia released its Position Statement, Low-Carb Eating for People with Diabetes [10].

While these diets are very safe and effective in normalizing blood sugar, individuals who are taking insulin or insulin analogues must first have their doctor de-prescribe them before adopting a low-carbohydrate diet, as blood sugar normalizes quickly and can become much too low if still taking insulin. 

While Physicians are very familiar with prescribing medications such as sulfonylureas, SGL2 inhibitors, and GLP-1 agonists, and others to lower blood sugar, not many are experienced with reducing these medications when one of their patients wants to adopt a low-carbohydrate diet. 

A paper published in July 2019 in the British Journal of General Practice about adapting diabetes medication for low-carbohydrate management of type 2 diabetes explains to Physicians how to safely do this [11].

When someone comes to me wanting to adopt a lower-carbohydrate diet to manage their blood sugar, lose weight, and improve their metabolic health, or to put the symptoms of type 2 diabetes into remission, I will offer to liaise between them and their doctors in providing them with a copy of these guidelines, should they want.

The use of low-carbohydrate and very low-carbohydrate (keto) diets in the treatment of diabetes has been in existence for 100 years. They are not a fad.

Final Thoughts

For those who want to take a diet-first approach to lowering their blood sugar or putting the symptoms of type 2 diabetes into remission, a low-carbohydrate diet and, when needed, a very low-carbohydrate (ketogenic) diet can do that.

Type 2 diabetes remains a disease of carbohydrate intolerance.

Some people can eat 100g of carbohydrate per day while keeping their blood sugar in range, while others need to keep their carbohydrate intake to less than 40 g of carbohydrate daily. Every person’s carbohydrate tolerance is different, which is why their low-carbohydrate diet needs to be developed for them.  This is what I do.  

I have almost a decade of experience helping people follow a low-carbohydrate or very low-carbohydrate (ketogenic) diet, and have been following one myself since 2017.

More Info

If you would like me to design a low-carbohydrate diet for you to help you accomplish your goals, please look at the Routine Health packages under the Services tab to find the one that best suits your needs.  

To your good health,

Joy

Follow me on:

Twitter: https://twitter.com/jyerdile

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

 

Note: Special thanks to Jan Vyjidak of London, England, Founder and CEO at Neslazeno.cz, for locating Wilder’s historic book, A Primer for Diabetic Patients [1].

References

1. Wilder RM, Foley MA, Ellithorpe D. A Primer for Diabetic Patients. Mayo Clinic, W.B. Saunders Co, 1922. [https://www.amazon.ca/Diabetic-Patients-Outline-Principles-Treatment/dp/B017A5829S [https://www.amazon.ca/Diabetic-Patients-Outline-Principles-Treatment/dp/B017A5829S]

2. Wheless JW. History of the ketogenic diet. Epilepsia. 2008;49 Suppl 8:3–5. doi:10.1111/j.1528-1167.2008.01821.x [https://pubmed.ncbi.nlm.nih.gov/19049574/]

3. The History of Insulin. diabetes.co.uk. https://www.diabetes.co.uk/insulin/history-of-insulin.html

4. Krochmal M. 10 Facts About the History of Diabetes. https://type2diabetes.com/living/10-facts-history-diabetes/

5. Wilder RM. “Recollections and Reflections on Education, Diabetes, Other Metabolic Diseases, and Nutrition in the Mayo Clinic and Associated Hospitals, 1919–50.” Perspectives in Biology and Medicine. 1958;1(3):237-277. [https://archive.org/details/sim_perspectives-in-biology-and-medicine_1957-1958_1_contents]

6. Scheen AJ. History of sulfonylureas. Diabetes Metab. 2004;30(5):487–492.

7. Bailey CJ, Day C. Metformin: its history and future. Diabetologia. 2019;62(3):482–487. https://doi.org/10.1007/s00125-018-4808-3

8. American Diabetes Association, Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes—2020
   American, Diabetes Care Jan 2020, 43 (Supplement 1) S48-S65; DOI: 10.2337/dc20-S005 [https://pubmed.ncbi.nlm.nih.gov/31862748/]

9. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate Diets for Adults with Diabetes: A Rapid Review, Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.

10. Diabetes Australia. Position Statement: Low-Carb Eating for People with Diabetes. 2021. https://www.diabetesaustralia.com.au/wp-content/uploads/Diabetes-Australia-Position-Statement-Low-Carb-Eating.pdf
11. Campbell M., Unwin D., Cavan D.,  Cucuzzella M. et al, Adapting diabetes medication for low-carbohydrate management of type 2 diabetes: a practical guide, British Journal of General Practice 2019; 69 (684): 360-361. DOI: 10.3399/bjgp19X704525 [https://pubmed.ncbi.nlm.nih.gov/31249097/]

 

 

Copyright ©2021 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 come to me with different goals concerning type 2 diabetes. Many people who have been diagnosed with type 2 diabetes come to see me to help them put their diabetes into remission, so they no longer meet the criteria for diagnosis. 

As stated throughout this website and on my forms, I do not counsel people with type 1 diabetes, or with insulin-dependent type 2 diabetes because I am not a Certified Diabetes Educator (CDE). 

As explained in this earlier article, the American Diabetes Association has defined partial remission, complete remission, and prolonged remission from type 2 diabetes, as follows;

• • Partial remission is having blood sugar that does not meet the classification for Type 2 Diabetes; i.e. either HbA1C < 6.5% and/or fasting blood glucose 5.5 — 6.9 mmol/l (100—125 mg/dl) for at least 1 year while not taking any medications to lower blood glucose.*

* some studies such s those from Virta Health define partial remission as a HbA1C < 6.5% and fasting blood glucose ≤ 5.5 (100 mg/dl) while taking  no medication, or only generic Metformin.

• • Complete remission is a return to normal glucose values i.e. HbA1C <6.0%, and/or fasting blood glucose < 5.6 mmol/L (100 mg/dl) for at least 1 year while not taking any medications to lower blood glucose.

• • Prolonged remission is a return to normal glucose values (i.e.
    HbA1C <6.0%, and/or fasting blood glucose < 5.6 mmol/L (100 mg/dl) for at least 5 years while not taking any medications to lower blood glucose.

Complete and prolonged remission can be achieved after bariatric surgery such as the roux-en-y procedure, and partial remission and complete remission have been documented with dietary and lifestyle changes, including a very low calorie diet and a very low-carbohydrate (ketogenic diet). To date, there is limited long-term data of 5 years or more documenting prolonged remission with dietary and lifestyle changes alone, although there are case studies.

I support people with a wide-range of goals when it comes to diabetes through my long-standing general dietetic practice, BetterByDesign Nutrition.  

• • Some people come to me with a diagnosis of pre-diabetes, wanting to implement dietary changes to avoid getting type 2 diabetes.
  • Others come to me once they are diagnosed with type 2 diabetes, wanting to control their blood sugar level through dietary changes and avoid complications.
  •  More and more come to me after diagnosis to have me help them put the disease into remission.

These are each valid goals.

Those who know that remission of type 2 diabetes is possible find it difficult to understand that not everyone with type 2 diabetes wants to do that. Some people simply don’t know that this is a possibility — believing that the disease is automatically both chronic (long-term) and progressive (getting worse with time). This type of situation allows me to explain to them that type 2 diabetes can be put into remission, and the different ways that I can support them in aiming to achieve that.

Other people may simply want to ‘manage’ their blood sugar levels to keep them from getting higher to avoid complications. They don’t want to have normal blood sugar, but just want to minimize erectile dysfunction, avoid losing toes, or going blind. These people have every right to choose these goals and to be supported by their healthcare team, including me, in meeting them. I will make sure that they know that it is possible to achieve remission (because many don’t know), but if they don’t want to make the significant lifestyle changes required, then I will help them manage their diet to keep their blood sugar from getting higher.

Since type 2 diabetes is, in essence, end-stage carbohydrate intolerance, the amount and type of carbohydrate on each person’s Meal Plan that I design focuses on specific types and amounts that don’t contribute to high blood sugar. 

The reason that the byline of my dietetic practice is “Nutrition is BetterByDesign” is that every Meal Plan needs to be designed for the individual.  A person who doesn’t eat meat for religious, cultural, or ethical reasons, for example, needs to have an individual Meal Plan that helps them achieve their health goals — in the same way that someone who eats meat.

Those who choose to live with diabetes have just as much right to dietary support to meet those goals as someone who desires to seek remission from diabetes. 

Individuals have different goals and various needs. People are also at different stages of change when it comes to having type 2 diabetes. Some may start with wanting to manage their symptoms, and only later arrive at a point where they want to seek remission.  If and when they do, I support them in doing that.

This is why I do, what I do, the way I do.

Please let me know if I can help.

To your good health!

Joy

You can follow me on:

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

Copyright ©2021 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.

I was excited when I saw a thread on social media over the weekend about Diabetes Canada’s new 7-day Low Carb Meal Plan. After all, last May they released a Position Statement summarizing the evidence for the role of low carbohydrate diets (<51-130g carbohydrate/day) and very low- carbohydrate diets (<50g carbohydrate/day) in the management of type 1 and type 2 diabetes and I thought “great!” — they are going to be providing support for people with diabetes to be able to choose a low carb or very low carb (keto) diet as one of the available healthy eating patterns.  Not quite.

This was the ad I saw on Facebook;

Clicking on the link associated with the ad, the text reads;

“Current evidence suggests that a low-carbohydrate diet can be safe and effective for people with diabetes. This dietary pattern can help with weight loss and blood sugar management. Keep in mind that a low-carbohydrate diet can also reduce the need for certain diabetes medications. People living with diabetes who want to follow a low-carbohydrate diet should seek professional advice from their healthcare provider to avoid any adverse effects, such as hypoglycemia (low blood sugar) or an increased risk for diabetic ketoacidosis (DKA).

This meal plan features healthy plant-based foods, low glycemic index carbohydrates, and less than 130 grams carbohydrates per day. [1]”

At the bottom of the meal plan it indicates;

While the promotion on Facebook indicated that it features ‘plant-based foods’, it is not a plant-based menu. It includes eggs and yogurt, fish (tuna, fish fillet, salmon),  a (bun-less) cheeseburger, beef or pork meatballs, and chicken breast — along with tofu, legumes such as chick peas and black beans. Not surprisingly given one of the sponsors of the menu, each day includes one or more servings of plant-based beverages and recipes use canola oil.

The Diabetes Canada “low carb” meal plan is like no other I have ever come across, as it includes servings of starches such as bread, potato, rice, pasta and legumes.

Breakfast on day 1, 3 & 5 of the menu features a smoothie made with 200 ml of a sugar-sweetened soy beverage manufactured by one of the menu’s sponsors, along with 65 g of blueberries, 85 g of pomegranate and 2 g of ginger. This is hardly the best way for someone with diabetes (an inability to adequately handle carbohydrate) to begin the day — and that’s all there is for breakfast! One little glass of smoothie totalling almost 30g of carbs and only 9 g of protein.

Lunches and Dinners included either a slice of whole-grain bread, 1 small baked potato, 1/2 cup cooked brown rice, 3/4 cup (150 ml) cooked pasta, 1/2 cup (125 ml) mashed sweet potato or chick peas or black beans. Sure, small amounts of sweet potato can be appropriate as part of a real, whole food low carbohydrate meal plan, and a small amount of chick peas or black beans can be included from time to time, but there is no established “low carb” diet that includes bread, rice and pasta!

Low Carb — and low protein and fat too

I was curious how much food there was at each meal on this plan, as well as  the total amount of carbs and protein per day, so I decided to analyze Day 1, Day 3 and Day 5 to get a rough idea.

Where a recipe was not provided as part of the menu, I looked up the food item in Cronometer and used the nutritional information for the specified quantity.

These meals were <130 g of carbohydrate per day — so technically these are considered “low carb“, but they are also low fat, and low or inadequate in protein.

Day 1

Breakfast on Day 1 had a small glass of the “smoothie” (28.4 g carbs, 8.9 g pro, 5.2 g fat) and that was it until lunch! Given the high amount of ground-up fruit in it as well as the low amount of fat and protein, the first thing I thought of was how soon an adult with diabetes would be ravenous after drinking this. Then I wondered how high would their blood sugar go?

[Note: February 5, 2021]: In an earlier article, I covered the effect of various types of food processing on blood glucose, including mechanical processing such as the pureeing of the fruit in this smoothie. While 60g of whole apple, 60 g of pureed apple, and 60g of juiced apple have the same amount of carbohydrate and similar Glycemic Index neither of these indicate how blood glucose responds to eating pureed fruit, versus intact fruit.  We know from a 1977 study published in the Lancet (reference below) that when pureed fruit or juiced fruit is consumed, the glucose response 90 minutes later is significantly higher than if the fruit were eaten whole. 

[Haber GB, Heaton KW, Murphy D, Burroughs LF. Depletion and disruption of dietary fibre. Effects on satiety, plasma-glucose, and serum-insulin. Lancet. 1977 Oct 1;2(8040):679-82. doi: 10.1016/s0140-6736(77)90494-9. PMID: 71495]

This is typical of what is seen with any ultra-processed carbohydrate. So, the first problem with someone with diabetes having a fruit smoothie such as this as a meal is that the fruit is ground up, and not whole.  A smoothie will spike blood glucose much more than if the same food was eaten not pureed. 

We also know from a 2015 study on the effect of food order on the response of glucose and insulin, that if carbs are eaten last, the glucose curve will be approximately 74% smaller, with a 49% smaller insulin spike.

[Shukla AP, Iliescu RG, Thomas CE, Aronne LJ. Food Order Has a Significant Impact on Postprandial Glucose and Insulin Levels. Diabetes Care. 2015;38(7):e98-e99. doi:10.2337/dc15-0429]

The second problem with someone with diabetes drinking a fruit smoothie like this for breakfast with no other food is that there is no way of having the carbs last!

Lunch on Day 1 was a small serving of vegetable frittata (3 g carbs, 13.6 g pro, 14.9 g fat), 1 slice whole-grain bread (13.2 g carbs, 4.5 g pro, 1.3 g fat) and 1 cup unsweetened plant based beverage such as Silk plain Oat milk (7.6 g carbs, 0.4 g pro, 0.3 g fat). A slice of frittata, a slice of plain bread and a glass of oat milk and that’s it for lunch. Maybe a nice lunch for child home from school?

Dinner was 1 cup of Indonesian tofu stew with vegetables (8 g carbs, 5 g pro, 8 g fat) and ½ cup (125 mL) cooked brown rice (24.2 g carbs, 2.8 g pro, 1.0 g fat). That’s it. This might be an adequate serving for an older adult with a small appetite.

So what did this day provide in terms of carbohydrate and total protein?

Well, it was low carb (84.4 g) but it was also inadequate in protein — having only 35.2 g PRO. Based on “average” body weight and a minimum 0.36 g of protein per pound of body weight (0.8 g protein per kg), this is less than the 46g protein required for the average sedentary woman, and much less than the 56g of protein required for the average sedentary man.

Day 3

Breakfast was small glass of the same smoothie (28.4 g carbs, 8.9 g pro, 5.2 g fat) and that was it until lunch!

Lunch was a “cup” of low fat cream of cauliflower soup that was actually only 3/4 cup / 175ml in size ( 10 g carbs, 7g PRO,  2g fat), 3.5 oz / 100 g grilled chicken breast (0 carbs, 41.7 g pro, 6.1 g fat) and a cup of unsweetened plant based beverage (7.6 g carbs, 0.4 g pro, 0.3 g fat). No salad, no side of veggies, that was it.

Dinner was 1 serving (3 oz) of grilled fish fillet (pink salmon – 0 g carbs, 17.4 g pro, 3.7 g fat), ½ cup (125 mL) cooked quinoa (17.1 g carbs, 4.1 g pro, 1.8 g fat) and 1.5 cups green salad with dressing (2.8 g carbs, 0.8 g pro, 2.5 g fat). What adult would find a small piece of fish, a small serving of quinoa and a small salad enough for supper — unless they had a big lunch?

What did this day provide, in terms of carbohydrate and total protein? Well, it was low carb (65.9 g) and adequate (71.4 g) protein, but had very few vegetables, little healthy fat, and very small portions.

Day 5

Breakfast was small glass of the same smoothie (28.4 g carbs, 8.9 g pro, 5.2 g fat) and that was it.

Lunch was 1 egg on 3/4 cup of Mexican baked black beans (19 g carbs, 12 g pro, 9 g fat) and 1 cup unsweetened plant based beverage (7.6 g carbs, 0.4 g pro, 0.3 g fat). Nothing else. No veggies, no salad, not even a dollop of guacamole!

Dinner was 1 serving (3.5 oz) of beef or pork meatballs without sauce (10.5 g carbs, 19.3 g pro, 16.6 g fat) and ¾ cup (150 mL) of plain cooked pasta (30.5 g carbs, 6.1 g pro, 1.0 g fat). How is this an appropriate “low carb” dinner for someone with diabetes? How is this a complete meal?

It was low carb (96.0 g) and adequate (46.7 g) protein for a sedentary woman but inadequate protein for even a sedentary man. It had few vegetables, very little healthy fat, and very small portions.

Final Thoughts…

There are parts of this menu that are certainly usable, and it can be modified to make it into a lovely low-carb meal plan.

The frittata, for example could be a great start to a low-carb lunch when paired with a nice big salad, with a bit of crumbled cheese, a few pumpkin seeds and a bit of avocado — and skip the bread!

Double the amount of tofu stew and vegetables, and make a nice Asian style cucumber salad on the side and skip the rice!

The cauliflower soup with a splash of cream and the grilled chicken breast would go every well with a nice helping of steamed veggies or mixed greens on the side — and why not? They are low carb, and high in micronutrients. The cooked ones would taste great with a dab of butter and the raw ones, with a squeeze of lemon and some extra virgin olive oil. Now there’s lunch!

And why on earth would a person with diabetes be encouraged to drink that smoothie 3 times per week if not to promote the product of one of the menu’s sponsors?  Why not suggest an omelette made with some leftover cooked veggies from the night before — and they could even add an ounce of sharp cheddar to it, which would easily get them through to lunch. Or, how about a bowl of Greek yogurt with 1/2 cup of blueberries and a tablespoon of hemp heart? That is a high protein breakfast with far fewer carbs than the smoothie and will keep a person going with stable blood sugars until lunch.

Ditch the carbs.  Who needs the bread and pasta and rice — especially on a “low carb” meal plan?

People can get all the B-vitamins they need, including B1 (thiamine), B2 (riboflavin), B3 (niacin) and folate from real, whole food such as chicken liver, sardines, eggs and sunflower seeds. They can plenty of the most bioavailable iron from seafood and meat and get ample magnesium from nut, seeds, dark chocolate and avocados, and selenium from Brazil nuts and eggs.

The American Diabetes Association understands that a low carbohydrate diet ”limits sugar, cereals, pasta, bread, fruit & starchy vegetables” and “consist mostly of protein foods like meat and dairy, fatty foods like oil, nuts, seeds, avocado, and butter, and non-starchy vegetables” [2].

Canadian with diabetes deserve to have a low carb menu based on these same principals, and which provides them with adequate protein, a good source of healthy fats and adequate size servings of food.

We can do better.

Canadians with diabetes deserve better.

If you would like more information about how I can help support your nutrition needs, please click on the Services tab to learn more.

To your good health!

Joy

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Reference

1. Diabetes Canada, 7-day low carbohydrate meal plan, https://diabetes.ca/nutrition—fitness/meal-planning/7-day-low-carbohydrate-meal-plan
2. American Diabetes Association, Diabetes Food Hub, Meal Prep: meals for any eating pattern, Low Carb, https://www.diabetesfoodhub.org/articles/meal-prep-meals-for-any-eating-pattern.html