Is Animal-based and Plant-based Protein Equivalent?

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

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

Amino Acids and Bioavailability

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

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

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

Plant Protein vs Animal Protein for Building Muscle 

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

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

Is Plant Protein Equivalent to Animal Protein?

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

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

plant protein equal to animal protein ? What about the Digestible Indispensable Amino Acid Score [DIAAS]
“ounce-equivalent” from [8] U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025, 9th ed

 

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

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

The Bioavailability of Plant Protein – Digestible Indispensable Amino Acid Score

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

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

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

Plant Protein versus Animal Proteins – conclusions of the study

plant protein vs animal protein for building muscle - steak as example of animal proteinThe study found that consuming meals with equivalent amounts of animal-based proteins versus plant-based proteins resulted in more essential amino acids in the blood compared with meals containing animal-based proteins in both young and older adults, separately and combined.

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

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

Final Thoughts…

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

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

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

More Info

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

To your good health, 

Joy

You can follow me on:

 

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

 

References

  1. Connolly G, Hudson JL, Bergia RE, Davis EM, Hartman AS, Zhu W, Carroll CC, Campbell WW. Effects of Consuming Ounce-Equivalent Portions of Animal- vs. Plant-Based Protein Foods, as Defined by the Dietary Guidelines for Americans on Essential Amino Acids Bioavailability in Young and Older Adults: Two Cross-Over Randomized Controlled Trials. Nutrients. 2023; 15(13):2870. https://doi.org/10.3390/nu15132870
  2. Gaudichon C, Calvez J. Determinants of amino acid bioavailability from ingested protein in relation to gut health. Curr Opin Clin Nutr Metab Care. 2021 Jan;24(1):55-61. doi: 10.1097/MCO.0000000000000708. PMID: 33093304; PMCID: PMC7752214.
  3. Layne E Norton, Donald K Layman, Leucine Regulates Translation Initiation of Protein Synthesis in Skeletal Muscle after Exercise12, The Journal of Nutrition,
    Volume 136, Issue 2, 2006, Pg 533S-537S, doi.org/10.1093
    (https://www.sciencedirect.com/science/article/pii/S0022316622080956)
  4. Bauer JI, Biolo G, Cederholm T, Cesari M, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc. 2013 Aug;14(8):542-59
  5. Nutrition Heart Beat, Leucine: perform better and maximize your muscle through diet, https://nutritionheartbeat.com/sports-nutrition/leucine-diet-muscle
  6. Thomas DT, Erdman KA, Burke LM. American College of Sports Medicine Joint Position Statement. Nutrition and Athletic Performance [published correction appears in Med Sci Sports Exerc. 2017 Jan;49(1):222]. Med Sci Sports Exerc. 2016;48(3):543-568. doi:10.1249/MSS.0000000000000852
  7. Berrazaga I, Micard V, Gueugneau M, Walrand S. The Role of the Anabolic Properties of Plant- versus Animal-Based Protein Sources in Supporting Muscle Mass Maintenance: A Critical Review. Nutrients. 2019 Aug 7;11(8):1825. doi: 10.3390/nu11081825. PMID: 31394788; PMCID: PMC6723444.
  8. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020–2025, 9th ed.; U.S. Department of Agriculture and U.S. Department of Health and Human Services: Washington, DC, USA, 2020. Available online: DietaryGuidelines.gov
  9. Herreman, LNommensen, PPennings, BLaus, MCComprehensive overview of the quality of plant- And animal-sourced proteins based on the digestible indispensable amino acid scoreFood Sci Nutr2020853795391https://doi.org/10.1002/fsn3.1809
  10. Food and Agriculture Organization of the United Nations. Dietary Protein Quality Evaluation in Human Nutrition: Paper 92. Rome, Italy: Food and Agriculture Organization of the United Nations; 2013.
  11. Marinangeli CPF, House JD. Potential impact of the digestible indispensable amino acid score as a measure of protein quality on dietary regulations and health. Nutr Rev. 2017 Aug 1;75(8):658-667. doi: 10.1093/nutrit/nux025. Erratum in: Nutr Rev. 2017 Aug 1;75(8):671. PMID: 28969364; PMCID: PMC5914309.

 

Copyright ©2023 BetterByDesign Nutrition Ltd.

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

 

 

Nutrition is BetterByDesign

Why A Smoothie is “Pre-Chewed” Food

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

Making a Smoothie 

Making a smoothie
For people with pre-diabetes or diabetes, a smoothie that has pureed fruit has a very different effect on blood sugar than eating the same ingredients as whole, intact foods. This is because the carbohydrate from the ingredients is now acellular, meaning “out of the cell”.

Cellular versus Acellular Carbohydrate

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

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

A Smoothie as “Pre-Chewed” Food

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

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

Final Thoughts…

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

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

How I Can Help

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

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

To your good health, 

Joy

You can follow me on:

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

 

References

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

Copyright ©2023 BetterByDesign Nutrition Ltd.

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

Nutrition is BetterByDesign

 

Types of Protein to Help Older Adults Retain Muscle

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

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

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

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

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

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

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

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

Protein Sources to Help Retain Muscle 

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

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

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

Prioritize Protein to Retain Muscle 

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

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

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

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

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

Final Thoughts…

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

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

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

To your good health, 

Joy

You can follow me on:

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

 

References

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

 

 

Copyright ©2023 BetterByDesign Nutrition Ltd.

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

 

Nutrition is BetterByDesign

 

 

 

The Death of Peers and Parents Should Change the Way We Live

Last week, I flew to Montreal to be with my mom in the last days before her death. While it was hard to see how much she had changed, it was sobering to be reminded of something I started to realize six years ago — that the death of friends and family should change the way we live.

The untimely death of two college friends in 2017 was the impetus for me to finally change my own diet and lifestyle. One of my friends died of a stroke and the other of a massive heart attack and both worked in healthcare their entire lives. As mentioned several times in “A Dietitian’s Journey,” I knew that my death would be next if I didn’t lose weight, lower my very high blood pressure and blood sugar.

While it took me twice as long as it should have to accomplish my health and weight goals due to undiagnosed hypothyroidism, I was successful in losing 55 pounds and taking a foot off my waist, and in putting my hypertension and type 2 diabetes into remission. Many times I was asked why I took accomplishing my goal so seriously and my reply was always the same, “I am doing this as if my life depends on it, because it does.”

When my dad was diagnosed with Alzheimer’s disease, I once again made some lifestyle changes. Even though I had put my type 2 diabetes into remission with diet, I began taking a low dose of the prescription medication Metformin preventatively, while continuing to eat a low carb diet. But, like many people, I became somewhat complacent and maybe even a little bit smug that diet alone was enough, and in the years since my dad’s death ended up discontinuing my medication, with my doctor’s knowledge.

Something that I was missing in my decision to discontinue this medication that I took prophylactically was that my health had changed, and I didn’t know it yet.

When I was diagnosed with profound hypothyroidism a little over a year ago, my doctor told me that even with taking thyroid hormone replacement medication that it would take a year and a half to fully recover due to how advanced it was. 

I wanted to understand how my body had changed, so I did lots of reading in the scientific literature and learned about how hypothyroidism affected my heart rate, my blood pressure and cholesterol and wrote about it here. For a while I took a “baby dose” of blood pressure medication and made hypothyroid-specific dietary changes but eventually stopped taking it, and waited for the thyroid medication to reverse the symptoms. In retrospect, that may have been a bit naive. I was assuming these metabolic markers would return to normal in time, thinking that all I needed to do was wait the full year and a half to fully recover. 

Recently, after an increase in thyroid medication I noticed that my blood sugar was significantly higher than it had been in years even though I had been compliant eating a low carb diet. Once again, I turned to the scientific literature to determine why. It was then that I discovered that all thyroid hormone replacement — even the “natural ones” raise blood sugar, and I wrote about that here

Given my higher blood sugar and my late dad’s diagnosis of Alzheimer’s disease, I started back on the half dose of metformin, but it wasn’t until my recent visit with my mom, that I became less complacent. 

Around the time my dad was diagnosed with Alzheimer’s, my mom was diagnosed with vascular dementia secondary to some mild strokes, known as TIAs. At first, the signs were subtle — things like difficulty organizing things she wanted to do into a list, but over the past few years, she lost the ability to read and write, and sometimes couldn’t organize her thoughts into coherent sentences. My mom didn’t have high blood pressure, but struggled her whole life with being overweight and was sedentary.

The important things for me — and that I wasn’t factoring in before was that my mom having had mini strokes, and later developing vascular dementia put me at risk because I now have moderate hypertension as a result of my thyroid condition. As well, my dad having had type 2 diabetes and developing Alzheimer’s disease increased my risk now that the thyroid medication wasn’t keeping my blood sugar in the non-diabetic range, as it had been for two years with diet alone.

It’s all nice and fine that I continue to eat low carb and workout at the gym, but in light of my thyroid meds raising my blood sugar, taking Metformin only makes sense. Likewise, it’s great that I achieved remission from hypertension with diet alone, but things have changed. My blood pressure has been moderately elevated since last year and discontinuing the low dose blood pressure medication hoping improved thyroid levels will normalize them is a bit naive. They may, but they may not.

While I was away in Montreal visiting with my mom, I made a phone appointment with my doctor. I told him about my mother’s diagnosis and my current blood pressure, and said I think it makes sense to take some blood pressure medication and to monitor it regularly. I also told him that I think given my blood sugar levels are higher even though I continue to eat low carb, that I think it only makes sense to begin taking Metformin again, and continue to monitor them regularly. He agreed.

Today I buried my mom.

While she died due to pneumonia and not vascular dementia, her death has changed how I will live. I realize that I can no longer be complacent that eating a good diet, and going to the gym several days a week is “enough.”

My dad is buried beside my mom and visiting his grave reminded me in a fresh way that his death was related to him having Alzheimer’s disease, and that he had type 2 diabetes for the last 40 years of his life. While my elevated blood sugar is a side-effect of the thyroid hormone medication that I have to take, taking Metformin and continuing to eat a low carb diet and exercising only makes sense. His death has changed how I will live. 

Final Thoughts

Dietary and lifestyle changes are very important and can effectively put both type 2 diabetes and hypertension into remission, however when circumstances change, it is necessary to consider medication as an adjunct. 

I have no choice but to be on thyroid medication in the same way that someone with type 1 diabetes has to take insulin. Given my lack of thyroid function, as well the side effects of taking thyroid hormones, I have chosen to let my parent’s deaths change the way I live. It may not be forever, and it may be — only time will tell. 

In the meantime, I will continue to eat a low carb diet to control my blood sugar as best I can, and to go to the gym several times a week to lift weights and do resistance training.

Taking medication is not a “failure”. Dying an unnecessary or premature death like my two girlfriends did, is.

And if taking medication, in addition to eating a good diet and being active helps avoid, or significantly slow dementia, all the better. 

To your good health, 

Joy

You can follow me on:

 

Twitter: https://twitter.com/lchfRD

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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.

 

Success is All About “Showing Up”

Whether it’s achieving significant weight loss or recovering one’s health, I believe that success is all about “showing up”.  As much as people would like to believe that eating certain foods or taking supplements will cause the “pounds to melt away” or for the symptoms of a health condition to “improve in just 6 weeks,” we know better.  Success requires making a commitment, consistency and “showing up” for yourself — if not every time, most times.

One of the first posts I made when I started my personal weight-loss and health-recovery story (March 5, 2017 – March 4, 2019) was a video of me walking around a track.  I was so overweight and out of shape that I could barely walk and talk at the same time. I was clearly out of breath!  So why on earth did I post it? Why didn’t I wait until I lost the 55 pounds and the foot off my waist and then post my success pictures? I believe that people relate to the struggle of watching someone doing it and that watching them succeed no matter how long it takes, gives them hope that they can, too! 

Here’s a clip from that video;

What I said in that video still rings true today, as I am continuing to work towards recovering from severe hypothyroidism;

“I want to encourage people that if they make a commitment to “do it” just do it! If you have to re-schedule other things to do it, just do it! It’s important. Exercise is a small component of this journey, but it is an important component. “

It’s about “showing up”.

By setting goals and by being intentional about following through, I went from looking like the photo on the left to being able to hike intermediate trails, and looking like the photo on the right. By “showing up” for myself in terms of my eating, I was able to put my extremely high blood pressure and type 2 diabetes into remission. But losing 55 pounds and a foot off my waist didn’t happen overnight. Even though I am a Dietitian and have helped many others achieve this in far less time, as my doctor told me a year ago, there indications that I probably had subclinical hypothyroidism for the past 10 years. In a sense, that I was able to accomplish the weight loss and for the most part maintain it, is evidence to the power of “showing up.”

Achieving and maintaining a healthy body weight has really about me making decisions on a consistent basis that move me towards that goal. 

It’s not about being “perfect,” but about being consistent.

It’s about “showing up” for myself when I plan my meals. It’s about prioritizing foods that will provide satiety (not feeling hungry), and ensuring that the foods I eat with them provide me with the nutrients I need, while supporting my ongoing metabolic health.

Setbacks are About “Showing Up”

Weight loss and health recovery rarely occur in a straight line. There are any number of setbacks that can, and do occur. It is what we do with setbacks that determines whether we regain all the weight we lost and then some, or becomes as sick or sicker than we used to be. 

It is still about “showing up”.

At my youngest son’s wedding last June, I was at my sickest but didn’t yet have a diagnosis.  I could barely walk or get up from a chair because of the edema in my legs, and my tongue was so swollen that it was difficult to talk. You can read more about that in this first post in this new series

What made it really hard for me was that I looked like I did when I was 55 pounds heavier, but I wasn’t. In short, I looked like a “failure.”

Recovery from Hypothyroidism is About “Showing Up”

I wrote a few posts about my recovery from hypothyroidism under “A Dietitian’s Journey (Part II)” but there were a lot of “silent” periods in between those posts, and since the last one where I simply had to “show up.”

I needed to continue to take my thyroid meds and have my thyroid hormones checked every few months. I needed to continue to work with my doctor to get my medication adjusted to a level that enabled me to feel well, and to accomplish what I needed to.  I am very thankful to have an incredibly knowledgeable and supportive doctor, but the bottom line is that I need to consistently “show up.”

I needed to prepare my meds each evening for the following days dosages I take them in — and it didn’t matter if I was tired.

I had to continue to “show up” for myself when it came to making decisions as to which foods I will eat and those I choose not to because I have Hashimoto’s disease, which is an autoimmune condition.

I needed to continue to “show up” for myself to get tested for nutrients of importance in hypothyroidism and to supplement accordingly.  Except for vitamin D3 and K2, and later magnesium, I never took supplements — choosing instead to get them by eating a range of real, whole foods.  Being diagnosed with an autoimmune condition necessitated me changing my mind on this and consistently “showing up” for myself by consistently taking the supplements that I needed to.

Every day with hypothyroidism is about “showing up.”

Restoring Health is About “Showing Up”

A few weeks ago, after my new thyroid medications took effect and it became possible to think about regaining my mobility and muscle mass, the question was “how.” 

My son who had been my “hiking buddy” recently married and moved out of province, and I was very aware that I wasn’t ready to re-join the ladies hiking group that I am a member of without regaining my strength.  I needed a plan.

Someone in the local Facebook group posted about a program available and I knew that was exactly what I needed.  It was close and would give me access to the weight-training facilities that I needed to rebuild my muscles, and the classes would provide me with some fun and aerobic exercise at the same time. They even had several pools where I could to rekindle my love of swimming, after I replaced my size 16 bathing suit. 

In order to “show up” I had to first get what I needed.

By the end last weekend, I had a 3-month renewable membership to the fitness center, a one year parking pass, a new gym bag, and a bathing suit in my size. While I wondered if I would even remember how to swim as it had been at least 30 years since I last did, I was going to be focusing on doing what I needed to do to rebuild my muscle mass, and that was to “eat sufficient protein at each of my meals” and to “lift, push and pull heavy things often“.  

I planned to go to the gym for the first time this past Wednesday, but make sure there was nothing slowing me down to “showing up”, my gym bag was already packed, and by the front door. 

My gym socks and training shoes were pulled out, and my sweat band was draped on top of them.

My driver’s license, debit card and health card were already in a small wallet attached to my keys and was laying on top of my gym bag.

My water bottle was ready to go, and I had the coins needed for the lockers.

I had no excuses.

As I grabbed my bag and water bottle, I was “ready” to “show up” for myself. I needed to, because there was no one there to coax or encourage me. I had to be there for “me” and I was.

During my first workout, I learned how to use one of the types resistance machines and did three reps of ten with a 45 second rest in between each set on most of them — or as much as I could. I focused on having good form and didn’t try to do more than my body was able to do.  This was the first workout, and I was already successful because I “showed up”. Everything else I did was moving me towards my goal of getting in good enough shape to hike again.

Yesterday, I woke up quite sore — especially my pecs. These are not muscles I use much, if at all. I had thought I might go swimming, but I was so sore I wasn’t sure that was such a good idea since it had been way too long since I last did it. I stretched my muscles and rested and prepared my gym bag to go on Friday.

When I awoke today, everything was prepared. The only thing I grabbed was a mask because of the smoke warning outside, and headed to the gym.

I had already determined I would do what I could, given I am new at it and still somewhat sore from Wednesday, and had a good workout. I was surprised that I could increase weight or reps on some machines but definitely did less on the pec press.  That’s okay. I “showed up.”

Final Thoughts…

Whether it is losing significant weight, restoring one’s metabolic health, or rebuilding one’s physical strength after an illness, the first thing that is necessary is to make a commitment to “do it”.

Then, put the pieces in place that are required to be successful. If that is weight loss or health recovery, have a plan of how you are going to do it and who will oversee your progress. If it’s rebuilding your strength after an illness, find something that you want to do, that’s realistic for you to consistently do, and then get whatever is needed to get started.

Then, as I said in the video above, once you’ve made the commitment to “do it,” just do it.

If you are consistent in “showing up” for yourself on a regular basis, you will be successful in achieving your goals. 

To your good health,

Joy

You can follow me on:

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

 

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 Dietitian’s Journey (Part III) – the next phase

Thirteen months ago, I was diagnosed with an auto-immune condition and was the sickest I had been in many years. Thankfully, I am entering the next phase, where I hope to restore my health to what it was before my diagnosis.

At the time of my youngest son’s wedding on June 3, 2022, I was incredibly swollen all over, had pronounced joint pain and muscle aches, and significant edema in my legs and ankles — so much so, that I was wearing compression stockings all the time, even at the wedding.

The skin on my cheeks was dry and  flaky and despite trying multiple types of intense moisturizers, nothing helped.  My mouth symptoms had progressed to the point that I found it difficult to say certain words because my tongue was swollen so much that it seemed too large for my mouth, and the salivary glands underneath my tongue were swollen.

The debilitating fatigue made life very difficult.

The muscle weakness had progressed to the point where it was difficult for me to get up from a chair, or to get out of the car without pushing myself up with my hands. My eldest son was helping me get to and from the beach for the photos for the wedding and he thought it was me aging. Even my other two sons began to assume the same thing because the changes occurred too slowly for them to see that they only started a few months ago.  I was thinking that I may have some form of “long-Covid,” but what got me starting to think that my symptoms may have had something to do with my thyroid was the very noticeable swelling in my face.

The phase immediately prior to diagnosis was the most difficult because on the occasion of my first son’s wedding, I looked like I did when I was 55 pounds heavier, but wasn’t. What was very stressful was not knowing why I was so sick.

LEFT: March 5, 2017, RIGHT: June 3, 2022 at my youngest son’s wedding.

The First Phase of Recovering from Hypothyroidism 

Just as weight loss and metabolic health recovery rarely take place in a straight line, the same is true with recovering from hypothyroidism.

At the end of October 2022, my thyroid hormones had improved significantly taking two types of thyroid medication. My free T3 (the active thyroid hormone) was at 65.5% of the reference range, however my free T4 was only at 41.75%.  Unfortunately, the medication adjustment we made at that time to “tweak things” made everything worse. By April, I was exhausted and cold, and found it very difficult to get through the day.

After having my thyroid hormones retested, it was evident why I felt awful, as my free T4 and free T3 had both dropped significantly.

Once again, my doctor adjusted my medication and thankfully my symptoms improved within a few weeks. Unfortunately, the less-than-optimal dose of thyroid hormones from January to April triggered another round of excessive hair shedding, but rather than “sweat the small stuff”, mid-June I opted for a new haircut which allowed my natural curls to fall where they may and it helped.

Since my condition is autoimmune, I continue to follow the specific dietary recommendations that I outlined here, as well as supplementing with the nutrients of importance in hypothyroidism while periodically having my serum nutrient levels tested.  I also continue to eat a lower carb diet that is high in highly bioavailable protein to support my continued metabolic health.

A Dietitian’s Journey Continues – the next phase

While I was feeling much better for the past few weeks I was bemoaning the fact that I was not well enough to resume hiking. I know, “first world problems”. Now that the son that got into hiking with me a few years ago was married and had moved out of town, it was up to me to figure out a way to regain my strength.

Last week, someone on social media posted about a local fitness program and I thought to myself, “I am going to join that“! It was perfect. It was close and would give me access to the weight-training facilities that I needed to rebuild my muscles, as well as classes that would provide me with some fun and aerobic exercise at the same time. They even had several pools where I could to re-discover my age-old love of swimming!  Realizing that the last bathing suit I owned was size 16 (from before I lost weight in 2017-2019), it was time to go shopping.

By the end of this past weekend, I already had a 3-month renewable fitness center membership, a one year parking pass, a new gym bag, and a bathing suit in my size. While I wondered to myself if I will even remember how to swim, but that was okay as I was determined to begin with “lifting, pushing and pulling heavy things often“.  Along with eating sufficient protein intake over each of my meals, weights and resistance training was the most important for restoring my muscle mass and avoiding sarcopenia (muscle-loss) so common in older adults. I was determined NOT to become one of those frail older people and this program would get me there.

A Dietitian’s Journey Continues

I was planning to start at the gym this past Tuesday but ended up taking one of my sons and daughter-in-laws to the airport. When I woke up on Wednesday morning, I was ready to go.  Not only was I ready, but I was excited to go, because for the first time in a year and a half to two years, it was possible. I was finally well enough again.

When I arrived at the fitness room, I asked the trainer to show me how to adjust the machines. She ushered me over to the cardio equipment, while encouraging me that this is where I should start.  I replied to her that my first priority is to rebuild lost muscle mass and asked her to please show me how to use the resistance equipment, which she did.  While cardio definitely has a place in my long-term goal of being able to hike again, lifting weights and doing resistance training will enable me to rebuild lost muscle, and strengthen joints and connective tissue as well as help with restoring my metabolism and mobilizing residual fat.

This is me after my first weight training session yesterday. I was sweaty and tired, but it felt amazing to finally be at this next phase of my journey one I have waited for as patiently as possible.

I hope that a Dietitian’s Journey – Part III encourages others who are recovering from Hashimoto’s as well as other types of auto-immune disorders.

If you would like more information about how I can support you in your health journey, please reach out to me through the Contact Me form on the tab above.

To your good health,

Joy

 

You can follow me on:

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

 

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 Ketogenic Diet for Mental Health

People’s interest in following a ketogenic diet to see if it offers improvements in mental health is continuing to increase, but not everyone is prepared for what is involved in adopting a Modified Ketogenic Diet that contains 75% fat, and little protein.  Based on emerging evidence and under the oversight of people’s doctors, I now offer clients the option of an alternative approach.

Different Types of Ketogenic Diets

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

Therapeutic Ketogenic Diets for Mental Health

Since the release of Psychiatrist Dr. Chris Palmer’s book, Brain Energy in November last year, I have had quite a number of people either referred to me by their doctors, or approach me themselves to design a therapeutic ketogenic diet for them. These people knew what the different types of ketogenic diets were, and were quite set on beginning with a Modified Ketogenic Diet (3:1).  As a result, they were fully prepared for how much their diet would change and were willing to trial the diet for three months, as is recommended.  I have clients that started a therapeutic ketogenic diet at the beginning of the year and who are continuing to eat this way, as their doctors oversee their health and medication adjustments. 

Like those who have come to me to design therapeutic ketogenic diets for seizure disorder or as adjunct treatment in glioblastoma (a form of brain cancer), these individuals wanted to do whatever it took to see if they could feel better.  Since all of these people were doing this under the oversight of their physicians, my role was simply to design a diet for them to trial, with some food substitutions to keep it interesting.

Another Type of Ketogenic Diet for Mental Health

Recently, I have had people approach me about wanting to adopt a ketogenic diet for mental health, yet feeling apprehensive about the significant change that would be involved with adopting a Modified Ketogenic Diet (3:1). They wanted something that was easier to adopt and something that they would be more likely to be able to sustain, long term.

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

As a result, I now offer a 2:1 ketogenic diet approach to those working with their doctors who don’t feel they could maintain a 3:1 ketogenic diet (75% fat, with carbohydrate and protein equaling 25% altogether), but who want to try a ketogenic diet to see if they feel better.

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

Working with Your Doctor to Support Mental Health

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

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

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

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

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

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

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

Steps to Getting Started

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

1. Have your doctor determine if a ketogenic diet might be appropriate for you. 
2. If your doctor agrees, then you can ask if they are already working with a Dietitian who is familiar with designing these types of specialized diets, or (if you are in Canada) you can reach out to me.
3. Be aware that you will remain on your medication while trialing a ketogenic diet for several months, and during this time you will be under your doctor’s supervision. 
5. If after a period of time your doctor thinks that you might do better adjusting the diet more towards a Modified Ketogenic Diet (3:1), they might recommend that.
6. If you are doing well and your doctor is assured you will remain on the diet without taking breaks, he or she may consider gradually deprescribing some medications.  

More Info

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

To your good health!

Joy

 

You can follow me on:

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

References

  1. 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.

 

Is High Fructose Corn Syrup (HFCS) Linked to Fatty Liver Disease?

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.

twitter post that was almost viral about high fructose ketchup

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].

academic presentation about fructose and NAFLDAn 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.

Nutrition is BetterByDesign

Use of a Therapeutic Ketogenic Diet in Mental Health

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

Therapeutic Ketogenic Diet for Mental Health 

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

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

“Brain Energy” Book – role for therapeutic ketogenic diet 

The release of the best-selling book Brain Energy in mid-November 2022, written by Harvard psychiatrist Dr. Chris Palmer, one of the pioneers in the use of a therapeutic ketogenic diet in treating psychiatric disorders [2,3,4], brought the use of this type of diet in mental health to public awareness. As a result of the book, I have had many more individuals contact me about designing such a diet to see if it would improve their mental health.  

But what is a therapeutic ketogenic diet?

Types of Therapeutic Ketogenic Diets

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

Classic Ketogenic Diet (KD)

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

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

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

Modified Ketogenic Diet (MKD)

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

Modified Atkins Diet (MAD)

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

Calculating Ratios Based on a Percentage of Calories

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

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

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

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

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

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

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

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

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

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

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

On a Modified Ketogenic diet, the ratio of calories from fat to calories from protein plus carbohydrate is 27:4. This means that for every 31 calories consumed, 27 calories come from fat and 4 calories come from protein and/or carbohydrate. Thus, 90% of the calories comes from fat (27÷31=87%), and 13% comes from protein and carbohydrate (4÷31=13%) [5]. 

A Dietitian’s Role in Therapeutic Ketogenic Diets

In a recent Psychiatry and Psychotherapy podcast where Dr. Chris Palmer was interviewed, he talks about how Psychiatrists can incorporate use of a therapeutic ketogenic diet in their practice [6].  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. For people considering using a ketogenic diet as adjunct treatment to support their mental health, the first place to start is by having this discussion with your doctor.

[For those on some very specific types of medications, I will request for a note from people’s doctors (either their Psychiatrist or GP) to ensure that they are aware that their patient intends to follow a therapeutic ketogenic diet, and to ensure that they will be monitoring their patient’s health and medications, as they do.] 

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

    1. 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 [6], and if the doctor finds that the diet is helping, they may begin to gradually deprescribe some medications. As mentioned in the “Don’t Try This at Home” article, changing dosages of medication is not something people should do on their own. 

In the podcast, Dr. Palmer makes an important point. With the gradual decrease in medications, people must realize that they are more reliant on the ketogenic diet to keep symptoms under control. Since the ketogenic diet is therapeutic, taking “cheat days” is not an option. Dr. Palmer notes that it takes several days to get back into ketosis after breaking the diet and during this time, symptoms can dramatically reappear [6].

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

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

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

Steps to Getting Started 

If you are wondering if a therapeutic ketogenic may be worth trialing for improved mental health, then reach out to your doctor. 

1. Have the MD determine if ketogenic diet may be appropriate for you. 
2. If yes, the doctor can either recommend — or you can reach out to a Registered Dietitian knowledgeable in therapeutic ketogenic diets to partner with. 
3. Understand that you will remain on your medication while implementing a ketogenic diet. 
4. Be prepared for the commitment of trialing a ketogenic diet for 3 months, under your doctor’s supervision. 
5. If after that time you are doing well and provided you are committed to remaining on the diet, your MD may consider slowly deprescribing some medications. 

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

More Info

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

To your good health!

Joy

 

You can follow me on:

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

 

References

  1. Danan A, Westman EC, Saslow LR, Ede G. The Ketogenic Diet for Refractory Mental Illness: A Retrospective Analysis of 31 Inpatients. Frontiers in Psychiatry, 06 July 2022. https://doi.org/10.3389/fpsyt.2022.951376 

  2. 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
  3. 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

  4. 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. 

  5. Eastman, M., KetoConnect, The Ketogenic Ratio Explained, September 16, 2014, https://www.myketocal.com/blog/the-ketogenic-ratio-explained/

  6. Dr. David Puder, MD, Psychiatry Podcast, Episode 163, Dr. Chris Palmer: Ketogenic Diet for Mental Health, M=November 15, 2022, https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/163-treating-mental-health-disorders-with-a-ketogenic-diet

 

Copyright ©2023 BetterByDesign Nutrition Ltd.

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

 

Nutrition is BetterByDesign - therapeutic ketogenic diets

Thyroid Medication can Worsen Blood Sugar Control in People with Diabetes

Did you know that thyroid medication can worsen blood sugar? The ‘highlights of prescribing information” sheets available to pharmacists and doctors for medications such as Synthroid® (generic: levothyroxine) and Cytomel® (generic liothyronine) warn that both these types of thyroid medication can worsen blood sugar control in diabetics, and increase the need for diabetes medications, including insulin. 

I didn’t know this.

Even though I had been diagnosed with type 2 diabetes more than twelve years ago and with hypothyroidism this past August, when I was prescribed thyroid medication, the pharmacist didn’t mention it when I first filled my prescription, nor was I provided with any printed information when my thyroid medication was delivered. My doctor didn’t mention it either but understandably, he knew I had been in remission of diabetes for three years prior to be diagnosed with hypothyroidism and probably didn’t think of me as being diabetic.  He was well-aware that for three years prior to be diagnosed with hypothyroidism, I did not meet the diagnostic criteria for type 2 diabetes either on the basis of fasting blood glucose or HbA1C because I controlled my blood sugar through diet.

When I began taking thyroid medication after my diagnosis of hypothyroidism, I began to periodically feel unwell as I did when I had high blood sugar.  I began to test my blood glucose more often and discovered that it was routinely spiking as high as the mid- to high 10 mmol/L (~190 mg/dl) for seemingly no reason. 

Effect of thyroid medication on blood sugar

I was totally puzzled as to why.  I didn’t eat simple carbs or starch-based food. I wasn’t sick, or under any new stress. I was sleeping well, was  properly hydrated, and there was no reason that I could think of that my blood sugar would keep spiking. In my search for answers, I stumbled across information that indicated that it should be well known that thyroid medication can worsen blood sugar control in people diagnosed with diabetes. For some reason, this information was not communicated to me, and when I asked others with both disorders, they were also unaware.

While I have already been eating low carb for the past three years, I began eating very low carb in order to get a better handle on the blood glucose spikes, and it is helping. I am also, in conjunction with my doctor, adjusting the timing of my thyroid medication around the timing of my meals to minimize the impact of the thyroid medication on my blood sugar and will continue to monitor my blood sugar several times per day. If need be, I will have my doctor either prescribe a medication such as Metformin to support normal blood sugar and/or trial different doses of thyroid medications. The important factor is I now know and can monitor this and make changes, as necessary. 

How many people have no idea?

Diabetes and Thyroid Medication 

It is essential that people diagnosed with any form of diabetes (type 1, type 2, gestational diabetes) as well as hypothyroidism know that their thyroid medication can impact their blood sugar control, as well as their need for diabetes medications, if they take any. Since those with type 1 diabetes and gestational diabetes have to monitor their blood glucose very closely, they would notice any changes, but many people with type 2 diabetes rarely regularly check. 

Thyroid Medication — highlights of prescribing information (product monographs) 

The “Highlights of Prescribing Information” sheets for both Synthroid® and Cytomel® that are available to doctors and pharmacists warn that therapeutic used of “these medications in patients with diabetes mellitus may worsen glycemic control and result in increased antidiabetic agent [i.e., diabetes medications] or an “increase in insulin requirements.” In addition, there is a warning on prescribing both medications to “carefully monitor glycemic control (i.e., blood sugar) after starting, changing, or discontinuing thyroid hormone therapy.” This means that people with diabetes need to be continuing to monitor their own blood sugar and contact their doctors if there is a need to address worsening blood sugar control related to taking thyroid replacement medication.

The “Highlights of Prescribing Information” for Synthroid® [1] is a 19-page product monograph about this medication which states that it does “not include all the information needed to use this medication safely and effectively.” For that, there is the need to read the full prescribing information. In other words, these 19 pages are only a summary of all that is needed to use the medication safely and effectively! 

Below is page 1 of the 19 of the “Highlights of Prescribing Information” for Synthroid®.

Highlights of Prescribing Information for Synthroid – page 1 of 19 highlighted

If the relevant section wasn’t highlighted in yellow by me, how likely would it be that a pharmacist or physician would have noticed this warning amongst the 19 pages of fine type?

The “Highlights of Prescribing Information” for Cytomel® [2] is an 11-page product monograph about that medication. It also states that it does “not include all the information needed to use this medication safely and effectively.” Those sheets are just a summary, and there is the need to read the full prescribing information.

Below is page 1 of the “Highlights of Prescribing Information” for Cytomel®.

Highlights of Prescribing Information for Cytomel – page 1 of 11 highlighted

Again, if the relevant section wasn’t highlighted in yellow by me, how likely would it be that a pharmacist or physician would have noticed this warning amongst the 11 pages of fine type?

 


[Post publication note (May 1, 2023)] 

Since natural desiccated thyroid (NDT) also called natural desiccated extract (NDE) are not approved by the FDA or Health Canada as medications, there are no Prescribing Information sheets for products such as the US product Armour Thyroid®, or equivalent ERFA desiccated thyroid®,  in Canada, but both products contain the same warning.

Page 3 of 24 of the Product Monograph from Armour®  contains a warning under Contraindications;

“Thyroid hormone therapy in patients with concomitant diabetes mellitus or diabetes insipidus or adrenal cortical insufficiency aggravates the intensity of their symptoms. Appropriate adjustments of the various therapeutic measures directed at these concomitant endocrine diseases are required.”

Page 3 of 24 of the Product Monograph from Armour thyroid®

Page 1 of 9 of the Product Monograph from ERFA desiccated thyroid®  contains the same warning under Precautions;

page 4 of 9 Product Monograph Erfa Thyroid®

Recently published studies report that 11%–23% of people with type 2 diabetes also have hypothyroidism [6] making it essential that people with both diagnoses know about the possible effect of thyroid replacement on blood sugar control.

For those interested in the mechanism, a paper published last month explains how thyroid hormones contribute to a rise in blood glucose.  In the liver, thyroid hormones increases expression of glucose transporter 2 (GLUT2), which increases in both gluconeogenesis and glycogenolysis.  In liver, the thyroid hormone T3 increases gluconeogenesis by increasing activity of phosphoenolpyruvate carboxykinase (PEPCK), and in adipose tissue, thyroid hormones increase lipolysis, resulting in an increase in free fatty acid that stimulates hepatic gluconeogenesis [7].

Additional References

4.  Product monograph for Armour Thyroid: https://dailymed.nlm.nih.gov/dailymed/getFile.cfm?setid=56b41079-60db-4256-9695-202b3a65d13d&type=pdf

5. Product monograph for Erfa: https://pdf.hres.ca/dpd_pm/00034857.PDF

6. Talwalkar P, Deshmukh V, Bhole M. Prevalence of hypothyroidism in patients with type 2 diabetes mellitus and hypertension in India: a cross-sectional observational study. Diabetes Metab Syndr Obes. 2019 Mar 20;12:369-376. doi: 10.2147/DMSO.S181470. PMID: 30936734; PMCID: PMC6431000.

7. Eom YS, Wilson JR, Bernet VJ. Links between Thyroid Disorders and Glucose Homeostasis. Diabetes Metab J. 2022 Mar;46(2):239-256. doi: 10.4093/dmj.2022.0013. Epub 2022 Mar 24. PMID: 35385635; PMCID: PMC8987680.


Final Thoughts…

If you have any type of diabetes and have also been diagnosed with hypothyroidism (including Hashimoto’s disease, the autoimmune form), it is very important that you monitor your blood glucose regularly. 

Contact your doctor if you notice a worsening in your blood sugar control, and to have your doctor evaluate your need for an increased dosage of existing diabetes medications, or the introduction of these medications if you don’t currently take any.

Consider adopting a style of eating that is lower in carbohydrate than you currently eat. According to a 2019 consensus report from the American Diabetes Association, reducing overall carb intake has “the most evidence for improving glycemia [blood sugar]” [3] . But please keep in mind that while a low carb diet is safe and effective for those with diabetes, if you take certain types of medications it is necessary to have medical oversight before adopting a very low carbohydrate (“keto”) diet.

More Info

If you have diabetes or pre-diabetes* and would like information on how I can support you in better managing your blood sugar, please send me a note through the Contact Me form at the top of this page.

To your good health!

Joy

*Please note that I do not design Meal Plans for people currently taking insulin or insulin-analogue medication for diabetes as I do not have CDE certification.

You can follow me on:

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

 

References

  1. Food and Drug Administration, Highlights of Prescribing Information for Synthroid, https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/021402s034lbl.pdf
  2. Food and Drug Administration, Highlights of Prescribing Information for Cytomel, https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/010379s054lbl.pdf
  3. Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With
    Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014

 

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.

 

Hypothyroidism Update – six months of treatment since diagnosis

This update marks just over six months since I was diagnosed with profound hypothyroidism and began medication and nutritional treatment. It is written from a subjective perspective and thus is categorized as part of my personal story.


At the beginning of June 2022, our family was in Tofino (Vancouver Island) for the marriage of my youngest son. The groom’s eldest brother assumed that my inability to walk on the sand for family photos, up the path to the hotel, or to get up out of a chair was a result of me having “aged.” He had no idea that I was hiking in North Vancouver and Golden Ears Provincial Park for several hours at a time just the summer prior.

I knew something was wrong, and for several months, I assumed my feeling exhausted and having joint and muscle pain was a carry-over effect from having had Covid. But a cell phone picture of myself taken just before the wedding told me it had to be something else. Gradually, over several months, I went from looking as I had been the previous two years after losing 55 pounds to looking like I had regained everything. I later found out, it wasn’t fat but an accumulation of mucin in the skin that is one of the hallmark signs of myxedema. You can read more about myxedema and the skin changes associated with hypothyroidism here

Since it was a special occasion, I didn’t say anything to my family about how sick I felt, but I was beginning to think that I had become significantly hypothyroid since I last saw my doctor in person (due to Covid protocols). My plan was to contact him when I returned to the mainland, which I did.

Two weeks later, my doctor confirmed that my symptoms were consistent with a diagnosis of hypothyroidism. In fact, I was surprised when he mentioned that it was not unexpected in light of my lab work over the previous nine years, my past thyroid surgery several decades ago, and my having experienced periodic hypothyroid symptoms since that time. Nevertheless, it took almost a decade for me to get diagnosed because of the limitations placed on doctors regarding which tests they can requisition under what circumstances (more about the challenges of getting diagnosed with hypothyroidism here).

In addition to the clinical challenges of getting diagnosed, there is also the reality that the most common symptoms of hypothyroidism are often assumed to be “just aging.” For example, many people believe it is normal for ‘older adults’ to have body aches, joint pain, fatigue, feel chilled when others do not, experience constipation, have dry skin or hair loss, be forgetful, or to even experience depression. Unfortunately, many don’t realize that these are not typical signs of aging but ARE common symptoms of hypothyroidism. What compounds the challenge of getting diagnosed is that the symptoms of hypothyroidism are so non-specific that many would not give them a second thought. An older person limited to a “one-issue-ten-minute remote doctor’s appointment” would be unlikely even to bring them up.

For those who have been following this story, my diagnosis was not the end but the beginning of my journey. Three months later, I lost half my hair due to telogen effluvium, the most common form of diffuse hair loss that can occur after a profound stress, shock or traumatic event including childbirth, a thyroid disorder, or rapid weight loss. You can read more about that here.

When my hair loss continued due to androgenic alopecia (also common in hypothyroidism), I began to research which nutrients of importance had evidence for helping restore hair loss, and wrote this article. Knowing I had a second son’s wedding mid-February, I incorporated both nutritional supplements (oral and topical) to support me in my recovery from what my doctor called “profound hypothyroidism.”

This weekend was my second son’s wedding, and the difference between how I felt in June and now is incredible! Instead of wearing medical compression stockings and orthopedic shoes so I could walk, I wore regular nylons and dress pumps.

While my doctor said it would still take another six months or longer for the mucin to resolve in my legs and trunk of my body, I was SO pleased that my legs didn’t look like water-logged tree stumps, as they did in June! In addition, my face was no longer swollen beyond recognition. I looked like “me” rather than like I had been “inflated” with an air pump.  I felt human and presentable and unlike I did in June, I wasn’t self-conscious being in the family photos.

Looking at the two wedding pictures side-by-side (see below), it is evident that being on the correct dose and mix of thyroid hormones (thanks to the excellent support of my doctor) has made a significant difference! In addition to thyroid medication, I have also been supplementing with nutrients of importance in hypothyroidism, as well as nutritional supplements with evidence to restore hair loss in androgenic alopecia which I developed secondary to my diagnosis. My hair is gradually growing back in, and where once there was a bald shiny scalp, I have hair an inch or two long. I also have eyelashes again, and the outer thirds of my eyebrows are also coming back in. 

 

It is my hope that when the most recent newlyweds celebrate their first anniversary, that the residual symptoms of hypothyroidism will be behind me.

Final thoughts…

If you have wondered if you have symptoms that may be consistent with hypothyroidism, you can download a checklist of common hypothyroid symptoms here to help you have an informed discussion with your doctor to determine whether thyroid hormone testing is warranted.

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/

 

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.

 

 

Alopecia Universalis – a clinician’s personal story of complete hair loss

Three years ago, Tim Rees, a clinician from Germany, lost all his hair a second time to alopecia universalis (AU).  As a registered clinical nutritionist he felt he had lost his credibility to help others with autoimmune conditions, and when he expressed those feelings in a recent blog (link below), it struck a chord with me. 

Tim Rees with his son in 2022

“All my hair fell out, but it was my response to it that destroyed me. You could be forgiven for thinking this is all centered around vanity, but the thing that crushed me was that it made me feel like a fraud.” ~Tim Rees, registered clinical nutritionist

As a clinician, I felt similarly when I lost half my hair in September of 2022. I wondered if others would consider me a “failure” for not having been able to prevent it.

Neither Tim nor I are physicians and thus are not qualified to diagnose conditions (in ourselves or in others). Our role is to provide nutrition education or medical nutrition therapy for conditions diagnosed by physicians. 

I was so struck by Tim’s recent post sharing about his complete hair loss and how he felt about it as a clinician, that I asked his permission to share his story. Below is an excerpt of his recent post. My goal in sharing this is so that people can understand what alopecia universalis is, and how it feels as a clinician to be diagnosed with an auto-immune disorder. It is my hope that sharing Tim’s post will enable people to better understand that clinicians with health conditions (whether autoimmune or not) are no less able to support their clients. What makes a clinician knowledgeable is their training and ongoing study in their area of clinical practice and I do not believe that a clinician diagnosed with an autoimmune disorder or metabolic disease is disqualified from being able to help others. On the contrary, provided they remain objective, I think a clinicians’ ability to understand their clients’ clinical struggles from “both sides of the clinical desk” while offering evidence-based support may be an asset.

I will begin with a very brief explanation of the disorder itself, so Tim’s words make sense.

Alopecia Universalis

Alopecia universalis (AU) is an advanced form of alopecia areata (AA) which is a condition that causes round patches of hair loss. This recent article describes alopecia areata and shows pictures of what it looks like.

In alopecia universalis, there is a complete loss of hair on the scalp and all over the body and it is thought to be an autoimmune condition in which the person’s immune system mistakenly attacks the hair follicles [1].


This Year I Stopped Hiding – a clinician story

(written by registered clinical nutritionist, Tim Rees)

“Three years ago my hair started falling out for the second time. In fact, I’d only had it all back for about 6 months before I got gut-punched standing before the mirror. “It’s not as bad as last time,” I said to myself.

But like an unstoppable rebel force (name the movie) my immune system killed my hair follicles and the hair dropped away like oak leaves in autumn, minus the orange. Alopecia Universalis, not a single hair remained on or in (I’m told) my body.

At the same time, the entire world went into lockdown and the corporate presenting side of my business died along with my self-esteem, my confidence and my monthly hairdressing appointment. There had never been a better time to hide.

You could be forgiven for thinking this is all centered around vanity, but the thing that crushed me was that it made me feel like a fraud. I was so embarrassed the thought of people discovering my secret presented as physical pain. Alopecia, one of the most visible autoimmune diseases one can have, undermined my work and, I thought, my credibility as a nutritionist helping people with autoimmune conditions.

But that’s not true. I’ve done amazing things with nutrition for myself and my clients. Until fairly recently I had lost my hearing to the point that I could no longer use the phone and was conducting sessions using Skype subtitles and talking non-stop in the hope I’d cover their questions before they thought them up. I have a whole list of reasons-why-I’m-not-a-fraud but I won’t bore you with them, after all, most of these insecurities are in my head.

But, here’s the thing. I think I can reverse this condition. Two years ago I stuck to my exclusion diet for four months by which time I had quite a lot of regrowth. Fluffy like a baby owl but still, living follicles. In fact, I remarked to my helpless doctor that I wasn’t worried about the hair, that it was coming back and all was fine. Ever the optimist. But after some bad luck, I began compromising a little here, and a little there, it was Christmas after all, and before I knew it I was doing a passable impression of a bowling ball again.

This year will be different. I’m plastering this all over social media for a number of reasons. Firstly, it’s a part of my acceptance. I fought hard against acceptance mistaking it for defeat. The truth is, you must accept how things are today in order to make a difference tomorrow.

Secondly, after posting a couple of photos on Twitter, I already feel better. And, thirdly it’ll help to keep me motivated and compliant for however long it takes to allow my body to heal.

I’ve been drifting and failing as a husband, as a new father and as a man. Not because I have alopecia but because I’ve let it destroy me. There’s a stoic lesson in there.”

[Shared with permission from Tim Rees’ blog.]


As Tim outlines in the full article, it is his goal this year to reverse his alopecia universalis, and like I did when I set out to recover my own hair loss from telogen effluvium and androgenic alopecia, he will be sharing his progress on social media for all the world to see. 

Tim plans to use an exclusion diet as well as nutritional supplements and to document why he is using them.  He also intends to integrate other approaches which he hopes will support his goal, including the use of sauna, cold thermogenesis, exercise, circadian rhythm / light exposure, etc. and document what he found helpful. While this will be Tim’s personal account of what he is doing to improve his hair loss, I am confident that as a clinician, he will document his choice of approaches and provide references.

I applaud Tim’s boldness and bravery to stop “hiding” and to live his hair loss story and goal of hair loss restoration in a public way. I wish him all the very best in achieving his goal.  

Final Thoughts…

It is important to keep in mind that what may work for Tim may not work for others diagnosed with the alopecia universalis, anymore than the nutrients I took would work for others diagnosed with telogen effluvium and androgenic alopecia. I chose to not write about which nutrients I took and in what dosages because it was not relevant to anyone other than me. I did write two referenced articles related to nutrient supplementation and hair loss and the first one was Hair Loss in Hypothyroidism (Part 2) – Nutrients of Importance  and the second was Nutritional Supplements With Evidence to Restore Hair Loss.

Since taking some nutritional supplements is not without risk, I would encourage anyone considering doing this to first consult with a qualified healthcare professional. Let them assess you to help determine which nutrients may be low or deficient based on dietary intake, and lab work.

A registered clinical nutritionist such as Tim Rees, BSc mBANT rCNHC from Ebersberg, Germany is licensed to support people in that country and I can support people in several provinces in Canada. If you would like more information on how I can help, please send me a note through the Contact Me form at the top of this page and you can reach out to Tim on his blog.

[Please note that I do not know Tim personally and as such this article is not an endorsement.]

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
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References

  1. National Institute of Health, Genetic and Rare Diseases Information Centre, Alopecia universalis, https://rarediseases.info.nih.gov/diseases/614/alopecia-universalis

 

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