JOURNAL OF INTEGRATIVE NUTRITION
SYSTEMATIC REVIEW
Defining Macronutrient Standards for the Paleo Diet and Consistency in Intervention Trials: A Systematic Review
Hollywood JB, Sobel D, Orten D
FIRST PUBLISHED
February 1, 2025
Article:
-
Can be printed.
-
Can be downloaded.
-
Can NOT be distributed.
ABSTRACT
Introduction: The need to establish standardized macronutrient requirements for future trials investigating the dietary efficacy of the Paleolithic diet (PD) on human health is lacking. Providing standardized guidelines will allow for consistent evaluation of the diet's impact and comparison of results across studies, ensuring reliable and valid conclusions regarding the potential benefits or associated risks.
Objective: The aim was to find the average macronutrient ranges or exact percentages in the non-domesticated diets of indigenous populations.
Methods: From April 2nd, 2022, to May 27th, 2023 electronic databases were searched to identify relevant literature on macronutrient utilization in the PD or amongst ancient or modern-day indigenous tribes. Macronutrients, energy intake, fiber, and saturated, monounsaturated, and polyunsaturated fatty acids were tabulated. Diet characteristics and plant consumption patterns were evaluated.
Results: The study found the average percentages for a PD to be 27% protein, 46% carbohydrates, and 27% fats making the average intake of macronutrients moderate across all macronutrient categories. Guidelines for Americans comparisons were discussed and contrasted against results.
Conclusion: The PD is moderate in macronutrients percentages, not ranging high or low in any specific category. It is proposed to utilize these set macronutrient ranges for both clinical recommendations considering the ancestral or PD practices and all future PD trials to solidify evidence-based research.
COI STATEMENT
The authors declare no competing financial interests.
REFERENCES
1. Degioanni A, Bonenfant C, Cabut S, Condemi S. Living on the edge: Was demographic weakness the cause of Neanderthal demise? PLoS One. 2019;14(5)
https://doi.org/10.1371/journal.pone.0216742
2. Salazar-García DC, Power RC, Sanchis Serra A, et al. Neanderthal diets in central and southeastern Mediterranean Iberia. Quatern Int. 2013;318:3-18.
https://doi.org/10.1016/j.quaint.2013.06.007
3. Richter J. Neanderthals in their landscape. In: Demarsin B, Otte M, eds. Neanderthals in Europe. Eraul 117 & Atvatvca 2; 2006:51-66.
4. Shipley GP, Kindscher K. Evidence for the Paleoethnobotany of the Neanderthal: A Review of the Literature. Scientifica (Cairo). 2016;2016:8927654.
https://doi.org/10.1155/2016/8927654
5. Weyrich LS, Duchene S, Soubrier J, et al. Neanderthal behaviour, diet, and disease inferred from ancient DNA in dental calculus. Nature. 2017;544(7650):357-361.
https://doi.org/10.1038/nature21674
6. Ghaedi E, Mohammadi M, Mohammadi H, et al. Effects of a Paleolithic diet on cardiovascular disease risk factors: A systematic review and meta-analysis of randomized controlled trials [published correction appears in Adv Nutr. 2020;11(4):1054]. Adv Nutr. 2019;10(4):634-646.
https://doi.org/10.1093/advances/nmz007
7. Pontzer H, Wood BM, Raichlen DA. Hunter-gatherers as models in public health. Obes Rev. 2018;19(suppl 1):24-35.
https://doi.org/10.1111/obr.12785
8. Churuangsuk C, Griffiths D, Lean MEJ, Combet E. Impacts of carbohydrate-restricted diets on micronutrient intakes and status: A systematic review. Obes Rev. 2019;20(8):1132-1147.
https://doi.org/10.1111/obr.12857
9. Kyriacou K, Blackhurst DM, Parkington JE, Marais AD. Marine and terrestrial foods as a source of brain-selective nutrients for early modern humans in the southwestern Cape, South Africa. J Hum Evol. 2016;97:86-96.
https://doi.org/10.1016/j.jhevol.2016.04.009
10. Ruiz-Núñez B, Dijck-Brouwer DA, Muskiet FA. The relation of saturated fatty acids with low-grade inflammation and cardiovascular disease. J Nutr Biochem. 2016;36:1-20.
https://doi.org/10.1016/j.jnutbio.2015.12.007
11. Amiri M, Karabegović I, van Westing AC, et al. Whole-diet interventions and cardiovascular risk factors in postmenopausal women: A systematic review of controlled clinical trials. Maturitas. 2022;155:40-53.
https://doi.org/10.1016/j.maturitas.2021.10.001
12. Blomquist C, Chorell E, Ryberg M, et al. Decreased lipogenesis-promoting factors in adipose tissue in postmenopausal women with overweight on a Paleolithic-type diet. Eur J Nutr. 2018;57(8):2877-2886.
https://doi.org/10.1007/s00394-017-1558-0
13. Boers I, Muskiet FA, Berkelaar E, et al. Favourable effects of consuming a Palaeolithic-type diet on characteristics of the metabolic syndrome: a randomized controlled pilot-study. Lipids Health Dis. 2014;13:160. Published 2014 Oct 11.
https://doi.org/10.1186/1476-511X-13-160
14. Cordain L, Eaton SB, Miller JB, Mann N, Hill K. The paradoxical nature of hunter-gatherer diets: meat-based, yet non-atherogenic. Eur J Clin Nutr. 2002;56 Suppl 1:S42-S52.
https://doi.org/10.1038/sj.ejcn.1601353
15. Frassetto LA, Schloetter M, Mietus-Synder M, Morris RC Jr, Sebastian A. Metabolic and physiologic improvements from consuming a paleolithic, hunter-gatherer type diet. Eur J Clin Nutr. 2009;63(8):947-955.
https://doi.org/10.1038/ejcn.2009.4
16.Frassetto LA, Shi L, Schloetter M, Sebastian A, Remer T. Established dietary estimates of net acid production do not predict measured net acid excretion in patients with Type 2 diabetes on Paleolithic-Hunter-Gatherer-type diets. Eur J Clin Nutr. 2013;67(9):899-903.
https://doi.org/10.1038/ejcn.2013.124
17. Konner M, Eaton SB. Paleolithic nutrition: twenty-five years later. Nutr Clin Pract. 2010;25(6):594-602.
https://doi.org/10.1177/0884533610385702
18. Masharani U, Sherchan P, Schloetter M, et al. Metabolic and physiologic effects from consuming a hunter-gatherer (Paleolithic)-type diet in type 2 diabetes. Eur J Clin Nutr. 2015;69(8):944-948.
https://doi.org/10.1038/ejcn.2015.39
19. Otten J, Ryberg M, Mellberg C, et al. Postprandial levels of GLP-1, GIP, and glucagon after 2 years of weight loss with a Paleolithic diet: a randomized controlled trial in healthy obese women. Eur J Endocrinol. 2019;180(6):417-427.
https://doi.org/10.1530/EJE-19-0082
20. Sohouli MH, Fatahi S, Lari A, et al. The effect of paleolithic diet on glucose metabolism and lipid profile among patients with metabolic disorders: a systematic review and meta-analysis of randomized controlled trials. Crit Rev Food Sci Nutr. 2022;62(17):4551-4562.
https://doi.org/10.1080/10408398.2021.1876625
21. Anton SD, Hida A, Heekin K, et al. Effects of Popular Diets without Specific Calorie Targets on Weight Loss Outcomes: Systematic Review of Findings from Clinical Trials. Nutrients. 2017;9(8):822. Published 2017 Jul 31.
https://doi.org/10.3390/nu9080822
22. Bligh HF, Godsland IF, Frost G, et al. Plant-rich mixed meals based on Palaeolithic diet principles have a dramatic impact on incretin, peptide YY and satiety response, but show little effect on glucose and insulin homeostasis: An acute-effects randomised study. Br J Nutr. 2015;113(4):574-584.
https://doi.org/10.1017/S0007114514004012
23. Eaton SB, Eaton SB 3rd, Konner MJ. Paleolithic nutrition revisited: a twelve-year retrospective on its nature and implications. Eur J Clin Nutr. 1997;51(4):207-216.
https://doi.org/10.1038/sj.ejcn.1600389
24. Fadó R, Molins A, Rojas R, Casals N. Feeding the Brain: Effect of Nutrients on Cognition, Synaptic Function, and AMPA Receptors. Nutrients. 2022;14(19):4137. Published 2022 Oct 5.
https://doi.org/10.3390/nu14194137
25. Frączek B, Pięta A, Burda A, Mazur-Kurach P, Tyrała F. Paleolithic diet-effect on the health status and performance of athletes? Nutrients. 2021;13(3):1019.
https://doi.org/10.3390/nu13031019
26. Genoni A, Lyons-Wall P, Lo J, Devine A. Cardiovascular, Metabolic Effects and Dietary Composition of Ad-Libitum Paleolithic vs. Australian Guide to Healthy Eating Diets: A 4-Week Randomised Trial. Nutrients. 2016;8(5):314.
https://doi.org/10.3390/nu8050314
27. Kuipers RS, Luxwolda MF, Dijck-Brouwer DA, et al. Estimated macronutrient and fatty acid intakes from an East African Paleolithic diet. Br J Nutr. 2010;104(11):1666-1687.
https://doi.org/10.1017/S0007114510002679
28. Lee JE, Titcomb TJ, Bisht B, Rubenstein LM, Louison R, Wahls TL. A Modified MCT-Based Ketogenic Diet Increases Plasma β-Hydroxybutyrate but Has Less Effect on Fatigue and Quality of Life in People with Multiple Sclerosis Compared to a Modified Paleolithic Diet: A Waitlist-Controlled, Randomized Pilot Study. J Am Coll Nutr. 2021;40(1):13-25.
https://doi.org/10.1080/07315724.2020.1734988
29. Metzgar M, Rideout TC, Fontes-Villalba M, Kuipers RS. The feasibility of a Paleolithic diet for low-income consumers. Nutr Res. 2011;31(6):444-451.
https://doi.org/10.1016/j.nutres.2011.05.008
30. Sanches Machado d'Almeida K, Ronchi Spillere S, Zuchinali P, Corrêa Souza G. Mediterranean diet and other dietary patterns in primary prevention of heart failure and changes in cardiac function markers: a systematic review. Nutrients.2018;10(1):58.
https://doi.org/10.3390/nu10010058
31. Stomby A, Simonyte K, Mellberg C, et al. Diet-induced weight loss has chronic tissue-specific effects on glucocorticoid metabolism in overweight postmenopausal women. Int J Obes (Lond). 2015;39(5):814-819.
https://doi.org/10.1038/ijo.2014.188
32. Titcomb TJ, Bisht B, Moore DD 3rd, et al. Eating Pattern and Nutritional Risks among People with Multiple Sclerosis Following a Modified Paleolithic Diet. Nutrients. 2020;12(6):1844. Published 2020 Jun 20.
https://doi.org/10.3390/nu12061844
33. Wahls TL, Chenard CA, Snetselaar LG. Review of Two Popular Eating Plans within the Multiple Sclerosis Community: Low Saturated Fat and Modified Paleolithic. Nutrients. 2019;11(2):352. Published 2019 Feb 7.
https://doi.org/10.3390/nu11020352
34. Fenton TR, Fenton CJ. Paleo diet still lacks evidence. Am J Clin Nutr. 2016;104(3):844.
https://doi.org/10.3945/ajcn.116.139006
35. Jönsson T, Granfeldt Y, Ahrén B, et al. Beneficial effects of a Paleolithic diet on cardiovascular risk factors in type 2 diabetes: A randomized cross-over pilot study. Cardiovasc Diabetol. 2009;8:35.
https://doi.org/10.1186/1475-2840-8-35
36. Jönsson T, Granfeldt Y, Erlanson-Albertsson C, Ahrén B, Lindeberg S. A Paleolithic diet is more satiating per calorie than a Mediterranean-like diet in individuals with ischemic heart disease. Nutr Metab (Lond). 2010;7:85.
https://doi.org/10.1186/1743-7075-7-85
37. Challa HJ, Bandlamudi M, Uppaluri KR. Paleolithic Diet. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482457/
38. Chenard CA, Rubenstein LM, Snetselaar LG, Wahls TL. Nutrient composition comparison between a modified paleolithic diet for multiple sclerosis and the recommended healthy U.S.-style eating pattern. Nutrients. 2019;11(3):537.
https://doi.org/10.3390/nu11030537
39. Manheimer EW, van Zuuren EJ, Fedorowicz Z, Pijl H. Paleolithic nutrition for metabolic syndrome: Systematic review and meta-analysis. Am J Clin Nutr. 2015;102(4):922-932.
https://doi.org/10.3945/ajcn.115.113613
40. Mårtensson A, Stomby A, Tellström A, et al. Using a paleo ratio to assess adherence to paleolithic dietary recommendations in a randomized controlled trial of individuals with type 2 diabetes. Nutrients. 2021;13(3):969.
https://doi.org/10.3390/nu13030969
41. Singh A, Singh D. The Paleolithic diet. Cureus. 2023;15(1).
https://doi.org/10.7759/cureus.34214
42. Ge L, Sadeghirad B, Ball GDC, et al. Comparison of dietary macronutrient patterns of 14 popular named dietary programmes for weight and cardiovascular risk factor reduction in adults: systematic review and network meta-analysis of randomised trials. BMJ. 2020;369.
https://doi.org/10.1136/bmj.m696
43. Kwon YJ, Lee HS, Park JY, Lee JW. Associating intake proportion of carbohydrate, fat, and protein with all-cause mortality in Korean adults. Nutrients. 2020;12(10):3208.
https://doi.org/10.3390/nu12103208
44. Ryan-Harshman M, Aldoori W. New dietary reference intakes for macronutrients and fibre. Can Fam Physician. 2006;52(2):177-179.
45. Kelly OJ, Gilman JC, Ilich JZ. Utilizing dietary nutrient ratios in nutritional research: expanding the concept of nutrient ratios to macronutrients. Nutrients. 2019;11(2):282.
https://doi.org/10.3390/nu11020282
46. Manore MM. Exercise and the Institute of Medicine recommendations for nutrition. Curr Sports Med Rep. 2005;4(4):193-198.
https://doi.org/10.1097/01.CSMR.0000306206.72186.00
47. Pramuková B, Szabadosová V, Soltésová A. Current knowledge about sports nutrition. Australas Med J. 2011;4(3):107-110.
https://doi.org/10.4066/AMJ.2011.520
48. Carreiro AL, Dhillon J, Gordon S, et al. The macronutrients, appetite, and energy intake. Annu Rev Nutr. 2016;36:73-103.
https://doi.org/10.1146/annurev-nutr-121415-112624
49. de Souza RJ, Swain JF, Appel LJ, Sacks FM. Alternatives for macronutrient intake and chronic disease: a comparison of the OmniHeart diets with popular diets and with dietary recommendations. Am J Clin Nutr. 2008;88(1):1-11.
https://doi.org/10.1093/ajcn/88.1.1
50. Ruffett A, Collard M. An assessment of the impact of cross-cultural variation in plant macronutrients on the recommendations of the Paleo Diet. Am J Clin Nutr. 2023;117(4):777-784.
https://doi.org/10.1016/j.ajcnut.2022.12.003
51. Sacks FM, Bray GA, Carey VJ, et al. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med. 2009;360(9):859-873.
https://doi.org/10.1056/NEJMoa0804748
52. Venn BJ. Macronutrients and human health for the 21st century. Nutrients. 2020;12(8):2363.
https://doi.org/10.3390/nu12082363
53. Wall JD, Yang MA, Jay F, et al. Higher levels of Neanderthal ancestry in East Asians than in Europeans. Genetics. 2013;194(1):199-209.
https://doi.org/10.1534/genetics.112.148213
54. Casazza K, Dulin-Keita A, Gower BA, Fernández JR. Relationships between reported macronutrient intake and insulin dynamics in a multi-ethnic cohort of early pubertal children. Int J Pediatr Obes. 2009;4(4):249-256.
https://doi.org/10.3109/17477160902763366
55. Cawthorn DM, Hoffman LC. The bushmeat and food security nexus: a global account of the contributions, conundrums, and ethical collisions. Food Res Int. 2015;76:906-925.
https://doi.org/10.1016/j.foodres.2015.03.025
56. Steyn NP, Nel JH, Malczyk S, Drummond L, Senekal M. Provincial dietary intake study (PDIS): energy and macronutrient intakes of children in a representative/random sample of 1-<10-year-old children in two economically active and urbanized provinces in South Africa. Int J Environ Res Public Health. 2020;17(5):1717.
https://doi.org/10.3390/ijerph17051717
57. Vorster HH, Kruger A, Margetts BM. The nutrition transition in Africa: can it be steered into a more positive direction?. Nutrients. 2011;3(4):429-441.
https://doi.org/10.3390/nu3040429
58. Gibson R, Knight A, Asante M, Thomas J, Goff LM. Comparing dietary macronutrient composition and food sources between native and diasporic Ghanaian adults. Food Nutr Res. 2015;59:27790.
https://doi.org/10.3402/fnr.v59.27790
59. Grech A, Rangan A, Allman-Farinelli M. Macronutrient composition of the Australian population's diet; trends from three national nutrition surveys 1983, 1995, and 2012. Nutrients. 2018;10(8):1045.
https://doi.org/10.3390/nu10081045
60. Mchiza ZJ, Steyn NP, Hill J, et al. A review of dietary surveys in the adult South African population from 2000 to 2015. Nutrients. 2015;7(9):8227-8250.
https://doi.org/10.3390/nu7095389
61. Truman SC, Wirth MD, Arp Adams S, et al. Meal timing, distribution of macronutrients, and inflammation among African-American women: A cross-sectional study. Chronobiol Int. 2022;39(7):976-983.
https://doi.org/10.1080/07420528.2022.2053702
62 Ali R, Lee ET, Knehans AW, et al. Dietary intake among American Indians with metabolic syndrome - comparison to dietary recommendations: the Balance Study. Int J Health Nutr. 2013;4(1):33-45.
63. Brooking LA, Williams SM, Mann JI. Effects of macronutrient composition of the diet on body fat in indigenous people at high risk of type 2 diabetes. Diabetes Res Clin Pract. 2012;96(1):40-46.
https://doi.org/10.1016/j.diabres.2011.11.021
64. Fialkowski MK, McCrory MA, Roberts SM, et al. Estimated nutrient intakes from food generally do not meet dietary reference intakes among adult members of Pacific Northwest tribal nations. J Nutr. 2010;140(5):992-998.
https://doi.org/10.3945/jn.109.114629
65. Navarro JC, Prado SM, Cárdenas PA, Santos RD, Caramelli B. Pre-historic eating patterns in Latin America and protective effects of plant-based diets on cardiovascular risk factors. Clinics (Sao Paulo, Brazil). 2010;65(10):1049-1054.
https://doi.org/10.1590/S1807-59322010001000022
66. Sarkar D, Walker-Swaney J, Shetty K. Food diversity and indigenous food systems to combat diet-linked chronic diseases. Curr Dev Nutr. 2019;4(Suppl 1):3-11.
https://doi.org/10.1093/cdn/nzz099
67. Batal M, Chan HM, Ing A, et al. Nutrient adequacy and nutrient sources of adults among ninety-two First Nations communities across Canada. Can J Public Health. 2021;112(Suppl 1):29-40.
https://doi.org/10.17269/s41997-021-00490-y
68. Kenny TA, Hu XF, Kuhnlein HV, Wesche SD, Chan HM. Dietary sources of energy and nutrients in the contemporary diet of Inuit adults: results from the 2007-08 Inuit Health Survey. Public Health Nutr. 2018;21(7):1319-1331.
https://doi.org/10.1017/S1368980017003810
69. Kuhnlein HV, Receveur O, Soueida R, Berti PR. Unique patterns of dietary adequacy in three cultures of Canadian Arctic indigenous peoples. Public Health Nutr. 2008;11(4):349-360.
https://doi.org/10.1017/S1368980007000353
70. Cordain L, Eaton SB, Sebastian A, et al. Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr. 2005;81(2):341-354.
https://doi.org/10.1093/ajcn.81.2.341
71. Fiorenza L, Benazzi S, Henry AG, et al. To meat or not to meat? New perspectives on Neanderthal ecology. Am J Phys Anthropol. 2015;156 Suppl 59:43-71.
https://doi.org/10.1002/ajpa.22659
72. Hardy K, Bocherens H, Miller JB, Copeland L. Reconstructing Neanderthal diet: The case for carbohydrates. J Hum Evol. 2022;162:103105.
https://doi.org/10.1016/j.jhevol.2021.103105
73. Mellberg C, Sandberg S, Ryberg M, et al. Long-term effects of a Palaeolithic-type diet in obese postmenopausal women: a 2-year randomized trial. Eur J Clin Nutr. 2014;68(3):350-357.
https://doi.org/10.1038/ejcn.2013.290
74. Eaton SB. The ancestral human diet: what was it and should it be a paradigm for contemporary nutrition? Proc Nutr Soc. 2006;65(1):1-6.
https://doi.org/10.1079/PNS2005471
75. Cordain L, Miller JB, Eaton SB, Mann N, Holt SH, Speth JD. Plant-animal subsistence ratios and macronutrient energy estimations in worldwide hunter-gatherer diets. Am J Clin Nutr. 2000;71(3):682-692.
https://doi.org/10.1093/ajcn/71.3.682
76. Cordain L. Implications of Plio-Pleistocene hominin diets for modern humans. In: Ungar PS, ed. Evolution of the Human Diet: The Known, the Unknown, and the Unknowable. Oxford: Oxford University Press; 2006:363-383.
https://doi.org/10.1093/oso/9780195183474.003.0019
77. Cordain L, Miller JB, Eaton SB, Mann N. Macronutrient estimations in hunter-gatherer diets. Am J Clin Nutr. 2000;72(6):1589-1592.
https://doi.org/10.1093/ajcn/72.6.1589
78. Eaton SB, Konner M. Paleolithic nutrition. A consideration of its nature and current implications. N Engl J Med. 1985;312(5):283-289.
https://doi.org/10.1056/NEJM198501313120505
79. The Nature Conservancy. Helping the Hadza protect their homeland. The Nature Conservancy. Available from:
80. U.S. Department of Health and Human Services, U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for Americans. 8th ed. December 2015. Available from: https://www.dietaryguidelines.gov/sites/default/files/2019-05/2015-2020_Dietary_Guidelines.pdf
81. Shan Z, Rehm CD, Rogers G, et al. Trends in dietary carbohydrate, protein, and fat intake and diet quality among US adults, 1999-2016. JAMA. 2019;322(12):1178-1187.
https://doi.org/10.1001/jama.2019.13771
82. Oh R, Gilani B, Uppaluri KR. Low-carbohydrate diet. [Updated 2023 Aug 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK537084
83. Centers for Disease Control and Prevention. FastStats - diet and nutrition. Centers for Disease Control and Prevention. Updated April 28, 2023. Available from: https://www.cdc.gov/nchs/fastats/diet.htm
84. Lindeberg S, Jönsson T, Granfeldt Y, et al. A Palaeolithic diet improves glucose tolerance more than a Mediterranean-like diet in individuals with ischaemic heart disease. Diabetologia. 2007;50(9):1795-1807.
https://doi.org/10.1007/s00125-007-0716-y
CITATION
Hollywood JB., Sobel D, & Orten D. Defining Macronutrient Standards for the Paleo Diet and Consistency in Intervention Trials: A Systematic Review. J Int Nutr. 2025;1(1):10-22. doi: 10.64437/jin0124015.