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Ketogenics for managing Type 2 Diabetes

What are the benefits of low carbohydrate (ketogenic) diets in managing Type 2 Diabetes?

Ketogenic or very low carbohydrate diets are becoming increasingly popular due to their positive effects in weight reduction, improved lipidemia (fat in the blood) and glucose tolerance1. Because of this, low carbohydrate diets are being used in the management of diabetes, with outstanding results.

A systematic review, looking at the effects of using low carbohydrate diets (20-60g carbs/day) for >6mths in people with Type 2 diabetes, showed a significant 0.5% reduction in HbA1c, which was similar to that achieved by using medication2.

When compared again low fat and low GI diets, low carbohydrate diets resulted in superior weight loss, glycaemic control and lipid profile, with a 10% improvement in HDL ‘good’ cholesterol2.

A low caloric intake has also shown overwhelming results in the management of diabetes.

One study recruited 306 individuals with Type 2 diabetes and divided them into two groups. Group one was assigned to 825-853 calories per day for 3-5 months and group two was the control. Findings showed, that at 12 months, almost half (46%) of participants in group one had achieved remission to a non-diabetic state and required no diabetic medication3.

 

Nutritional ketosis vs diabetic ketoacidosis

When we restrict carbohydrates (<60g/day), our bodies start to utilise our stored carbohydrates (glycogen). Once our glycogen stores are depleted, this brings on a mild form of nutritional ketosis or ‘fat-burning’ where we start to break down fat (either dietary fat or stored body fat) to produce ketones for fuel (average range from 0.6-1.5mmol/L).

Alternatively, diabetic ketoacidosis (DKA) is a life threatening condition that occurs mostly in Type 1 diabetes but occasionally in Type 2 diabetes. Without enough insulin, the body’s cells cannot use carbohydrates (glucose) for energy. The body goes through a similar transition, switching from a ‘carbohydrate burning’ state to a ‘fat burning’ state, however this leads an accumulation of ketones in the blood at a dangerously high concentrations. Symptoms may include abdominal pain, vomiting and dehydration, requiring hospital admission4.

Effects of low calorie/low carbohydrate diets on diabetic medication

For some individuals with Type 2 diabetes, low calorie and low carbohydrate diets have resulted in the reduction/elimination of diabetic medication. This includes both oral hypoglycaemic medication and insulin5.

When commencing a low calorie/low carbohydrate diet, it is important to cease diabetic SGLT2 inhibitor medication such as Jardiance and Forxiga6-7.

These drugs assist in lowering blood sugar levels by causing the kidneys to remove sugar from the body through the urine. They also increase lipolysis and fat oxidation and enhanced ketogenesis. This can result in increased ketone production when following a ketogenic diet and therefore result in the development of DKA.

Although DKA is usually seen alongside high blood sugar levels (>14mmol/L), in a number of cases associated with SGLT2 inhibitors, individuals may present with only a moderately increased blood sugar level (<11mmol/L), which might delay diagnosis and treatment6-7.

It is important to note that SGLT2 inhibitors can continue to cause metabolic acidosis for several days after the cessation of the drug.

References
  1. Paoli A, Bosco G, Camporesi EM, Mangar D. Ketosis, ketogenic diet and food intake control: a complex relatopnship. Front Psychol. 2015 February; 6(27):1-9.
  2. Ajala O, English O, Pinkney J. Systematic review and meta-analysis of different dietary approaches to the management of type 2 diabetes. Am J Clin Nutr. 2013;97:505-16.
  3. Lean MEJ, Leslie WS, Barnes AC, Brosnanhan N, Thom G, McCombie L, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. The Lancet . 2018 February; 391(10120):541 – 551.
  4. Gosmanov AR, Gosmanova EO, Dillard-Cannon E. Management of adult diabetic ketoacidosis. Diabetes Metab Syndr Obes. 2014;7:255–264.
  5. WestmanEC, Yancy WS, Mavropoulos JC, Marquart M, McDuffie JR. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutr Metab. 2008;5:36.
  6. Ogawa, Sakaguchi. Euglycaemic diabetic ketoacidosis induced by SGLT2 inhibitors: possible mechanism and contributing factors. ‎J Diabetes Investig. 2016 March;7(2):135-138.
  7. Kohli J, Goldfarb S. Metabolic acidosis in a patient with type 2 diabetes. Am J Kidney Dis. 2017;69(6);11-13
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Iron sources for vegans

Iron can be a tough mineral to get enough of, particularly for those who don’t eat a lot of red meat, or are pregnant, or follow a vegetarian or vegan diet.

Iron is a vital nutrient in the diet, it is essential for blood production, and for oxygen transportation throughout the body. If you don’t have enough iron, your body can’t make enough healthy oxygen-carrying red blood cells.

Adult men need approximately 8mg/day, while the recommended daily intake for women is 18mg/day. Here are the best vegan iron sources to help you achieve your target:

  • Beans: 1 cup = 9.8mg
  • Lentils: 1 cup cooked = 6.6mg
  • Tofu: 100g = 6.5mg
  • Leafy greens: 1 cup cooked = 6.5mg
  • Quinoa: 1 cup cooked = 3mg
  • Tempeh: 1 cup = 4.5mg
  • Soy beans: 1 cup = 4mg
  • Chia seeds: 100g = 7.7mg (*you’re not likely to eat 100g of chia! 1 tablespoon is more realistic, therefore providing 1.5mg)

Non-animal sources of iron (non-haem iron) are not as readily absorbed by the body compared to haem iron (animal sources). This is way it’s extra important to follow the below tips to ‘boost’ absorption:

  • Add Vitamin C to your iron rich meal – think leafy green vegetables, tomatoes, capsiusm, citris fruit.
  • Avoid calcium rich foods within 30 minutes of having your iron. Calcium hinders iron absorption.
  • Avoid tea or coffee with your iron rich meal, the tannins also hinder iron absorption. Wait 30 minutes either side of your meal before enjoying a cuppa.
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Does caffeine improve performance for everyone?

We know that caffeine is ergogenic, meaning that it has been shown to improve performance, particularly for endurance sports. It acts on the central nervous system  to reduce perception of fatigue and reduce rate of perceived exhaustion. The current guidelines recommend 3-9mg/kg body weight of caffeine 60 minutes before exercise. However, the difference in performance enhancement changes significantly between individuals ranging from highly effective to potentially worsening performance to no effect.

You may have noticed that some people can drink coffee all day, even before bed and have no issues with sleep or anxiety or over-stimulation, whereas others, if they touch coffee after midday, they’re awake all night.

It has now been shown that depending on how much and what type of CYPA12 enzyme you have will influence how you digest caffeine. This enzyme is needed to break down caffeine (much like lactase is needed to break down lactose) and some people have much more than others and difference variations of the gene exist.

This study showed that just under 50% of subjects were fast metabolisers of caffeine and in these people, a small amount of caffeine (2mg/kg body weight) reduced their cycling time trial time by 5% and a larger amount (4mg/kg body weight) reduced it by 7%.

A second subtype of this enzyme was found in 43% of participants and for them, caffeine had no effect on their time. It did not improve it or worsen it.

A third group, making up about 8% of the athletes, found that 4mg/kg body weight caffeine worsened their cycling time by 14%!

Of course, there are other factors that influence response to caffeine including habitual caffeine use, circadian rhythm, medication and expectancy of effect. However, this study highlights the need to take an individual approach to caffeine supplementation, especially for those 8% of people in which it could be doing more harm than good!

You can probably work out whether you respond well to caffeine or not if you are a regular coffee drink or caffeine user. However, if you are not sure or want some further guidance as to how best to use caffeine to improve your sports performance, book an appointment with an Accredited Sports Dietitian to get individualised advise on how, when and how much (if any!) you should be using for optimal results.

Pickering, C., Kiely, J. (2018). Are the Current Guidelines on Caffeine Use in Sport Optimal for Everyone? Inter-individual Variation in Caffeine Ergogenicity, and a Move Towards Personalised Sports Nutrition. Sports Med, 48(1), 7-16.
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Understanding ulcerative colitis

Ulcerative colitis (US) is a chronic inflammation of the large intestine (colon). The colon is the part of the digestive system where water is removed from undigested material and the remaining waste material is stored. The rectum is the end of the colon adjacent to the anus. In patients with ulcerative colitis, ulcers and inflammation of the inner lining of the colon can lead to symptoms of abdominal pain, diarrhoea, and rectal bleeding and mucous.

During an acute flare up, the capacity to absorb water is usually reduced, which can further worsen the symptoms of diarrhoea. Due to the fact that ulcerative colitis only affects the colon, it is less common to see nutritional deficiencies.

In ulcerative colitis, the inflammation may extend to varying degrees. When the entire colon is involved, the terms pancolitis or universal colitis are used.  There can also be some involvement of the terminal ileum.

The treatment of ulcerative colitis involves medications and/or surgery. Surgery may be used for treating severe conditions, individuals that don’t respond well to treatment, or to prevent the development of cancer. Almost always, the entire colon is removed during surgery since ulcerative colitis frequently involves the entire colon or can spread to unaffected parts of the colon after the diseased part is removed.

It is important to remember that there is no evidence to suggest that dietary factors are the cause of Irritable Bowel Disease (Ulcerative Colitis or Chron’s Disease). In addition, it is not possible to make your condition ‘go away’ permanently by adding or eliminating certain foods from your diet or by eating only particular types of food. In some cases, a particular food may aggravate symptoms and eliminating this food can make a positive difference.

However, for most people however the key to managing their condition is to eat a well-balanced diet that includes items from all major food groups. Good nutrition improves overall health status, supports the healing process and can enhance the response to medications.

A PPN Accredited Pracitising Dietitian can help you develop an eating plan that will reduce your GI symptoms, help identify trigger foods, prevent nutritional deficiencies and manage flare ups.

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Nutrition for PCOS

Polycystic Ovarian Syndrome (PCOS) is a hormonal condition that effects up to 20% of women.

An increasing number of women are developing PCOS due to weight gain during teen and adult years, increasing insulin levels which can cause cysts on the ovaries.

Why nutrition is important?

Women with PCOS often are insulin-resistant – meaning that the body can’t use insulin properly to help transfer sugars in the blood to the cells to be used for energy. Having high amounts of insulin leads to fat storage/weight gain. And long term, it is a risk factor for Type 2 Diabetes.

Eating high amounts of carbohydrates and carrying excess weight can increase your insulin levels and increase your body fat. Dietary management of PCOS requires a lower carbohydrate, low GI diet to prevent spikes in insulin levels and support weight loss.

Losing as little as 5% body weight can have huge health benefits. For example, if you weigh 90kg, losing 4.5kg is enough to decrease total body fat, visceral fat (the dangerous fat around your organs) and liver fat. Plus it can lower blood pressure, improve insulin sensitivity and all together this lowers the risk of developing type 2 diabetes.

Nutritional tips for managing PCOS

  1. Know what foods contain carbohydrate (breads, cereals grains, fruit, potato/sweet potato, dairy (except cheese), foods with added sugar)
  2. Remove processed carbohydrates – white bread, biscuits, cakes, sweets
  3. Portion control – small regular meals rather than big meals
  4. All fluids should be calorie free
  5. Meals should be built around a palm size piece of protein and non-starchy vegetables
  6. Follow a low carbohydrate diet (studies show limiting carbohydrates to 50g per day reduces fasting glucose, reduces body fat, and reduces risk of diabetes)

Day on a plate

Breakfast 1 slice of wholegrain toast with 2 eggs, gilled tomato and spinach

 

Lunch tuna ricotta and avocado salad – 60g reduced fat ricotta, 100g tin of tuna, 1 cup salad vegetables, 1/2 avocado
Dinner chicken and almond stir fry – 150g raw chicken breast, 2 cups mixed vegetables, basil, ginger, chilli, garlic, 2 tsp canola oil, 1/4 cup chopped almonds
Snacks 25g mixed nuts, 100g low fat yoghurt, coffee with 100ml skim milk

Dietitians are able to personalise your plans as no diet is ‘one size fits all’. Feel free to book in with one of the Accredited Practising Dietitians at Peninsula Physical Health and Nutrition (PPN).

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Protein for weight loss… how much do you need?

How much protein do you need to maintain performance and muscle mass during weight loss?

It is often necessary for athletes or those undertaking high levels of exercise or training to lose weight, whether that be for optimal body composition, aesthetics, requirements of the sport or weight gain over the off-season. It is also desirable to be able to maintain performance and training at optimal levels during weight loss, to maintain muscle mass and to prevent injury.

To do this we need to consider the amount of protein that will give us high quality weight loss while enabling the individual to continue to perform at their best. For health, we require 0.8g protein per kg per day, which for example means a 70kg person requires 56g of protein a day to meet general requirements. However, protein requirements during calorie restriction are much higher in this group of people. Studies show they need somewhere between 1.6-2.4g per kg body weight per day (1) – so the same 70kg person is looking at 112-168g protein per day.

Now, the total amount of protein is not the only consideration we need to make. Our bodies can only use 20-30g protein for muscle repair and synthesis every 3-4 hours. So, it is unhelpful to consume more than 100g of protein at once. Instead, it is best to spread protein intake evenly throughout the day, making sure each meal and snack contains 20-30g of high quality protein in order to meet their individual protein requirements. Another key time point to consume adequate protein is in the hour or two after training or exercise, particularly resistance exercise, when the rates of muscle protein synthesis are higher. This will ensure you are meeting your protein requirements necessary for good quality weight loss, or in other words body fat loss rather than muscle mass loss.

So, what does that look like in food? You can get 20-30g of high quality protein from:

  • 2-3 large eggs
  • 1 serving Whey Protein
  • 120g lean red meat or chicken
  • 120g fish
  • 1-2 tins of tuna or salmon
  • 250g (2 tubs) high protein yoghurt
  • 2 large glasses of milk
  • ½ tub cottage cheese

If you are unsure about how much protein you should be eating or would like further advice about weight loss, feel free to book in with one of the Accredited Practising Dietitians at Peninsula Physical Health and Nutrition (PPN).

  1. Hector, A.J., Phillips, S.M. (2018). Protein Recommendations fr Weight Loss in Elite Athletes: A Focus on Body Composition and Performance, Int J Sport Nutr Exerc Metab, 28, 2, 1701-77.
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What exactly is ‘energy availability’?

Energy Availability (EA) refers to the amounts of energy left over and available for your body’s functions after the energy expended for training is subtracted from the energy you consume from food.

Food energy intake – Exercise Energy Expenditure = Energy Available for your body systems

Low EA is when the energy available after exercise is insufficient to meet you baseline physiological needs. Basically, your body doesn’t not have enough energy to maintain normal, healthy functions which lead to hormonal and metabolic adaptions to reduce the amount of energy your body can function on.

As a result, low EA can lead to:

  • Impaired ability to use glucose effectively for energy
  • Increased fat stores
  • Slower metabolic rate
  • Increase cholesterol
  • Decreased production of growth hormone
  • Changes to menstrual cycle such as amenorrhea

This condition was traditionally thought only to affect athletes, adolescents and people suffering with eating disorders, however, people who exercise recreationally, of any body shape or size, are also at risk; especially in a society that pushes the message of eat less and move more. A study of 109 female recreational exercisers, published in the International Journal of Sports nutrition and Exercise Metabolism, showed that 45% were classified as at risk of Low EA.

Some signs to look for if you suspect you may have low energy availability:

  • Training hard, but not improving performance
  • Fatigue
  • Easily injured
  • Recurrent illness or infection
  • Decreased muscle strength
  • Altered menstrual cycle
  • Gastrointestinal problems
  • Low iron or anemia
  • Stress fractures

What to do to prevent it?

Now I am not suggesting that we move less as exercise has numerous benefits for physical and mental health, nor am I suggesting that everyone needs to eat more. Rather restricting your intake while pushing your body to the limits in the pursuit of weight loss, health or fitness as this approach will ultimately fail you, I’d suggest that it is about finding that balance between fueling your body and mind adequately for the amount of exercise that you are doing. Look out for the signs of low EA and seek support if you think this may be you.

Try to listen to your body, if you are hungry or low in energy, try a nutritious snack or meal; if you are tired, have a rest or try a lighter form of exercise that day. Eat regularly and nutritiously without depriving yourself of any particular food. Eat mindfully and learn about the foods and nutrients needed to fuel your body properly.

If you are still confused about how much or what you should be eating, or if you think that you may have low energy availability, it is worth seeking the support and advice of an Accredited Practising Dietitian (APD).

References:
Logue,D., Madigan, S.M, Delahunt, E., Heinen, M., McDonell, S., et al. (2018). Low Energy Availability in Athletes: A Review of Prevalence, Dietary Patterns, Physiological Health, and Sports Performance, Sports Medicine, 48,1,73-96.
Slater, J., McLay-Cooke, R., Brown, R., Black, K. (2016). Female Recreational Exercisers at Risk for Low Energy Availability, International Journal of Sport Nutrition and Exercise Metabolism, 26, 5, 421-427.
Fagerberg, P. (2017). Negative Consequences of Low Energy Availability in Natural Male Bodybuilding: A Review, International Journal of Sport Nutrition and Exercise Metabolism, 22, 1-31.
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Why do I need branched-chain amino acids?

Leucine, isoleucine and valine are the three branched-chain amino acids. These 3 BCAAs are also essential amino acids, meaning they cannot be made by the body and must be obtained from dietary sources. BCAAs are unique as they can be metabolised by the skeletal muscle, while the other essential amino acids are metabolised in the liver.

BCAAs have been commonly used in body building communities for years, but now they are gaining popularity with other athletes and the general active population.

BCAAs have been suggested to be beneficial by:

  • Stimulating muscle protein synthesis (through leucine)
  • Preventing muscle protein breakdown
  • Reducing markers of exercise induced muscle damage and so reducing muscle soreness
  • May have the potential of acting as a fuel source for muscles during exercise
  • May reduce fatigue by interfering with tryptophan transport to the brain and reducing serotonin.

However, studies have shown that they do not always correlate with improved performance and the evidence for the above benefits is only low to moderate at this stage.

The evidence is not conclusive whether BCAA supplementation is superior to whole protein supplementation or carbohydrate intake. Athletes with a tight energy budget may benefit as they may help to build muscle without a large kilojoule load.

For the best effect, BCAA supplementation should be used in amount to provide 2-3g leucine and so far, no negative or toxic effects have been found.

However, It is important to keep in mind that many protein sources contain BCAAs such as meat and eggs and those already consuming adequate protein may not need supplementation.

When considering any supplementation, it is important to consider what is right for you as an individual and consult an Accredited Sports Dietitian or Accredited Practising Dietitian if you’d like more information and guidance of safe and effective supplementation.

References
Foure, A., Bendahan, D. (2017). Is Branched-Chain Amino Acids Supplementation an Efficient Nutritional Strategy to Alleviate Skeletal Muscle Damage? A Systematic Review, Nutrients, 21, 9(10).
Cheng, I.S., Way, Y.W., Chen, I.F., Hsu, G.S., Hsueh C.F. et al. (2016) The Supplementation of Branched-Chain Amino Acids, Arginine, and Citrulline Improves Endurance Exercise Performance in Two Consecutive Days, Sport Sci Med, 5,15 (3), 509-515.
Ferreria, M.P., Li, R., Cooke, M., Kredier, R.B., Willoughby, D.S. (2014) Periexercise coingestion of branched-chain amino acids and carbohydrate in men does not preferentially augment resistance exercise-induced increases in phosphatidylinositol 3 kinase/protein kinase B-mammalian target of rapamycin pathway markers indicative of muscle protein synthesis. Nutr Res, 34 (3), 191-198.
Kephart, W.C., Mumford, P.W., McCloskey, A.E., Holland, A.M., Shake, J.J., et al. Post-exercise branched chain amino acid supplementation does not affect recovery markers following three consecutive high intensity resistance training bouts compared to carbohydrate supplementation, J Int Soc Sport Nutr, 26, 13, 30.
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Gut microbiome and obesity…

The microbiome is a collection of bacteria that lives in the digestive tract that is critical to health and well-being. A symbiotic relationship exists between gut bacteria and host, where they both benefit from one another.

Recently, there has been great interest in the role that gut bacteria plays in obesity and how we might be able to control our weight by manipulating or changing our gut microbiome through probiotics and prebiotics.

A link between gut microbiome and obesity was first recognized during mice experiments when gut bacteria from genetically engineered obese mice were put into germ free mice. These germ free mice experienced a 60% increase in body fat over a 2 week period, despite eating less food. This bacterium has been identified as firmicutes, which is efficient at extracting energy from the food we eat. From this, and other similar studies, it has been suggested that the composition of gut bacteria in obese individuals may have an increased capacity to harvest energy (calories) from food.

As a consequence, we are now looking at ways to manipulate or ‘improve’ our gut microbiome to assist with weight management. The ingestion of probiotics has been a key focus, however we have only just scraped the surface.

Probiotics are defined as the ‘good’ microorganisms expected to have a beneficial impact on our health and can come in different forms such as capsules (Inner Health Plus) or fermented foods and drinks (Kombucha). To date, there is no recommendations for adequate intake of probiotics.

While it is important to ensure that we have adequate ‘good’ gut bacteria in our digestive tract, it is just as important to make sure that we feed these bacteria adequately. This is done through the consumption of prebiotics, non-digestible carbohydrates that trigger the growth of good bacteria. Foods that are high in prebiotics include onion, garlic, leeks, artichokes, stone fruit, watermelon, dried fruit, barley, rye, wheat based products and legumes.

The role that our gut microbiome plays in obesity and our overall health is very complex and more research needs to be undertaken before we can make any conclusive recommendations. This is an exciting area so watch this space!

  1. Ley RE, Turnbaugh PJ, Klein S, Gordon JI. Microbial ecology: Human gut microbes associated with obesity. Nature; 44. 1022-3.
  2. Turnbaugh PJ, Ley RE, Mahowald MA, Magrini V, Mardis ER, Gordon JI. An obesity-associated gut microbiome with increased capacity for energy harvest. Nature. 2006;444-1027-31.
  3. Musso G, Gambino R, Cassader M. Interactions between gut and microbiota and host metabolism predisposing to obesity and diabetes. Annu Rev Med.
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What is ‘intermittent fasting’?

‘Intermittent fasting’ diets refer to any diet where you calorie restrict for a certain period of time, then eat ‘as normal’ for the rest of the week, with the aim of losing weight. 

The 5:2 diet popularised ‘intermittent fasting’, where a person fasts for 2 days per week, then eats normally for the remaining 5 days. The idea is that on fasting days the individual consumes approximately 25% of their requirements only, leading to overall weight loss over the course of a week. 

There is some talk around suggesting that intermittent fasting has greater benefits than just weight loss. That it can assist in reducing cholesterol and blood glucose levels, thus reducing risk of diabetes and cardiovascular disease. Dr Michael Mosley tested this theory himself in his recent BBC documentary ‘Horizon: Eat, Fast, Live longer’, and while he admits that the evidence is not solid yet, he did see positive changes in his own cholesterol and blood glucose levels after trialling the 5:2 diet for 5 weeks. 

Is it right for you: while the evidence shows that Intermittent Fasting is beneficial is achieving weight loss, so are many other types of diets. This diet can work well if you can stick to it and if it fits into your life, otherwise good old fashion ‘reduced calorie diets’ will work just as affectively. As for whether it reduces blood markers and disease risk – the jury is still out.  

Here is an example of a ‘fasting day’ diet (approximately 500 calories per day allowed)

Breakfast: 2 egg white omelette (30cal) + 1/2 cup spinach wilted (15cal)

Lunch: Tuna in olive oil (115cal) + 1 cup salad leaves (20 cal) + 8 cherry tomatoes (10cal) + 2 vita wheat crackers (45cal)

Dinner: 100g poached chicken breast (150cal) + 2 stalks broccolini (10cal) + 4 spears steamed asparagus (10cal) + 1/2 cup sautéed mushrooms with no added fat (25cal)

Snack: 6 carrot sticks + 1 tablespoon hummus dip (50cal)

Total: 485calories/2029kJ, 63g protein, 15g fat, 18g carbs, 12g fibre

Link to further readings: BBC News, The Power of Intermittent Fasting. http://www.bbc.com/news/health-19112549
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