High vs. Low Protein

A few wks ago, @ScepticalDoctor & @theproof brought up this ??. I was too busy @ the time, & it's a tough topic - limited base of quality evidence to draw from.

Got more time now.

Time for a protein tweetorial?

For starters, how high is "high"?

g? %?
And how low is "low"?
There aren't correct answers. There is no consensus on grams or % of what qualifies as "low" or "high".

And there is the important consideration of plant vs. animal protein, and translating "protein" into "food". But I'll save that topic for another day.
In 2009, the POUNDS LOST weight loss diet study was published in NEJM. The idea was to simultaneously test differences in protein, fat and carbohydrate.

2 protein levels: 15% vs 25%
2 fat levels: 20% vs. 40%
4 carb levels: 65%, 55%, 45%, 35%

Elegant eh?

Let’s make you nutrition Czar for the day, and you get to review this study design proposal and suggest changes before it is ever conducted.

Do you think the choice of 15% vs. 25% was the best choice for “low” vs. “high”, or would you have picked something else?
The real reviewers agreed that 15% vs. 25% was an appropriate choice.
That was what they tried to implement

Design is one thing.
Implementation is another.
Adherence can be challenging in human studies.
At the end of 2 years, whadya think the ACTUAL protein intake levels were?
According to the extensive dietary assessment methods they used, the actual difference at the end of 2 years was JUST 20% vs. 21%

At that level of differentiation, they actually couldn’t test their hypothesis as to whether “low” vs. “high” was better for weight loss.

Important note: These were top researchers at Harvard and Pennington.

Adherence to dietary change in research studies is very challenging on two counts:
1.Achieving the change
2.Documenting adherence accurately
We found something very similar in our 2007 JAMA publication of the #ATOZ weight loss diet study.

Early on, when enthusiasm was likely highest, the reported protein intakes ranged from 16% for Ornish, to 28% for Atkins.

But look out to 1 year: Full range was just 19% - 22%
Similar in our #DIETFITS study (JAMA 2018).
Baseline protein intake is 17-18%
Early differences in study (3 months) 22% vs. 26%
But 1 year out, when we still had substantial fat vs. carb diffs, protein difference was just 21% vs. 23%

(Note: protein Kcal similar to baseline)
And just a few weeks ago, @sguyunet shared the impressive graphic from USDA ERS data showing that while fat and carb intake underwent notable changes from 1909-2006, protein intake levels were stunningly stable.
So here is my “avoid-the-real-question” response to @scepticalDoctor and @theproof regarding low vs. high protein.

Moot point: In general, people consume very similar amounts of protein

MOST people don’t/can’t achieve & SUSTAIN meaningfully diff levels of protein


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More from @GardnerPhD

Mar 27

I believe most people who have access to a reasonably diverse diet get ⬆️⬆️ protein than the RDA, especially athletes.

Do you?

Simple math

How much do you weigh?
Doubly-labeled water
% Protein in diet

@mackinprof – please check my math

Wanna play?
Let's start with the % of protein in your diet.
Do you have any idea what that might be?
You don't need to know to play.
If you know great,
If not, have some fun and guess.
Yesterday @ScepticalDoctor provided screen shot below (source?)
Meat eaters ~16%
Vegetarians ~13%
Vegans ~12.5%

@MrBigNoodle noted this:
with higher amounts (although, in grams).

I find few examples in published lit. of ave’s outside the 15-20% range Image
Read 13 tweets
Mar 26
Vegans eat the least protein.
That doesn't mean they don't eat enough protein.
The RDA does not reflect individual requirement.

Here is a brief RDA tweetorial.

>50 years ago, individual protein requirements were assessed in rigorous studies.
Requirements ranged...
The estimated average requirement (EAR) was determined to be 0.66 g protein per kg body weight.

Hypothetical question: What if 100 individuals were provided with a day of food that contained EXACTLY the EAR....how many of them would NOT meet their individual requirement?
By definition, half the individuals would meet their requirement.

But there is also another subtle point to be made here, technically, 50% would meet OR EXCEED their requirement.

Get it, the range tends to be a normal distribution. Most people are either above or below ave.
Read 9 tweets
Mar 19
It Depends - Coffee vs Tea

I'm working on a book. One of the chapters will be Coffee vs Tea.

Thought it would be fun to preview some of the content. I'll try turning this into a Tweetorial. (17 in 🧵)

Several polls, several fun facts.

Are you a coffee or a tea drinker?
Coffee vs Tea and health

Which do you think is a HEALTHIER choice?

How many of you paused in trying to answer the previous question thinking.....it depends?

Doesn't it depend on what you add?
Maybe even what type of coffee or tea?

Most common additions, sweetener & dairy

Start with sweetener, do you add:

Read 16 tweets
Mar 13, 2021
Week #5

For past 4 wks, we've been sharing study design details of forthcoming Keto vs Mediterranean Study

This week, we want to share the 36-wk time point & get your thoughts.

Poll on next post in thread - vote on time point you think is most interesting 🤔
Which is most interesting?

Adherence best at Wk #4 of each phase (food delivered)
⬆️rigor (efficacy)

Wk #12 of each phase

36 wk - reality check (effectiveness)
Who is following what?


Primary outcome=HbA1c (ct.gov)
12wk Keto vs 12wk Med, relative to baseline

HbA1c not appropriate for assessing 4 wk change

We have Hba1c @ wks 0, 12, 24 & 36
We have CGM glucose @ wks 0, 4, 12, 16, 24

(Not enuf $$ to get CGM @ wk 36) 🙁
Read 5 tweets
Feb 13, 2021
Just completed trial
Keto vs Mediterranean

Just submitted Design & Adherence paper PRIOR to main results paper

While waiting for reviews & decision…
 ~10 weekly mini-threads - #KetoMedStudy

⬆️design understanding &
⬆️twitter civility?🙏
Week #1
Main study question Image
US calories: 1999-2016

Low quality carbs
Added sugars, refined grains: ~40%

High quality carbs (whole grains, legumes, fruits): ~10%

3 types fat: ~10% each

Protein: Animal ~10%; plant ~5%

***Biggest impact potential - ⬇️ low quality carbs Image
Most/all healthy diet patterns recommend avoiding/minimizing added sugars & refined grains, while including non-starchy vegetables

Is there additional overall health benefit to also eliminating:
*Whole intact grains

Poll next tweet Image
Read 9 tweets
Sep 30, 2019
Series of 6 papers published today in Ann Int Med from “NutriRECS” group.

They recommend people continue to consume unprocessed & processed red meat at current rates

I disagree, in USA

My perspective - in 17 tweets
#ReduceRedMeat in USA

2 of 17

I seek to dispute it
As does @TrueHealthINIT & @HSPHnutrition

It isn’t hard
3 of 17

The recommendations are stated to be “weak, with low-certainty evidence”.
I agree.

Beyond weak, they are reckless.
They will confuse the public & undermine scientific credibility.
Potential to harm public health & environment.
Read 17 tweets

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