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.