Protein-rich Diet (Liver Shrinking Diet) vs PSMF



I was blown away when I heard Dr. Ken Berry on the last 2KD podcast rant about his friend who tries to get people to shrink their livers to make bariatric surgery easier on the surgeon and nurses. I had to research it more, partly out of skepticism and partly out of sheer horror and sadness. Turns out it’s very true as seen here:


A few months ago I saw Dr. Ted Naiman who turned me on to this idea of a PSMF (protein sparing modified fast). Essentially the idea that you can eat too much fan on keto and many people who are stalled do indeed do so:

In Amber’s blog she references a Naiman tweet which brought me back full circle:


It’s interesting because there isn’t a ton of info on PSMF that I could find. By far some of the best references are this blog post by Marty Kendall:

And of course the PSMF bible is Lyle McDonald’s Rapid Fat Loss Handbook

But it turns out that the concept of the liver shrinking diet and a PSMF are the same. Almost exact really. Give your body the protein and nutrients it needs and not much else. The medical community has known for decades that a version of a PSMF is the most effective way to lose excess fat. It’s not something a person can do indefinitely but many moderately obese people could see great results from doing a PSMF for a 8-12 weeks. I’m fascinated by this concept, the science is there and it passes the sniff test. To me, eat all the fat you want and still lose weight has never really passed the sniff test. And as Naiman and Berger have stated many times, when your body is already HF all you really need is LC.

I’m thankful I’ve learned about some of this stuff before I was looking weight-loss surgery in the face, it’s a shame more people aren’t as lucky. It disgusts me that many of these doctors know effective non-surgical interventions but are either withholding the information or not connecting the dots. Wouldn’t it be a novel concept to suggest some of these interventions before recommending surgery? Call me crazy but I sure think so.

(Adam Kirby) #2

What doesn’t pass muster with this idea is that if you are stalled due to high fasting insulin, a PSMF will just put your body into starvation mode. If your insulin is low then sure, you’ll be able to draw on body fat. The amount of insulin decrease people get on low carb seems to vary wildly, therefore before putting Ted’s idea into practice you kinda have to know your basal insulin situation.

(G. Andrew Duthie) #3

Well said.

Really important…folks like Naiman who appear to be pretty insulin sensitive likely have more latitude in terms of being able to lower fat intake and have the body respond by burning body fat. For those who are insulin resistant, or who currently have high basal levels of circulating insulin, the ability to access body fat may be limited.

If you look at the advice provided on this forum, on a regular basis, it is never “eat all the fat you want.” Rather, the advice is:

  • Limit carbs to 20g (or less) per day, preferably from green leafy vegetables (definitely not from sugar or starch)
  • Consume adequate protein to support lean body mass
  • Eat fat to sateity

Notice the emphasis on that last point. Sateity is the key. Not “as much as you want”. Not “eat sticks of butter,” nor any other canard that has been raised against eating fat to sateity.

Each of us has our own metabolism, and the hormonal milieu will vary from person to person, so how much protein and fat we can, and/or should, eat will vary from person to person. But in general, the three points above are a good starting point for most of those who are metabolically deranged by overconsumption of carbs.


What they more often put you on are either shakes like Slimfast - with skimmed milk of course - or just milk. This is usually for 2 weeks but can be more in a few cases. It is very restrictive in calories (and fat of course) and those are indeed made up of protein but also sugar, a LOT of sugar! It works of course because it is so restrictive - anything you ate would work if it was very low calorie for a given time until your body decides to start slowing you down to compensate. You can’t extrapolate out from the short time people do it because it is not intended to be done for long. People HATE it and often cite it as the hardest thing they have to do in their WLS journey.

And what Naiman spectacularly fails to mention in this comment is that the post-bariatric diet is RELATIVELY high in protein proportionally in what you eat per day because you cannot eat much. It is not a high protein diet at all, you just mostly eat (a moderate amount of) protein because that is all you can eat. It is true that you are told to eat protein first but nobody would dispute the wisdom of that if that is all you can eat! I have always laughed at this comment of his because it is so misleading.

Add to this the fact that bypass and DS operate on restriction and malabsorption, you also lose part of what you eat anyway. The specific amounts vary but are not that high. For the sleeve you would be looking at about 80g (often less), the bypass a bit higher and the DS (most restrictive and malabsorptive) higher still but even this level tops out around 120g.

(Liz Myers) #5

Thank you Daisy, I was going to point that about the protein.

I had gastric bypass 15 years ago. I was told to try to get 60-70 grams of protein a day from day one. That amount stayed the same through all the meal plans.
“High protein”, indeed.

(Adam Kirby) #6

Ted has fully transitioned to a “protein is magic” mindset recently. The lean protein experiment Jimmy Moore is doing at the moment should be quite interesting, he seems to feel like crap on it.

and BTW I am totally in the camp of erring on the side of “too much” protein rather than “too little” (in the form of meat not protein shakes), and that being “kicked out of ketosis” is a thing that simply doesn’t matter to most individuals.* Still though, the idea that you can protein your way to fast loss doesn’t take into account someone with a pathological level of fasting insulin on keto. In such a person wouldn’t a calorie-restricted protein diet operate like any other calorie-restricted diet?

*unless you need therapeutic neurological effects from ketones

(G. Andrew Duthie) #7

Beyond whether or not a post-bariatric surgery diet is high protein, I’m puzzled as to why anyone would use that as a benchmark for whether or not high-protein is a good idea, outside of the context of having had bariatric surgery.

I don’t make the claim that keto is necessary for someone who doesn’t have insulin resistance or diabetes, though it might well help them avoid getting those conditions. So why would one suggest that a diet proposed for surgical patients who’ve had their stomach capacity severely limited is a good idea for those who have not?


I realize Naiman’s post refers to post surgery. My original comparison was more directed at pre-surgery. As in essentially curing your fatty liver with diet but then still getting surgery.

Is an insulin level high enough to block the burning of body fat really that common? How long does it take to come down when fasting? Can you be so fat and so insulin resistant that if you fast you will die of starvation with hundreds of pounds of body fat? That doesn’t sound like it’s very common.

(Adam Kirby) #9

Well, my wife’s recent fasting insulin after 1.5 years of low carb was 24.9. Which is pathologically high IMO. And that was after 12 hours of fasting! She might be an extreme outlier.


Satiety seems to be a vague and misleading term. What does it mean in this context and how much can we trust this signal? If a person can fast for say 4 days then surely they are capable of using body fat for fuel. So then why when that person is eating keto would they have hunger signals for 200 grams of fat for example? Why is the body asking for that fat when it’s proven to be perfectly capable of using the fat it already has? Because it’s easier maybe?


It is s drastic intervention done to get the size down in a short space of time. Most people can tolerate a hideous diet for a couple of weeks. This will have very little impact though on the severe obesity that they are still dealing with - that is where the surgery comes in. They aren’t having the surgery specifically to reverse their fatty liver.


We agree on this. Essentially it’s the same method for different outcomes. The gist of the PSMF is to give your body exactly what it needs over a short period of time and nothing more.

I just think the mindset of prioritize protein might have more applications that just bariatric surgery. The protein leverage hypothesis is an interesting concept.


It’s weird because I don’t know anyone who doesn’t prioritise protein! Nobody disputes the fact that a certain amount of protein is essential! and delicious of course :smiley:


Agreed, it’s on the need for all the excess amounts of fat intake on keto that I seem to be struggling with.

(G. Andrew Duthie) #15

Where are you coming up with the notion of dying of starvation? Who said anything about that?

As for an insulin level high enough to block the burning of body fat, @richard has posted many, many times on this forum a simple chart that illustrates the phenomenon, and has mentioned in most if not all of those posts that his basal insulin level sits at a level too high to allow substantial access to body fat. That obviously doesn’t speak to how “common” it is, but for those who have IR and/or T2DM, I suspect it’s higher than you might think. But that’s just a guess.

For carb-burners, sateity may be fundamentally broken, since carbs tend to lead to hunger and cravings. Once carbs are out of the picture, the body tends to have better sateity signaling, but it can take some time to learn to listen. But a simple definition of the term is (courtesy of Phinney :phinney:) “don’t leave the table hungry”.

Precisely because of the basal insulin level already discussed. Or at least that’s one possibility. Over time with low carb/keto and/or fasting, insulin levels do appear to drop, but they may not drop to a level that allows full access to body fat. This is why Phinney’s position is that as we lose weight, we will tend to automatically use the right amount of plate fat vs. body fat, based on sateity signaling.

At the end of the day, I think that the advice to eat protein to build up your body, and eat fat for fuel, is the correct way (pretty sure that’s a @richard-ism, but not sure if he originated it, or was quoting someone else). Obviously, that’s going to mean a significant variance in protein intake, based on differences in lean body mass, activity level, and whether or not one is engaging in resistance exercise requiring additional protein for recovery.

Naiman is, of course, entitled to his opinions on appropriate protein intake. I believe @richard has more than adequately explained why there is reason to be concerned about over-consuming protein, both because it’s not a great fuel, and because there are health risks involved once you exceed the body’s ability to clear urea. But the truth is there is no one right answer on the subject, at least not one that’s applicable across the board.

(Adam Kirby) #16

“Excess” is a fairly subjective term. What is your fasting insulin? If you are in the single digits you should have reasonable success restricting dietary fat.

(G. Andrew Duthie) #17

Again, where does this come from? Who is advocating “excess amounts of fat intake”?

“To sateity” does not imply excess. You may find people advocating that newbies to keto not worry about counting how much fat they’re eating, and I think that’s good advice because until they get the insulin under control and get rid of the carbs, they will be unlikely to get enough energy just from protein and their own body fat. But even then, no one is saying “eat all the fats!”


Your keto, your rules. Eat as much or little fat as you want! By its nature, keto is going to be high fat but you get to decide how high. Ultimately, if you want to follow the Naiman high protein, low fat method then that is fine too. It’s your body :smiley:

(Adam Kirby) #19

Definitely one of the hotly-contested areas of low carb! You’ve got people on the spectrum all the way from Fung and Rosedale to Naiman. You can’t really listen to the experts because they disagree. Gotta try different things on yourself.

(G. Andrew Duthie) #20

I agree with the latter half of the statement, but disagree with the first part. I would phrase it as that we need to avoid blindly following the experts. The fact that experts disagree is due in part to the immaturity of the science in this area, and in part to the “blind men describing an elephant” problem. Context is key…and all too often left out of the discussion, so it appears that opposite conclusions are being drawn from the exact same facts. I say an elephant is like a tree, while you say it is like a rope, and someone else says it’s like a snake. We’re all correct, but operating from different contexts.