Dr Greger’s How Not to Die Cookbook (review)

To celebrate the release of the How Not to Die Cookbook I thought it would be interesting review some of Dr Greger’s recipes to see how they stack up nutritionally.

Well presented

Firstly, I’ve got to give kudos on the layout.

Rather than wait for a hard copy to ship to Australia, I bought my copy on Apple iBooks and was impressed at how you could interactively explode the ingredients list to full screen on my phone.

This feature would be invaluable when actually using the book in the kitchen, especially on a phone where showing a full page of small text on a screen is impractical, and all you want to see is the ingredients from a distance.

Whole food

The recipes in the How Not to Die Cookbook are full of nutritious minimally processed whole food, which is a win for me.

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There are heaps of colour on the pages, which is indicative of the range of vitamins and minerals present in these minimally processed foods.

In the introduction, Dr Greger makes the critical distinction between a vegetarian diet (which could be filled with highly processed grains and sugars) and minimally processed plant-based whole foods.

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Most of the issues with nutrition come when we overly process our food and make it shelf stable for increased profit margins.  Some of the recipes in the How Not To Die Cookbook call for some whole wheat bread, pasta and date sugar and the like, but overall, the recipes rely on minimally processed whole foods.

If you want quick and easy, this may not be the book for you.  Although there are headings of ‘easy’ and ‘moderate’ on the recipes, most of the recipes have a significant number of ingredients, including a range of herbs and spices.  You may have to gear up your kitchen with a range of new ingredients if you are not already following this way of eating.  However, for the experienced WFPB enthusiast who wants to add some flair and variety to their diet and dinner parties, this book is ideal.

Plant-based

In spite of being the Director of Public Health and Animal Agriculture for the Humane Society by day, Dr Greger doesn’t overtly focus on being vegan or vegetarian in the book.

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Unlike many others in this field, he doesn’t lead with animal welfare as the primary basis for not eating animals.  In the introduction to the cookbook, he talks about his personal experience of seeing his grandmother’s life turned around by this way, under the guidance of Nathan Pritikin (pictured below).

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Greger is a self-confessed “nutrition nerd” who appears to find genuine excitement in unpacking the research to find links between different aspects of diet and their impact on health.  His Nutrition Facts YouTube channel has become the primary source of nutritional information for many.

nutritionfacts[1]

Frame of reference

Nutrition is still an emerging science.  We seem to still be fumbling trying to understand the mechanisms, the cause and effect relationships of the food we eat on our health, well-being and longevity.

To deal with complexities of a topic like nutrition, we adopt a simplified frame of reference to help us navigate our reality without our mind exploding.  These simplified frames of reference are never perfect.   Over time we strive to create new and more useful frames of reference that suits use best.[1]For example, the Paleo frame of reference says we should eat foods that we evolved with.

  • The vegan frame of reference says we should eat foods that don’t harm other sentient life forms.
  • The hedonistic frame of references says, “if it tastes good, eat it.”
  • The cost frame of reference optimises for the lowest cost per calorie with minimal consideration of nutrition.
  • The Heart Association frame of reference believes that minimising fat, especially saturated fat, will help us avoid heart disease.
  • The conservationist frame of reference tries to eat in a way that we should eat in a way the minimise our impact on the environment.
  • The Seventh Day Adventist Church, which has a large influence through its food companies and medical evangelism, believes that we should eat plants and herbs (and not meat) because that’s how it was in the Garden of Eden before the fall (Genesis 1:29-30 and 2:19-20).
  • The low carb/keto frame of reference suggests that minimising carbohydrates and maximising fat will lead to optimum health for most people.

As a doctor, Dr Greger relies on the medical research frame of reference.  He draws associations between different food properties and health outcomes and tries develop a system that avoids the properties of food that he believes to be dangerous.

While some people suggest that Greger cherry picks the studies and interprets the data to fit his plant-based perspective,[2][3][4] the research-based frame of reference is at least a refreshing contrast to the fear-based sensationalist frame of reference in more militant vegan presentations such as What the Health and Cowspiracy.

The Optimising Nutrition framework

Nutrient density

While I don’t call myself a Nutritarian, my frame of reference has more in common with Dr Joel Fuhrman’s focus on nutrient density.  Rather than focusing on foods to avoid I think we need to focus on foods that contain the nutrients we need, which tends to automatically manage the things that aren’t good for us in excess.  The food we eat should give us the nutrients without having to ingest too much energy to get those nutrients.

Dr Mat Lalonde’s take on nutrient density has also been a major inspiration.  Lalonde took Fuhrman’s approach and re-ran the analysis to consider only essential vitamins, vitamins, amino acids and essential fatty acids for which there are widely available data and some consensus on the minimum nutrient intakes.

The problem with Lalonde’s approach, though, is that amino acids are very easy to find in our food system, so the system ends up optimising for very high protein foods at the expensive of vitamins and minerals which can be harder to obtain in our food system.

Dr Greger is also a big fan of nutrient density as shown in this NutritionFacts.org video.

Rather than emphasising all nutrients, the Nutrient Optimiser algorithm identifies the nutrients that you are not getting in large quantities and identifies foods that will boost those nutrients.

If you want to follow a particular dietary template (e.g. vegan, paleo, ketogenic, low carb, whole food plant based, pescetarian, vegetarian, bivalve vegan etc) the algorithm can work within those parameters.  However, the optimal nutritional outcome tends to be to simply focus on the most nutrient-dense foods available.

Insulin load

Being married to someone who has Type 1 Diabetes, I also see the importance of eating food that doesn’t require massive amounts of insulin to maintain normal healthy blood sugar levels.

There is value in moderating dietary insulin load to make sure you don’t need industrial levels of insulin to stabilise your blood sugar.  The food insulin index data demonstrates that our glucose response is proportional to the carbohydrate we eat.[5][6]image10.png

While our insulin response is related to the non-fibre carbohydrates minus about half the fibre.

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Energy density

And lastly, I think energy density can be a useful tool to help us moderate our food intake.

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This is another area where the WFPB approach shines in contrast to the low carb or ketogenic approaches, which can be energy dense and make it possible to overeat.

Without the use of added oils or a significant amount of processed grains and sugars, it will be practically impossible to overeat using only the meals set out in the How Not to Die Cookbook.

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Meals analysed

Rather than entering in the whole book, I chose representative meals from the various sections of the book.   If you click on the recipes listed below, you will see the meal entries in Cronometer (but if you want the photos and directions, you’ll have to buy the book).

●     portabellas and greens on toast
●     curried cauliflower soup
●     skillet sweet potato bake
●     white bean soup
●     spinach and mushroom black bean burritos
●     summertime oatmeal
●     whole wheat pasta with lentil bolognese
●     superfood breakfast bites
●     chocolate-cherry-banana soft-serve
●     morning oatmeal bowls
●     chocolate oatmeal

 

micronutrient profile

The figure below shows the nutrient profile of Dr Greger’s recipes in terms of nutrients provided as a proportion of the recommended daily intake.

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As you might expect, we get a ton of vitamin K1, vitamin A and vitamin C.  However, at the top of the chart, we’re not meeting the DRI levels of vitamin D and vitamin B12.

For a full analysis check out Dr Greger’s Nutrient Optimiser report.

Nutrient score

The Nutrient Score is a relative comparison of the quantity of essential nutrients in our food.

If your diet provided twice the minimum level of nutrients, then we would achieve a perfect score of 100%.  This approach doesn’t reward massive amount of a small number of nutrients, but rather leads people to rebalance their diet so they can obtain a substantial intake of all the essential nutrients.

In his Perfect Health Diet, Paul Jaminet notes that “a nourishing, balanced diet that provides all the required nutrients in the right proportions is the key to eliminating hunger and minimising appetite and eliminating hunger at minimal caloric intake.”[7]  Similarly, studies by Dr Joel Fuhrman indicate that a nutrient dense diet will reduce cravings and provide satiety with a lower energy intake.[8]Overall, the recipes from the How Not to Die Cookbook get a respectable Nutrient Density Score of a score of 79%.   For comparison, the lowest Nutrient Density score is 20% while the highest score to date has been 92%.

Bioavailability

After posting a number of readers noted that I had failed to mentioned bioavailability of plant-based nutrients.  The recommended daily intake levels are given based on a mixed diet, and limited work has been done to confirm how these nutrient requirements change when we go to extremes such as purely plant-based, purely animal based or low glucose / high fat ketogenic.  So, while this deserves a much longer discussion, I will touch on a couple of relevant considerations here.

Iron

A large proportion of the iron Dr Greger’s recipes comes from the chard in the portabella mushrooms.  Chard, like spinach, has a fantastic nutrient profile.  Many women are deficient in iron, while many men have too much iron (haemochromatosis) due to the fact that there is no way to excrete iron.

Iron from animal-based sources is much more easily absorbed.  It is estimated that between 14 and 18% of iron in a mixed diet can be absorbed, while vegetarians may only absorb 5 to 12% (Hurrel and Eli, 2010).

A common ferritin blood test will give you a good indication of whether you are absorbing enough iron from your food.

Omega 3

The Omega 3 in the Dr Greger’s plant-based diet foods comes from flax and chia seeds in the oatmeal recipes, however, this is in the alpha-linolenic acid (ALA) form and this needs to be converted to EPA and DHA for use by the body.

Women tend to convert ALA to EPA and EHA better than men.  A high intake of Omega 6 will hinder this conversion along with a lack of vitamins B3, B6 and C as well as zinc and magnesium.  It is estimated that the conversion of ALA to EPA varies between 8 to 20% and ALA to DHA ranges from 1 to 9%.  In view of our reduced ability to convert plant-based omega 3 for use by the body, Dr Greger recommends supplementing with an algae-derived omega 3 DHA supplement.  He says this is non-negotiable for pregnant and breastfeeding women.

Vitamin A

The vitamin A on Dr Greger’s recipes comes from the kale and chard.  Now there are two types of vitamin A which are both counted as vitamin A in the USDA database:

  • retinoids (aka retinol), which is the bioavailable form of vitamin A found in animal-based foods such as liver and eggs, and
  • carotenoids, which are precursors found in plant foods.

The rates of conversion vary widely depending on the source (spinach is 21:1, carrots is 15:1) and your ability to convert carotenoids to retinol will also be affected by genetics, digestive problems, alcohol use, certain medicines, toxic exposures, and medical conditions that interfere with the digestion of fat (including Crohn’s disease, cystic fibrosis, pancreatic enzyme deficiency, and gallbladder and liver disease).

Blood retinol levels can be tested if you show symptoms of vitamin A deficiency such as:

  • poor night vision,
  • dry eyes, skin and hair,
  • repeated infections, and
  • anaemia.

Vitamin B12

For the most part, Vitamin B12 is only found in animal products or supplements.  The Vitamin B12 in Dr Greger’s recipes is from nutritional yeast which is fortified with Vitamin B12.

Fat-soluble vitamins

Vitamins A, D, E and K are said to be “fat soluble” meaning that they may be more easily absorbed when there is fat in the diet.  Higher levels of fat will assist in the production of bile to enable full utilisation of these vitamins.

Macronutrients

The macronutrient split of the recipes is shown in the chart below.     While these foods are 70% carbohydrates, there are only 54% non-fibre carbohydrates once we account for fibre.

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Carbohydrates

As shown in the chart below of nutrient density score vs non-fibre carbohydrates and as discussed in detail in this article, we can get a reasonable amount of nutrition with net carbs anywhere in the range of 0 to around 60% non-fibre carbs.  So, while not optimal, this level of non-carbohydrates may not be excessive (unless you already have diabetes).

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Fat

Similarly with fat at 14%, we’re still within an acceptable macronutrient range (although nutrient density seems to be optimised at around 40% fat).

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Protein

For the sake of analysis, I have assumed that we are running the Nutrient Optimiser analysis for a male who is 80 kg (176 lbs) with 15% body fat to achieve a maintenance energy intake of 2000 calories per day.

Dr Greger’s recipes provide on average 84 g of protein per day which equates to 1.2 g/kg lean body mass (LBM) or 1.05 g/kg total body mass per day.

What constitutes optimal protein is a contentious topic.  However, we can say that the intake level provided by Dr Gregor’s meals would exceed the estimated average protein intake of 0.86 g/kg, and is about equivalent to the recommended daily intake.[9]

Where things get murky is when we talk about the bioavailability of plant-based protein versus animal protein; however, Dr Gregor generally appears more concerned about not getting too much “animal protein” for longevity considerations.

Research in yeast and worms that shows that energy restriction and/or protein restriction causes slower growth and overall longevity, though quality of life may be compromised.[10]   However, I’m not aware of any research in humans that demonstrates that we live longer by actively restricting protein consumption.

What appears clear is that having higher levels of lean muscle mass and lower levels of body fat is helpful.[11]   We need to find the balance between excess growth and obesity versus being too frail and weak to be resilient as we age.

NF-Sarcopenia[1].jpg

As shown in the chart below, there is an optimal balance between growth and wasting.[12] Too much insulin and you grow to the point that you get complications of metabolic disease.  Too little growth and you become frail, lose your muscle and bone strength then you may fall, break your hip and never get up again.

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As indicated by the chart below from Peter Lemon, if you are lifting heavy and trying to build muscle, you may benefit from consuming at least 1.8g/kg total body weight.[13]

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And if you are dieting and trying to lose body fat, then it seems to be beneficial to have anywhere between 1.4g/kg total body weight (for a moderate energy deficit) and up to 2.6g/kg body weight (for an aggressive energy deficit) if you want to preserve your lean muscle mass.[14][15]image7.png

For most people, listening to their appetite and focusing on nutrient dense foods and meals will get you the right amount of protein.  However, if you’re not getting the results you want you may need to tweak up or down to finding the optimal balance point for you.

Dr_Greger_at_Pure[1]

Insulin load

Insulin load is the amount of the food in your diet that will require insulin to process due to the non-fibre carbs and protein.  This video from Dr Greger got me thinking about insulin load nearly there three years ago.

While having plenty of vitamins and minerals from whole foods helps to improve blood sugar control, so does lower levels of processed carbohydrates.

Dr Greger’s diet would provide an insulin load of around 341g per day with 67% insulinogenic calories.   For those of you that are used to thinking in terms of carbohydrates, this is 294g per day of non-fibre carbohydrates.

Insulin load is actually quite closely correlated with nutrient density.[16]  While 67% insulinogenic calories is just inside the nutrient density envelope, such a high insulin load would be a problem for someone like my wife Monica who has Type 1 diabetes.  While people with Type 1 diabetes are relatively rare, the number of people who have prediabetes or some level of insulin resistance is exploding!

As discussed in the vegan vs keto for diabetes article, a whole food diet can provide benefits in terms of higher levels of beneficial nutrients to help with insulin sensitivity and generally means people eat less due to a lower energy density of fruit and vegetables, it seems to be those on a reduced carbohydrate higher protein approach that have the best diabetes control.[17][18]image9.png

As shown in the chart above, optimal nutrient density appears to align with an around 40% insulinogenic calories.  People who are already insulin resistant or who have diabetes should work to reduce the insulin load of their diet to the point that they can achieve stable blood sugar levels.

It is harder for someone not consuming any animal products or seafood to reduce their insulin load.  However, we will look at how someone following a WFPB diet can minimise their insulin load as much as possible.

Potential Renal Acid load (PRAL)

It’s also worth noting that Dr Greger’s recipes have a solid amount of alkalising minerals, such as:

  • calcium (207% of the DRI),
  • potassium (210%),
  • magnesium (269%), and
  • sodium (234%).

While I’m a proponent of getting adequate protein, I also think getting adequate minerals is critical to metabolic health, as well as muscle building.[19][20][21][22][23][24]

 

Some people operate from a nutritional paradigm that there is a magic about not eating animals.  However, I think one of the major benefits of a WFPB approach over a grain-based diet (or even a typical ketogenic or low carb diet managing diabetes) is the fact that it gives you plenty of alkalising minerals, which serves to reverse metabolic acidosis which leads to diabetes.  Perhaps many people who switch from a grain and meat heavy diet to a whole foods plant-based diet suddenly feel better because they get a shot of alkalinity that cleanses their kidneys and improves their insulin resistance?

Nutrient balance ratios

The table below shows the nutrient balance ratios of Dr Greger’s recipes.

  • It seems there are lower levels of zinc and higher levels of copper is a concern.
  • The potassium : sodium ratio is above 2 which is great, though I would have expected this to be even higher given that his approach also includes salt avoidance.
  • The iron : copper ratio is high due to higher levels of copper from the plant-based diet.
  • The calcium : phosphorus ratio is low due to the lower levels of calcium and higher levels of phosphorous.
ratios ratio target recommendation
Omega 6 : Omega 3 2.1 < 4 Omega 6 : Omega 3 ratio is good.
Zinc : Copper 3 8 – 12 Zinc : Copper ratio is outside limits.
Potassium : Sodium 2.3 > 2 potassium : sodium ratio is good
Calcium : Magnesium 1.8  < 2 calcium : magnesium ratio is good.
Iron : Copper 8 10 – 15 iron : copper ratio is within range.
Calcium : Phosphorus 0.9 > 1.3 calcium : phosphorus ratio is low.

Nutrients to prioritise

The aim of the Nutrient Optimiser is to help you rebalance your nutrients at a micronutrient level by identifying foods that will provide more of the nutrients that you are currently not getting in large quantities.

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The table below lists the nutrients that someone eating Dr Greger’s diet would be getting less of relative to the other nutrients.  The right-hand column indicates whether we want to prioritise these nutrients.  While six of the thirteen less-available nutrients are amino acids, we will only prioritise the vitamins and minerals, given that Dr Greger has a range of videos warning of the perils of “excess” animal protein.[25]

nutrient % DRI prioritise
Vitamin D 17% yes
Cobalamin (B12) 26% yes
Leucine 101% no
Zinc 124% yes
Methionine 124% no
Lysine 157% no
Pantothenic Acid (B5) 174% Yes
Selenium 188% yes
Valine 192% no
Isoleucine 197% no
Tyrosine 199% no
Calcium 207% yes
Potassium 207% yes

The nutrients that we want to prioritise are shown in the chart below in yellow.

image18.png

Optimal foods – nutrient dense plant-based

The image below shows the plant-based foods that would provide the nutrients that are not being provided in large quantities by Dr Greger’s meals.  (You will note that vegetables are coloured green, spices dark green, nuts are brown, oils grey and fruits pink)

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Optimal foods – most nutrient dense

Meanwhile, the image below shows the foods that would provide the harder to find nutrients without the plant-based constraint.  (Seafood is coloured green, offal red and dairy blue)

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Even though we did not prioritise any amino acids or essential fatty acids, the Nutrient Optimiser algorithm seems to rebalance the diet with more protein (50%), more fat (35%) and less non-fibre carbs (3%).

Optimal foods – diabetes-friendly plant based

Meanwhile, if we were trying to manage diabetes and insulin resistance, these are the foods that the Nutrient Optimiser algorithm would recommend to manage insulin load while also being nutrient dense and filling in the nutrient gaps in Dr Greger’s meal while also remaining plant-based.

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However, if we weren’t trying to avoid animal products, the foods listed below would provide the harder to find nutrients required with a lower insulin load.   It’s interesting that the system prioritised butter, cream and cheese to help reduce insulin load and rebalance micronutrients in Dr Greger’s recipes.  Most of the time when I have run the analysis for people following a low carb diet the system recommend much more nutrient-packed green veggies that are often neglected by people following a low carb or keto diet.

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Optimal meals

Where this gets really cool is when we use the same process to identify meals to boost the harder to find micronutrients.   The list below shows a selection of meals identified by the Nutrient Optimiser algorithm to fill the micronutrient gaps in Dr Greger’s meal plan.

●     Bootcamp Omelette
●     eggs, sardines, oysters and broccoli
●     spinach, mussels, sardines, eggs, sauerkraut
●     spinach, egg and oysters breakfast bowl
●     mussels, spinach, egg and sauerkraut
●     sardines, spinach and egg breakfast bowl
●     spinach, mackerel, peanuts and cheese
●     anchovies, spinach and egg breakfast bowl
●     oysters and salmon
●     Rhonda Patrick smoothie 1
●     mackerel, spinach, egg breakfast bowl
●     nutritional omelette 2
●     nutrient omelette 1
●     high cruciferous juice
●     cauliflower cream soup
●     green juice
●     lift day omelette

The chart below shows the nutrients provided by these meals.  Compared to the 78% provided by the meals from the How Not to Die Cookbook, these meals from the Nutrient Optimiser would provide an almost perfect score of 99%!

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The higher nutrient density provided by these meals will mean that you would need to consume less energy to get the nutrients you need, while also improving insulin resistance, mitochondrial function and overall energy levels with the higher levels of essential and nonessential nutrients from whole foods.

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For more discussion check out Dr Greger’s full Nutrient Optimiser report.

Summary

  • The recipes in the How Not to Die Cookbook are nutritious while remaining whole food plant based.
  • The protein content meets the recommended minimum intake levels. However, higher protein levels may be required to maximise muscle protein synthesis for someone who is active or wanting to maintain lean muscle mass while losing body fat.
  • The meals are relatively low fat but relatively high in non-fibre carbohydrate. While not excessive for someone who is metabolically healthy, someone who has diabetes may benefit from foods with a lower insulin load while also still maximising the nutrients that are provided by non-starchy vegetables.
  • We can use the Nutrient Optimiser algorithm to identify foods that contain more of these harder to find nutrients regardless of our preferred nutritional constraints.

 

 

references

[1]https://www.amazon.com/Win-Bigly-Persuasion-World-Matter/dp/0735219710

[2]https://deniseminger.com/2017/05/22/critical-review-of-michael-gregers-how-not-to-die/

[3]http://www.nourishbalancethrive.com/blog/2016/06/09/foodloose-recap-transcript/

[4]https://robbwolf.com/2017/07/03/what-the-health-a-wolfs-eye-review/

[5]https://optimisingnutrition.com/2017/10/21/redesigning-nutrition-from-first-principles/

[6]https://optimisingnutrition.com/food-insulin-index/

[7]http://perfecthealthdiet.com/

[8]https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-9-51

[9]https://www.nrv.gov.au/nutrients/protein

[10]https://optimisingnutrition.com/2017/10/15/high-protein-vs-low-protein/

[11]https://optimisingnutrition.com/2016/03/21/wanna-live-forever/

[12]http://press.endocrine.org/doi/full/10.1210/jc.2011-1377

[13]https://www.ncbi.nlm.nih.gov/pubmed/29182451/

[14]https://www.ncbi.nlm.nih.gov/pubmed/29182451/

[15]https://www.dropbox.com/s/1if7n957u66htiy/10.1123%40ijsnem.2017-0273.pdf?dl=0

[16]https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

[17]https://optimisingnutrition.com/2017/07/25/vegan-vs-keto-for-diabetes-which-is-optimal/

[18]https://optimisingnutrition.com/2015/08/02/standing-on-the-shoulders-of-giants/

[19]https://optimisingnutrition.com/2016/11/19/the-alkaline-diet-vs-acidic-ketones/

[20]http://suppversity.blogspot.com.au/2013/04/science-round-up-seconds-macro-mineral.html

[21]https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/diet-induced-acidosis-is-it-real-and-clinically-relevant/D7F03DFEF497996E90BB6DA487C777B8/core-reader

[22]https://www.ncbi.nlm.nih.gov/pubmed/21481501

[23]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4935236/

[24]https://www.ncbi.nlm.nih.gov/pubmed/16736444

[25]https://nutritionfacts.org/topics/animal-protein/

optimal meals and foods for fat loss and muscle building

Ever wondered what foods and meals are optimal for fat loss and muscle building?

Ketogains’ Luis Villasenor recently put a call out for recipes for their upcoming Ketogains Boot Camp.  So I thought it would be interesting to see what the Nutrient Optimiser had to say about optimal foods and meals that align with the Ketogains approach.

luis villasenor

The essence of the Ketogains approach is to:

  1. consume adequate protein,
  2. limit carbohydrates, and
  3. use ‘fat as a lever’.[1]

image34.png

In this article, I’ll unpack each aspect of the Ketogains system and look at how we can further optimise nutrition.

Protein as a goal

The Ketogains macro calculator recommends a minimum protein intake of 0.8g per pound of lean body mass (LBM) (i.e. 1.8g/kg LBM), increasing to with 1.0g/lb LBM (or 2.2g/kg LBM) on lifting days.

This protein intake level is more than would be recommended in a therapeutic ketogenic approach or even the average protein intake.[2] [3] It does, however, aligns with Steve Phinney’s recommended protein intake level for athletes and performance.[4] [5] [6]

From a sports nutrition standpoint, more than 2.2 gram per kilogram of total body weight is regarded as “high protein”.[7]  This could be as high as 3.0g/kg LBM when fat mass is taken into account.  So, while the Ketogains protein recommendations might be considered high in therapeutic keto and vegan circles, the Ketogains recommendations would be ‘moderate’ in a sports nutrition and bodybuilding circles.[8]

This chart above (from Lemon, 1998[9]) shows that, for a strength athlete, muscle protein synthesis is maximised when they consume at least 1.8g/kg BW of protein.

image53.png

Protein is, however, potentially more critical when we are trying to lose weight.  The higher the energy deficit, the greater is our need for protein to prevent loss of lean muscle mass.  If we are active and/or doing resistance training, then our requirement for protein is even higher.  As shown in the chart below from a recent review paper by Stuart Phillips, muscle mass is best preserved best when we have higher levels of protein, particularly if you are targeting an aggressive deficit.[10] [11]

image37.png

More protein won’t be detrimental and won’t turn to chocolate cake.  Higher levels of protein may not build more muscle, but it can be beneficial to preserve lean body mass when losing weight.[12]

image16.png

Protein contributes to your energy intake.  So if your goal is fat loss, then you want to target the minimum effective dose of macronutrients and micronutrients.  As a general rule, a higher protein intake tends, up to about 45% of your intake leads to a better nutritional profile[13] and increased satiety.[14] [15]  Very high protein diets (i.e. above than 80% energy from protein) will likely rely on supplements and may minimise other foods that provide more vitamins and minerals.  As you can see on the far left of this chart, actively targeting a low protein intake can lead to a poor nutritional outcome.[16]

protein (%) vs nutrient density score [click to enlarge]
[note: If your goal is therapeutic ketosis for the management of epilepsy, dementia, cancer, Parkinson’s or Alzheimer’s you will need to pay particular attention to ensure you get your share of micronutrients.]

Carbs as a limit

As you can see in the chart below,[17] you can get a reasonable level of nutrition if you consume anywhere between 0 and 60% of your energy from non-fibre carbs.[18]  However, with an exploding diabetes epidemic,[19] [20] [21] it’s probably fair to say that the majority of people would do better if they reduced their consumption of refined grains and sugars.

carbohydrates (%) vs nutrient density score [click to enlarge]
If you have already developed insulin resistance or diabetes, then reducing your carbohydrate intake to the point you achieve normal blood glucose levels is a good idea,[22] both in terms of overall health and controlling appetite that can be driven by extreme blood sugar swings.

The fact that much of the population is already insulin resistant is likely part of the reason the Ketogains approach, with its limit on carbs, has been so successful.

image57.jpg

Low carbers are fond of saying “there is no such thing as an essential carbohydrate”.  However, unless you are focusing on getting lots of organ meat, shellfish, or fresh meat, you may benefit from consuming some non-starchy veggies to get your essential vitamins and minerals.

Twenty or thirty grams of non-fibre carbs doesn’t sound like much in the context of grains or sugars, but it can feel like a LOT of food to consume if it’s from non-starchy veggies.[23]

image62.png

Fat as a lever

So to recap:

  1. Adequate protein is critical to support muscle growth and repair.
  2. Non-starchy veggies (which contain a small amount of non-fibre carbohydrates) provide vitamins and minerals (unless of course, you are eating heaps of shellfish, organ meat or drinking blood like the Maasai).

Recently, many people are swinging back from their fear of fat to embrace dietary fat again.

Carbohydrate is a more explosive fuel source for emergencies, while fat is a slower burning and more efficient fuel source.

While there are essential fats, we don’t require that fat each day.[24]  Beyond this, where you get your energy doesn’t matter that much.  As you can see from the chart below, we can achieve a a respectable nutritional outcome with a fat intake of between 10 and 65%.   More fat is not necessarily better, but very low-fat levels are not great either as they tend to have minimal amounts of protein and other essential nutrients.

fat (%) vs nutrient density score [click to enlarge]
If you are trying to reduce body fat, then maximising the nutrient density and reducing the energy density of your food is a worthy goal.  A protein sparing modified fast, an extreme version of this, provides adequate protein while limiting both fat and carbohydrates.

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If you are looking to gain weight, add muscle or perform extended feats of endurance exercise on a regular basis, it may be beneficial to load up on more energy dense fat.  However, conversely, if are not an endurance athlete but trying to use your body fat for fuel, you may want to wind your dietary fat intake back.

Micronutrients

Once you’ve worked out your macros using the Ketogains calculator and got the hang of using fat as a lever to manage energy intake, the next step is to ensure you are getting your share of micronutrients.

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Focusing purely on macros (e.g. Flexible Dieting, IIFYM, etc.) is short-sighted because it fails to consider micronutrients.  Chronic energy restriction without attention to micronutrients can lead to chronic nutrient deficiencies,[25] a lack of energy, increased hunger,[26] rebound bingeing due to cravings and even death.[27]

You’re likely aware that the branched-chain amino acids (BCAAs) trigger muscle protein synthesis and ensures you use the rest of the amino acids to build and repair your muscles.[28]  However, recent research has found that the amino acids arginine and lysine trigger satiety and hence we find foods that contain these amino acids more filling.[29] [30]

The chart below shows what your micronutrient profile would look like if you focused on branched chain amino acids (valine, isoleucine, and leucine) and the satiety-related amino acids (lysine and arginine) while also keeping carbohydrates low.

image59.png

While we get plenty of protein with this approach, we would not obtain the recommended minimum levels of a large number of the essential vitamins, minerals, and essential fatty acids.

As much as we like to focus on macronutrients (i.e. fat, protein, carbohydrates, fibre, ketones), micronutrients are arguably a more useful to assist us in our nutritional decision making.

Getting adequate minerals is especially important for:

  • avoiding the symptoms of the keto flu,[31]
  • reversing insulin resistance and minimising the amount of basal insulin circulating in your body,[32] [33] [34] and
  • maximising athletic performance.[35]

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The chart below shows what happens to our micronutrient profile when, in addition to BCAAs, we also prioritise foods that contain the harder to find micronutrients (shown in yellow).

Optimal foods

In case you were wondering which foods will give you the most micronutrients while also having a lower energy density and fewer carbs, I have listed them below.

Vegetables

  • watercress
  • spinach
  • lettuce
  • endive
  • asparagus
  • Chinese cabbage
  • chard
  • cauliflower
  • zucchini
  • white mushroom
  • spirulina
  • escarole
  • alfalfa
  • chicory greens
  • okra
  • portabella mushrooms
  • coriander
  • shiitake mushroom
  • cabbage
  • parsley
  • seaweed (laver)
  • summer squash
  • broccoli
  • arugula
  • snap beans
  • mung beans
  • artichokes
  • yeast extract spread
  • chives
  • beet greens
  • sauerkraut
  • cucumber
  • pickles
  • turnips
  • soybeans (sprouted)
  • celery
  • seaweed (wakame)
  • turnip greens
  • peas
  • radicchio
  • banana pepper
  • radishes
  • seaweed (kelp)
  • Brussel sprouts
  • amaranth leaves
  • mustard greens
  • collards
  • eggplant
  • onions
  • pumpkin
  • edamame
  • chayote
  • pinto beans
  • kale
  • rhubarb
  • red cabbage
  • butternut squash

Seafood

  • halibut
  • white fish
  • rockfish
  • salmon
  • pollock
  • sturgeon
  • flounder
  • fish roe
  • haddock
  • crayfish
  • cod
  • whiting
  • crab
  • lobster
  • mussel
  • perch
  • trout
  • clam
  • shrimp
  • molluscs
  • scallop
  • octopus
  • caviar
  • oysters
  • anchovy
  • sardine
  • herring
  • tuna
  • orange roughy

Offal

  • kidney
  • heart
  • liver
  • tripe

Animal products

  • chicken breast
  • pork chops
  • leg ham
  • ground pork
  • chicken drumstick
  • pork shoulder
  • veal
  • whole egg
  • cream cheese (low fat)
  • pork (lean)
  • turkey
  • ground beef (lean)
  • roast pork
  • roast ham
  • sirloin steak (lean)

You should ideally focus on the foods closer to the top of these lists.  But once you’ve eaten as much endive, alfalfa, liver and caviar as you can, feel free to move down the list to more energy dense foods or ones that you might enjoy eating more.

We can use a similar approach to ranking meals.   I have included a range of meals at the end of this post.

Supplements

If you can’t get enough nutrient-dense foods, it may be beneficial to use supplements.[36]  Keep in mind though, the nutrients from whole foods are likely to be better absorbed.  Too many minerals at once will ‘give you a dose of the salts’ and all your expensive supplements will end up in the toilet.  Whole foods are also more likely to contain all the other beneficial non-essential nutrients that come along with nutrient-dense foods.

What to track

“What gets measured gets managed”.[37]

But we can only manage a handful of things at a time.

“If everything is a priority, nothing is a priority.”

You need to identify a few things to track to ensure you are moving towards your goals, but not too many.

In the context of losing fat and gaining muscle the best things to track appear to be:

  1. weight/body fat,
  2. macros/calories, and
  3. performance (e.g. weight on the bar).

weight / body fat

Most people want to have more energy and look good naked.  While it’s much easier to track body weight, this is really about losing body fat.

There are a ton of different ways to measure body fat (e.g. DEXA, comparison photos, bioimpedance scales, Skulpt, the Navy Method, etc.) and they are all inaccurate to some degree.  You can do your head in focusing on the fluctuations on the scale or body fat from day to day.  However, you want to see your overall weight and body fat reducing toward your target levels.  It seems that people who successfully lose weight and keep it off manage their food intake, measure their weight regularly and are active![38] [39]

If you’re a fitness model you might want to measure yourself daily.  If you’re just starting to focus on eating well and lifting, then you might just want to weigh yourself weekly or monthly.[40]

If you are not moving towards your goals over the long term, something needs to change.

body fat chart.png

But first, you need to set some realistic goals.  Take the time to determine your current and target body weight, fat (in kg and %) and lean body mass (LBM).

  current target
body weight (kg)
body fat (%)
body fat (kg)
LBM (kg)

If you are disciplined, it is possible to lose 1% of your mass per week, but 0.5% is a more realistic and less aggressive target.  If you are already lean, then it will be harder to lose fat without losing muscle so you may need a less aggressive deficit.[41]

It’s not all about the weight on the scale.  You can be losing fat and gaining muscle, the weight on the scale probably is the most reliable indicator that you’ve got your inputs right.  If you’re getting enough protein and working out, then the muscle should be looking after itself, and any loss should be mainly fat.[42]

Weighing yourself can have a negative mental effect on some people.  So if it does your head in, don’t do it too often.

Keep in mind that body weight is a lagging measurement that tells you whether you’re on the right track.  Tracking inputs (e.g. food intake and exercise) will be much more useful.

macros / calories

Personally, I don’t enjoy tracking my food, so I’ve designed a range of food lists and meals that will help most people improve from where they currently are.  It will be pretty hard to get/stay morbidly obese if you eat only the foods and meals listed above.

But if you want to look like a fitness model, or you are not getting your desired results from ‘eating ad libitum’ you will likely need to track your food to overcome your inbuilt impulse to maintain a higher body weight and prepare for a possible famine ahead.

As noted by Luis below, tracking your food in an app like Cronometer can be a useful educational experience.

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The Ketogains calculator will give you a starting point in terms of calorie intake based on your current weight and activity levels.  If, after a few weeks, you are not seeing the progress you were hoping for you will need to adjust your inputs.

Performance/weight on the bar

Building muscle or achieving a performance goal is probably more important than weight loss, particularly if you are not trying to get down to a very low level of body fat.

The great thing about using a performance goal is that it is both a leading and lagging measure.  By going harder, faster and heavier you are providing a greater stimulus for growth.  And by measuring your performance outputs, you are ensuring that you are getting fitter/faster/healthier.

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While being strong doesn’t guarantee weight loss, being stronger will improve your metabolic health, insulin sensitivity and ability to burn fat more effectively than nearly anything else.

Having more lean muscle mass will ensure you burn both glucose and fat more efficiently.  Lean muscle mass is a key predictor of longevity.[43]

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The Ketogains boot camp uses a 5×5 strength progression.  The Stronglifts 5×5 or Starting Strength uses a similar progressive overload approach.  These programs involve compound lifts (squat, deadlift, bench press, overhead press, row etc.) and progressive overload meaning that you add weight to the bar each time and continue to get stronger.   By doing this, you train your body to produce energy from your food more and more efficiently.

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Don’t be surprised if your appetite ramps up during the first few months of intensive lifting as your body goes into anabolic overdrive to recover and build new muscle.  This will settle down after a while, and you can then focus on dialling your diet in if you want to gain strength as well as lose body fat.[44]  You have a unique window of ‘newb gains’ during initial this period of lifting that you may never get again.  You can focus on getting to single digit body fat later.

Other stuff that you could track

There are other things that you might like to track, but they will be less useful than the ones mentioned above.

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Most people have limited time and don’t really want to live a completely quantified life.  Unless this is your only hobby or you are a professional athlete or fitness model, you may quickly hit ‘analysis paralysis’ and give up.

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There is no guarantee that technology will help you reach your goals.  In fact, it seems that you are more likely to gain weight if you use wearables like a Fitbit.[45]  It’s hard to know whether this is due to the EMF or perhaps the wearer is always allowing themselves to consume the extra calories that their technology told them that they just burned with exercise.

So, coming from a bit of a biohacker nerd….  don’t try to track too many things at once!  OK?

Heart Rate Variability

Heart Rate Variability (HRV) is a measure of the variability between your heart beats.  If you are stressed and/or exhausted your heart will be more rhythmically as well as more rapidly.   If you are relaxed and well rested your heart will be more to stresses and quickly return to rest.

HRV.png

Measuring your Heart Rate Variability (HRV) can tell you if you’re pushing too hard and need to rest recover or you’re not pushing hard enough and should be working harder to maximise your progress.  Training when you are burning out can be counterproductive and lead to injury or under recovery.

Elite HRV.jpg

HRV tells you whether your sympathetic and parasympathetic nervous system is balanced.

  • If you are “parasympathetic nervous system dominant” you might be overstressed from too much activity, not enough sleep, too much caffeine or work stress.
  • If you are “sympathetic nervous system dominant”, then it probably means your body wants to rest. You’ll probably do better if you listen to it and let it recover.
  • If your overall HRV is dropping, it means you are burning out and should consider slowing down.

After 1.5 years of measuring my HRV each morning, it’s uncanny how many times I will see my HRV fall a few days before you get the flu or hit the wall.  I don’t like to stay still long enough to meditate, so tracking each day with Elite HRV is part of my relaxation, breathing and focus at the start of each day.

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Blood sugar

Your blood sugar and glucose control is a powerful indicator of metabolic health.  But blood sugar readings can vary depending, not just due to the food you eat or your metabolic health, but also exercise and stress.  For most people, blood sugar readings can be more confusing than helpful.

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If you have diabetes, then refining your food choices to normalise your blood sugars is critical. However, regular blood sugar tracking is likely a waste of time and money for most people who are following a Ketogains style approach (i.e. tracking their food to ensure they are moving towards an optimal weight, getting adequate protein and lifting regularly), because it’s simply not necessary.

Blood ketones

Unless you require therapeutic ketosis to help manage epilepsy, cancer, Alzheimer’s or Parkinson’s measuring your blood ketones is also largely an irrelevant distraction.

Lots of people get caught up chasing ‘optimal ketosis’ by eating more dietary fat and less protein.  However, this is exactly the opposite of what you need to gain strength and lose body fat.

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Blood ketones do increase when we don’t eat. But high ketone levels don’t mean you are burning your body fat.  It could just be three Bulletproof coffees and exogenous ketones you just had to get that are driving your high ketone levels.

Some people, especially those who are physically fit and/or have been practising a low carb diet for a long time, seem to have lower blood ketone levels, even if they are eating a ‘ketogenic’ diet.  It’s hard to know whether this is due to the more efficient use of ketones or the fact they are burning more fat through non-ketogenic pathways.

image29.jpg
Ketones are just one of a number of ways that we burn fat (chart from Dave Feldman)

Someone who is not so metabolically healthy can load up on exogenous ketones, butter and MCT oil and get a high blood ketone reading on their meter.  But this may just mean that they have eaten a lot of fat that they are not burning (because of their lack of activity and/or poor metabolic health) and the fat is backing up in their bloodstream.

A healthy metabolism seems to keep the total energy circulating in the bloodstream fairly low (i.e. from glucose, ketones or free fatty acids).  If you are metabolically healthy, you can easily access your fat stores so you don’t need to build up high energy stores in the blood.  By contrast, someone with a less healthy metabolism seems to maintain higher energy stores in the blood (i.e. glucose, ketones, free fatty acids) as well as on their body.[46]

image26.png
This chart shows more than 3000 data points of blood glucose and ketones together from a range of people following a low carb and ketogenic diet.  Having high blood ketones and high blood sugar at the same time is not good!  Healthy people tend to have lower blood sugar and moderate level ketones.

Most people don’t need to worry about their blood glucose and ketone levels consciously.  If you focus on nutrient dense food to optimise your mitochondrial function and strength building to keep pushing your mitochondria to produce energy at peak efficiency, then your body will probably look after the rest.

[At the risk of getting too technical, it’s worth pointing out that blood ketones rise because there is a lack of Oxaloacetate (from protein and carbs) available to burn Acetyl CoA from fat in the Krebs cycle, so the body defaults to a starvation protocol to produce ketones (AcetoAcetate). 

image54.png
Figure from Amy Berger showing how fat can be burned in the Krebs cycle or via ketosis when there is not enough Oxaloacetate from protein and carbs turn the Krebs cycle.

If your NAD+ is low, AcetoAcetate will not be converted to Acetone so there will be lots of beta-hydroxybutyrate left in the blood to be measured on your meter.  So, other than fasting and/or exercising to deplete your liver glycogen levels, one ‘hack’ to achieve high blood ketone is to avoid protein and eat a nutrient-poor diet low in niacin and other B vitamins (which produce NAD+).  But don’t try this at home.  It’s not a recipe for optimal health, just high ketone levels]  

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Ketogains’ Tyler Cartwright has lost nearly three hundred pounds without exceeding 0.4mmol/L blood ketones on his ketone metre (other than that time he ate nothing but lard for two weeks as an experiment and got to 0.5mmol/L).[47]

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Breath ketones

Breath ketones are an interesting indication of your metabolic health.  But again, they’re not necessary if you are already focusing on a nutrient-dense diet without too much energy and plenty of activity.

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Waist measurement

BMI is often used to assess whether or not someone is at a healthy weight.

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However, BMI is notoriously problematic for people with more muscle.

image42.png

Waist to height ratio is a much better predictor of the years of life that you will lose due to your poor health.[48]

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Micronutrients and nutrient score

You may have gathered that I’m a big fan of micronutrients.  Focusing on the nutrient-dense whole foods above and the meals below will get you most of the way to optimal nutrition.  However, you can also track your macronutrients in Cronometer which will help you identify the nutrients you are not getting from your diet.

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But then, once you’ve tracked your food in Cronometer, you are left wondering what foods and meals you should eat.  If need to supplement, how much of each supplement do you require and how much?

The Nutrient Score is a measure of the micronutrient quality of your diet.  If you were able to get two times the recommended daily intake of all the essential micronutrients, you would get a perfect score of 100%.

To demonstrate what this looks like in practice, Ted Naiman’s diet got a very respectable nutrient score of 70%.

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Luis’ got 72%.

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Nutrition nerd Alex Leaf (and regular reviewer of my blog posts… thanks so much Alex!!!!) scored an impressive 74%.

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Mike Berta also scored 74%.

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Brianna Theroux’s scored a very healthy 79%.

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And sitting at the top of the leaderboard is Dr Rhonda Patrick with a score of 82%.

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But the coolest competition is against yourself.  Andy Mant managed to seriously up his nutritional game…

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… by eating a LOT of nutrient-dense seafood…

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… in preparation for his Paris wedding.

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By following the recommendations of the Nutrient Optimiser analysis, Robin was able to improve her nutrient score to 32% (junk food diet) to 68% over a number of iterations (see report 1, report 2 and report 3).

In the process, she was able to significantly improve her blood glucose levels, dropping her HBA1c from 10.6% to 6.4%.  Robin was also able to progress from taking hundreds of units of insulin per day to only needing occasional correcting doses to fine tune her blood sugars.  She also managed to lose 2.6lbs per week!

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And after a couple of rounds of following the Nutrient Optimiser recommendations and a couple of Ketogains boot camps the Matt Standridge (aka The Ketodontist) has stepped up from a nutrient score of 48% to 73%.  He says he is feeling great and continues to gain muscle and lose fat.

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The Nutrient Optimiser

While there are common themes, each person’s micronutrient fingerprint is unique.  The optimal foods and meals that will balance your micronutrient profile are unique to you.

The Nutrient Optimiser is the only tool that will tell you what foods are ideal to balance your diet while also aligning with your goals.

Currently, the Nutrient Optimiser is a manual report that will help you optimise your nutrition from the micronutrients based on your food log in Cronometer.  We’re working hard to develop an automated system that will use your goals and whatever data you have to help you refine your nutrition to achieve your goals.

If you don’t want to track your food, the system will tell you what meals and foods will align with your goals.  But if you want to step up your game and provide other data we can work with that to further refine your nutritional prescription to fill in your micronutrient gaps.  The system will also adapt with you to improve your nutrition, ideally from diabetic, to weight loss to achieve your performance goals.

nutrient optimiser.png

It might just be your secret weapon to help you blitz is #transormationtuesday.

Summary

  • The Ketogains protocol involves getting adequate protein (to support muscle growth and recovery) and adequate carbs to get essential vitamins and minerals. Fat is used as a level to manipulate energy intake to suit your goals.
  • If you are limiting your energy intake, maximising your nutrient : energy ratio is critical!
  • The Nutrient Optimiser can help you identify foods and meals that align with your goals and fill in your micronutrient deficiencies.
  • Chose what you track wisely. Trying to manage too many things can lead to ‘analysis paralysis’.  If you manage the most important inputs, results should naturally follow.

 

 

Meals

I’ve been building a database of to help identify, not just the individual foods, but also the meals, that provide you with the nutrients you need more of and align with your goals.

If you are tracking in Cronometer, you can sign up for a Nutrient Optimiser analysis and report here to find out which foods and meals will help you move forward.  I’ve also been working with Alex from Nutrient Hero for the past few months building a massive database of recipes we can use to optimise your nutrition.

It feels like it’s been a long time coming, but it won’t be too long before it’s all automated and online.  If you want to be the first to trial the beta version then make sure you enter your email in the pop on this page or head over to NutrientOptimiser.com now to learn more.

The recipes below are some of the highest ranking when we prioritise some of the harder to find vitamins and minerals (potassium, magnesium, calcium, zinc, vitamin D, thiamine and choline) as well as higher protein and a lower energy density.

I have included the link to the Cronometer entry as well as the nutritional profile and a list of foods that will help you balance the nutritional profile of the recipe.

Bootcamp omelette

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Gayle Louise created this simple omelette recipe for her Ketogains boot camp workout days.   Nutritional yeast has a fantastic nutritional profile and adds a cheesy taste without the calories, minimising fat and maximising nutrient density.

ingredients

method

  • cook the spinach first with ghee or butter.
  • whisk 4 eggs with salt and pepper and add too cooked spinach
  • sprinkle with nutritional yeast, cover and cook until firm.

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Cronometer analysis

https://nutrienthero.com/recipe-analysis/boot-camp-omelette

 

Potassium salted caramel coffee

potassium caramel coffee.png

Everyone loves coffee, and most people find potassium harder to get in their diet than sodium.  So why not potassium coffee?!?!  The milk and caramel syrup are not essential, but they give you that indulgent salted caramel taste.

Getting adequate minerals is critical to ensuring insulin sensitivity, nutrient partitioning, muscle building and recover and avoiding diabetes.

While most people don’t need to worry about getting too much salt, having a potassium : sodium ratio greater than two is hard to achieve for most people, even if they do eat a lot of greens.

My friend Raymund Edwards of Optimal Ketogenic Living has been doing a LOT of research into the wide-ranging benefits of alkalising electrolytes, in particular, potassium.  This recipe was inspired by Raymund after hearing that he was adding potassium to his coffee.

Raymund said, “A potassium enriched coffee in the morning really wakes the muscles.  It’s better than any warm up.  Loose and alive we can feel the difference as they soak up actively the potassium especially after the night fast (where muscles have been releasing potassium).  And  the coffee in my view tastes so much better too.”

It’s hard to get a significant amount of potassium from tablets as they are limited to 99 mg which is only a fraction of the 3,800 mg of potassium that we need each day (you would need to take forty tablets to get the DRI for potassium!).

potassium.png

You can also add the potassium citrate powder to your drinking water, coffee or pre-workout mix.  You would need more than 10g of the citrate powder to get your recommended daily intake of potassium, but, like all things, start slowly. However, in time, it might just make you feel amazing!

ingredients

method

  • Pour coffee shot from fresh grounds
  • Add potassium citrate powder
  • Add caramel syrup (optional)
  • Add a dash of full cream milk to taste (optimal)
  • Add hot water to taste (depending on how you like your coffee)

Cronometer analysis

nutritional analysis

 

Greens + eggs + seafood

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Dom D’Agostino infamously told Tim Ferriss in his sound check that his breakfast was sardines, oysters, eggs and broccoli.  It might sound bizarre, but it packs a nutritional punch.

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Most days my breakfast is some variant on frozen greens (spinach, broccoli, kale) + eggs + seafood (sardines, mackerel, oysters, mussels, anchovies) + nutritional yeast.

If you’re not focusing on losing body fat you can add cheese or peanuts for some extra indulgent taste, but leaving these out will help you increase your protein : energy and nutrient : energy ratio which is ideal if you are trying to lose body fat (and will make Ted Naiman and Luis Villasenor proud).

You could take more time to fry these ingredients up and plate them up nicely, but most of the time breakfast only needs to be time efficient and doesn’t need to look good.  If you can start the day with a high protein nutrient dense breakfast, you’ll be less likely to succumb to other cravings later in the day.

ingredients:

  • 250g frozen veggies. Spinach is always best, but broccoli or kale work too.
  • Three eggs. Consider removing the yolks if you are focussed on lower fat higher protein fat loss phase, though this will decrease the overall nutrient profile.  The yolk is where all the vitamins and minerals are!
  • 1 can of seafood (e.g. mackerel, sardines, oysters, mussels or anchovies).
  • 1 teaspoon of nutritional yeast
  • Peanuts (optional, only if not looking to lean out)
  • 1 oz mozzarella cheese (optional, only if not looking to lean out)
  • Salt (No Salt, Celtic Sea or Redmond Real Salt) & pepper to taste.

method

  • Defrost greens in bowl for five minutes in the microwave.
  • Add eggs and cook for a further minute or until done. (I often find that the eggs need a bit more cooking but stir everything in at around three minutes and then cook for another two minutes).
  • Add other ingredients
  • Salt liberally to taste.

Nutritional analysis

Cronometer entry

Photos of other variants (hey, they ain’t pretty, but they work).

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Bacon, egg, spinach and mushroom

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This is a variant on the common bacon and eggs recipe. The spinach mushroom and tomato round out the nutritional profile of the stock standard bacon and eggs.

The spinach provides a wide range of vitamins and minerals, particularly vitamin K and vitamin A.  Most people think kale is the ultimate nutrient-dense green vegetable.  However, kale just has a lot of Vitamin K1 and not so as much of everything else.  Spinach has a much better nutritional profile across the board.

If you are focusing on reducing body fat and maximising nutrient density, consider eliminating the cream, draining the bacon fat and keeping the butter to a minimum for cooking.  If your goal is bulking and recover, then you can be more liberal with the cream and cheese to taste.  Remember, fat is a lever.

ingredients:

  • 3 large eggs
  • 200g fresh spinach
  • 2 mushrooms
  • 30g cream (optional)
  • 30g mozzarella cheese (optional)
  • butter
  • Salt (No Salt, Celtic Sea or Redmond Real Salt) & pepper to taste.

method

  • Fry bacon separately. If your priority is reducing body fat then you can let the bacon rest on a paper towel to drain the fat.  Alternatively, bacon grease can be used to fry the spinach, mushroom and eggs.
  • Fry eggs separately.
  • Add cream and cheese if not looking to lean out.
  • Salt to taste.

Nutritional analysis

Cronometer entry

 

Steak, egg, tomato, avo spinach and lettuce

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This is a fairly standard Sunday night family dinner at our place.  A solid piece of steak on the BBQ with salad.

ingredients:

method

  • Grill BBQ steak
  • Cook spinach with some butter or coconut on BBQ plate when grilling the steak.
  • Serve with boiled egg (or fried on the BBQ) along with salad (avocado, tomato and lettuce shown here).
  • Salt (No Salt, Celtic Sea or REdmond Real Salt) & pepper to taste.

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Nutritional profile

Cronometer

 

Be sure to check out the more than 300 meals on the Nutrient Optimiser Facebook Group.  You might even want to add some of your own.

 

 

 

references

[1] https://ketogains.com/2017/06/energy-balance-macros-nutrient-density/

[2] https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5304a3.htm

[3] http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32252-3/abstract

[4] http://www.artandscienceoflowcarb.com/the-art-and-science-of-low-carbohydrate-performance/

[5] https://www.amazon.com/Art-Science-Low-Carbohydrate-Performance/dp/0983490716

[6] https://www.youtube.com/watch?v=GkQYZ6FbsmI

[7] https://optimisingnutrition.com/2017/10/15/high-protein-vs-low-protein/

[8] https://jissn.biomedcentral.com/articles/10.1186/s12970-017-0201-z

[9] https://www.ncbi.nlm.nih.gov/pubmed/9841962

[10] https://www.ncbi.nlm.nih.gov/pubmed/29182451/

[11] https://l.facebook.com/l.php?u=https%3A%2F%2Fwww.dropbox.com%2Fs%2F1if7n957u66htiy%2F10.1123%2540ijsnem.2017-0273.pdf%3Fdl%3D0&h=ATNppfskJJ6fMuIVoJrC0rX_8H9KCT2SeryF0MeRrAnJz6X9p_3FPhPYUK3RGSOE-kDTeOLxKdw26vel3zBWDbOlaCQzxkxpDU8CjFs9Moo51fC9NByHYvs83uU7PvjFolOxvqx3Pw

[12] https://optimisingnutrition.com/2017/06/03/why-do-my-blood-sugars-rise-after-a-high-protein-meal/

[13] https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

[14] https://www.ncbi.nlm.nih.gov/pubmed/15836464

[15] https://www.ncbi.nlm.nih.gov/pubmed/24588967

[16] https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

[17] https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

[18] https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

[19] https://www.reuters.com/article/us-health-diabetes/cost-of-diabetes-epidemic-reaches-850-billion-a-year-idUSKBN1DD2SW

[20] http://www.diabetesincontrol.com/the-true-cost-of-diabetes-and-preventing-it/

[21] http://www.diabetes.co.uk/cost-of-diabetes.html

[22] https://optimisingnutrition.com/tag/insulin-load/

[23] https://www.dietdoctor.com/low-carb/20-50-how-much

[24] https://www.nrv.gov.au/nutrients/fats-total-fat-fatty-acids

[25] https://www.ncbi.nlm.nih.gov/pubmed/17593855

[26] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988700/

[27] https://optimisingnutrition.com/2017/06/17/psmf/

[28] https://metabolicnutrition.com/branched-chain-amino-acids-bcaas-benefits-for-muscle-growth/

[29] https://www.sciencedaily.com/releases/2017/09/170927093254.htm

[30] http://suppversity.blogspot.com.au/2013/09/the-satiating-secret-of-arginine-lysine.html

[31] https://ketogains.com/2017/06/keto-flu-electrolyte-imbalances/

[32] https://www.ncbi.nlm.nih.gov/m/pubmed/21036373/

[33] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC301822/

[34] https://diabetesmealplans.com/6285/magnesium-and-diabetes-type-2/

[35] https://www.ncbi.nlm.nih.gov/pubmed/22150427

[36] https://ketogains.com/2016/08/ketogains-seven-must-supplements/

[37] https://athinkingperson.com/2012/12/02/who-said-what-gets-measured-gets-managed/

[38] https://www.ncbi.nlm.nih.gov/pubmed/24355667

[39] https://en.wikipedia.org/wiki/National_Weight_Control_Registry

[40] http://www.nourishbalancethrive.com/podcasts/nourish-balance-thrive/keto-masterclass-robb-wolf/

[41] https://www.ncbi.nlm.nih.gov/pubmed/15615615

[42] https://www.bodyrecomposition.com/muscle-gain/calorie-partitioning-part-1.html/

[43] https://optimisingnutrition.com/2016/03/21/wanna-live-forever/

[44] https://startingstrength.com/articles/clarification_rippetoe.pdf

[45] https://jamanetwork.com/journals/jama/fullarticle/2553448

[46] https://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

[47] https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0ahUKEwjpo5y5qu_XAhWHFpQKHV8VAXgQFggvMAE&url=http%3A%2F%2Fketogeek.libsyn.com%2F14-tyler-cartright&usg=AOvVaw04xLzYxE3tS8oa8LWvLkZk

[48] http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0103483

how to get the minimum effective dose of nutrition

The goal of Optimising Nutrition is to help you design the minimum effective dose of nutrition to support your goals (e.g. performance, weight loss, diabetes management, therapeutic ketosis, bodybuilding, etc.).

When we break it down, we require food that:

  • provides adequate micronutrients,
  • with enough energy (but not too much), that
  • enables you to maintain healthy hormone levels.

In nutrition, we talk about parameters such as:

  • macronutrients (protein, carbs, fat, and fibre),
  • carnivore vs plant-based,
  • energy density, and
  • insulin load.

Unfortunately, talking about “high”, “low” or “adequate” often leads to unproductive circular arguments due to a lack of definition.

Optimal typically lies somewhere between the extremes.

A ‘Goldilocks zone’ of not too little.  Not too much.

A ‘minimum effective dose’ if you will.

image32

If we want to design the minimum effective dose (MED), we need to understand which parameters have the most significant impact on the quality of our nutrition.

With all the discussion about ‘high,’ ‘low’ and ‘not too much’ we need to understand the acceptable range for each of the key parameters to ensure we don’t stray too far from optimum.

What is the ‘minimum effective dose’?

The ‘minimum effective dose’ (MED) is the smallest dose that will produce the desired effect.

In terms of medication, the MED is the minimum amount that will give the desired effect for most people.  Too much of a drug can be expensive and harmful.  Too little won’t have the enough of an effect.

image30

In fitness, the minimum effective dose is the point beyond which any additional stress would be redundant or even counterproductive to strength and fitness goals.

image7

In biohacking, the MED is about getting the desired outcome with the minimum investment of time, money or effort.

image19

What does MED mean regarding nutrition?

There are a handful of interacting factors that help us determine the minimum effective dose of nutrition.  Unfortunately, it’s not possible to optimise all parameters at once.  We need to decide which ones we want to prioritise and which ones we are prepared to sacrifice based on our context and goals.

image29

Before we get into the details of how we determine the MED of nutrition, let’s set the context with a review of some parameters.

Nutrients

The body needs a range of essential nutrients and benefits from an even more extensive range of non-essential nutrients.

Recommended Dietary Intake (RDIs) or are given as the minimum amount to prevent diseases of malnutrition for most people (i.e. not necessarily optimal health and longevity).

Nutritional requirements vary due to a wide range of factors.  Men need more than women (unless they are pregnant or breastfeeding).[1]

Many nutrients are easy to obtain, but we need to pay particular attention to getting adequate quantities of others.

If we are obtaining the recommended minimum levels for the majority of the essential nutrients, we are likely to significantly exceed the Recommended Daily Intake[2] for a number of these nutrients.

We tend to get a better nutritional outcome when we prioritise the foods that contain the harder-to-find nutrients, and the other nutrients tend to look after themselves.

The upper limit (UL) for most nutrients is difficult, if not impossible, to exceed without supplementations (except for those Arctic explorers that gorged on polar bear liver and felt ill due to hypervitaminosis[3]).

If you are an athlete, you will need more nutrients.  However, you will be able to consume a lot more energy, thus letting you achieve the minimum intake level for most nutrients rather easily.

At the other extreme, if you are restricting energy to lose weight, it may be hard to get enough nutrients from the food you eat.  Focusing on foods with a high nutrient : energy ratio will be critical.

In his Perfect Health Diet,[4] Paul Jaminet notes that:

a nourishing, balanced diet that provides all the required nutrients in the right proportions is the key to eliminating hunger and minimising appetite and eliminating hunger at minimal caloric intake.

Bruce Ames’s Triage Theory[5] warns that the body will prioritize available nutrients for short-term functions and at the expense of longevity where nutrients are limited.

image12.png

Francis Pottenger demonstrated that poor nutrition has generational impacts with his cats that progressively became more deranged to the point that they couldn’t procreate after three generations.[6]

image17.png

There is also a growing body of fascinating research suggesting that different nutrient deficiencies are related to specific conditions and boosting these nutrients (ideally with whole foods) will improve these chronic diseases.[7] [8]

image16

Maximising the nutrient content of our diet with the minimum amount of energy seems to be central to our short-term and our long-term health!

We crave nutrients like salt and protein and go out of our way to make sure we get them.[9] [10] [11]

The Protein Leverage Hypothesis shows that we keep eating until we get enough protein.[12]

A pregnant woman will crave weird foods and obscure flavours to ensure she’s getting the nutrients to grow a healthy baby.

image23

As you will see below, nutrition and protein are tightly interrelated.  Rather than the ‘Protein Leverage Hypothesis’, I think it’s reasonable to think that there is a ‘Nutrient Leverage’ effect such that we seek out more food until we get the nutrients we need.

It’s not unreasonable to think that getting adequate nutrients from the food we eat is a critical component of our satiety mechanism and managing our appetite.  If we don’t obtain sufficient nutrients from our food, we will be more likely to seek out more food in search of nutrients, and thus end up over-consuming energy and become obese and/or diabetic.

With our modern trend towards processed foods that are optimised for bliss point[13] and profit margin rather than nutrient content, it’s not surprising that we have an epidemic of malnourished obese people.[14] [15]

image24

Adequate energy

While we have developed our appetite to seek out foods that contain the nutrients we need, our drive for energy is even stronger.

Adapted biologically to scarcity, we tend to consume a little more energy than we need in preparation for leaner times.  However, today in our modern processed food environment with fossil fuels, chemical fertilisers, and artificial flavourings, winter never comes.[16]

Before the advent of processed foods, energy always came packaged with adequate nutrients.  However, this is no longer always the case.

image9

To thrive in our modern world with primal instincts, we need to find a way to reverse-engineer our food environment to ensure that we prioritise foods with the nutrients we require without too much energy.

Perhaps we need a shortlist of optimal foods and meals that will provide the minimum effective dose of nutrients that we require without having to consume excess energy.

Insulin load

Insulin is arguably the most important metabolic hormone that helps us build muscle, use glucose and keep stored energy locked away for a later day.

Adequate levels of insulin are critical to survival.  People with Type 1 diabetes die without insulin.  However, today’s processed foods tend to drive our insulin levels too high for too long, thus leading to insulin resistance and the majority of modern disease.[17]

Low carb and ketogenic diets help us bring insulin and blood sugar levels under control.  At the same time foods with an extremely low insulin load are tend to be mostly fat and do not contain the vitamins and minerals that we need.

We need to balance the reduction in insulin load that will help us stabilise blood sugars and insulin levels in our body without excessively and unnecessarily compromising nutrient density.

The official “Acceptable Macronutrient Distribution Range”

The table below shows the Acceptable Macronutrient Distribution Range for macronutrients to reduce chronic disease risk whilst still ensuring adequate micronutrient status along with the currently typical macronutrient” according to the Institutes of Medicine (IOM) [18][19].

macronutrient lower upper
protein 15% 35%
fat 20% 35%
carbohydrates 45% 65%

The Australian Ministry of Health notes that only 10% of energy is required from protein to cover physiological needs.  However, this level is insufficient to provide adequate micronutrients levels.  Active communities have much higher protein intake levels with no apparent adverse health effects.[20]

The chart below shows that our carbohydrate intake is trending up while fat has trended down as we have followed the official guidance to avoid fat to avoid heart disease over the past four decades.[21]

image13

The table below shows the typical macronutrient intake for the US, UK and eighteen non-Asian countries from the PURE study.

parameter protein fat carbs
United States (NHANES, 2000)[22] 15% 33% 52%
United Kingdom 16% 35% 50
non-Asia (PURE) 17% 28% 55%
Asia (PURE) 15% 21% 65%

A number of people such as Gary Taubes[23] and Nina Teicholz[24] have argued that the unnecessary fear of fat and retreat to processed carbohydrates has contributed to the obesity epidemic.

image27

One of the main goals of this article is to consider whether the ‘Acceptable Macronutrient Ranges’ set by the Institute of Medicine actually allows us to optimise nutrient density.

The data analysis

I’ve previously discussed the relationship between macronutrients and the nutrient density of individual foods (see Micronutrients at Macronutrient Extremes and Which Nutrients is YOUR Diet Missing?).  However, I thought it would be interesting to look at things in terms of the nutrient score for each nutritional approach.

To understand the relationship between nutrition and various food parameters I updated the analysis for a wide range of nutritional approaches as shown in the table below (sorted in descending order for nutrient density).  The table below shows the nutrients provided by 43 different nutritional approaches along with the shortlist of foods associated with each goal.  (This took me a LOT of time to re-run, so I’d love you to check it out).

approach score foods pdf nutrients
most nutrient dense 96% foods pdf nutrients
adrenal fatigue 96% foods pdf nutrients
weight loss (insulin resistant) 96% foods pdf nutrients
pregnancy 96% foods pdf nutrients
alkaline 96% foods pdf nutrients
asthma 96% foods pdf nutrients
testosterone 96% foods pdf nutrients
nutrient dense paleo 96% foods pdf nutrients
weight loss (insulin sensitive) 96% foods pdf nutrients
hypertension 96% foods pdf nutrients
excess estrogen 96% foods pdf nutrients
autism 96% foods pdf nutrients
hypothyroidism 95% foods pdf nutrients
pescetarian 95% foods pdf nutrients
breastfeeding 95% foods pdf nutrients
female fertility 95% foods pdf nutrients
sleep and insomnia 95% foods pdf nutrients
nutrient dense maintenance 94% foods pdf nutrients
depression 94% foods pdf nutrients
mitochondrial health 94% foods pdf nutrients
autoimmune friendly 94% foods pdf nutrients
bodybuilder 92% foods pdf nutrients
nutrient dense athlete 91% foods pdf nutrients
nutrient dense low carb 91% foods pdf nutrients
nutrient dense paleo (low carb) 90% foods pdf nutrients
mitochondrial health (low carb) 89% foods pdf nutrients
gestational diabetes 89% foods pdf nutrients
bivalve vegan 87% foods pdf nutrients
autoimmune (low carb) 84% foods pdf nutrients
nutrient dense plant based 81% foods pdf nutrients
nutrient dense carnivore 80% foods pdf nutrients
lowest energy density 77% nutrients
plant based (low carb) 76% foods pdf nutrients
highest protein 70% nutrients
well formulated ketogenic 63% foods pdf nutrients
lowest carb 56% nutrients
most ketogenic 44% nutrients
highest fat 43% nutrients
lowest fat 35% nutrients
highest carb 26% nutrients
highest energy density 22% nutrients
lowest protein 16% nutrients
most insulinogenic 3% nutrients

This table shows the macronutrient split of each of these approaches.  To make sense of all this data, I have plotted each these parameters against nutrient density and included some discussion on what I think this means in the following sections.

approach score protein fat net carbs fibre density
most nutrient dense 96% 40% 16% 29% 16% 104
adrenal fatigue 96% 47% 18% 23% 13% 107
weight loss (insulin resistant) 96% 42% 24% 18% 15% 101
pregnancy 96% 41% 18% 27% 15% 113
alkaline 96% 33% 20% 28% 18% 112
asthma 96% 41% 16% 27% 16% 102
testosterone 96% 40% 17% 28% 15% 115
nutrient dense paleo 96% 47% 17% 22% 14% 92
weight loss (insulin sensitive) 96% 51% 18% 19% 12% 85
hypertension 96% 42% 16% 27% 15% 105
excess estrogen 96% 50% 19% 19% 12% 109
autism 96% 48% 17% 22% 13% 103
hypothyroidism 95% 52% 18% 9% 9% 122
pescetarian 95% 37% 16% 31% 16% 108
breastfeeding 95% 42% 17% 26% 15% 101
female fertility 95% 55% 20% 16% 9% 110
sleep and insomnia 95% 44% 16% 28% 12% 134
nutrient dense maintenance 94% 42% 23% 26% 9% 240
depression 94% 59% 21% 12% 8% 114
mitochondrial health 94% 34% 14% 35% 17% 126
autoimmune friendly 94% 53% 21% 17% 10% 102
bodybuilder 92% 64% 23% 8% 5% 120
nutrient dense athlete 91% 39% 40% 15% 5% 366
nutrient dense low carb 91% 28% 50% 10% 12% 222
nutrient dense paleo (low carb) 90% 26% 53% 10% 11% 260
mitochondrial health (low carb) 89% 25% 47% 13% 14% 211
gestational diabetes 89% 27% 56% 8% 9% 257
bivalve vegan 87% 21% 14% 45% 20% 129
autoimmune (low carb) 84% 26% 58% 8% 8% 285
nutrient dense plant based 81% 20% 16% 45% 20% 151
nutrient dense carnivore 80% 65% 30% 5% 0% 143
lowest energy density 77% 20% 10% 52% 18% 30
plant based (low carb) 76% 17% 29% 35% 19% 241
highest protein 70% 77% 22% 1% 0% 132
well formulated ketogenic 63% 16% 73% 4% 6% 423
lowest carb 56% 30% 70% 0% 0% 361
most ketogenic 44% 15% 80% 3% 2% 466
highest fat 43% 14% 81% 3% 1% 470
lowest fat 35% 8% 1% 84% 7% 143
highest carb 26% 3% 1% 90% 6% 141
highest energy density 22% 6% 64% 28% 2% 599
lowest protein 16% 1% 27% 68% 3% 308
most insulinogenic 3% 6% 2% 90% 2% 190

The table below shows the correlation coefficient between nutrient density and each of the parameters along with the P value indicating that there is a reasonable degree of statistical significance.

parameter R2 P
protein 0.89 < 0.0001
% insulinogenic 0.66 < 0.001
carbs 0.62 < 0.0001
net carbs 0.60 < 0.0001
fibre 0.47 < 0.0001
fat 0.41 < 0.0001
density 0.32 0.004

Protein vs nutrient density

Given that protein has the highest correlation with nutrient density score (R2 = 0.89) let’s start by looking at the relationship between protein and nutrient density.

The chart below shows the relationship between the nutrient density score and the percentage of energy from protein.   It seems that nutrient density peaks in around 45% of calories from protein.

If we were to use a nutrient density score of 70% as our cut off for our minimum effective dose of nutrition we would have a lower limit of 19% protein and an upper limit of 78% energy from protein.

This optimal level is significantly above the typical protein intake of around 16% of energy and even greater than the upper end of the official Acceptable Macronutrient Distribution Range of 15 to 35%.

The chart below shows the micronutrients provided by the most nutrient-dense foods.  That is, the highest ranking 10% of foods in the eight thousand foods in the USDA food database when we boost the harder to find nutrients (shown in yellow).[25]    These foods provide the best balance of micronutrients to meet the Recommended Daily Intake Levels.

What’s worth noting here is that this shortlist of nutrient-dense foods are NOT identified by prioritising any of the amino acids.  We just happen to get plenty of protein from foods that contain more of the harder-to-find nutrients (i.e. omega 3, choline, vitamin D, calcium magnesium potassium, zinc and thiamine).

The nutrient score in this analysis is calculated based on the proportion of the area between 0 and 300% of the RDI for the various nutrients.  If we could find a group of foods that provided 300% of the recommended daily intake (RDI) of all nutrients we would get a perfect score.

If your goal was just to maintain weight or fuel your endurance activities you could argue that such high a high level of nutrient density is excessive.  You may end up fueling up with some more energy dense fat or refined carbs.  However, maximising the nutrient : energy ratio of your diet would be very useful if you were trying to reduce your energy intake to lose weight.

According to Bruce Ames’ Triage Theory,[26] maximising nutrient density enables us to maximise both our short-term and long-term health and vitality.

Perhaps with a higher nutrient : energy ratio, the body would be happier with a lower energy intake for longer without overwhelming cravings that may derail our weight loss efforts?

On the far right of the plot of protein vs nutrient density above we have the highest protein foods.  Prioritising amino acids alone gives us a massive 77% of energy from protein!  However, as you can see from the chart below, we will miss out on a number of essential vitamins and minerals (e.g. vitamin A, vitamin K, folate, manganese, vitamin D, calcium etc.).

Just prioritising high protein foods doesn’t achieve optimal outcomes.  We need to prioritise nutrients!

At the other extreme, the nutrient profile of the lowest protein foods is shown below.  If we actively avoid protein, we end up with an inferior nutritional outcome.

image25

If there is such as thing as ‘too much protein’ we could say that it occur when we are getting more than half our energy intake from protein (which is hard to do!).

image6

Lately, a lot of people are concerned about reducing protein to minimise insulin and mTOR.[27] [28]  While chronically high overall energy intake is indeed a problem, I am concerned that an intentionally low protein dietary approach will have a very poor nutrient outcome.  We then risk being driven to overeat in an effort to find nutrients that we are not getting from our low protein diet.

As suggested by Ames’ Triage Theory, if we miss out on nutrients by prioritising low protein foods, our body diverts our nutrients to short-term survival rather than longevity.  Pottenger’s cats suggest that our descendants will develop degenerative diseases, become lazy and eventually not be able to procreate due to our poor nutritional status.  The most logical solution seems to be to increase our nutrient intake without overdoing energy intake.

The ‘problem’ however with really high nutrient foods is that they, ironically, provide you with too much nutrition.  It’s hard to overeat highly nutrient-dense foods.  Your appetite switches off and you will lose body fat.  As shown in the chart below, it seems we have the lowest ad libitum energy intake when 40 to 50% of our energy comes from protein.[29]  This seems to align with the highest nutrient density foods shown above.

image2

Excessively high levels of protein is not a good idea from an evolutionary perspective because protein is very satiating.  We need the more energy-dense fat and carbs to fuel us to chase our food down and help us get in enough energy to store body fat to make it through the winter.

However, forcing ‘rabbit starvation’ may be a useful hack if you have body fat to lose.  For someone wanting to lose weight, a higher percentage of protein with a lower overall energy intake might be optimal.

image31

So is 40 to 50% protein optimal for everyone?

Not necessarily!  It depends on who you are and your goals.

For most people, consuming a nutrient-dense diet will increase the proportion of energy from protein beyond the typical 16% intake.  At the other extreme, it seems that increasing protein beyond 50% of energy intake would dilute nutrient density as well as be too satiating!

When it comes to protein, the minimum effective dose is whatever comes with more nutrient-dense foods, but not so much that satiety kicks in so hard that you can’t maintain your body weight.

The minimum effective dose appears to be around 19% of energy from protein with higher levels providing more overall nutrition.

If you are active and need to consume a lot of energy, then the optimal 45% protein will be impractical.  However, if you are aggressively cutting calories and eating a very nutrient-dense energy-restricted diet with a high nutrient : energy ratio then closer to 45% may be optimal.

Insulin load

After protein, the parameter that is most correlated with nutrient density is insulin load.  Insulin load is a proxy for the amount of insulin that our pancreas will need to produce and is proportional to the carbohydrates, minus fibre plus about half the protein.

If you have diabetes, you need to invest your available insulin wisely.  Consuming highly insulinogenic foods will make insulin dosing hard to calculate if you have Type 1 diabetes.  People with Type 2 won’t have enough insulin to keep up to overcome their insulin resistance and maintain excellent blood sugars.

Someone who already has diabetes will benefit by reducing the insulin load of their diet to help normalise their blood sugars, particularly if they have been overloading their pancreas with processed carbs and sugars.

A typical western diet has about 60% or more insulinogenic calories.  The chart below shows that we get the minimum effective dose (i.e. a nutrient density score of 70%) with an insulin load of 19%, optimal at around 41% of energy and an upper limit of 65%.  Overall nutrient density starts to suffer outside these limits and we would have to pay more particular attention to our nutrition.

image14

The current typical macro intake suggests that we are 65% insulinogenic calories on average in non-Asian countries and 73% in Asian countries.  And if this is typical it is likely that many people are consuming much more than this.

Perhaps highly insulinogenic low nutrient density processed foods could be playing a role in the epidemic of diabesity?

Carbohydrates vs nutrient density

This chart shows the relationship between nutrient density and total carbohydrates…

… and nutrient density vs net carbohydrates.

It seems the minimum effective dose of net carbs is 0% and 8% in terms of total carbs with an optimal nutritional outcome at around 30% net carbs or 35% total carbs.  The upper limit is 60% net carbs or 65% total carbs.

This upper limit aligns with the official “Acceptable Macronutrient Distribution Range” for carbohydrates of 65%.  What is worth noting here is that the typical intake is 55% which is greater than the optimal nutrient intake.  The lower limit of the official AMDR is 45% which appears to be unnecessarily high, especially for someone who is not active or is already developing metabolic syndrome.

Many people in low carb circles are fond of point out that ‘there is no such thing as an essential carbohydrate’.  However, foods that contain essential vitamins and minerals also often come packaged with carbohydrates.  At the same time, you can also get plenty of vitamins and minerals from organ meats and shellfish if green leafy veggies aren’t your thing.

If you already have diabetes you should lower your carbohydrate intake to the level that lets you achieve excellent blood sugar control.  In order to control your blood sugars, you will need to reduce your carbohydrates to a level less than the typical level of 55% and most likely less than the optimal level of 30%.

You can continue to refine your approach and ‘eat to your meter’ until you get the blood sugars you are chasing.  However, unless you require therapeutic ketosis (i.e. to manage chronic conditions such as cancer, epilepsy, dementia or Alzheimers), there is probably no need to drive carbohydrate intake much lower than 8% as you may struggle to obtain the broad range of essential nutrients.

Fat vs nutrient density

While there is a lot of talk about “high fat” or “low fat”, fat is actually a relatively poor predictor of nutrient density (R2 = 0.41).  The minimum effective dose seems to set at around 10% of energy intake with an upper limit of 65% fat.   Outside this window, it tends to be harder to get excellent nutrition.

The average intake of fat in western diets is around 28%.   Most people would benefit from consuming more than, particularly if they are not trying to lose weight.  However, there might not be any benefit in going over 65% of energy from fat, particularly if your primary goal is to lose body fat.  If your goal is to control your blood sugar and insulin levels then increasing fat is probably a better option than increasing energy from carbs if you can’t fit any more protein in.

Overall, I don’t think we need to target a specific fat or carb intake.  In the days before we had refrigerators, we would naturally cycle our intakes seasonally between more carbs in summer and more fat in the winter.  However, these days our macronutrient intake seems to be driven more by profit margins and shelf lives (i.e. less protein and more refined fats and sugars) which keeps us in a higher carb summer-like phase.

Fibre

Foods with more fibre tend to be more nutritious and less process.  I don’t think this is necessarily due to the fibre (i.e. you may not benefit by loading up on fibre supplements), but rather because plant-based foods often have nutrients that are harder to find in animal-based foods.

image20

Some people seem to thrive on a zero carb diet, especially when switching from a processed high carb diet which can cause gut dysbiosis.  However, it can be challenging to get as much of the essential vitamins and minerals from a diet with no fibre (although if you are eating nose to tail including minerals from blood this may be another matter).

Energy density

Energy density has the lowest correlation with nutrient density (R2 = 0.32).  However, as a general rule, less energy-dense foods tend to more nutritious.

image8

Energy density can be a useful tool to help us identify foods that are more filling with less energy if we are looking to lose weight.  Alternatively, we can look for higher energy-dense food that is still nutritious if we are looking to fuel high levels of activity.

image1

Carnivore vs plant based

Another nutritional battle that seems to be raging is the plant-based versus carnivorous diets (i.e. no plants).  The good thing about either extreme here is that they both generally eliminate highly processed foods.

A whole food plant based dietary approach will remove processed junk foods and leave low energy density high fibre foods that will make it hard to lose weight.  As you can see it is hard to get omega 3 or vitamin B12 on a plant-based diet there are a number of amino acids that are harder to get due to the amount in the plant-based foods and the bioavailability of plant-based proteins.  If you are consuming a diet that is predominantly plant-based you should look out for symptoms of deficiencies associated with omega 3, vitamin B12 and even protein and consider supplementing accordingly.

image10

The chart below shows the micronutrient profile of a nutrient-dense carnivore diet.  As you can see, there are a number of nutrients that are harder to obtain with this approach.  However, there is some evidence to suggest that you may not need as much of some nutrients if you are not consuming as much glucose.  Again, understanding which nutrients you are not getting in large quantities may be useful to help you identify supplements or look out for symptoms.

image5

Suggested updates to the Acceptable Macronutrient Range

The table below shows suggested minimum effective dose, optimal and upper limit macronutrient splits along with the current intake levels for comparison.

parameter protein fat total carbs insulin load
minimum effective dose 19% 10% 8% 19%
optimal* 45% 36% 35% 41%
upper limit 78% 65% 65% 65%
current (NHANES, 2000) 15% 33% 52% 60%
United Kingdom 16% 35% 50% 59%
non-Asia (PURE) 17% 28% 55% 65%
Asia (PURE) 15% 21% 65% 73%

It seems that to improve their nutrition, most people would benefit from:

  • more protein,
  • more fat,
  • less carbs, and
  • a lower insulin load.

However, food doesn’t come in neat packages of carbs, fats and protein.  Trying to increase protein by adding protein powder or fat by increasing butter or cream may not lead to an optimal nutritional outcome.  But if you focus on meeting your micronutrient requirements with real food the macronutrients will typically look after themselves.

* If you are astute you might notice that the optimal macros actually sum up to 116%.  This is to be expected given that it is not a closed system.  In reality, most people will struggle to consume “optimal” protein levels.  As a general rule of thumb starting with a three-way split of protein, fat and carbs is a reasonable starting point if you insist in thinking in terms of macros.  You can then make refinements from there to suit your goals (e.g. diabetes control, therapeutic keto, weight loss, athlete etc) and preferences (e.g. low carb, high carb, paleo, vegan etc).

Suggested minimum effective dose levels

In the end, nutrition is about getting enough nutrients without too much energy.  Percentages also don’t mean that much for a real person wanting to know what to eat.

The table below shows you the minimum amount of each macronutrient you might need to also provide a solid level of nutrition in terms of your current lean body mass (i.e. total weight minus your fat) and grammes per kilo and grams per pound of LBM.

LBM (kg) LBM (lbs) minimum effective dose (g)
protein fat  net carbs total carbs insulin load
40 88 72 17 0 30 72
45 99 79 18 0 33 79
50 110 85 20 0 36 85
55 121 91 21 0 38 91
60 132 97 23 0 41 97
65 143 104 24 0 44 104
70 154 110 26 0 46 110
75 165 116 27 0 49 116
80 176 123 29 0 52 123
85 187 129 30 0 54 129
90 198 135 32 0 57 135
95 209 142 33 0 60 142
100 220 148 35 0 62 148
g/kg LBM 1.8 0.4 0 0.75 1.8
g/lb LBM 0.8 0.2 0 0.3 0.8

These minimum levels will leave you with a shortfall of energy that you will have to make up from your body fat or other dietary inputs.  There is endless debate about which diet is optimal and leads to longevity.  However, the one thing that nearly everyone seems to agree on is that taking in too much energy is a problem.  So erring on the side of less rather than more is going to be a good thing.

Optimal intake levels

This table shows you the levels that you would need to hit the optimal nutritional outcome for each of these parameters.  In practice, most people will find such high levels of protein difficult to consume and may end up making up any energy shortfall from body fat, dietary fat or dietary carbs.  Nutrient density is important, however, it’s not the only thing.  Most people will end up diluting their nutrient density somewhat in order to get in energy from higher fat or higher carb foods.

LBM (kg) LBM (lbs) optimal intake (g)
protein fat  net carbs total carbs insulin load
40 88 171 61 114 133 156
45 99 186 66 124 145 169
50 110 201 71 134 156 183
55 121 216 77 144 168 197
60 132 231 82 154 180 210
65 143 246 87 164 191 224
70 154 261 93 174 203 238
75 165 276 98 184 215 251
80 176 291 103 194 226 265
85 187 306 109 204 238 279
90 198 321 114 214 249 292
95 209 336 119 224 261 306
100 220 351 125 234 273 319
g/kg LBM 4.3 1.5 2.9 3.3 3.9
g/lb LBM 1.9 0.7 1.3 1.5 1.8

I could show the upper limit of each nutrient too, however, don’t think there’s much practical use precisely quantifying these amounts.  If you are active then your appetite will increase to encourage you to get more food.  If you are gaining unwanted weight then you probably need to back off the intake.

Food lists

I encourage you to make use of the food lists in the table below.  Click on the ‘foods’ hyperlink to open the food list as an image or the ‘pdf’ to download to print.  You can also check out the nutrient profile to see what nutrients these food lists contain and which nutrients have been profiled.  Once you reduce the nutrient-poor foods, you will be able to trust your appetite to guide you to the foods that contain the nutrients you need.

approach score foods pdf nutrients
most nutrient dense 96% foods pdf nutrients
adrenal fatigue 96% foods pdf nutrients
weight loss (insulin resistant) 96% foods pdf nutrients
pregnancy 96% foods pdf nutrients
alkaline 96% foods pdf nutrients
asthma 96% foods pdf nutrients
testosterone 96% foods pdf nutrients
nutrient dense paleo 96% foods pdf nutrients
weight loss (insulin sensitive) 96% foods pdf nutrients
hypertension 96% foods pdf nutrients
excess estrogen 96% foods pdf nutrients
autism 96% foods pdf nutrients
hypothyroidism 95% foods pdf nutrients
pescetarian 95% foods pdf nutrients
breastfeeding 95% foods pdf nutrients
female fertility 95% foods pdf nutrients
sleep and insomnia 95% foods pdf nutrients
nutrient dense maintenance 94% foods pdf nutrients
depression 94% foods pdf nutrients
mitochondrial health 94% foods pdf nutrients
autoimmune friendly 94% foods pdf nutrients
bodybuilder 92% foods pdf nutrients
nutrient dense athlete 91% foods pdf nutrients
nutrient dense low carb 91% foods pdf nutrients
nutrient dense paleo (low carb) 90% foods pdf nutrients
mitochondrial health (low carb) 89% foods pdf nutrients
gestational diabetes 89% foods pdf nutrients
bivalve vegan 87% foods pdf nutrients
autoimmune (low carb) 84% foods pdf nutrients
nutrient dense plant based 81% foods pdf nutrients
nutrient dense carnivore 80% foods pdf nutrients
plant based (low carb) 76% foods pdf nutrients
well formulated ketogenic 63% foods pdf nutrients

Once you feel you have got the hang of eating mostly nutrient dense foods, you may wish to use the Nutrient Optimiser to identify the nutrient gaps as the foods and meals that will help you optimise your nutrition.

image28

 

 

references

[1] https://optimisingnutrition.com/2017/05/23/personalised-nutrition/

[2] https://www.nhmrc.gov.au/guidelines-publications/n35-n36-n37

[3] https://en.wikipedia.org/wiki/Hypervitaminosis_A

[4] https://www.amazon.com.au/Perfect-Health-Diet-Regain-Weight-ebook/dp/B007USA6MM

[5] https://www.bruceames.org/Triage.pdf

[6] https://en.wikipedia.org/wiki/Francis_M._Pottenger_Jr.

[7] https://www.dropbox.com/s/to3f84z77sckvjx/Interactive-Library-Nutrient_Correlation_Wheels-2.pdf?dl=0

[8] https://www.amazon.com/Nutrient-Bible-Henry-Osiecki/dp/1875239545/ref=tmm_pap_title_0?_encoding=UTF8&qid=&sr=

[9] https://www.ncbi.nlm.nih.gov/pubmed/28121382

[10] https://www.dropbox.com/s/zej4razn4dn993y/protein%20leverage%20hypothesis%20-%20simpson2005.pdf?dl=0

[11] https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=5&cad=rja&uact=8&ved=0ahUKEwigtuWKl_7WAhUIQLwKHeDdC74QFghFMAQ&url=http%3A%2F%2Fwww.sciencedirect.com%2Fscience%2Farticle%2Fpii%2FS2212877817305379&usg=AOvVaw3NNHJwsTp33sDHvoOVdpAA

[12] https://www.ncbi.nlm.nih.gov/pubmed/15836464

[13] https://en.wikipedia.org/wiki/Bliss_point_(food)

[14] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3313629/

[15] https://www.ncbi.nlm.nih.gov/pubmed/16332298

[16] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4209489/

[17] https://optimisingnutrition.com/2015/03/22/diabetes-102/

[18] https://www.ncbi.nlm.nih.gov/pubmed/16004827

[19] https://www.nrv.gov.au/chronic-disease/summary

[20] https://www.nrv.gov.au/chronic-disease/summary

[21] https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5304a3.htm

[22] http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32252-3/abstract

[23] http://garytaubes.com/

[24] https://thebigfatsurprise.com/

[25] Note: we have not prioritised using Vitamin E and Pantothenic Acid due to the fact that the DRI targets are based on population averages rather than deficiency studies.

[26] https://www.bruceames.org/Triage.pdf

[27] http://www.meandmydiabetes.com/2010/05/07/ron-rosedale-protein-the-good-the-bad-and-the-ugly/

[28] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4209489/

[29] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3192127/

redesigning nutrition from first principles

In a sea of nutritional gurus, theories and conflicting opinions, have you ever wondered,

“What should I eat to optimise my blood sugars, weight and health to feel great and thrive?”

If your answer is “yes,” you’re in luck!

This article sets out a bold proposal and methodology to redesign nutrition from the ground up using first principles.

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It also gives you a peek under the hood of the Nutrient Optimiser, an exciting new tool to help you identify optimal foods to incorporate into your diet to achieve your goals.

Overview

But before you dive in, let me give you an overview of where we’re going.

  • Humans require food that contains:
    • adequate nutrients,
    • energy (but not too much), and
    • the ability to maintain healthy hormone levels.
  • The Nutrient Optimiser algorithm considers insulin load, nutrient density and energy density to identify optimal foods to suit different people with different goals.
  • People with diabetes or some degree of metabolic syndrome are on a blood sugar/insulin rollercoaster which drives appetite and fat storage.
  • Stabilising blood sugars and insulin levels using a lower insulin load dietary approach can help to normalise appetite and improve energy levels and often leads to a degree of spontaneous weight loss.
  • Being able to accurately quantify the insulin load of our food enables us to ensure we invest it wisely on protein and other nutrient-dense foods while still maintaining excellent blood sugar levels.
  • The foods that require the least insulin are typically high-fat foods which may not contain adequate amounts of vitamins and minerals.  We need to find the balance between a lower insulin load and adequate nutrient density.
  • Some nutrients are easier to obtain than others. The nutrient density index embedded in the Nutrient Optimiser algorithm prioritises foods that contain more of the harder to find nutrients.
  • People on a low carb or ketogenic diet often miss out on a number of nutrients, particularly electrolytes (e.g. potassium, magnesium, calcium and sodium) and our pancreas will increase insulin levels to enable our kidneys to hold on to these nutrients if we are not getting enough of them from our diet, and thus drive insulin resistance.
  • We can use energy density to manage how filling our food is to suit our goals.  For example, someone wanting to lose weight by eating less by decreasing their energy density or someone wanting to eat more by increasing energy density.
  • The Nutrient Optimiser considers what you are currently eating and identifies nutrient-dense whole foods that will provide the nutrients that you are not getting enough of while also managing your blood sugars and weight goals.
  • The Nutrient Optimiser can help retrain people to make progressively better food choices and reduce nutrient-poor processed foods using a quantitative algorithm that eliminates the emotion, belief and conflicts of interest that often derail our best nutritional ntentions.

My why

My name is Marty Kendall, and my journey into nutrition started fifteen years ago when this happened…

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…and we started thinking about having these.

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My wife Monica has Type 1 Diabetes.  Not too long after we got married we started researching how we could optimise her blood glucose control to minimise the risks associated with a diabetic pregnancy.

And personally, I have a family history and my own struggles with prediabetes and obesity (as you can see from the “before and after” below).

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By day I’m an engineer.  I like to use data to optimise things quantitatively.

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I even spent a period of time developing trading systems.  In this environment, it is critical to eliminate emotion, belief and confirmation bias.

As they say, necessity is the mother of invention.  I got frustrated with the lack of useful information for people with diabetes and decided to take matters into my own hands to create the optimal nutritional solution for my family.

The key components of optimal nutrition

You may have noticed that there is a lot of argument and conjecture about what is the best diet.  Unfortunately, decades of expensive epidemiological studies don’t seem to have provided any clarity.

Paleo, vegan, low carb, fruitarian, pescetarian, Mediterranean, vegetarian, plant-based, ketogenic, the list of nutritional camps goes on and on.

But when you peel away the dogmatic belief and conflicts of interest I think what we really need from our food is:

  • adequate nutrients,
  • enough energy (but not too much), and
  • the ability to maintain healthy hormone levels (e.g. insulin, ghrelin, leptin, mTOR etc.).

After experimenting with a range of parameters to optimise nutrition, the three that I have found to be most useful are:

While not as useful by themselves, we can combine these parameters using a multi-criteria analysis and apply different weightings to each parameter to optimise food choices to suit different people with different goals.

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Given that the diabetes epidemic is exploding, let me start by discussing how we can quantify the insulin load of the food we eat to optimise our blood sugar control.

The blood sugar rollercoaster

Someone with diabetes is on a constant rollercoaster of treating blood sugars with insulin.

You eat, and your blood sugars go up.  You dose with insulin, and eventually, your blood sugars start to come down.  Then you find your blood sugars have dropped too low so you feel compelled to eat again.  Maybe something sweet or a glucose tablet that you wouldn’t have otherwise eaten.  This cycle continues night and day.

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The blood sugar – insulin roller coaster leaves you feeling fatigued and hangry, often gaining weight due to fat storage effects of excess insulin.

When the inputs of food and insulin are both large, it’s impossible to match the right amount of insulin to the food you eat.  There is always a massive error!  And the blood sugar swings are like a bad theme park ride.

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So logically, the goal for someone wanting to manage their blood sugars is to reduce the dietary inputs that need insulin.[1]   But then, the next question is:

“What exactly is it in our food that raises blood glucose and requires insulin, and then how can we accurately quantify it so we can more effectively manage it?” 

The food insulin index data

A couple of years back, I stumbled across a motherload of Food Insulin Index data in a University of Sydney thesis[2] that I thought might hold some clues about how we could more accurately manage insulin.

So I exported the data into a spreadsheet and started tinkering with it to better understand the relationship between the food we eat, our glucose response and the insulin we need.

Our blood sugar response to glucose

It’s not a great surprise for most people to see that our blood glucose response is correlated with the carbohydrate we eat.

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However, things get more interesting when we look at the insulin response to the food we eat.

Measuring our insulin response to food relative to glucose

The Food Insulin Index quantifies the area ‘under the curve’ insulin response to a range of foods.  Pure glucose is assigned a score of 100%, and everything else is measured relative to that.

The food insulin index is a little bit like the Glycemic Index.  However, rather than just measuring the maximum rise in blood glucose, the food insulin index measures the insulin response to the food we eat over time.

Understanding our insulin response to the food we eat is much more useful for someone who cannot keep their blood sugars at normal levels due to insulin resistance (type 2 diabetes) or not being able to produce enough insulin (type 1 diabetes).

Carbohydrates versus insulin response

When we plot carbohydrates against the Food Insulin Index, we find that, while high-fat foods such as bacon and avocado have a small insulin response, high protein foods (e.g. steak and fish) have a significant insulin response even though they don’t contain any carbs.

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People with Type 1 diabetes find that they need insulin to cover the protein they eat.  However, the details of why and how much are often not well understood which leads to poor blood sugar control.

Fats versus insulin response

Higher fat foods have a smaller insulin response, while low-fat foods (which are typically processed grain products) have a high insulin response.

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[Note: There are a couple of situations where fat will require insulin.  The glycerol backbone that holds fat molecules together can be converted to glucose via gluconeogenesis which will need insulin to metabolise.  Also, when we consume more energy than we require over the long term, regardless of macronutrient source, the pancreas secretes insulin to keep energy stored in the liver while the energy coming in from our diet is used up.   However, the changes in insulin levels due to dietary fat are negligible in the short term compared to the carbohydrates and protein.]

The insulin response to dietary protein

Although protein needs some insulin to help us build and repair our muscles and organs, higher protein foods tend to have a lower insulin response because they force out refined carbohydrates from our diet.

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Does protein turn into chocolate cake?

When I first started looking into this issue, I thought the reason that protein requires insulin was because the glucogenic amino acids in protein were being converted to glucose which needs insulin.[3]

But I have since come to understand that it’s not quite that simple.  Protein does not turn to chocolate cake in our bloodstream.

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I feel partially responsible for propagating that misunderstanding with my early posts on the food insulin index.[4] [5]  Many people are avoiding protein to minimise insulin, and I’ve been trying to set the record straight.[6]

Insulin has many critical roles in our body.

  • Most people are aware that insulin helps the body take glucose into the cells to be used for energy.[7]
  • Bodybuilders are well aware that insulin is an anabolic hormone that helps us use the protein we eat to build and repair muscle and organs.[8] [9] [10]
  • The third, lesser-known function of insulin, is that it works to hold glucose in the liver (i.e. glycogen) for later use when we’re not eating.[11]

Type 2 diabetes occurs when we become resistant to the effects of insulin, and stored glucose leaches out into our bloodstream.  Similarly, Type 1 diabetes occurs when the pancreas can’t produce enough insulin to keep glycogen stored in the liver, and we see our blood sugars rise.  Effective and efficient use of insulin in our body is critical to our metabolic health.

Most of the amino acids that make up protein can be converted to glucose via gluconeogenesis, but converting protein to ATP it’s really difficult compared to just using fat and/or carbs. for energy[12]  It takes a lot of energy to convert protein to glucose (we use 6 ATP to yield only 2 ATP of energy!).  So the body tends to look for other energy sources once you’ve consumed enough protein.

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That’s why you can quickly become full-on lean protein, but we always have a “dessert stomach” with enough room for carbs and fat which are much easier for the body to use for energy.

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Let me clarify this with a real-life example that is close to home.

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Pictured above is my wife Monica’s blood glucose response measured with a continuous glucose meter) to this meal of steak and veggies shown below.

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Over the first few hours after finishing the meal the carbohydrates in the veggies digest and raise her blood sugars.  Then the insulin that she injected with the meal kicks in and brings the blood sugars down.

But then over a period of about ten hours, we can see that she is slowly metabolising the steak which requires insulin for the anabolic process of muscle repair.  While the insulin is going to work on the protein, Monica doesn’t have enough insulin to stop the glucose being released into the bloodstream.

You could be forgiven for thinking that protein is being converted to sugar.  But it’s actually the glycogen in the liver leaching into the blood due to a lack of insulin.  Monica actually needs more insulin here to enable her to build and repair her muscles as well as keep glucose in storage in the liver at the same time!

Most people see their blood sugar decrease after a high protein meal due to the effect of insulin (the insulin released to metabolise the protein also brings the blood sugars down and keeps the glycogen shut in the liver).  If you find that your blood sugars rise significantly after a high protein meal, it might be a sign that you actually need more insulin to ensure you are effectively using the protein you are eating.

According to the Protein Leverage Hypothesis, (Simpson, 2005) rather than minimising protein, someone with diabetes eating less carbohydrate may actually require more protein.

“One source of protein loss is hepatic gluconeogenesis, whereby amino acids are used to produce glucose. This is inhibited by insulin, as is the breakdown of muscle proteins to release amino acids, and therefore occurs mainly during periods of fasting.

“However, inhibition of gluconeogenesis and protein catabolism is impaired when insulin release is abnormal, insulin resistance occurs, or when circulating levels of free fatty acids in the blood are high.

“These are interdependent conditions that are associated with overweight and obesity and are especially pronounced in type 2 diabetes. It might be predicted that the result of higher rates of hepatic gluconeogenesis will be an increased requirement for protein in the diet.”  [13] 

Type 1 Diabetes guru Richard Bernstein says he found it hard to build and maintain muscle before he understood the importance of matching insulin with protein.

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However, after matching adequate protein with the right amount of insulin this is no longer a problem, even after more than seven decades of living with Type 1 Diabetes.

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At the same time though, there’s no point choking down more protein beyond what you have an appetite for.   Regardless of the macronutrient source, there’s no use consuming more energy than you need, particularly as the errors in matching food with insulin can exacerbate the glucose/insulin rollercoaster.

Anyone who is somewhere on the spectrum of metabolic disease needs to invest their limited supply of insulin wisely (e.g. to metabolise protein to build and maintain muscle and metabolise limited glucose from nutrient dense green leafy veggies) rather than squander it (on refined grains and sugars).

I hope this interlude into protein metabolism gives you an insight into why a good understanding of our insulin response to protein is important.   While there are a wide range of other hormones that drive our metabolism (e.g. mTOR, leptin, ghrelin and PPK) most of these fall in line if we optimise insulin and blood glucose levels.

Fibre

As a general rule, indigestible fibre does not require insulin and does not raise blood sugar levels.  High fibre foods such as All Bran and navy beans tend to have a lower insulin response due to their high indigestible fibre content.  Hence, it appears that a ‘net carbs’ approach makes sense, at least for whole foods.[14]

[Note:  Many people with Type 1 find that they do require insulin or have a blood sugar response to sugar alcohols and other fibres used in manufactured foods so it may be prudent to adopt a total carbs approach when dealing with foods that come in a packet and claims to have low ‘net carbs’.]

Fructose

Fructose (a.k.a. fruit sugar) is processed in the liver without requiring insulin.  However, some of it is converted to glucose via gluconeogenesis.[15]   Analysis of the food insulin index data suggests that 25% of the fructose we eat requires insulin.   However, this is typically such a small component and difficult to calculate, so it’s generally not worth worrying about.

The solution

After playing around with the Food Insulin Index data for a while, I found we can more accurately predict our insulin response to the food we eat when, in addition to carbohydrate, we also consider the effect of indigestible fibre and protein.

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[If you want to dig into this data a little more you can check out these charts in an interactive Tableau format here.]

With this improved understanding, we can then develop these formulas to calculate the insulin load and the percentage of insulinogenic calories.

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Understanding the insulin load of our food helps us to more accurately calculate the insulin people with diabetes would need to inject, including for protein.   Or conversely, it can help them make better food choices so their pancreas can keep up and maintain healthy blood sugar levels.

Being able to calculate the proportion of insulinogenic calories allows us to identify the most ketogenic foods that will elicit the smallest insulin response in our pancreas.  Understanding the percentage of insulinogenic calories can be beneficial for people who require therapeutic ketosis to help with the management of cancer, epilepsy, Alzheimer’s or dementia.

With better food choices that require smaller inputs of insulin, we are able to smooth out the blood sugar-insulin roller coaster.

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This is a big deal for someone with Type 1 diabetes.  However, the same principles apply to anyone on the spectrum of metabolic disease (which is a growing portion of the population).

I believe our first priority should be to normalise blood sugar and insulin swings.  Often satiety and weight loss will naturally follow as we are able to access our own body fat more efficiently and are not driven to eat by fluctuations in blood glucose and insulin.

Lack of nutrients in fattiest foods

However, after looking at the foods that elicit the smallest insulin response, I realised we may have another problem.  The least insulinogenic foods tend to be mainly fat!

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While an unnecessary fear of fat has driven the unfortunate low-fat processed food saga that has been in place for most of my lifetime, I think we also need to acknowledge that the highest fat foods typically do not contain a lot of the essential vitamins and minerals.

This chart shows the nutrients contained in the fattiest foods as a percentage of the recommended daily intake for each of the essential nutrients.  The nutrients are then sorted to identify which nutrients these foods fail to provide in adequate quantities.

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So if you ate a little bit of the eight hundred fattiest foods of the eight thousand foods in the USDA database you would not be getting the DRI for the following micronutrients:

  1. Vitamin D
  2. Folate
  3. Potassium
  4. Choline
  5. Manganese
  6. Vitamin C
  7. Magnesium
  8. Calcium
  9. Pantothenic acid
  10. Vitamin K
  11. Riboflavin
  12. Vitamin B6
  13. Vitamin A
  14. Vitamin E

Nutrients lacking in the most ketogenic foods

Rather than sorting by percentage fat, this chart shows the nutrients contained in the most ketogenic foods using the percentage insulinogenic calories formula shown above.

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While these foods (refer summary below) are an improvement on the nutritional profile of the fattiest foods, they still do not provide the recommended daily intake for about a third of the essential nutrients.

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So the next question is, what can we do to maintain low insulin levels and while still getting the micronutrients we need?

Enter nutrient density.

Nutrient density

Building on the work of the likes of Dr Mat Lalonde and Dr Joel Fuhrman I developed a nutrient density index to identify foods that contain more of the nutrients that are harder to find.

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Dr Lalonde’s nutrient density system considered all the essential nutrients in terms of nutrients per weight of foods and ended up with a very protein heavy (e.g. 60 to 70% of energy) array of foods.

Dr Fuhrman’s Aggregate Nutrient Density Index considered vitamins and minerals (but not amino acids or essential fatty acids) along with a range of other factors as noted below.

The following nutrients were included in the evaluation: fiber, calcium, iron, magnesium, phosphorus, potassium, zinc, copper, manganese, selenium, vitamin A, beta carotene, alpha carotene, lycopene, lutein and zeaxanthin, vitamin E, vitamin C, thiamin, riboflavin, niacin, pantothenic acid, vitamin B6, folate, vitamin B12, choline, vitamin K, phytosterols, glucosinolates, angiogenesis inhibitors, organosulfides, aromatase inhibitors, resistant starch, resveratrol plus ORAC score.[16]

Rather than prioritising all nutrients, I think we only need to worry about boosting the nutrients that we are currently not getting enough of.   To reduce any percieved bias or conflict of interest, my version of the nutrient density index only considers the essential nutrients that have established targets.

While there are many other nutritional parameters that are nice to have (e.g. phytonutrients, lycopene, lutein, zeaxanthin, phytosterols, glucosinolates, organosulfides, resistant starch etc.), they tend to come along for the ride if we focus on getting the essential nutrients from whole foods.

Unfortunately, we currently only have data for the nutrients that are actually in a food.  Hopefully one day we will also be able to account for your digestion, the effect of anti-nutrients and the bioavailability of nutrients from different food sources.

Most of the time these are not a problem as focusing on nutrient-dense foods eliminates most anti-nutrients.  Most people get plenty of amino acids, iron, zinc and vitamin A which are less bioavailability in plant-based sources.  However, if you are consuming a 100% plant-based diet, you may need to pay extra attention to getting adequate of these nutrients.

A well-formulated ketogenic diet

So, going back to the ketogenic foods, once we emphasise the harder-to-find nutrients, we get a massive boost in the micronutrient content of our diet, while still maintaining a ketogenic macronutrient ratio.

The image below shows the ketogenic foods with and without consideration of nutrient density.  When we boost the harder to find nutrients all of the nutrients get a significant boost.

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The nutrient score that you see on each of these charts enables us to compare the nutrient density of each these dietary approaches quantitatively.  While the recommended daily intake levels are not set in stone, and your body doesn’t flip an on/off switch once the minimum levels are achieved, I think we ideally want to meet the recommended intake levels for as many nutrients as we can.  However, there’s probably not much use chasing more than twice the recommended daily intake levels.   So, if we filled the whole red rectangle, we would get a perfect score of 100%.

As you’ll see below, we can create a theoretical list of foods that get us pretty close to a perfect nutrient density score of 100%.  However, in real-life, it’s hard to achieve such a high nutrient density score.  Dr Rhonda Patrick currently holds the top position on the Nutrient Optimiser Leaderboard with a score of 82%.

Low carb is more nutritious than keto

If we tweak the weightings in the multi-criteria analysis and put less emphasis on insulin load and more on nutrient density we get a more nutritious group of low carbohydrate foods and the nutrient score increases from 64% to 97%.

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A summary of these foods is shown below.

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While I could go on about the importance of the various vitamins, minerals and fatty acids, the thing I see most regularly with low carb diets is a lack of alkalising minerals such as potassium, magnesium and calcium.

The chart below shows a typical nutrient profile for someone following a ketogenic diet.  Notice the cluster of lower levels of potassium, magnesium and calcium at the top of the chart.  There has been a lot of talk about sodium lately.  However, it seems that these other minerals are actually harder to get in sufficient quantities.

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Dr James Dinicolantonio references this study in his recent book, The Salt Fix, that shows that low sodium diets tend to lead to insulin resistance.

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The kidneys call on the pancreas to secrete more insulin to help them hold onto sodium when there isn’t much coming in from our diet.[17]

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Volek and Phinney point out that the fundamental problem with low salt diets is that they cause a loss of potassium which is critical for building and maintaining muscle.

“Salt depletion causes a compensatory loss of potassium, which has a negative impact on muscle mass since potassium is a necessary cofactor for building muscle.”

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Managing sodium and potassium is a massive deal for our body, with 40% of the body’s energy and 70% of the brain’s energy used just to manage the sodium-potassium pump that is fundamental to our energy production.

As well as for sodium, the body upregulates our basal insulin to hold on to other electrolytes such as potassium and calcium.[18]

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Ironically, a low carb or ketogenic diet that minimises total carbohydrates in an effort to reduce the bolus insulin required for our food, may actually lead to a reduction in electrolytes that drives insulin resistance through an upregulation of basal insulin to enable our kidneys to hold onto precious electrolytes if we’re not getting sufficient quantities from our diet!

Paul Jaminet points out that Palaeolithic diets were naturally high in potassium and low in sodium.  Salt was rare and highly valued, so we evolved mechanisms for protecting against the threat of low sodium levels.  However, because potassium was plentiful back then, we have not developed similar evolutionary mechanisms to protect us against low potassium levels, even though they are every bit as devastating to our health.[19]

Today, potassium tends to be hard to obtain from our diet or even from supplements (which are limited to 99mg when the RDI is 4800mg or nearly 50 capsules), so we need to pay particular attention to make sure we get enough of it.

While I don’t think it’s ideal to focus on just one nutrient, we get a respectable amount of nutrients if we just chase high potassium foods.

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And while there are a number of fruits (like bananas) in the high potassium foods list, there are still a ton of non-starchy veggies if you need to manage your blood sugar levels.

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Energy density

Once you have normalised your insulin and blood sugar levels to that of a metabolically healthy person, there may not be any use in doubling down on more dietary fat if your goal is to lose body fat.

If your goal is further weight loss, I believe the ideal approach is to maximise the nutritional content of your diet so you can minimise energy intake without risking nutrient cravings.  The image below shows how the weight loss phase of a ketogenic diet includes a substantial amount of fat coming from the body with a more modest dietary intake of fat and lower overall calories.[20]

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Foods with a lower energy density (in terms of calories per weight of food) tend to be more filling and allow you to reduce energy intake naturally which will, in turn, allow your body fat to be used for fuel.

Optimal foods for weight loss if you’re still insulin resistant

These weight loss foods prioritise low energy density while also prioritising nutrient density and a low insulin load to help you lose weight if your blood sugars are still a little elevated.

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And they contain a very respectable amount of nutrients.

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Maximum nutrients with minimum energy

Meanwhile, the foods in this list just prioritise a low energy density and high nutrient density and hence provide a lot of nutrition without too much energy.

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And the nutrient profile is spectacular!

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A Protein Sparing Modified Fast is often used in weight loss clinics to maximise the rate of fat loss while ensuring you get adequate protein to maintain your lean muscle mass.

Adding nutrient density to this protocol will further improve your chances of success by avoiding cravings and nutrient deficiencies while maintaining an aggressive energy deficit.

What I find really interesting here is that, even though we are not prioritising any of the amino acids, we are getting tons of protein!  It seems that when we focus on the harder-to-find nutrients, protein becomes a non-issue.

It’s also interesting to note that the macronutrient split of these the most nutrient dense foods is similar to the macronutrients that generate the lowest ad lib energy intake.[21]

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Conversely, actively avoiding protein tends to have a diabolical impact on the essential vitamin and mineral content of our diet as shown in the chart of the lowest protein foods below.

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As you can see from the food list below, it’s hard to minimise protein without going very high carb or relying on a lot of refined fats.

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Optimal foods for bodybuilders

If you’re a bodybuilder trying to build muscle you can focus on boosting the more anabolic branched chain amino acids (i.e. valine, leucine and isoleucine).

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The foods listed below will help you recover and build muscle if you are working out.

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Optimal foods for endurance athletes

If you are an endurance athlete who doesn’t want to rely on pasta and energy gels to get enough energy you can focus on high energy density foods while still keeping nutrient density high.

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Foods with a higher energy density are not as nutrient dense.  However, these foods are still pretty good.

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Micros > macros?

You may have noticed that the macronutrient splits of the various dietary approaches vary significantly.  However, what is consistently missing from these optimal food lists are sugars and processed grains which contain a pitiful amount of nutrition.  The contrast between the cereals, baked goods, snacks and fast foods…

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… and the most nutrient dense foods is dramatic!

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A low carb diet will ensure that you avoid the majority of these dangerous Franken foods along with the sugars, seed oils, anti-nutrients and chemicals that are often associated with processed grains.

However, what I’ve found, after playing around with all these food lists for a few years, is that everything seems to work out pretty well when we start by prioritising the harder-to-find micronutrients and tweak from there to suit our goals.

Personalised nutrition

A further problem that I identified with these lists is that they do not consider what YOU are currently eating.

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Each person’s interpretation of a low carb, ketogenic or paleo diet will vary depending on preferences, finances, culture, appetite and activity levels.

I think what you really want to know is:

which foods will provide you with more of the nutrients you are not getting from your diet right now?

So this year I’ve developed the Nutrient Optimiser algorithm, a tool that will tell you:

  • what foods you should be eating more of,
  • which foods you should be eating less of, and
  • which new foods you should look for next time you go shopping.

Rather than adopting the Pete Evans diet or the Tom Brady diet for a period and then falling off the wagon once the meal plans run out, the Nutrient Optimiser will help you help you make continual incremental improvements in your journey towards optimal nutrition.

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The algorithm takes your food log, entered in Cronometer, and analyses it to see which nutrients you are currently not getting enough of.

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Nutrient imbalances

We also look at the critical ratios to make sure we’re not prioritising nutrients that are going to exacerbate any current imbalances.  The chart below shows an example of how we can use these ratios to refine the nutrients we want to prioritise.

ratios ratio target recommendation
Omega 6 : Omega 3 0.3 < 4 omega 6 : Omega 3 ratio is good.
Zinc : Copper 7 8 – 12 zinc : copper ratio is outside limits.
Potassium : Sodium 1.5 > 2 potassium : sodium ratio is low.
Calcium : Magnesium 2.3  < 2 calcium : magnesium ratio is high.
Iron : Copper 11 10 – 15 iron : copper ratio is within range.
Calcium : Phosphorus 0.6 > 1.3 calcium : phosphorus ratio is low.

Tailoring nutrition to suit blood sugar and weight loss goals

The Nutrient Optimiser algorithm also helps you choose your ideal dietary approach based on your blood sugars as well as our performance and weight loss goals.

approach average glucose (mg/dL) average glucose (mmol/L)
well formulated ketogenic diet > 140 > 7.8
diabetes and nutritional ketosis 108 to 140 6.0 to 7.8
weight loss (insulin resistant) 100 to 108 5.4 to 6.0
weight loss (insulin sensitive) < 97 < 5.4
most nutrient dense < 97 < 5.4
nutrient dense maintenance < 97 < 5.4
bodybuilder < 97 < 5.4
endurance athlete < 97 < 5.4

Targeted nutrients to suit your symptoms

We can also factor in additional nutrients that relate to your current symptoms such as diabetes, low testosterone, fertility or a wide range of other conditions associated with nutrient deficiencies.

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Optimal food to suit your goals

The algorithm then generates a suite of personalised food sorted in descending order lists tailored and prioritised to suit your goals.  And coming soon, optimal meals and meal plans that will align with your goals.

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Best and worst days

The algorithm also gives a nutrient score for each day of your food log.  You can learn a lot by reflecting on what you are consuming on your best and worst days.

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Leaderboard

To date, I’ve run the Nutrient Optimiser analysis for about seventy different people.

It’s exciting to see the competitive types try to work their way up the leaderboard.

And if you’re a nutrition nerd like me you may find it interesting to head over to the leaderboard and drill down to see what each of these people is actually eating to achieve these high and low nutrient scores.

Sitting in first place at the top of the leaderboard is Dr Rhonda Patrick who, as you can imagine, does look like she eats pretty healthy.

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But the best competition is against yourself, with incremental improvements by implementing the recommendations of each iteration of the Nutrient Optimiser analysis.  For example, we can see Andy Mant has made leaps and bounds in his diet in preparation for his recent Paris wedding.

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Andy had some great success with plenty of seafood and oysters (check out his report here).  Meanwhile, people like Amy boost their nutrients with organ meats on a zero carb approach.  Others achieve a high level of nutrient density with plenty of green veggies.

The Nutrient Optimiser still doesn’t force you to eat specific foods but allows you the latitude to find the best selection of foods that align with your preferences.

Want to learn more?

If you’re interested, all the food lists (and a whole lot more) are available for free here.

If you want to learn more about the Nutrient Optimiser you can check out the FAQ over at NutrientOptimiser.com.

There are also a number of Facebook groups where you can participate in the discussion about Optimising Nutrition and share the journey.

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My hopes for the future

I presented the guts of this article as a presentation at Low Carb Down Under Gold Coast in October 2017.  A frequent comment was that it was apparent that I had spent a LOT of time developing the food lists and the Nutrient Optimiser.  Yes indeed, this has been a labour of love.  A challenging problem to solve with personal ramifications.

I would love to see the Nutrient Optimiser take off and help a lot of people and perhaps pay for a little of the time that I have invested into it.  Getting some income will enable it to be developed into a quality system that will help a lot more people.

But I really do hope that the system that I have developed will educate people to start an underground revolution by enabling them to confidently make food choices that provide them with the nutrients they need with enough energy while also optimising their hormones.

Decades of epidemiological studies have been fruitless in providing a clear direction as to the optimal human diet.  Nutrition research and education are so fraught with entrenched belief systems, confirmation bias and with conflicts of interest.

It’s impossible for the everyday person to know what they should eat to feel OK and thrive at life.  It seems Big Food is just winning and Big Pharma (also owned by the same companies) is making a killing cleaning up the mess.  The current system is broken and needs to change!

The Nutrient Optimiser algorithm gives us the chance to redesign and rebuild nutrition from the ground up.  My dream is that it will empower educated enthusiasts, then dieticians and personal trainers, then doctors, then insurance companies and then medical systems.  At that point, big food will catch on and realise they need to provide nutritious foods that enable people to thrive and win at life.

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references

[1] http://www.diabetes-book.com/laws-small-numbers/

[2] https://ses.library.usyd.edu.au/handle/2123/11945

[3] https://optimisingnutrition.com/2015/07/06/insulin-index-v2/

[4] https://optimisingnutrition.com/2015/03/30/food_insulin_index/

[5] https://optimisingnutrition.com/2015/03/23/most-ketogenic-diet-foods/

[6] https://optimisingnutrition.com/2017/06/03/why-do-my-blood-sugars-rise-after-a-high-protein-meal/

[7] http://www.medscape.org/viewarticle/438374

[8] https://www.ncbi.nlm.nih.gov/pubmed/16705065

[9] https://www.bodybuilding.com/fun/max_insulin_response.htm

[10] https://www.t-nation.com/diet-fat-loss/anabolic-power-of-insulin

[11] https://www.youtube.com/watch?v=VjQkqFSdDOc

[12] https://chrismasterjohnphd.com/2017/08/19/29-gluconeogenesis-expensive-essential-mwm-2-29/

[13] https://www.ncbi.nlm.nih.gov/pubmed/15836464

[14] https://optimisingnutrition.com/2015/03/30/what-about-fibre-net-carbs-or-total-carbs/

[15] https://optimisingnutrition.com/2016/01/25/fructose-victim-or-villain/

[16] https://www.drfuhrman.com/learn/library/articles/95/andi-food-scores-rating-the-nutrient-density-of-foods

[17] https://www.ncbi.nlm.nih.gov/pubmed/21036373

[18] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC301822/

[19] http://perfecthealthdiet.com/

[20] https://www.youtube.com/watch?v=2KYYnEAYCGk

[21] https://www.ncbi.nlm.nih.gov/pubmed/24588967

“high protein” vs “low protein”

In a recent Facebook thread Richard Morris of 2 Keto Dudes fame said:

The lipophobics and the aminophobics are both talking past each other at strawmen.  

The hysteria is not just humorous, it’s confusing and turning away novices.  

This phony controversy causes people to recommend insane amounts of protein at BOTH ends of the spectrum.

Protein tends to be a passionate topic of discussion n the online macronutrient wars.  So I thought it would be useful to set out arguments at both extremes of the ‘protein controversy’ and detail some responses to bring some balance.  My hope is that this article will bring some clarity to the civil war in the low carb/keto community.

The TL:DR summary is:

  • appetite is a reliable driver to make sure you get enough protein to suit your needs,
  • our appetite decreases when we get enough protein,
  • it’s hard to overeat protein because it’s hard to convert to energy, so the body doesn’t want more than it can use,
  • most people get adequate protein without worrying about it too much,
  • people who require a therapeutic ketogenic approach should pay attention to their diet to ensure that they don’t miss out on essential micronutrients while maintaining a low insulin load, and
  • if you prioritise nutritious whole foods, you’re likely getting enough protein but not too much.

If you want more detail, read on! The arguments and responses of the two sides are outlined below.  The article then concludes with some learnings and observations from the Nutrient Optimiser about how we can optimise protein intake to suit our goals and situation.

High protein bros

This section outlines the arguments and responses from the “high protein bro” extreme end of the debate.

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“There is no such thing as too much protein.”

Refined protein supplements do not contain the same quantity of much vitamins, minerals or essential fatty acids as whole foods.

As shown in the plot of percentage protein vs nutrient score, a focus on obtaining adequate vitamins, minerals and essential fatty acids from whole foods typically leads to obtaining plenty of amino acids.  Meanwhile, actively avoiding protein tends to dilute overall nutrient density in terms of vitamins and minerals.

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The body typically down-regulates appetite before it consumes ‘too much protein’.  It is physically difficult to eat ‘too much protein’ from whole foods (although hyperpalatable whey protein shakes may be another matter).

While protein is beneficial, we also need a balanced diet that provides the other vitamins and minerals (e.g. electrolytes that will enable the kidneys to maintain acid/base balance which is critical to insulin sensitivity which is hard to obtain from protein supplements).

In summary, it is possible to focus too much on protein to the point that you are missing out on other important micronutrients.  Conversely though, if you chase micronutrients from whole foods you will get adequate amounts of protein.

“Fasting will cause you to lose muscle due to a lack of protein intake.”

A high-fat diet reduces the need for glucose and therefore the requirements for protein from gluconeogenesis decrease.  Someone who is ‘fat adapted’ with lower insulin and blood glucose levels will also be more readily able to access their stored body fat for fuel.

The body defends lean muscle loss by upregulating appetite.[1]  People with more body fat and/or lower insulin levels will likely find fasting easier than people who are lean and/or have high insulin levels.

Fasting will drive autophagy, which is beneficial, to an extent.  Fasting and feasting is a cyclic process of building and cleaning out.  We need to balance both parts of the cycle.  Humans generally do this well in the absence of hyper-palatable processed foods.

One of the benefits of fasting is that when you re-feed, your body will be more insulin sensitive so you will build back new muscle more efficiently with less protein and insulin required.  People doing regular multi-day fasts should ensure their average protein intake is adequate over a number of days and not just on the days they eat.

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You should target more nutritious foods on your eating days to ensure you are getting adequate nutrients over the long term.  If your goal is to lose body fat, then re-feeding to satiety on very high-fat foods may be counterproductive in terms of fat loss and micronutrient sufficiency.[2]

“Everyone needs to lift heavy weights and be jacked.”

Not everyone wants to look good with their shirt off or is willing to invest the dedication that it takes to have a six-pack.  However, being active and having sufficient lean muscle mass is important to maintaining insulin sensitivity and delaying the diseases of ageing.  Doing something is better than nothing.  Having sufficient lean muscle mass is arguably better than manipulating macronutrients if your goal is glucose disposal and fat burning.

Low protein “ketonians”

This section outlines a number of arguments against ‘too much protein’ along with some responses.

“Too much protein will turn to glucose like chocolate cake in your bloodstream”

Protein can be converted to glucose via gluconeogenesis if there is no other fuel available.  However, gluconeogenesis does not come easily, and the body only resorts to increased levels of gluconeogenesis above baseline levels in emergency situations.  Gluconeogenesis yields only 2 ATP from 6 ATP.[3]

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“Too much protein is dangerous for your kidneys”

High levels of protein are only a concern if you have a pre-existing kidney issue,[4] and even then not everyone is in agreement.

“Protein is expensive and a waste to use for fuel”

The fact that using protein for fuel is metabolically expensive can be beneficial if our goal is fat loss as it increases overall energy expenditure.[5] [6]  By contrast, fat and carbs are more efficient fuel sources.  Higher levels of protein intake will drive satiety as well as being less efficient and cause more losses.

High protein foods are often financially expensive.  Processed high fat and high carb foods are cheaper to produce and hence can have a higher markup applied to them.  Thus, food companies tend to promote cheaper foods with a higher carb and/or fat content.

“Too much protein is dangerous for people with diabetes.”

People with diabetes convert more protein to glucose through uncontrolled gluconeogenesis (i.e. due to insulin resistance in Type 2 and a lack of insulin in Type 1).[7]  They also find it harder to build muscle due to a lack of insulin.  Hence, people with diabetes may benefit from consuming more protein to maintain or gain muscle.

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Conversely, people who are insulin sensitive may require less protein because they can use it more efficiently to build and repair muscle.

Older people tend to require more protein to prevent sarcopenia.[8]  A loss of lean muscle mass is a significant risk factor for older people.[9]

As shown in the chart below, people with diabetes (yellow lines) produce more insulin in response to protein than metabolically healthy people (white lines).[10]  Forcing more protein beyond satiety may make diabetes management more difficult.  However, most people get the results they require from reducing carbohydrates.  The fact that protein turns to glucose can be a useful hack for people with brittle diabetes who want to get their glucose without the aggressive swings that refined carbohydrates can provide.

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“Too much protein will make it hard maintain healthy blood sugar levels because protein stimulates insulin and glucagon.”

Protein requires insulin to metabolise.  Insulin also works to keep glycogen stored in the liver.

As shown in the charts below,[11] an increase in protein in the diet typically forces out processed and refined carbohydrate and so decreases your insulin and glucose response to food.[12] [13] [14] [You can check out the interactive Tableau version of these charts here.]

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People with Type 1 diabetes don’t have enough insulin to metabolise protein and maintain healthy blood sugars at the same time and hence require exogenous insulin.

People with Type 2 diabetes often have plenty of insulin but need to ‘invest’ their insulin wisely on metabolising protein to build muscles and repair their vital organs rather than ‘squandering it’ on refined carbohydrates.

People with hyperinsulinemia will often see their blood sugars decrease after a high protein meal as the insulin released to metabolise the protein also works to reduce their blood sugars.[15]

If you see your blood sugars rise after a high protein meal you may have inadequate insulin.  IF you have an insulin insufficiency, you may need to learn to accurately dose with insulin for protein rather than avoiding protein.[16]

“High protein will shorten life due to excess mTOR stimulation.”

Humans need to balance growth (i.e. increased IGF-1, insulin and mTOR) with repair (i.e. autophagy, fasting and ketosis).  Driving excess growth through unnatural means may not be beneficial for long-term health.

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However, the research into protein restriction and longevity is either theoretical or in worms in a petri dish where they grew more slowly when protein and/or energy was restricted.  Free-living humans typically don’t manage to voluntarily restrict energy intake.  We seem to have an inbuilt drive to protect ourselves from a loss of muscle mass, depression (note: good nutrition, especially amino acids is crucial to brain function) and loss of sex drive, and generally feeling cold and miserable.

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Longevity research in monkeys suggests that energy restriction or at least a reduction in modern processed foods is beneficial.  However, there is no research in mammals that demonstrates that protein restriction extends lifespan or health span.

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The low target protein values proposed by some for longevity (i.e. 0.6g/kg lean body mass or LBM) are practically impossible to achieve from whole foods without the addition of a significant amount of oils and refined fats and/or substantial calorie restriction to the point of rapid weight loss (e.g. check out the Nutrient Optimiser analysis of Dr Rosedale’s diet here).

There is a difference between lifespan and healthspan. Humans in the wild who are frail risk fractures and other complications related to muscle wasting and lethargy.

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As shown in the chart below, there is an optimal balance between growth and wasting.[17]  Too much insulin and you grow to the point that you get complications of metabolic disease.  Too little growth and you become frail, lose your muscle and bone strength then you may fall, break your hip and never get up again.

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“Just eating protein won’t give you gainz!”

Yes indeed!  You need to force an adaptive stress to cause muscle gains, not just eating protein.  If you work out, you will likely crave more protein.  This is natural and healthy and ensures that we can recover, adapt and get stronger.

“Overeating protein will make you fat.”

Excess consumption of any macronutrient will make you fat.  However, eating more protein and fewer carbs and fat tends to increase satiety.[18]

Research in resistance-trained athletes shows that overeating protein does not cause an increase in fat mass.[19] [20]  Research in sedentary adults shows that overeating protein causes a more favourable change in body composition than overeating the same amount of calories from fat and/or carbohydrate.

“Too much protein will lead to rabbit starvation.”

Healthy people can metabolise up to 3.5g/kg protein per day and digest up to 4.3g/kg per day.[21]  This makes sense in an evolutionary context (or even in more recent times before we had refrigerators) when there wouldn’t have been a regular supply of food but we would have needed to be able to use the food when we came across a big hunt after a long famine.

Theoretical research suggests there is no upper limit to protein intake to the point it is dangerous.   However, the practical upper limit seems to be around 50% of energy intake.  If you force extreme levels of protein, you get thirsty and pee out the excess protein.

Growing children and active people tend to crave higher levels of protein to build and repair their muscles (i.e. 10-year-old Bailan Jones, shown on the right here with his brother, who is a growing young man with Type 1 who consumes 4.4g/kg LBM).

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If you’re obese and eat only lean protein, your body will be forced to use body fat for fuel.  If you are very lean and eat nothing but very thin protein satiety will kick in and you will not have enough body fat to burn.  This is dangerous and leads to death.  So if you are already very lean and going to live in the wilderness with only wild rabbits to eat, make sure you take some butter.  However, most people will have adequate body fat to use for fuel for a significant period of time before rabbit starvation would be an issue.

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“If you’re not losing weight, you should cut your protein and your carbs and eat fat to satiety.”

Reducing processed carbs helps to lower insulin and stabilise blood sugars and helps a lot of people reduce their appetite and lose body fat.[22] [23]  However, not everyone reaches their optimal weight with this method.

LCHF / keto works until it doesn’t.

Many people find that they need to reduce dietary fat in addition to carbohydrates to ensure they burn body fat.

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Restricting protein and carbs while eating ‘fat to satiety’ may lead to an inadequate intake of vitamins and minerals which can lead to cravings and a lack of satiety.[24] [25]

While reducing the insulin load of your diet to the point that we achieve healthy blood glucose levels often helps improve satiety, effective weight loss diets typically involve some permutation of reduced fat and/or carbs to achieve a reduction in energy intake.

Medical weight loss clinics typically use a version of a protein sparing modified fast which provides adequate protein to prevent loss of lean muscle mass while restricting carbohydrates and fat.[26] [27] [28]

People on a low carb or keto diet may have an increased requirement for protein due to the body’s increased reliance on protein for glucose compared to someone who is getting their glucose from carbohydrate.[29]  Protein is the most satiating macronutrient and eating more fat when your appetite is actually craving protein, or other nutrients may lead to excess energy intake.[30]

“Too much protein will kick you out of ketosis and halt fat burning.”

Contrary to popular belief (which is often propagated by people marketing ketogenic products), ketosis is only one of a number of pathways that we burn fat.

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Ketones (i.e. AcetoAcetate or AcAc) are produced when there we don’t have enough Oxaloacetate (OAA) to produce citrate in the Krebs cycle.[31]

If you are consuming enough protein and/or carbs to provide OAA you will still burn fat but through the Krebs cycle rather than via ketogenesis.  Thus, you may be “kicked out of ketosis” if you eat more protein but you’re still burning plenty of fat.[32]

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fat burning via Krebs cycle or ketosis (via Amy Berger)

If you have high levels of NADH (which is associated with ageing and diabetes),[33] [34] [35] more of your AcAc will be converted to BHB in the liver.

Most people will see ketones in their blood increase when fasting or restricting energy intake due to the lack of OAA as they burn body fat.  As shown in the chart below, blood glucose levels decrease while BHB increases.

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There are a number of beneficial processes (e.g. autophagy, increased NAD+, increase in sirtuins) that current during fasting/energy restriction that is associated with increased BHB.  It is possible that many of the benefits related to BHB may actually be due to these other beneficial processes that occur in endogenous ketosis (i.e. it’s probably not the ketones).

We can force higher levels of BHB in the blood by eating more dietary fat and less protein and carbohydrates.  In this case, high BHB may be an indication that you are eating more fat than can be burned in the Krebs cycle and it is building up in the blood.   High levels of BHB in the blood do not mean you are achieving the same benefits via exogenous ketosis as we do in endogenous ketosis.

If your AcAc is not converted to BHB due to a low NAD+:NADH ratio you will tend to see more breath acetone (BrAce).  If you do not have metabolic syndrome, you may see higher levels of BrAce (i.e. measured with the Ketonix) and lower levels of BHB in the blood.   You should also be aware that exercise and an adequate intake of B vitamins in the diet will also increase your NAD+ levels and ‘kick you out of ketosis’.

Before you get caught up chasing ketones by whatever means possible, you should keep in mind that someone who is metabolically healthy and easily able to access their body fat stores for fuel (i.e. low insulin levels) will have lower overall levels of energy floating around in their blood (i.e. from blood glucose, ketones or free fatty acids).  Higher levels of energy in the bloodstream is a sign of poor metabolic health and reduced ability to access and burn fat.

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High levels of glucose lead to glycation.  High levels of free fatty acids lead to oxidised LDL.  High levels of glucose and free fatty acids tends to lead to glycated LDL.  High levels of ketones can similarly lead to metabolic acidosis if not balanced with an adequate mineral intake which may also ‘kick you out of ketosis’.[36]

Learnings from the Nutrient Optimiser

What is everyone else doing?

The Nutrient Optimiser Leaderboard demonstrates that low carbers have a wide range of protein intakes.

  • The average fat intake of these people is 60%, with half the people between 54% and 68% calories. The average carb intake is 11% with half the people between 6 and 15%.   So, we can see that this is generally a CLHF population.
  • Half of the people lie between about 1.4 and 2.5g/kg LBM with an average of 2.1g/kg LBM. In terms of percentage, half of the people sit somewhere between 18 and 29% of energy from protein with an average of 24% energy from protein.
  • Dr Rhonda Patrick, who is sitting at the top of the leaderboard, seems to be eating about 2.5g/kg LBM protein even though she says she is not particularly active and eats heaps of veggies.
  • People who are active tend to eat more protein (e.g. Brianna, Andy Mant and Alex Leaf).
  • “High” protein advocates Luis Villasenor of Ketogains and Dr Ted Naiman both seem to be consuming around 2.4g/kg LBM to support recovery from their higher activity exercise levels.
  • People following a zero carb approach tend to be eating more protein (e.g. Shawn Baker at 6.1g/kg LBM and Amy on 3.3g/kg LBM) as more of their energy comes from animal food. Perhaps many of the satiety effects of a Zero Carb dietary approach are actually due to the high satiety effects of protein.
  • The people with less than 1.0g/kg LBM tend to be relying on a significant amount of added fats and do not tend to achieve the highest overall nutrient score (see examples here, here and here).

What are the recommendations?

The very wide range of protein intake levels can be confusing.  Some are outlined below for reference.

  • In long-term fasting, we use about 0.4g/kg LBM protein from our body via gluconeogenesis.
  • The Estimated Average Requirement is 0.68g/kg body weight for men to prevent protein related deficiencies and 0.6g/kg body weight for women.  For a woman with 35% body fat, this equates to 0.92g/kg LBM as a minimum protein intake.[37]  (Note: These standard values are in the context of someone eating a conventional diet where they would typically be getting plenty of glucose from carbohydrates and are not particularly active, and protein requirements may be higher where someone is active and using some protein for glucose via gluconeogenesis.)
  • The Recommended Daily Intake is 0.84g/kg body weight for men to prevent protein related deficiencies and 0.75g/kg body weight for women (Note: For a woman with 35% body fat this equates to 1.15g/kg LBM as a minimum for someone who is sedentary).[38]
  • Steve Phinney recommends 1.5 to 2.0g/kg reference body weight (see slide below from his recent presentation in Brisbane) which equates to around 1.7 to 2.2g/kg LBM for someone wanting to lose 10% of their body weight to achieve their ideal ‘reference weight’. This increased level allows for some glucose to come from protein via gluconeogenesis and allows adequate protein for people who are not eating carbs and active.

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  • Ketogains suggest 0.8 to 1.0g/lb LBM or 1.8 to 2.2g/kg LBM for people who are looking to maintain or build higher levels of muscle mass.
  • Mainstream bodybuilding recommends 1.7 to 2.5g/lb body weight or 3.7 to 5.5g/kg body weight.[39] For someone with 15% body fat, this equates to 4.3 to 6.4g/kg LBM!!!

What happens to micronutrients when we chase protein?

When I first started tinkering with nutrient density, I assumed that we would want to boost all the essential nutrients (i.e. similar to Dr Mat Lalonde’s approach[40]).  The chart below shows the nutrients provided when we prioritise foods that have higher amounts of all the essential micronutrients.  The amino acids are shown in maroon.

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The ‘problem’ with this array of foods is that, because protein is easy to obtain, this group of foods ends up being very high in protein!  Even the “high protein bros” won’t be able to consume seventy percent of their energy from protein.

grilld-healthy-guy-slider[1].jpg

As you can see from the figure below, we typically can’t eat more than 50% of our energy from protein.  However, satiety levels tend to be highest, and hence energy intake is the lowest at around 50% protein (dark blue area).[41]

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There is generally no need to prioritise amino acids because it is easy to meet the Recommended Daily Intake for amino acids if we eat whole foods.

Emphasise only harder to find nutrients

Rather than prioritising all the micronutrients, the chart below shows the micronutrient profile that we get if we prioritise the harder to obtain micronutrients (shown in yellow) without prioritising any of the amino acids (shown in maroon).   (Note:  Vitamin E and Pantothenic Acid haven’t been prioritised as the target levels are based on population averages rather than deficiency studies).

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As you can see, we still get heaps of protein. However, we get a much better micronutrient profile in the vitamins and minerals because we are only prioritising the harder to find micronutrients.

Maximising nutrient intake while minimising energy intake appears to be central to reducing natural energy intake and minimising nutrient related cravings and bingeing.  It’s not hard to see how we could reduce our energy intake eating these foods while still getting plenty of the essential micronutrients.

Highest protein foods

For comparison, the chart below shows the nutrient profile of the highest protein foods.   It seems when we prioritise foods based on their protein content we end up missing out on a number of the vitamins and minerals.  Thus, there appears to be a danger that we will miss out on micronutrients when we focus only on protein.

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Do plant-based diets provide enough protein?

The one situation I have seen people not meeting the recommended daily intake levels for protein is people following a purely plant-based diet.  In the nutrient profile shown below, Sidonie is only getting 11% of her calories from protein and you can see that leucine is not meeting the DRI levels while methionine and lysine are just meeting the minimum levels.  This may be a legitimate concern for someone on a plant-based diet as amino acids tend to be less bioavailable from plans in comparison to animals.

20637881_10154774580355544_1267803003644038293_n[1]

The image below shows the foods that will help to fill in the gaps in her current nutritional profile which is focused on high protein vegetables and legumes.

20638355_10154774580430544_4725061376075036243_n[1]

This food list shows the foods that would fill in Sidonie’s nutritional gaps if she was open to adding animal foods.  This is an interesting contast to the typical food list for someone on a low carb diet which has a much longer list of vegetables to rebalance the vitamins and minerals.

20664543_10154774580545544_5055478220757808800_n[1].jpg

Most ketogenic foods

The chart below shows the nutrient profile of the most ketogenic foods (i.e. the ones that require the lowest insulin by limiting carbs and moderating protein).  It seems that, if you actually require therapeutic ketosis (i.e. to manage epilepsy, cancer, dementia or Alzheimer’s), you will need to pay particular attention to getting adequate micronutrients (i.e. notably, choline, folate, potassium, calcium and magnesium).

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Lowest protein foods

And finally, the chart below shows the micronutrient profile if we actively avoid protein.

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It seems that actively avoiding protein has a diabolical impact on the micronutrient profile of our food.  However, when we focus on balancing our diet at a micronutrient level, everything else seems to work out pretty well.

So what should I eat?

With all the conflicting opinions it can be confusing to know what to eat.

In the end, it comes down to eat good food when hungry. 

If we remove hyperpalatable processed foods, I think we’ll have a much better chance of being able to trust our appetite to guide us to the foods that will be good for us.

The food lists below have been prepared to provide the most nutrients while aligning with different goals (e.g. therapeutic ketosis, blood sugar control weight loss, maintenance or athletic performance).  There are a whole lot of other lists in the Optimal Foods for YOU article that are tweaked to suit different goals.

I think if you limit yourself to these shortlists of healthy foods you will be able to listen to your appetite to guide you towards the protein rich foods, the mineral rich foods or the vitamin rich foods depending on your need right now.

approach average glucose (mg/dL) average glucose (mmol/L) PDF foods nutrients
well formulated ketogenic diet > 140 > 7.8 PDF foods nutrients
diabetes and nutritional ketosis 108 to 140 6.0 to 7.8 PDF foods nutrients
weight loss (insulin resistant) 100 to 108 5.4 to 6.0 PDF foods nutrients
weight loss (insulin sensitive) < 97 < 5.4 PDF foods nutrients
most nutrient dense < 97 < 5.4 PDF foods nutrients
nutrient dense maintenance < 97 < 5.4 PDF foods nutrients
bodybuilder < 97 < 5.4 PDF foods nutrients
endurance athlete < 97 < 5.4 PDF foods nutrients

Once you’re eating well and want to further refine your diet you want to check out the Nutrient Optimiser.

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references

[1] http://www.nature.com/ejcn/journal/v71/n3/full/ejcn2016256a.html?foxtrotcallback=true

[2] https://optimisingnutrition.com/2016/10/29/the-complete-guide-to-fasting-book-review/

[3] https://www.youtube.com/watch?v=Og8PTdjVAWE

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4031217/

[5] http://www.tandfonline.com/doi/abs/10.1080/07315724.2004.10719381

[6] http://ajcn.nutrition.org/content/87/5/1558S.long

[7] https://www.ncbi.nlm.nih.gov/pubmed/15836464

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555150/

[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4066461/

[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC524031/

[11] https://public.tableau.com/profile/marty.kendall7139#!/vizhome/foodinsulinindexanalysis/insulinloadvsFII

[12] https://optimisingnutrition.com/2015/06/29/trends-outliers-insulin-and-protein/

[13] https://public.tableau.com/profile/marty.kendall7139#!/vizhome/foodinsulinindexanalysis/fatandFII

[14] https://optimisingnutrition.com/2015/06/29/trends-outliers-insulin-and-protein/

[15] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC524031/

[16] https://optimisingnutrition.com/2015/08/10/insulin-dosing-options-for-type-1-diabetes/

[17] http://press.endocrine.org/doi/full/10.1210/jc.2011-1377

[18] http://ajcn.nutrition.org/content/97/1/86.full

[19] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617900/

[20] https://jissn.biomedcentral.com/articles/10.1186/1550-2783-11-19

[21] http://www.sciencedirect.com/science/article/pii/S0261561417302030

[22] http://annals.org/aim/article/717451/low-carbohydrate-ketogenic-diet-versus-low-fat-diet-treat-obesity

[23] https://jamanetwork.com/journals/jama/fullarticle/205916?rel=1

[24] https://optimisingnutrition.com/2017/03/19/micronutrients-at-macronutrient-extremes/

[25] https://optimisingnutrition.com/2017/03/11/which-nutrients-is-your-diet-missing/

[26] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

[27] https://www.dropbox.com/s/rjfyvfsovbg9fri/The%20protein-sparing%20modified%20fast%20for%20obese%20patients%20with%20type%202%20diabetes%20What%20to%20expect.pdf?dl=0

[28] https://optimisingnutrition.com/2017/06/17/psmf/

[29] https://www.ncbi.nlm.nih.gov/pubmed/15836464

[30] 2http://ajcn.nutrition.org/content/87/5/1558S.long

[31] http://www.tuitnutrition.com/2017/09/measuring-ketones.html

[32] https://itunes.apple.com/us/podcast/mastering-nutrition/id1107033358?mt=2#Really

[33] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869616/

[34] https://www.hindawi.com/journals/jdr/2015/512618/

[35] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683958/

[36] https://optimisingnutrition.com/2016/11/19/the-alkaline-diet-vs-acidic-ketones/

[37] https://www.nrv.gov.au/nutrients/protein

[38] https://www.nrv.gov.au/nutrients/protein

[39] https://www.youtube.com/watch?v=3PhVURDZi1c

[40] https://www.youtube.com/watch?v=HwbY12qZcF4

[41] https://www.ncbi.nlm.nih.gov/pubmed/24588967

vegan vs keto for diabetes… which is one optimal?

I recently watched the Mastering Diabetes teleseminar on ketogenic diets with high hopes of picking up some gems of wisdom from the rising stars of the plant-based diabetes community.

Unfortunately, I was underwhelmed with what I heard.

I shared my frustration on Facebook.

Robb Wolf suggested I put together a response to some of the misinformation in the teleseminar.  Hence this post.  [Robb did an excellent breakdown on the claims in the What the Health Netflix doco, What the Health: A Wolf’s Eye View, which I highly recommend checking out if you haven’t already.]

What’s actually wrong with the keto diet for diabetes?

Cyrus Khambatta (aka Mangoman) and Robby Barbaro (The Mindful Diabetic) should be uniquely qualified, both academically and experientially having themselves lived with type 1 diabetes for decades.

If I were was going to attack keto for diabetes management, then there would have been a couple of ‘free kicks’ I think they could have taken.  So, in fairness to both sides, I’ll touch on a few of what I see as legitimate issues with ‘popular keto’ before I dissect the Mastering Diabetes presentation.

Giving fat a free pass

Humans like things to be straightforward and binary.

Yes or No.

Black or white.

High fat or low fat.

Low carb or high fat.

High protein or low protein.

Plants only or animals only.

For the last four decades, we have been told that fat, particularly saturated fat, is bad because it causes heart diseases and should be avoided.

The tide is now turning.  However, there will always be people who take things to the extreme.

Now fat is healthy.  But is more is better?

Ketones are good.  So more is better?

For many people, a higher fat diet will be more satiating, particularly compared to processed grains and sugars.  However, not everyone can ‘eat fat to satiety’ without some level of restraint and self-discipline.  We can’t all trust our appetite to kick in to effortlessly provide the lean and chiselled body that they dream of.

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My personal experience is that you can overdo the fat and drive insulin resistance by pushing fat too hard.  If you exceed your ‘personal fat threshold’[1], your adipose tissues will become insulin resistant, and the body will start pushing excess energy to the vital organs.

While there is no need to fear fat, there is no reason to go hog wild to compensate for the butter and bacon deficiencies that we all developed over the past four decades.

When it comes to nutrition, you need to get your big rocks in place first (i.e. the nutrient dense foods).  You can then fill up with fuel such as fattier foods if you do not want to burn any body fat.  You could even add some starchy carbs if your blood sugars allow.

Having some level ketones is an indication that your insulin levels aren’t too high and your metabolism is working.  However, if you are not yet metabolically healthy, chasing ‘fauxtosis’ by loading up on butter, coconut oil, cream and exogenous ketones to achieve high blood ketone levels can be a recipe for hypercaloric metabolic disaster that will drive insulin resistance.

People with type 1 diabetes (such as the Mastering Diabetes guys and my wife Monica) have a unique insight into the various factors that affect their insulin sensitivity.  They can monitor their daily insulin dose.

I know some people with type 1 diabetes who have made an effort to chase higher ketones with more refined fat and less protein but found that they ended up needing more insulin.  Retreating to a moderate to high protein approach with less added fat (as per Dr Bernstein’s recommended approach for Type 1 diabetes) enabled them to improve their insulin sensitivity (e.g. check out Allison’s Nutrient Optimiser analysis here).

This phenomenon is not unique to people with type 1 diabetes.  There seem to be more and more people start out believing calories don’t count, only hormones.  They then put their faith in the ‘magic ketone fairy’ and end up driving insulin resistance and obesity chasing ‘optimal ketone levels’ with more and more added fat.[2]

I have a dream

Before we get into the nutritional analysis, permit me this indulgence to share my vision (with a hat tip to Martin Luther King) from Martin Laurence Kendall.

I have a dream that one-day nutrition will be defined by the nutrients that a food contains and the health benefits that it confers rather than religious and ethical beliefs or commercial interests.

I have a dream that all people, mothers and children, fathers and brothers, would be able to clearly understand the foods that are truly optimal for them.

I have a dream that one day all people afflicted with diabetes will be able to choose foods that will enable them to achieve normal blood sugars and restore the health and vitality that they deserve. 

Further, that they will be able to choose optimal foods, with engineering precision, without being affiliated with the needless ridicule that they will needlessly die of a heart attack due to unnecessary fears about ‘artery-clogging saturated fat’ or ‘harmful animal proteins’. 

I have a dream that one day people will have, freely in their grasp, quality nutritional information that enables them to make informed choices that will, in turn, bring about a new day in the commercial food environment. 

I dream that one day all people, obese, diabetic, children and athletes alike,  will be free from the corruption of Big Food and Big Pharma working through diabetes educators, diabetes associations, heart associations, medical institutions and animal welfare advocates.   

Free at least.  Free at last. 

I hope that one day we will be free at last. 

Indulgence over.  On with the data.

On with the data.

Nutrient deficiencies in a high-fat diet

Another fact that I thought Cyrus and Robby would mention was that very high-fat foods tend to have a weak nutrient profile, especially compared to non-starchy vegetables.

The chart below shows the nutrients provided by the 800 highest fat foods out of the 8000 foods in the USDA database.   If we prioritise fat, we will likely be lacking in around half of the essential nutrients.

A summary of some of the highest fat foods is shown below.

[For some real-life examples of the poor nutrient profiles achieved by people chasing high ketone levels in the misguided pursuit of weight loss check out the Nutrient Optimiser reports here, here, here here and here.]

Vitamins and minerals,  in particularly electrolytes such as potassium, magnesium and calcium are critical to support our mitochondria, enabling them to produce energy and maximise insulin sensitivity.

People in the keto community are conscious that electrolytes are essential and go out of their way to supplement with magnesium, calcium, sodium and potassium as well as taking bone broth.

The kidneys let go of water and electrolytes when insulin levels drop.  A ketogenic diet without attention to green leafy veggies is at risk of being very low in electrolytes.  This will cause the pancreas to secrete more insulin to hold onto the scarce electrolytes.  This increase in insulin levels may[3] ironically drive insulin resistance.

Whether you call them electrolytes or alkaline foods[5], our bodies need enough substrate to allow our kidneys to maintain a good acid/base balance without having to work too hard.  Focusing on minerals can helps us maximise insulin sensitivity and ensure oxygen is efficiently be carried around our bloodstream.

There are plenty of foods available to provide the micronutrients that you need if you actually require therapeutic ketosis as an adjunct to cancer, epilepsy or dementia.  We can achieve the Daily Recommended Intake (DRI) for most of the nutrients while still maintaining a low dietary insulin load.

The short list of foods that comprise a ‘well formulated ketogenic diet’ are shown below.

However, if you just need to manage diabetes with a low-carb diet (rather than therapeutic ketosis), you can achieve even higher levels of nutrition while maintaining stable blood sugars.

Given my family history of Type 2 and my wife Monica’s Type 1 diabetes, we generally focus on the foods listed below.  Lots of people have found these lists useful.  You can pin them to the fridge as a reminder of what you should focus on or print it out to take shopping next time when you need some inspiration.   (There is a complete list of nutrient dense foods to suit different goals at the end of this article.)

Now my blood glucose levels are more stable, I’ve been trying to back off on the higher fat foods and focus on more nutrient-dense foods to build muscle and lose fat.

The ‘problem’ with the most nutrient-dense foods (as shown below) is that they typically have a very low energy density so it will be nearly impossible to get enough energy to prevent rapid weight loss.

Prioritising nutrient-dense foods is the secret to obtaining the nutrients you need with the lowest energy intake.  If you don’t want to keep losing weight or want to run a marathon then adding some higher energy density foods will be useful.

High carbohydrate foods are not  nutritious

After watching the Mastering Diabetes teleseminar, you will get the feeling that the Mastering Diabetes guys believe carbohydrate can do no wrong and we should only fear fat.

The reality, however, is that the foods with the least fat are generally even more nutritionally corrupt than the highest fat foods.

Not all of the low-fat foods are going to be beneficial.

Defining your nutritional approach as ‘high carbohydrate’ is not wise, especially if you are trying to manage diabetes.  The foods with the most carbohydrates in our food system are typically very nutritionally deficient as well as highly insulinogenic.

If a ‘low carb diet’ leads you to avoid processed foods you may be better off.  However, I don’t think defining nutrition in terms of macronutrient extremes is particularly useful. [6]

Plant-based versus animal-based foods

One area where vegans potentially have it over carnivores is vitamins and minerals.  As shown in the chart below, a zero carb diet does not provide really high levels of many nutrients.

2017-06-26-5[1]

At the same time, there are plenty of people who appear to be thriving on a zero carb dietary approach.  Many people with severe autoimmune related digestive issues succeed when they switch to a zero carb approach.   Zero carb advocates will also tell you that they don’t need the recommended daily intake levels of the various micronutrients that are based on limited data or deficiency studies in people eating a standard high carb western diet.

2017-06-26-4[1]

A plant-based diet can provide a reasonably nutrient dense outcome.  However, it will be hard to get adequate levels of omega 3, vitamin D and vitamin B-12.  People following a strictly plant-based approach may need to supplement with these nutrients.

Achieving the minimum protein intake levels is possible.  However, many people have concerns about the reduced bioavailability of plant based proteins and whether or not the minimum protein intake levels are actually optimal, particularly if you are active or older.

It’s also worth noting that other nutrients such as iron, vitamin A and omega 3 will be more bioavailable from animal-based sources.  So it’s not as simple as comparing the nutrients in the food, what gets into your body is what really matters.

If you are going to follow a plant-based diet then prioritising the food listed below will give you the best chance of success.  Most people are going to do best somewhere on the spectrum between exclusively plant-based and solely animal-based foods.

The real problem comes when we start to heavily process our food.  Rather than prioritising the most nutrient dense and minimally processed vegetables, fruits and legumes, many vegans end up living on processed grains, cereal, sugar and soy products that have been treated with a host of fertilisers and pesticides.  Meanwhile, many zero carbers or keto peeps end up living on nothing but bacon or processed meats from animals that were fed nutrient poor corn and grains with added antibiotics to make them grow quicker.

The vegan echo chamber

I have spent a good chunk of time hanging out in many vegan or plant-based groups trying to understand their position and gain insights about nutrient density.  I have learned a lot from people like Professor Christopher Gardner, Ray Cronise and Dr Joel Fuhrman.  Much of the analysis in this is based on the integration of my learnings their work with Dr Richard Bernstein and Dr Matt Lalonde.

Unfortunately, it seems that the vast majority of vegan/plant-based education comes from Dr Michael Greger through his sanitised, highly processed and hyper-palatable “Nutrition Facts” videos.

While Greger covers a lot of relevant research and raises some valid points, a lot of the time he seems to twist the science to ensure that the moral of the story is always ‘eat plants, not animals’.  Plant-based is better.  Eating animals will be bad for your health.

Without evolutionary context, we are asked again and again to believe that fat (particularly saturated fat) and ‘animal protein’ (whatever the hell that is!) is the primary cause of heart disease, the complications of diabetes and practically every other modern health ill.

There is no demonstrated biochemical mechanism provided as to how we suddenly became allergic to animal products.  Meanwhile, vegans advocates generally give a free pass to sugar and processed grains.

With more than six million views and an estimated earnings of more than $100k per year from YouTube[7] (not to mention donations[8]), there appear to be a LOT of people eager to lap up the nutritional and medical justification of their ethical position.

Greger’s unique ‘interpretation’ of the scientific data all starts to make sense once you understand that he is the Director for Public Health and Human Agriculture for the Humane Society International.[9]

The mission of the Humane Society is to celebrate animals, confront cruelty and shape public opinion.

I wonder if Greger does his researching, writing, filming and editing the Nutrition Facts videos as a hobby after he gets home after working 50 hours a week and commuting?   Or perhaps he creates these videos as an employee of the Humane Society as part of their stated goal to shape public opinion on animal cruelty?

It seems Mangoman and Robby are pretty tight with Greger.[10]  Makes me wonder if Mastering Diabetes is a coordinated and strategic assault by the Humane Society on the low carb/keto/diabetes community who have become immune to Dr Greger.

I am by no means advocating animal cruelty.  However, as a human,  if you are looking for the best advice on human nutrition, is it wise to put your blind faith and unswerving trust in someone whose explicitly stated primary goal is animal welfare?

Do you really want to save the planet?

Worrying about whether we eat plants or animals exclusively is a modern luxury, an intellectual indulgence of sorts.

For the majority of human history, we have been opportunistic omnivores.  When plants were the only thing that was available, we would eat them.  When we could, we would chase down an animal to get the protein we need to thrive.  We never had to worry about nutrient density because the foods we ate grew in fertile soil without pesticides.  The animals we ate were eating their natural foods which were also nutritious for them.

Humans thrived and were able to populate the world because we learned to hunt, store, cook and process food.  We became very good at getting the nutrients we needed with the minimum amount of effort.[11][12] [13]

Unfortunately, we have now become too good at processing food.

Many of us are now fantasising nostalgically about Paleo times.

Related image

It’s one thing to worry about saving animals, but ultimately we need to save the planet and our human race from accelerated extinction.

Our newfound ability to harvest fossil fuels enables us to move around in cars and grow a massive amount of food with chemical fertilisers.  These foods grow quickly and give us plenty of energy, but few nutrients that we then process and feed to animals or humans.[14]

Take a moment to think about how your life would be different if we had never discovered fossil fuels (e.g. coal or oil).  For as long as it lasts we are gorging ourselves on stored energy that is making us lazy and obese and driving not just us, but life as we know it to an early grave. If you want to care about something it should be the sustainability of the global environment (including animals and humans).

If you want to care about something it should be the sustainability of the global environment (including animals and humans).

While humans are probably the biggest threat to the long-term sustainability of earth as we know it, most of us aren’t willing to volunteer ourselves or our family as the first ones to check out to save the planet.

[If you want some challenging thoughts on this topic you should check out Daniel Vitalis’ Why I Hunt podcast.]

The plural of anecdote is not data

So, finally, onto the Mastering Diabetes video.

Cyrus and Robbie look like genuinely nice guys.

They are both living with type 1 diabetes.

They look like they’re happy and thriving on a plant-based diet full of fruits and vegetables.

To be honest, they look a lot healthier than many recovering diabetics in the low-carb scene.

But at the same time, the zero carbers will hold up anecdotes of people who have not eaten a plant for decades and look as great as the Johnson Family.

Or Dr Shawn Baker who is setting world records as a masters athlete since cutting plants out of his diet.

Then the keto folks will point to Dr Dominic D’Agostino who thrives on high fat and exogenous ketones and is exceptionally smart and can lift very heavy stuff at the same time.

 [15]

While it’s useful to look at populations of people following a particular diet to look for trends, anecdote does not equal data.

It is more useful to look at underlying metrics (such as nutrient density and insulin load) that we can use to identify the optimal diet for humans.

I thought they would know better

Cyrus Khambatta is a smart guy.  He was studying mechanical engineering at Stanford before he got type 1 and changed course to study nutritional biochemistry.

However, for all his ability in nutrition, engineering and mathematics (I took those classes, and I know how hard they are!), I thought he would have more to offer than what was presented!

People with diabetes get screwed around by the mainstream medical system and ‘diabetes education’ system.  The system doesn’t really understand how it works, so they give them bad advice (e.g. “just eat like we tell everyone else to and cover it with insulin”)!

I remember clearly the anxiety and confusion we experienced after going to an appointment with the hospital endocrinologist when my wife Monica was pregnant with our daughter.

At her visits, she would routinely be told that she needed to reduce her blood sugars to avoid the many serious risks and complications and risks for her and the baby.  Monica asked what else she could do to get the blood sugars down, but they had no advice.  They just wanted to see them lower.

We now have two healthy and wonderful kids, but I if I can I would love to see other people spared the anxiety as well as minimise the genuine health risks related to diabetes.  Hence my quest to understand how we can make intelligent food choices to optimise blood sugar and insulin levels.

What is the actual relationship between insulin and the food we eat?

The food insulin index data is a highly valuable resource that helps us to understand what causes us to secrete insulin and our blood sugars to rise.   The chart below shows the results of the food insulin index testing on more than 100 different foods (click to enlarge).

The food insulin index testing demonstrates clearly that we have the lowest insulin response to fats and oils while we have the highest insulin response to high carbohydrate foods like jelly beans and rice bubbles.   However, when we plot this data, we see that carbohydrate does not fully explain our insulin response.

We get a much better prediction of our insulin response when we account for protein (which requires insulin to metabolise) and non-digestible fibre.

Eating more fat will decrease the amount of insulin required to keep our blood sugars stable.

Eating more protein will reduce the amount of insulin your pancreas has to produce because it will push the more insulinogenic processed carbohydrates and sugar out of your diet.

How to improve your insulin sensitivity

If you reduce your intake of processed carbs and sugars, your insulin requirements will come down.  Once your organs and muscles are no longer swimming in insulin, you will become more insulin sensitive (just like you become more sensitive to coffee or alcohol if you cut back your intake).

If you are injecting insulin, reducing the insulin load of your diet will enable you to significantly reduce your insulin dosage which will, in turn, allow you to more easily access your own body fat stores for fuel.[16]

This data is an inconvenient truth for both high carb vegans or the nutritional recommendations such Food Pyramid / My Plate generated by the US Dept of Agriculture.  But I think it could be beneficial for people who want to effectively manage their diabetes.

Granted, if you switch your processed grains and sugar for fruits and vegetables, you will do better.  But is it really optimal?

If you can’t win, move the goalposts!!!!

So what do you do if you can’t win with science?

You change the rules!  You move the goalposts.

It was Cyrus and Robby’s unique definition of insulin resistance that really frustrated me.

So you can understand my frustration, I need to explain the difference between basal and bolus insulin which is a daily reality for someone with type 1 diabetes.

  • Bolus insulin is taken with food and is proportional to the insulin load of the food they eat (i.e. carbs – fibre + half protein)[17].
  • Basal insulin is the insulin that your pancreas would produce through the day and night whether or not you eat anything.  It’s the basal insulin that keeps your fat in storage and your muscles from being used for fuel.

You need both, but their function is different.

For someone eating a standard western diet about one-third to a half of their insulin will be basal insulin with the majority being bolus insulin for the food you eat.

When you switch to a low carb or keto diet this ratio flips and the majority of your insulin is basal insulin.  You only need a little bit of bolus insulin to cover the small amount of carbohydrates and protein that you eat.   With less glucose to deal with, you don’t need as much insulin, and your blood sugars stabilise.[18]

A significant portion of the Mastering Diabetes video was devoted to explaining their new creative definition of insulin sensitivity.  The fundamental problem with this central piece of the Mastering Diabetes argument is that it conflates basal and bolus insulin.  Your basal insulin is irrelevant if you are trying to do this sort of insulin sensitivity calculation!

It’s just the bolus insulin (i.e. for food) that matters when it comes to insulin sensitivity.  The calculations in the table below demonstrate my point.   If you take the denominator to your insulin sensitivity calculations to be the basal + bolus insulin, then the high carb approach has a better insulin sensitivity.  If you only consider the bolus insulin (the only sensible approach in my view), then you declare the low-carb approach to be the winner.

  low carb high carb conclusion
ISF (g carb/unit insulin) 6 5
carbs (g) 50 500
bolus insulin (units) 8.3 100
basal insulin (units) 20 20
total daily insulin (per day) 28 120
24 carb / 24-hour insulin (basal + bolus) 1.8 4.2 High carb is better
24 carb / 24-hour insulin (bolus only) 6.0 5.0 Low carb is better

The chart below shows the difference in the daily blood sugar fluctuations of someone on a standard western diet and then after switching to a lower carb diet.  The difference in the blood sugar levels is night and day!  The difference in the quality of life between these two situations when it comes to energy levels, anxiety, depression, mood etc. is also immensely different.

I pinged Mastering Diabetes on their Facebook page to clarify if the cornerstone of their whole argument includes basal and bolus insulin.  Unfortunately, my fears were confirmed (though they have since deleted their response and kicked me out of their Facebook Group).

Tight blood sugar control isn’t that important after all?

The next argument they try to run is that tight blood sugars really aren’t that necessary.

Cyrus (who is very active and practices intermittent fasting) has a Hba1c in the high 5s.

Robbie has a Hb1c in the low 6s.

Granted, this is good compared to the majority of the Type 1 population. They’ll have a better chance of thriving with good blood sugars if they are eating lots of vegetables and fruit compared to more processed grains and sugars that make up the typical diet.  But it’s still a far cry from the blood sugar control of people following the type of low-carb approach advocated by Dr Richard Bernstein.

The problem I see with defining your diet as vegan or plant-based is that most people don’t have the self-discipline to stick with eating only vegetables and fruit and end up filling up on more processed (but still technically vegan) processed junk food.

Cyrus and Robbie argue that normal blood glucose fluctuations are between 70mg/dL to 145 mg/dL or 3.8 to 8.0mmol/L.

The problem with this argument is that what currently passes for ‘normal’ is far from optimal.[19]  Complications from diabetes start to kick in well below what is widely considered “normal”.


Just because it’s normal for most people to do Facebook on their phone while they drive doesn’t mean it’s ideal or optimal.  Just because it’s normal to have poor blood sugar and most people are dying of metabolic diseases doesn’t sound like a persuasive argument for plant-based diet being optimal to me!

If you’re happy to settle for less than optimal blood sugar control because you have a strong ethical position, then that’s fine, but don’t construe it as optimal for everyone when it’s not.

The reality is that many people over at Type 1 Grit following Dr Bernstein’s approach are doing fabulously!  Not everyone will achieve optimal, but it’s useful to know what to aim for and how to get there.

If you had a child or loved one with Type 1 diabetes would you want the opportunity to choose the approach that would yield the best results or would you prefer your advice to be tainted with ethical or commercial bias?

Check out the video the Type 1 Grit group put together for Dr B’s 83rd birthday to thank him for changing their lives.

Insulin resistance and metabolic syndrome are a big deal, so let’s not ruin more lives than we need to with bad advice that is based on bad math or putting ethical convictions or religious beliefs ahead of human health.

Understanding physiological insulin resistance

Cyrus and Robbie argue that someone on a low carb diet won’t deal with carbohydrate well when they are exposed to them.  This phenomenon is real, but is typically due to what is termed ‘physiological insulin resistance’.

Someone who eats a lot of carbohydrates will have high levels of insulin floating around in their bloodstream.  Then when they eat a carb bolus, their pancreas is primed to shoot out some more insulin to mop up the glucose and stop more glucose being released into the bloodstream via the liver.  By contrast, someone who doesn’t eat a lot of carbohydrates will have low levels of insulin in their bloodstream and need to wind up their pancreas to produce insulin to bring down the glucose.

This phenomenon is also referred to the first phase versus second insulin response.  Someone who is not eating a lot of carbs will have a slower first phase insulin response.

It’s like comparing someone’s time over 100m when they are starting from a standstill versus someone using a rolling start.  It’s not a relevant comparison.  This phenomenon will go away after a few days on a high carb diet.

At the same time though, micronutrients such as potassium, magnesium and calcium are critical to maintaining healthy insulin sensitivity and glucose uptake.   Metabolic acidosis (caused by a lack of dietary electrolytes) appears to cause an upregulation in insulin by the pancreas to hold onto precious electrolytes.  Over the long term, this could be another driver of insulin resistance, metabolic syndrome and diabetes. [20]

Getting adequate dietary electrolytes from green leafy vegetables will make it easier for our body to maintain acid/base balance.  However, I don’t think we need to feed all diabetics a high carbohydrate exclusively plant-based diet to achieve this.

Eating fat makes you fat?

The vegan community seems to confuse eating fat and storing fat.  The Ancel Keys / vegan story is that we store fat in our body because we overeat dietary fat.  However, the reality is that we get fat because we eat more than we burn.

As shown in the graphic below from Ray Cronise’s Oxidative Priority paper, we will only burn fat (from our body or diet) once we’ve burned through the alcohol, ketones, protein and carbohydrate and fat that we eat (in that order).[21]

When we eat our body prioritises the refilling of our glucose and glycogen stores in our blood stream and liver (which can hold about 1200 to 2000 calories) before we start to store the excess energy in our adipose tissue.  Our body fat stores can hold a lot more energy, but not an unlimited amount.  Once our fat stores are full and can hold no more, they become insulin resistant.  We then start to store the excess energy in our vital organs such as our liver, kidney, brain, eyes, heart, etc.

The trick to weight loss is to keep your blood sugar levels low enough so that your liver glycogen is being replenished from your body fat rather than always having overfull glycogen stores, so we need to offload excess energy to our fat stores.[22]

One of the many roles of insulin is to shut off the flow of stored energy from the liver into the bloodstream.  If energy is coming in the pancreas will upregulate insulin to stop the flow of glucose from the liver back into the bloodstream (regardless of whether you’re eating carbs, fat or protein from animal or plant-based sources).  The best way to reduce insulin is to stop eating and let your stored energy flow back into your bloodstream.

In a way, you can think of your liver as your fuel tank and you your blood glucose meter as the fuel gauge.  If your blood sugars are high, you should think twice about whether you really need more fuel now.

If you are insulin sensitive, the bad news is that you can easily store excess energy as body fat very efficiently.  Insulin is an anabolic hormone that will help you to grow.  However, when you are insulin sensitive, you can lose fat relatively quickly when you reduce energy intake.  If you are insulin sensitive your circulating insulin levels will be low, and fuel will more easily flow from storage.  Hence you won’t be such a mindless slave to your uncontrollable appetite.

If you are insulin resistant and have high levels of circulating insulin, you may struggle to release your stored body fat.  Your appetite will drive you to seek out food because you can’t efficiently access it from your body stores.   You won’t be able to go very long between meals.

A low-carb diet can be helpful for someone who is insulin resistant because it can help lower insulin which in turn help them to normalise their appetite.  Teaching that we get fat because we eat fat is just outdated science.

Even Dr Joel Fuhman will tell you that actively avoiding fat is stupid.  He will also tell you that there is some value in eating fish on a regular basis to ensure you get adequate amounts of omega 3s and vitamin B-12.

Complications on a ketogenic diet

There are plenty of studies that show the shortcomings of a ketogenic diet.  Sarah Ballantyne did a great job of summarising these on her Paleo Mom Blog here.

When you look in detail however you find that the adverse reactions the ketogenic diet are typically due to ‘keto in a can’ formula products.

While these food substitutes will help achieve therapeutic ketosis to help manage epilepsy or other chronic conditions, many of these keto formula products end up being very low in micronutrients.[23]

Obtaining a significant amount of your energy intake from processed food-like products that have been separated from nutrients is not a good idea (e.g. whether it be sugar, processed grains, refined oils or exogenous ketones).

Is a low-carb diet actually good for diabetes?

Unfortunately, Cyrus and Robby didn’t mention the benefits of a low-carb diet for people with diabetes which are fairly well documented.  The seminal paper that summarises much of the latest work in this area is documented in Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base.

Anyone who is on the fence about using a low-carb diet to manage diabetes should check out this paper which shows that a low-carb diet is better for weight, HbA1c, glucose, HDL and triglycerides compared to low GI or a grain-based diet.

Another well-known study is Christopher Gardener’s A to Z trial[24]  where they found that the Atkins diet did much better than the low-fat, particularly if you were already insulin resistant.[25]

Image result for atkins at to z

What should you eat if you are a vegan with diabetes?

So, after all this, what should we eat to maintain optimal blood sugar levels?  Cyrus and Robby’s view is shown below.    Unfortunately, it appears that their recommendations are driven more by their philosophical and ethical views rather than the nutrient content of the food or their ability to stabilise blood sugars.

  • In the green column, most people with diabetes aren’t going to do too well with a lot of fruits, starchy veggies, and beans. Intact whole grains do contain substantial nutrients but are very hard to find in our modern food system.  Who actually eats wheat bran as a significant part of their diet?  The vast majority of grains are processed with the nutrients discarded, so they are tasty and shelf stable.
  • In the red column, dairy eggs, meat, fish and poultry can be nutrient dense and keep your blood sugars stable (as long as you’re not afraid of fat in whole foods or ‘animal protein’).
  • In the orange column, higher fat foods like nuts, seeds, avocados, coconut and olives can be useful to help stabilise your blood sugars, but it is possible to overconsume them if your goal is to lose weight.

We want to maximise nutrient density as much as possible while keeping the insulin load of our diet down to the point that we keep blood sugars stable.

This does not end up being super high fat or super low fat.  Fat just comes along with nutritious whole foods.

If you have diabetes, then a little more dietary fat initially may help to stabilise blood sugars.  Once your blood glucose levels have stabilised, you can start to decrease the dietary fat and increase nutrient density as much as you can while still maintaining excellent blood sugar levels.

A low insulin load diabetes-friendly plant-based nutritional approach will be lacking omega 3 and vitamin B-12.

The shortlist of nutrient dense low insulin load plant-based foods is shown below.  The foods at the top of each section should be reasonably safe for most people with diabetes.  You should test your blood sugars to see how you respond to some of the foods further down the list.

Many people who are conscious of animal welfare will eat fish (i.e. pescetarian).  Adding some fish will provide a much better nutritional profile than eating plants alone, with plenty of vitamin B12 and omega 3 available from the seafood.

I hope this is helpful for people who want to choose a plant-based approach to maximise nutrient density and maintain excellent blood sugar control.

If you’re still confused, I have designed the Nutrient Optimiser to identify what foods you should add or remove from your diet to ensure you are getting the nutrients you need while maintaining excellent blood sugar levels.

So which approach is optimal?

It depends.

The optimal approach for you will depend on your situation and goals.

Going plant based may be an improvement if your diet is currently full of sugar and processed grains, but it is not the singular solution to every ill.  (For an excellent example of a very nutrient dense plant-based dietary approach check out David’s Nutrient Optimiser analysis here.)

To help you make more informed food choices, I have devised two different ways of measuring food quality:

  • Proportion of insulinogenic calories, and
  • Nutrient density.

The proportion of insulinogenic calories is the percentage of the food you eat that will require insulin to metabolise.  The table below lists a range of nutritional approaches ranked by the percentage of insulinogenic calories (right-hand column).

If you’re interested in any of these approaches, you can download the list and save it to your phone or print it out to take shopping for some inspiration.

approach pdf foods nutrient profile % insulinogenic
well formulated ketogenic diet pdf foods profile 21
low carb pdf foods profile 34
plant based (diabetes friendly) pdf foods profile 56
weight loss and insulin resistance pdf foods profile 59
low carb pescitarian pdf foods profile 61
the most nutrient dense foods pdf foods profile 67
plant-based pdf foods profile 68
plant based (without ND) profile 73

Simply switching to a plant-based nutritional approach will leave you with 73% of your diet requiring insulin to metabolise.  The diabetes-friendly plant-based approach will be an improvement, but a low-carb or ketogenic diet may be better if your goal is stable blood glucose levels.

Another way to look at things is nutrient density.  You may have noticed the nutrient profiles shown above have a red dotted box.  If a particular nutritional approach provides two times the Daily Recommended Intake for all essential nutrients, then you would get a perfect score of 100%.  You can see below that the most nutritious foods below are pretty close to 100%.

By contrast, if we only focus on ‘plant-based foods’ nutritional outcome is not so flash.  Thinking only in terms of plant-based is not automatically nutrient dense.

I have sorted the various food lists in the table below based on their nutrient score.  My suggestion is to start at the top with the most nutrient dense foods and work your way down until you find an approach that suits your ethical framework or religious beliefs that will also enable you to stabilise your blood glucose levels (i.e. lower % insulinogenic calories).

approach score pdf foods nutrient profile % insulinogenic
the most nutrient dense foods 99.7% pdf foods profile 67
weight loss and insulin resistance 99.3% pdf foods profile 59
low carb pescitarian 94.5% pdf foods profile 61
low carbohydrate 81.0% pdf foods profile 34
plant based 78.0% pdf foods profile 68
plant based (diabetes friendly) 76.0% pdf foods profile 56
well formulated ketogenic diet 74.0% pdf foods profile 21
plant based (without ND) 57.0% profile 73

Summary

  • While many people chose exclusively plant-based foods, they are not necessarily a better dietary choice compared to a more varied diet.
  • Someone following an exclusively plant-based approach will require supplementation with vitamin B-12, vitamin D and omega 3s.
  • Fat is not necessarily good or bad. Swinging to macronutrient extremes will not lead to an optimal outcome.
  • Reducing the insulin load of your diet will help to normalise your blood sugar and insulin levels.
  • Ideally, you should aim to achieve the blood sugars of a metabolically healthy person while maximising nutrient density at the same time.

 

references

[1]https://www.ncbi.nlm.nih.gov/pubmed/25515001

[2]https://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

[3]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC301822/

[4]https://www.quackwatch.org/01QuackeryRelatedTopics/DSH/coral2.html

[5]https://authoritynutrition.com/the-alkaline-diet-myth/

[6]https://optimisingnutrition.com/2017/03/19/micronutrients-at-macronutrient-extremes/

[7]https://socialblade.com/youtube/user/nutritionfactsorg

[8]https://nutritionfacts.org/donate/

[9]http://www.hsi.org/about/who_we_are/leadership/subject_experts/michael_greger.html

[10]https://www.facebook.com/mangomannutrition/videos/656469947843978/

[11]https://optimisingnutrition.com/2016/10/23/energy-density-food-hyper-palatability-and-reverse-engineering-optimal-foraging-theory/

[12]https://en.wikipedia.org/wiki/Optimal_foraging_theory

[13]http://www.hoajonline.com/obesity/2052-5966/2/2

[14]https://www.amazon.com/Dorito-Effect-Surprising-Truth-Flavor/dp/1476724237

[15]https://fineartamerica.com/featured/8-muscleart-marius-poser-classic-jake-hartz.html

[16]https://www.ncbi.nlm.nih.gov/pubmed/21241239

[17]https://optimisingnutrition.com/2015/08/10/insulin-dosing-options-for-type-1-diabetes/

[18]https://www.facebook.com/Type1Grit/

[19]https://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

[20]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC301822/

[21]http://online.liebertpub.com/doi/full/10.1089/met.2016.0108

[22]https://optimisingnutrition.com/2016/02/15/how-to-use-your-glucose-meter-as-a-fuel-gauge/

[23]http://ketotalk.com/2016/06/23-responding-to-the-paleo-mom-dr-sarah-ballantynes-claims-against-the-ketogenic-diet/

[24]http://jamanetwork.com/journals/jama/fullarticle/205916

[25]http://onlinelibrary.wiley.com/doi/10.1002/oby.21331/full

 

post udpated September 2017

 

 

protein sparing modified fast (PSMF) diet foods

The Protein Sparing Modified Fast (PSMF) is regarded by many to be the most effective way to lose body fat while preventing loss of lean muscle and rebound binge eating due to nutrient deficiencies.

First developed in the 1970s, the PSMF has seen various permutations in weight loss clinics and the bodybuilding community.

While the details vary depending on context, a PSMF generally defined as an energy-restricted diet with adequate protein while simultaneously limiting carbohydrates and fat.

Technically, the PSMF will be ketogenic because a significant amount of body fat will be burned due to a restricted energy intake.

Adequate protein is provided to prevent loss of lean muscle mass.  Supplements are often used to prevent nutrient deficiencies.

This article outlines the key principles of the PSMF that can be applied to weight loss or maintenance over the long-term.

Optimal nutrient dense foods are identified for someone looking for an aggressive weight cut (e.g. a bodybuilder leading up to a competition) as well as a hybrid low carb – PSMF approach for someone who is insulin resistant wanting to lose a significant amount of weight over a longer period.

2017-06-17 18.34.52

IMG_9149

IMG_9138

Medical applications of the PSMF

In the medical application of the PSMF patients obtain the majority of their energy from protein while keeping energy from carbohydrates and fat low.[1]

  • Protein levels are set at 1.2 to 1.5 g/kg of ideal body weight per day.  (For someone with 30% body fat wanting to get to 10% body fat this would be equivalent to 1.5 to 1.9g protein per kilogram of lean body mass or LBM.)
  • Carbohydrate intake is typically restricted to less than 20 to 50 g/day.
  • Additional dietary fat beyond what comes with lean protein sources is minimised.
  • Patients in the weight loss clinic setting are restricted to less than 800 kcal/day.

The Cleveland Clinic has done extensive research into the use of adequate protein low-calorie diets for aggressive weight loss with the following encouraging findings:[2] [3] [4]

  • patients are encouraged by the initial period of rapid weight loss which leads to a lower dropout rate;[5]
  • meal replacements in the form of commercial shakes or bars can be used, however learning to make meals from whole foods critical to developing habits that lay the foundation for long-term success;
  • the PSMF is effective for people with normal glycemic control as well as pre-diabetes or type 2 diabetes;[6]
  • people on a whole food-based PSMF are significantly less hungry and preoccupied with eating compared to those on a liquid-formula based version of the PSMF; and
  • most of the weight lost during a PSMF is from fat tissue rather than muscle.[7]

Adherence to a very-low-calorie, ketogenic PSMF program results in major short-term health benefits for obese patients with type 2 diabetes. These benefits include significant weight loss, often more than 18kg, within 6 months. 

In addition, significant improvements in fasting glucose and haemoglobin A1c levels are linked to the caloric and carbohydrate restriction of the PSMF.

Insulin resistance was also attenuated, with possible partial restoration of pancreatic beta-cell capacity.[8] [9]

Body building applications

Lyle McDonald reinvented the PSMF in body building community with his 2005 Rapid Fat Loss Handbook.

McDonald details how someone can individualise the PSMF based on their goals and context.

  • Someone who is already very lean and undertaking heavy weight training will need higher levels of protein.
  • Someone who isn’t yet lean may do better with a less aggressive approach over a longer period.
  • McDonald’s recommended protein intake ranges from 2.2g/kg LBM to 4.4g/kg LBM!
  • Unlimited green leafy fibrous veggies are strongly encouraged as they are filling and provide the vitamins and minerals with minimal calories.
  • McDonald also recommends supplementing with a good multivitamin, sodium potassium, magnesium, taurine, calcium and fish oil.
  • A PSMF is typically not a long-term proposition due to nutrient deficiencies.

KetoGains’ Luis Villasenor added:

McDonald’s recommendations seem “massive” to most people due to the book being geared toward strength athletes who DO require more protein as they are effectively breaking it down when strength training. 

Bodybuilders who diet down to 4 – 5% bodyfat need an increased protein intake when preparing for a contest as their aim is to maintain as much as lean mass as possible; and for that, one needs protein and resistance exercise. 

With my clients, to avoid nutrient deficiencies, we use a “Ketogains PSMF” which adds 3-4 whole eggs a day, at least 150g spinach, plus other green veggies, and some avocado. The rest is lean sources of protein and more veggies, plus electrolytes.  This effectively puts the person in between 35 to 50g fats and 20g net carbs.  The rest of their energy comes from lean protein.

Protein drives satiety

The body actively defends loss of muscle mass by increasing appetite after periods of fasting or low protein consumption to ensure that muscle mass is retained.[10]

Conversely, the Protein Leverage Hypothesis (Simpson, 2005) suggests that we continue to eat food until we get enough protein for critical bodily functions.[11] [12]

“Protein generally increases satiety to a greater extent than carbohydrate or fat and may facilitate a reduction in energy consumption under ad libitum dietary conditions.”[13] [14]

If we eat lower protein foods, we may end up consuming more energy to obtain our adequate protein.   Conversely, we can ‘hack’ our appetite by prioritising adequate protein while minimising energy from carbohydrate and fat.

  • Minimum carbohydrate requirement: While there is a need for the vitamins and minerals that are often packaged with carbohydrate containing foods (i.e. vegetables), there is indeed no such thing as an essential carbohydrate.
  • Minimum fat requirement: Most people have plenty of body fat stores that they can draw on and hence do not have an immediate need for dietary fat other than the essential Omega 3 fatty acids.

So, theoretically, if we get adequate protein as well as vitamins, minerals, the essential fatty acids can go a long way to providing everything that we need for long-term survival with less energy which is really the holy grail of weight loss and long-term maintenance.

Thermic effect of food

The other advantage of consuming a higher protein diet is increased thermogenesis (i.e. the energy lost in the process of converting food into energy).  The thermic effect (or specific dynamic action) is 5 to 15% for carbohydrates and fat and 20 to 35% for protein.[15]

The thermic effect of food is illustrated nicely by these images from Physioqonomics.[16]  We lose a lot more calories metabolising protein compared to fat or carbohydrates.

While we can convert protein to glucose (i.e. gluconeogenesis), it is really hard, and our body doesn’t like to do unless it has to.[17]

Satiety typically kicks in quickly once we have had adequate protein and we go in search of fat or carbs which are easier to convert to energy.  Just think, you can only eat so much steak, but you always have a ‘dessert stomach’, even after a big meal.

While there is much debate over the “metabolic advantage” of fat vs. carbohydrates with claims that we can eat more calories of fat than carbs, there is actually an advantage’ when it comes to how many calories of protein we eat versus how much we can convert to energy.

Should you just eat the highest protein foods?

So, the obvious question is:

What should I eat on a PSMF?

The table below lists the foods with the highest protein content as a percentage of energy.  These foods may be useful if you are looking to boost your protein intake.

food % protein
cod 92%
haddock 92%
white fish 92%
orange roughy (fish) 92%
crab 91%
lobster 91%
egg white 91%
mozzarella cheese (non-fat) 90%
pollock 90%
protein powder (whey) 89%
turkey breast (fat-free) 88%
halibut 86%
crayfish 86%
whiting 86%
rockfish 86%
molluscs 86%
veal 84%
perch 81%
shrimp 81%
trout 81%
chicken breast 79%
lean beef 79%
whey protein concentrate (WPC) 78%
octopus 77%
ground beef 76%
pork chop 75%
flounder 74%
beef tripe 74%
pork shoulder 74%
scallop 74%
leg ham 74%
sirloin steak 73%
ham (lean only) 73%
beef heart 73%
turkey (skinless) 72%
clam 72%
turkey gizzard 72%
top round steak (fat trimmed) 72%
lamb kidney 71%
beef heart 70%
beef kidney 70%

I have summarised these in this image for easy reference.

The problem with a very high protein diet

But wait!

While you may be getting plenty of essential amino acids if you focus purely on high protein foods, there is a good chance that you may not be getting all the vitamins and minerals you need.

As shown in the chart below, there is a strong relationship between protein and nutrient density.  However, if we just focus on high protein foods, we may still end up missing out on the harder to find vitamins and minerals.[18]

The chart below shows the micronutrients provided by the top 10% of the foods in the USDA database when sorted for maximum protein content.

Now imagine, that rather than getting 2000 calories, we are getting only 800 or 400 calories during long-term fasting or extreme dieting.  We have a higher chance of becoming deficient in many key nutrients which may in turn increase appetite and drive us to eat more than we would like to.

Ensuring you are getting adequate micronutrients is a key component to long-term success in weight loss and maintenance.  

In the Rapid Fat Loss Handbook McDonald mentions ‘The Last Chance Diet’ which was popular in the 1970s and 80s.  It was essentially a PSMF centred around liquid nutrition which led to the death of a number of devotees due to some fatal flaws.[19] [20]

First, they picked the cheapest protein source available, collagen; a protein that provides essentially zero nutrition to the body.  Second, they provided zero supplemental vitamins and minerals (some of which would have been obtained if the dieters had been eating whole foods in the first place). This caused a couple of problems including cardiac heart loss (from the total lack of protein) and arrhythmias from the lack of minerals.

Basically, the problem wasn’t with the approach so much as with the food choices.

PSMF’s based around whole foods (which provide high quality proteins as well as vitamins and minerals) and with adequate mineral supplementation have shown no such problems.[21]

Bruce Ames’ Triage Theory

Nutrient density becomes even more important when we consciously try to limit our energy intake.

Attaining adequate micronutrients can help to mitigate metabolic/mitochondrial slow down and adaption to the severe calorie deficit.  If we are getting the range of micronutrients we need, the body is more likely to keep on feasting on our own excess fat stores without reacting like there is a famine and holding onto our excess fat stores.

Similar to the protein leverage hypothesis, it seems if we provide the body with low nutrient density food it is driven to consume more energy to ensure that it gets the nutrients it needs.

I get some comments in response to the Nutrient Optimiser analysis suggesting that the Daily Recommended Intakes (DRI) for various micronutrients are excessive because an individual person has done fine on a diet per for a period of time with a less than optimal nutrient profile.

While we can argue that the some of the DRIs for various nutrients are overly conservative, you also don’t have to look too far to find people that argue that we need multiple times the DRI for another particular nutrient to optimise our health and longevity.

I don’t think we need to worry about precisely meeting the daily recommended intake for every single micronutrient every single day.  There is no diet that meets the daily recommended intake for every nutrient without overdoing others.  I think a healthy well-balanced diet will achieve the DRI for the majority of the essential micronutrients most of the time.

More research is required to understand whether our requirements for different nutrients change depending on our diet (e.g. how much less vitamin C do we need if we are not consuming as much glucose) and how much more bioavailable nutrients are from plants versus animals.

However, if you are an order of magnitude under the DRI for a handful of nutrients, perhaps you should consider focussing on foods that contain that contain higher levels of that cluster of nutrients.  If you are an order of magnitude over the DRI for a particular group of nutrients you don’t need to prioritise foods that contain those nutrients.

Bruce Ames’ sobering Triage Theory suggests that if we are low in critical nutrients, the body will prioritise those nutrients for functions essential to short term survival rather than longevity and preventing the diseases of ageing (e.g. cancer, heart disease, Parkinson’s, Alzheimer’s, etc.).

“The triage theory posits that some functions of micronutrients (the approximately 40 essential vitamins, minerals, fatty acids, and amino acids) are restricted during shortage and that functions required for short-term survival take precedence over those that are less essential.  Insidious changes accumulate as a consequence of restriction, which increases the risk of diseases of ageing.”[22] [23]

So, while we might do OK with poor nutrition for a period of time, we will probably do better if we obtain a solid amount of all the essential nutrients.  Ideally, we would get these nutrients from whole foods which are more likely to contain all the non-essential but also beneficial vitamins and minerals that we don’t track.

Low energy density

Another way to maximise nutrient density and prioritise protein at the same time is to reduce the energy density of the food we eat.

As shown in the chart below there is a relationship between the harder to find nutrients and energy density.[24]  While fat is a great fuel source and should not be feared or avoided, refined high-fat foods do not typically contain high levels of the harder to find vitamins and minerals that we need to thrive.  Foods with more fibre and water are also more filling and are more difficult to overeat and will lead to increased short term satiety.

If we prioritise adequate protein while minimising fat and carbohydrates we make up the deficit from our own body fat stores. Hence there is no need to prioritise dietary fat.

The nutrient dense adequate protein diet

So, to recap:

  1. getting adequate protein is important, especially if we are fasting or restricting energy intake, and
  2. not getting adequate nutrients is potentially dangerous and possibly the fatal flaw of the PSMF.

We can use the Nutrient Optimiser to prioritise foods with the nutrients we want to obtain more of.   Listed below are the 20 nutrients that have been prioritised in the following list of prioritised foods.

  1. Alpha-linolenic acid
  2. EPA + DHA
  3. Vitamin E
  4. Vitamin D
  5. Choline
  6. Calcium
  7. Magnesium
  8. Potassium
  9. Thiamine
  10. Phosphorus
  11. Pantothenic acid
  12. Manganese
  13. Folate
  14. Zinc
  15. Niacin
  16. Riboflavin
  17. Valine
  18. Selenium
  19. Leucine
  20. Tyrosine

Prioritising amino acids is usually unnecessary because maximising vitamins and minerals generally leads to more than adequate protein.   However, in a PSMF where we are severely limiting energy we want to increase protein as well (hence valine, leucine and tyrosine have been included).  As well as nutrient density, we have also prioritised low energy density foods in the multicriteria analysis.

The chart below shows the resultant micro nutrient profile achieved if we ate 2000 calories per day of these foods.  In the chart above we saw that if we just focus on protein, we will not be meeting the DRI for eleven nutrients.  However, when we focus on nutrient density, we get adequate quantities of all nutrients other than the Omega 3 fatty acid alpha-linolenic acid.

The chart below shows the same foods if we only ate 600 calories per day rather than 2000.  Even with these highly nutrient dense foods, we miss the DRI for eight of the essential nutrients.  Hence, we may still benefit from supplementing with Omega 3, vitamin D, calcium, magnesium and potassium.   The nutrients provided by an energy restricted diet without also prioritising nutrient density would be much worse.

It’s not hard to imagine that our ability to maintain a low energy intake and achieve sustained weight loss is likely related to getting adequate levels of the various essential micronutrients without having to over consume energy.  Conversely, a nutrient poor diet will likely drive us to consume excess energy which will lead to obesity.

Best foods for a PSMF

The tables below summarise highest ranking 10% of foods in the USDA database when we prioritise for high nutrient density and low energy density.

Also included in the tables are:

  • the nutrient density score (based on the 20 nutrients listed above),
  • energy density, and
  • the MCA which is the overall ranking from the multi criteria analysis.

Compared to the highest protein food listed above which are 80% protein, these foods work out to be 59% protein, 20% fat, 13% net carbs and 8% fibre.  While this may seem high, as we will see in the ‘calorie math’ section below, it becomes more reasonable once we account for the energy from body fat.

Vegetables

It would be hard to imagine getting fat by overeating the vegetables listed below.

Maximising your intake of these vegetables will ensure you are getting adequate vitamins and minerals and hence maximise your chance of long-term success.

While these vegetables have a very high nutrient density score (ND) in terms of nutrients per calorie, they also have a low energy density which means you need to eat a lot of them to get the nutrients you need.

The downside of vegetables is that they can be expensive and take time to prepare fresh.

food % protein ND calories/100g MCA
watercress 60%  25  11  3.1
spinach 41%  23  23  2.9
seaweed (laver) 50%  22  35  2.7
asparagus 34%  21  22  2.7
basil 44%  20  23  2.5
endive 25%  19  17  2.5
white mushroom 43%  19  22  2.4
brown mushrooms 36%  18  22  2.4
portabella mushrooms 36%  18  29  2.4
Chinese cabbage 42%  17  12  2.3
lettuce 30%  16  15  2.2
coriander 31%  16  23  2.1
chicory greens 24%  16  23  2.1
alfalfa 52%  16  23  2.1
spirulina 64%  16  26  2.1
chard 30%  15  19  2.1
zucchini 24%  15  17  2.1
seaweed (wakame) 22%  15  45  2.0
parsley 27%  15  36  2.0
escarole 25%  15  19  2.0
okra 27%  15  22  2.0
beet greens 32%  14  22  2.0
shiitake mushroom 29%  15  39  2.0
turnip greens 36%  14  29  1.9
chives 35%  14  30  1.9
broccoli 23%  14  35  1.8
mung beans 35%  13  19  1.8
arugula 33%  12  25  1.7
dill 27%  12  43  1.7
cauliflower 26%  12  25  1.7
celery 16%  11  18  1.6
summer squash 18%  10  19  1.5
seaweed (kelp) 13%  11  43  1.5
yeast extract spread 52%  12  185  1.5
radicchio 22%  9  23  1.4
pickles 14%  9  12  1.4
cucumber 14%  9  12  1.4
mustard greens 34%  9  27  1.4
peas 26%  9  42  1.4
snap beans 18%  9  15  1.4
collards 27%  9  33  1.3
cabbage 18%  8  23  1.3
soybeans (sprouted) 34%  8  81  1.2
onions 19%  7  32  1.2
pumpkin 12%  7  20  1.2
kale 23%  7  28  1.2
radishes 16%  7  16  1.2
banana pepper 21%  7  27  1.2
bamboo shoots 43%  7  11  1.2
Brussel sprouts 28%  7  42  1.1
edamame 37%  8  121  1.1
artichokes 23%  6  47  1.1
sauerkraut 17%  5  19  1.0
red peppers 13%  6  31  1.0
eggplant 13%  5  25  1.0
chayote 9%  5  24  1.0

Animal products

These animal products are both nutrient dense and have a low energy density compared to fattier cuts of meat.  While the nutrient density scores are not as high as for the vegetables, the energy density is higher so you will be able to get more nutrients in using these foods.

food % protein ND calories/100g MCA
lamb kidney 71%  19  112  2.2
chicken liver 62%  19  172  2.2
beef liver 63%  18  175  2.1
veal liver 61%  18  192  2.0
lamb liver 61%  17  168  2.0
turkey liver 59%  17  189  2.0
ham (lean only) 73%  16  113  1.9
pork liver 66%  16  165  1.9
beef kidney 70%  15  157  1.7
chicken breast 79%  13  148  1.6
pork chop 75%  13  172  1.5
veal 84%  12  151  1.5
pork shoulder 74%  12  162  1.4
lean beef 79%  11  149  1.4
leg ham 74%  11  165  1.4
ground pork 69%  11  185  1.4
turkey heart 60%  11  174  1.3
lamb heart 65%  11  161  1.3
beef tripe 74%  9  103  1.3
ground beef 76%  10  144  1.2
sirloin steak 73%  10  177  1.2
beef heart 70%  10  179  1.2
turkey meat 66%  10  158  1.2
turkey drumstick 66%  10  158  1.2
bison 69%  9  171  1.1
chicken liver pate 27%  9  201  1.1
turkey gizzard 72%  8  155  1.1
lamb sweetbread 59%  8  144  1.0
chicken drumstick 62%  8  149  1.0
veal loin 63%  8  175  1.0
roast pork 53%  8  199  1.0

Seafood

Omega 3 fats (EPA, DHA and ALA) are essential and harder to get so you should prioritise fish in your nutrient dense PSMF.

food % protein ND calories/100g MCA
crab 91%  20  83  2.4
fish roe 58%  19  143  2.2
crayfish 86%  18  82  2.2
lobster 91%  18  89  2.2
halibut 86%  17  111  2.1
pollock 90%  16  111  1.9
salmon 68%  16  156  1.9
rockfish 86%  15  109  1.9
flounder 74%  14  86  1.8
oyster 46%  14  102  1.8
shrimp 81%  14  119  1.8
haddock 92%  14  116  1.8
perch 81%  14  96  1.7
cod 92%  16  290  1.7
sturgeon 64%  14  135  1.7
whiting 86%  13  116  1.6
trout 59%  13  168  1.6
octopus 77%  13  164  1.5
white fish 92%  12  108  1.5
anchovy 57%  13  210  1.5
clam 72%  12  142  1.5
tuna 68%  11  184  1.3
scallop 74%  9  111  1.3
caviar 36%  11  264  1.2
orange roughy 92%  8  105  1.2
sardine 49%  10  208  1.2
molluscs 86%  8  130  1.1

Egg and dairy

Eggs are nutritious.  Only a couple of low fat dairy products make the list.  Higher fat foods such as butter and cream need to be minimised on a PSMF to allow your body to use the fat from your butt and your belly.

food % protein ND calories/100g MCA
cream cheese (low fat) 61%  11  105  1.5
whole egg 36%  9  143  1.2
egg white 91%  7  52  1.1
cottage cheese (low fat) 51%  7  81  1.1

These nutrient dense PSMF foods are summarised in this image for easy reference.

Calorie math

To make this a little more practical let’s look at some calorie math using a hypothetical scenario.

Let’s say Super Ted is looking to get shredded for the Ketogains conference in two weeks where he wants to pose for shirtless but also wants to stay strong and to win the arm wrestle and beat the reigning champion, Mighty Mouse.

Super Ted currently weighs 160 lbs or 73kg and has 10% body fat.  His maintenance energy intake is 2336 cal/per day.

While getting the majority of your energy intake from protein might seem excessive…

… it’s not so dramatic when you also take into account the body fat being burned.

Between the 8% dietary fat (8%) his body fat stores (60%) Super Ted will be getting a ketogenic level of 68% of his energy from fat while also adequate protein to maintain his muscles and enough carb containing vegetables to get the vitamins and minerals that are also critical to his long-term success.

The details of the calorie math are shown below.  Once you take the energy deficit into account Super Ted is consuming 2.2g/kg LBM.

body weight (kg) 73
body weight (lbs) 160
body fat (%) 10%
lean body mass (kg) 62
maintenance (cal) 2336
deficit 60%
diet (calories) 934
protein (% diet) 59%
fat (% diet) 20%
net carbs (% diet) 13%
diet protein (g) 138
dietary fat (g) 21
body fat (g) 156
body fat (kg/week) 1.1
net carbs (g) 30
fibre (g) 19
protein (% energy burned) 24%
dietary fat (% energy burned) 8%
carbohydrate (% energy burned) 5%
protein (g/kg LBM) 2.2

These calculations assume that Super Ted’s insulin levels are going to be low enough to allow him to yield a significant amount of energy from his body fat stores.   Similar to fasting, it may take a few days before glycogen stores to be depleted enough for his insulin levels to drop which will allow his fat stores to more easily flow out of storage.  

These calculations also do not account for the metabolic slowdown that you will get during long term energy restriction.  This is the same with any way of eating that consciously restricts energy intake.  However, I think if we can minimise nutrient deficiencies we will have a better chance of avoiding an increase in which could drive our body to seek out the missing nutrients that it is not getting enough of.  

When you look at his Nutrient Optimiser analysis, you see that Ted Naiman (aka Super Ted) is actually consuming 2.4g/kg LBM.

Meanwhile, Luis Villasenor (aka Mighty Mouse) is also consuming protein at 2.4g/kg LBM during his PSMF.  Luis says his regular protein intake is around 140g increases this up to 180g during a strict PSMF.

Insulin resistant long-term fat loss scenario

For most of us, such an aggressive fat loss approach might be hard to maintain long-term.  So, let’s consider another scenario with another hypothetical character.

Introducing…  Big Ted.

As you can see, Big Ted doesn’t post shirtless for photos on the internet.

At 110kg and 30% body fat Big Ted is far from shredded.

Big Ted is also pre diabetic.

His doctor has warned him that if he doesn’t lose a significant amount of weight he will need to take Metformin and then insulin before too long.

Big Ted is motivated to drop a large amount of weight with perhaps a calorie deficit of 30% which will take him about 30 weeks to get to his goal weight of 90kg.

We can refine Big Ted’s PSMF approach given that his circumstances and goals are different from Super Ted’s.

Nutrients to prioritise

Given Big Ted is not looking to be as dramatically calorie restricted we only need to prioritise the following nutrients.

  1. Alpha-linolenic acid
  2. EPA + DHA
  3. Choline
  4. Vitamin D
  5. Vitamin E
  6. Calcium
  7. Magnesium
  8. Potassium
  9. Phosphorus
  10. Zinc

Although amino acids are not prioritised the resultant list of foods is still 36% protein, 30% fat and 20% net carbs.

Rather than just prioritising nutrient density and energy density, this scenario also prioritises a lower insulin load given Big Ted’s looming pre diabetes situation.

This is basically a hybrid between a PSMF and a low carb diet.

The chart below shows the nutrient profile of these foods once we take a 30% energy deficit into account.  Big Ted will be meeting the DRI for all his nutrient other than Omega 3s which he may need to supplement.

Calorie math

The charts below show the energy consumed and energy burned.

There is a significant amount of fibre which will not be metabolised for energy but rather feed his gut bacteria.  There is still a solid amount of net carbs from veggies. However, there is no sugars or processed grains to be seen, so they’re not about to boost his insulin or send him on a blood sugar roller coaster.

Once his body fat loss is accounted for, half of Big Ted’s energy expenditure is still coming from fat.

Although we didn’t prioritise amino acids we still get a solid 2.2g protein per kilogram LBM.

body weight (kg) 110
body weight (lbs) 242
body fat (%) 30%
lean body mass (kg) 77
maintenance (cal) 3000
deficit 30%
diet (cals) 1875
protein (% diet) 36%
fat (% diet) 30%
net carbs (% diet) 20%
fibre (%) 14%
diet protein (g) 169
dietary fat (g) 63
body fat (g) 100
body fat (kg/week) 0.7
net carbs (g) 94
fibre (g) 66
protein 23%
dietary fat 19%
carbohydrate 13%
protein (g/kg LBM) 2.2

Optimal foods for Big Ted are listed below.

Vegetables

food % protein ND calories/100g MCA
endive 25% 11 17 2.5
chicory greens 24% 11 23 2.4
coriander 31% 10 23 2.2
escarole 25% 9 19 2.1
spinach 41% 12 23 2.1
basil 44% 11 23 2.0
alfalfa 52% 7 23 2.0
zucchini 24% 9 17 1.9
chard 30% 11 19 1.9
arugula 33% 10 25 1.9
beet greens 32% 8 22 1.9
mustard greens 34% 8 27 1.8
watercress 60% 12 11 1.7
asparagus 34% 9 22 1.7
parsley 27% 9 36 1.7
Chinese cabbage 42% 9 12 1.6
curry powder 14% 6 325 1.6
collards 27% 7 33 1.6
summer squash 18% 8 19 1.6
lettuce 30% 8 15 1.6
paprika 15% 7 282 1.6
turnip greens 36% 7 29 1.5
broccoli 23% 8 35 1.5
cloves 6% 7 274 1.4
sauerkraut 17% 6 19 1.4
banana pepper 21% 5 27 1.4
okra 27% 7 22 1.4
pickles 14% 5 12 1.4
cucumber 14% 5 12 1.4
chives 35% 7 30 1.3
celery 16% 7 18 1.3
brown mushrooms 36% 10 22 1.3
sage 11% 5 315 1.3
artichokes 23% 6 47 1.3
marjoram 14% 5 271 1.3
thyme 10% 6 276 1.3
cauliflower 26% 6 25 1.3
edamame 37% 5 121 1.2
portabella mushrooms 36% 7 29 1.2
radishes 16% 5 16 1.2
eggplant 13% 4 25 1.2
cabbage 18% 6 23 1.2
blackberries 11% 3 43 1.2
shiitake mushroom 29% 6 39 1.1
radicchio 22% 8 23 1.1
jalapeno peppers 12% 3 27 1.1
caraway seed 19% 4 333 1.1
chayote 9% 4 24 1.1
rhubarb 15% 5 21 1.0
avocado 5% -0 160 1.0
snap beans 18% 6 15 1.0
red peppers 13% 3 31 1.0
olives 3% -1 145 1.0
turnips 26% 5 21 1.0
white mushroom 43% 7 22 1.0
dill 27% 6 43 1.0
poppy seeds 13% 3 525 1.0
kale 23% 5 28 0.9
seaweed (kelp) 13% 8 43 0.9
raspberries 8% 1 52 0.9
seaweed (laver) 50% 8 35 0.9
soybeans (sprouted) 34% 4 81 0.9
seaweed (wakame) 22% 8 45 0.9
Brussel sprouts 28% 4 42 0.9
celery flakes 14% 6 319 0.9
cumin 16% 4 375 0.8
bamboo shoots 43% 3 11 0.8
carrots 6% 3 37 0.8
onions 19% 5 32 0.8
carrots 9% 5 23 0.8
dill seed 15% 3 305 0.7
mustard seed 19% 2 508 0.7

Animal products

food % protein ND calories/100g MCA
beef brains 32% 5 151 1.5
turkey ham 63% 4 124 1.0
lamb brains 36% 2 154 1.0
lamb sweetbread 59% 4 144 0.9
turkey (skinless) 72% 3 170 0.8
turkey liver 59% 4 189 0.8
ground turkey 39% 2 258 0.8
lamb liver 61% 4 168 0.8
turkey drumstick (with skin) 50% 1 221 0.8
turkey bacon 29% 0 226 0.8
headcheese 36% –       0 157 0.8
lamb kidney 71% 4 112 0.8
turkey heart 60% 3 174 0.8
sweetbread 16% –       1 318 0.7

Seafood

food % protein ND calories/100g MCA
fish roe 58% 9 143 1.6
oyster 46% 10 102 1.5
mackerel 25% 4 305 1.4
caviar 36% 6 264 1.4
molluscs 86% 8 130 1.4
crab 91% 10 83 1.3
sardine 49% 6 208 1.2
flounder 74% 7 86 1.2
trout 59% 6 168 1.2
cisco 38% 4 177 1.2
sturgeon 64% 6 135 1.2
crayfish 86% 8 82 1.2
salmon 68% 7 156 1.2
lobster 91% 9 89 1.1
halibut 86% 8 111 1.1
anchovy 57% 5 210 1.0
perch 81% 7 96 1.0
herring 47% 4 217 1.0
rockfish 86% 7 109 1.0
pollock 90% 7 111 1.0
cod 92% 8 290 0.9
shrimp 81% 7 119 0.9
whiting 86% 6 116 0.8
white fish 92% 6 108 0.8
haddock 92% 6 116 0.7

Egg

food % protein ND calories/100g MCA
egg yolk 21% 4 275 1.4
whole egg 36% 4 143 1.3

Nut sand seeds

food % protein ND calories/100g MCA
tofu 43% 3 83 1.0
sunflower seeds 13% 2 546 0.9
pumpkin seeds 20% 3 559 0.8
flax seed 13% 1 534 0.8
almonds 13% 2 607 0.7

This image below summarises these foods for easy reference.

The nutrient profile of these foods is also excellent.  These foods will help Big Ted to minimise his chance of developing nutrient deficiencies which may lead to rebound binge eating and derail his long term weight loss efforts.

How often should I eat on a PSMF?

Big Ted is fond of intermittent fasting.  He finds it easier to not eat for a day or two and then eat to satiety rather than trying to count calories or restrict energy.

Meanwhile, Super Ted likes to eat two meals per day which save him time and helps him not overeat.

Personally, I don’t think it matters exactly when you eat as long as you stick to the foods that align best with your goals.  Recent research suggests that in the fasted state we can use up to 3.5 g/kg/day and digest up to 4.3 g/kg/day.[25]  This makes sense in an evolutionary context when there wouldn’t have been a regular supply of food but we would have needed to be able to use the food when we came across a big hunt after a long famine.

Either Super Ted or Big Ted could still utilise their required protein intake if they followed an alternate day fasting or 5:2 plan or indeed any other permutation of fasting.  What is important though is that they ensure that they stick to their nutrient dense diet when they break their fast rather than reaching for the more energy dense foods when they eat again.

How low can you go?

Hopefully, this article has given you some actionable principles:

  • During weight loss, you should ensure that you get adequate protein while fat and carbs can be limited to achieve the energy deficit required to suit your target rate of loss.
  • As well as protein intake, we should aim to maximise all micro nutrients (vitamins, minerals, essential fatty acids and amino acids) ideally using whole foods.
  • You will find it hard to obtain adequate vitamins, minerals and essential fatty acids at one extreme or the other of protein intake.

As discussed in the ‘How Much Protein is Too Much’ article I noted that the minimum intake of protein and minimum essential fats tally up to around 314 calories as shown in the table below.

If we could stick to this approach, we would have a massive and highly ketogenic 85% of our energy coming from our body fat.  However, you would be at an increased risk of inadequate vitamins, mineral and fatty acids with such a low energy intake.

macro DRI (g) DRI (calories) % energy
minimum protein 56 224 71%
essential fats 10 90 29%
total 66 314 100%

If you’re starving to death and only have lean protein available you might call it “rabbit starvation”.  However, if you still have plenty of body fat to burn it’s a PSMF.

#context matters


PSMFs for aggressive weight loss in a medical context generally aim for around 800 calories per day.

Lyle McDonald suggests that people following a PSMF for aggressive weight loss over a short period (e.g. cutting in the lead up to a bodybuilding show) might be eating between 400 and 800 calories per day.

Each person needs to find the ideal approach that they can live with for the long-term.

IMG_9148

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How to do a nutrient dense PSMF

  • Eat mostly foods from the lists below.  
    • The nutrient dense PSMF diet foods are ideal for aggressive short term weight loss (i.e. leading up to a bodybuilding comp).
    • The nutrient dense weight loss foods for insulin resistance may be more appropriate if you have more weight to lose over a longer period.
    • Minimum protein intake in a weight loss clinic setting is 1.2g/kg total body weight.
    • Appetite will likely drive you to eat more protein if you are working out.   2.4g/kg lean body mass is typical for someone lifting heavy.
    • The highest protein foodcan be used to increase protein intake if required.
    • Focusing on these foods will ensure you still get adequate protein as well as vitamins and minerals while minimising energy consumption.
    • Limit carbs to what comes with non-starch veggies (i.e. no processed grains or sugars).
    • Limit fat to what comes with the lean protein foods.
  • Don’t eat too much
    • It will be hard to overeat these high nutrient density low energy density foods.
    • You may not have to consciously limit your food intake if you can focus only eat these foods.
    • It may be beneficial to track or plan your energy intake to achieve your goals.
    • Ratchet down your energy intake until you achieve your desired rate of weight loss.
  • Lift heavy / exercise (optional)
    • Working out will help you to use the protein to build lean muscle and keep your metabolic rate up.
  • Repeat 

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Summary

  • The protein sparing modified fast (PSMF) provides adequate levels of protein to support lean muscle mass while restricting energy from carbohydrates and fat.
  • Protein intakes vary widely depending on the goals and the level of energy restriction between.
  • Providing adequate nutrients, ideally from whole foods, is critical to long term weight loss and maintenance.
  • Just maximising protein may not provide optimal levels of vitamins and minerals. Therefore, it’s important to prioritise nutrient dense foods to improve your chances of long-term success.
  • While the PSMF is commonly used in weight loss clinics and in the bodybuilding community, the principle can also be applied in other situations.

 

References

[1] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

[2] https://www.ncbi.nlm.nih.gov/pubmed/9149474

[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4784653/ama

[4] https://www.ncbi.nlm.nih.gov/pubmed/4037162

[5] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

[6] https://www.ncbi.nlm.nih.gov/pubmed/24513578

[7] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

[8] https://www.dropbox.com/s/rjfyvfsovbg9fri/The%20protein-sparing%20modified%20fast%20for%20obese%20patients%20with%20type%202%20diabetes%20What%20to%20expect.pdf?dl=0

[9] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

[10] http://www.nature.com/ejcn/journal/v71/n3/full/ejcn2016256a.html

[11] http://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2005.00178.x/abstract

[12] https://www.dropbox.com/s/zej4razn4dn993y/protein%20leverage%20hypothesis%20-%20simpson2005.pdf?dl=0

[13] http://ajcn.nutrition.org/content/87/5/1558S.long

[14] https://www.ncbi.nlm.nih.gov/pubmed/15466943

[15] https://en.wikipedia.org/wiki/Specific_dynamic_action

[16] http://physiqonomics.com/calories-child-friendly-version/

[17] http://www.biologydiscussion.com/biochemistry/energy-production/specific-dynamic-action-factors-and-example-energy-production/43998

[18] https://optimisingnutrition.com/2017/05/27/is-there-a-relationship-between-macronutrients-and-diet-quality/

[19] http://www.dietsinreview.com/diets/last-chance-diet/

[20] https://www.amazon.com/Last-Chance-Diet-When-Everything-Failed/dp/0818402393

[21] http://www.bodyrecomposition.com/the-rapid-fat-loss-handbook/

[22] https://www.ncbi.nlm.nih.gov/pubmed/19692494

[23] http://ajcn.nutrition.org/content/90/4/889.full.pdf+html

[24] https://optimisingnutrition.com/2017/05/27/is-there-a-relationship-between-macronutrients-and-diet-quality/

[25] http://www.sciencedirect.com/science/article/pii/S0261561417302030

 

post updated August 2017

how much protein is too much?

Now that fat is out of the spotlight, the focus for many in low carb and vegan circles has turned to protein as the macronutrient that needs to be avoided for health, good blood sugar control and longevity.

At the same time there are still are plenty of ‘meat heads’ who say that their ‘brotein’ can do no wrong and you can’t get enough of it.

In the sea of conflicting opinions and advice, how do we determine the optimal amount of protein that will suit our situation, goals and needs?

How much protein do we need?

How much is too little protein?

How much protein is too much?

This is an intriguing, controversial and multifaceted discussion.

So hold on as I try to unpack the various perspectives!

Typical guidance

First, let’s look at the general recommendations for protein intake.

Lean body mass

Protein recommendations are often given in terms of grams per kilogram of lean body (LBM) where “LBM” is your current weight minus your fat mass.

Protein is required to support your muscles, not your fat.

You can use a DEXA scan, bioimpedance scale or pictures (like the ones below) to estimate your level of body fat (% BF) and then calculate your LBM using the following formula:

lean body mass (LBM) = body weight weight x (100% – %BF) / 100%. 

None of these methods are particularly accurate.  However, calculating your body fat levels or protein intake to a high degree of accuracy is not necessary for most people.

Absolute minimum protein requirement

According to Cahill’s starvation studies[1] we burn around 0.4g/kg LBM per day of protein via gluconeogenesis during long term starvation.

After we burn through the food in our stomach and then the glycogen stored in our liver and muscle, the body will turn to its own internal protein stores (i.e. muscles, organs etc) and, to a lesser extent, fat (glycerol backbone) to obtain glucose via gluconeogenesis.

The figure below shows that we use less protein the longer we go without food.  After a couple of days of no food, fat and ketones kick in to supply the energy deficit.

People with better insulin sensitivity may burn through less protein as they are able to access their body fat stores for energy more easily when they go without food.  However, people who are lean and insulin sensitive may have less body fat to burn before the body will turn to protein during fasting.  Hence, extended fasting is not typically recommended if you are super lean.

Gluconeogenesis peaks at around two days and decreases thereafter as insulin levels decrease  and ketones rise further.  While chronic muscle loss is bad news (sarcopenia), particularly in old age, short term gluconeogenesis and autophagy is not necessarily a bad thing as the body will ‘self eat’ and clean out the old and sick and superfluous parts of the body for fuel.

After a fast the body is primed and highly insulin sensitive and ready to build new muscle.   Fasting can actually be beneficial for gaining muscle provided that the refeed has adequate amounts of amino acids to support muscle growth.

Daily recommended protein intake

The Daily Recommended Intake (DRI) for protein is 0.84g/kg of body weight (BW) while the Estimated Average Requirement (EAR) is 0.68 g/kg BW.[2]

This minimum protein level is based on nitrogen balance studies that indicate that if healthy test subjects eat less than around 0.6 g/kg BW you will be losing muscle and be at risk of the various diseases of malnutrition and then factored up to 0.8 g/kg BW as a factor of safety.[3] [4] [5] [6] [7]

Keep in mind though that the DRI is a recommended minimum per day to prevent diseases related to protein deficiency.  This is not necessarily optimal.

More recent studies have indicated that higher quantities of protein may be necessary, particularly for older people.[8] [9] [10] [11] [12] [13]

Older people appear to require 1.0 to 1.3 g per kilogram of total body mass per day protein to optimize physical function, particularly whilst undertaking resistance exercise recommendations.[14]

As discussed in the article Is there any relationship between macronutrients and diet quality (micronutrients) it’s actually quite hard to achieve adequate levels of vitamins and minerals while also hitting these minimum DRI levels.

According to Simpson and Raubenheimer in Obesity: the protein leverage hypothesis (2005) people with diabetes may actually need to eat more protein to ensure that they have adequate levels to build lean muscle mass given that gluconeogenesis can be higher due to insulin resistance.

Keep in mind too that minimum protein recommendations are given in terms of total bodyweight, not lean body mass.  For someone with 30% body fat 0.8g/kg BW will convert to 1.1 g/kg LBM.

If you fast for a day or two you should consider compensating with more protein on your feasting days.  If you are fasting for fat loss there is no need to replace additional fat when you feast.

DRI for individual amino acids

If we dig a little deeper we see that there are also requirements for individual amino acids as shown in the table below.[15] [16]  Depending on what you’re eating you can be deficient in some amino acids while getting enough other amino acids.

 

Amino acid(s) mg per kg body weight mg per 70 kg mg per 100 kg
Histidine 10 700 1000
Isoleucine 20 1400 2000
Leucine 39 2730 3900
Lysine 30 2100 3000
Methionine Cysteine 10.4 + 4.1 (15 total) 1050 1500
Phenylalanine + Tyrosine 25 (total) 1750 2500
Threonine 15 1050 1500
Tryptophan 4 280 400
Valine 26 1820 2600

The Nutrient Optimiser reviews the individual amino acids to make sure they are all adequate.     People who are running close to the minimum DRI for protein overall are typically deficient in a handful of individual aminos.

cropped-2017-04-22-2

Typical protein intake

The average protein intake for the general western population is about 1.2 g/kg LBM or around 16% of calories.[17]  This is greater than the minimum required to maintain nitrogen balance in the figure above and the DRI values.

It seems that most people get enough protein without trying too hard.   However, what constitutes as “enough” protein will vary depending on whether you are going through puberty, weight lifting,a middle aged sedentary office worker or an elderly person in a nursing home.

Appetite is a strong drive that ensures that you don’t stop eating until you get enough protein.  Average protein intake seems to be consistent across cultures and time.[18]

Practical maximum protein intake

Recent research indicates that, when fasted, we can use up to 3.5g/kg/day and breakdown and metabolise up to 4.3g/kg/day.[19]  This makes sense in an evolutionary context where would be primed to use a lot of protein after going without and then making up for lost time after a successful hunt.

Rabbit starvation’ is said to occur when people only have lean protein available and just can’t get enough calories in because they are eating only lean protein.  However, I have seen people eat higher levels of protein in an energy excess situation when they are trying to gain weight (e.g. Andy Mant who is trying to gain size eating and muscle 4.4g/kg LBM or Bailan Jones who is a growing young man with type 1 diabetes at 5.0g/kg LBM).

From a pure calorie standpoint we could theoretically eat up to around 7g/kg LBM using very protein foods.   However, most people will struggle to eat more than 3.5g/kg LBM because protein is very satiating and it is hard to find protein containing foods that don’t come with substantial amounts of fat.

The chart below shows the nutrient score for the highest protein 10% of the foods in the USDA database.  What we can see is that high protein foods provide a ton of amino acids while lacking key vitamins and minerals.  This is not an optimally balanced diet at a micronutrient level.  Rather than worrying specifically about ‘too much protein’ I think it’s more useful to think in terms of getting the range of micronutrients you need without having to consume excess energy.

I think the real problem eating ‘too much protein’ is that once our protein goes too high we end up reducing the amount of vitamins, minerals and essential fatty acids that our food contains.  While it is important to get adequate amino acids, it is also important to get adequate vitamins, minerals and essential fatty acids.

It’s also worth keeping in mind that protein has a net acidic load that the body needs to balance to maintain acid/base homeostasis.  If we eat a lot of protein without adequate amount of alkalising minerals (e.g. potassium, magnesium, phosphorus and calcium) our kidney may struggle to maintain an optimal pH balance which can lead to low level metabolic acidosis in the long term.[20] [21]

How will you spend your “discretionary calories”?

I think it’s important to keep in mind that the DRIs for protein are a minimum to prevent disease and should not be treated as optimal targets or maximum values.  Finding the right balance of all the essential nutrients is quite a balancing act.

In this video Dr Donald Layman points out that if we targeted the minimum DRI for protein, carbs and fat we would end up with only eight hundred calories per day whereas, on average, we eat around 2300 calories per day.  Hence, there is a window of “discretionary calories” that we can chose how we fill to make up our daily energy requirements.

People in low carb circles are fond of saying ‘there is no such thing as an essential carbohydrate’.  So, once we cut the carbs out we are left with only 314 calories to meet our essential macronutrient requirements as shown in the table below.

macro DRI (g) DRI (calories) % energy
minimum protein 56 224 71%
Essential fats 10 90 29%
total 66 314 100%

Now this might be reasonable if we were minimising calories for weight loss (e.g. we could try to live on protein powder and Omega 3 capsules).  However, this this would be impossible to achieve with whole food.

Discretionary calories from body fat

The chart below shows the break up of energy sources if we were living on the minimum DRI for protein and essential fatty acids.  85% of our energy would be coming from our body fat stores.  This would be the ultimate protein sparing modified fast (PSMF) however there is a pretty good chance we would struggle to obtain adequate levels of vitamins and minerals from 300 calories.

Then once we reached our goal weight we would need to work out what we are going to fill the rest of our intake with to prevent drastic weight loss (and literally starving to death)?

From carbs

Another option is to fill the window of ‘discretionary calories’ with carbohydrates which would look like this.

macro DRI (g) DRI (cals) % energy
protein 56 224 10%
carbs 497 1986 86%
fats 10 90 4%
total 563 2300 100%

From protein

Filling your energy deficit with protein would be impossible in terms of available foods (even with protein powders which are only 80% protein) as well as the strong satiety that would kick in well before then.

macro DRI (g) DRI (cals) % energy
protein 545 2181 91%
carbs 7 29 5%
fats 10 90 4%
total 250 2300 100%

From fat

The other option is to fill the remaining energy deficit with dietary fat.  This looks like a therapeutic ketogenic macro ratios.  This will be difficult without consuming the majority of your energy intake from butter, cream and MCT oil.

macro DRI (g) DRI (cals) % energy
protein 56 224 10%
carbs 7 29 5%
fats 227 2047 85%
total 291 2300 100%

Optimising for micronutrients and insulin load

My suggestion is to look to fill your remaining energy requirements with foods that provide the micronutrients you need while keeping an eye on the insulin load of your diet.

Keeping your blood sugar and insulin levels down will help normalise appetite and access your own fat stores for fuel.

However, ensuring that you are getting the micronutrients you need will help you prevent nutrient cravings with less energy which will be ideal for optimising longevity, insulin resistance and blood sugar levels.

How much protein are real people actually eating?

Protein in real life varies significantly, as evidenced by the fifty or so people on whom I have run the Nutrient Optimiser analysis.   As you can see in the table below, protein intake in real life is highly variable.  The average protein intake amongst these people who are generally following a low carb diet is 2.1g/kg LBM.

Name score protein (g/kg LBM) protein (%) fat (%) fibre (%) net carbs (%)
Rhonda Patrick 82% 2.5 17% 57% 10% 15%
Briana Theroux-Hulsey 79% 3.5 29% 21% 15% 35%
David Houghton 77% 0.6 17% 2% 21% 60%
Andy Mant v3 77% 4.4 27% 53% 5% 15%
Alber Van Zyl 75% 1 15% 77% 2% 6%
Alma Fuente 75% 5.3 27% 60% 7% 6%
Mike Berta 74% 2.1 31% 58% 4% 7%
Alex Leaf 74% 3.3 33% 26% 10% 32%
Alex Ferrari 74% 2 17% 54% 6% 24%
Deb Pinsky Lambert v2 72% 1.2 31% 61% 3% 6%
Luis Villasenor 72% 2.4 43% 48% 3% 5%
Gayle Louise 71% 2.4 40% 49% 4% 7%
Ted Naiman 70% 2.4 24% 64% 5% 7%
Andy Mant v2 70% 3 26% 54% 6% 15%
Robin Reyes v3 69% 1.6 18% 67% 6% 8%
Ruth Jamieson v2 66% 1.6 18% 67% 6% 8%
Amy 65% 3.3 41% 57% 0 1%
Paul Burgess 64% 1.9 28% 46% 6% 19%
Chris Hobson 63% 2.3 27% 63% 3% 8%
Ingunn Lovik 62% 1.5 21% 70% 1% 8%
Sophia Thom 62% 1.1 24% 65% 4% 7%
James DiNicolantonio 62% 3.3 26% 53% 5% 16%
Franziska Spritzler 61% 2.3 27% 55% 10% 8%
Sarah Koenck 58% 2.2 14% 77% 4% 6%
Ruth Jamieson v1 57% 1.4 19% 65% 7% 9%
Maria Fornarciari 52% 1.6 30% 61% 3% 6%
Matija Mlakar 50% 2.1 23% 49% 11% 17%
Nicole Jacobi 48% 2.8 32% 60% 3% 6%
Graeme Monteith 48% 2.6 18% 67% 5% 10%
Dave Knowles 46% 2.4 31% 63% 2% 3%
John Robertson 46% 1.4 16% 59% 4% 21%
Leah Williamson 44% 1.8 19% 75% 2% 3%
Nicole Ricine 43% 2.1 18% 79% 1% 2%
Balin Jones 43% 5 26% 66% 3% 5%
Kevin Tunis 37% 1.2 17% 76%% 1%% 7%%
Andy Mant v1 34% 3.7 35% 54% 2% 9%
George 34% 0.8 9% 69% 9% 12%
Robin Reyes v2 32% 1.6 21% 59% 4% 15%
Lorraine Ayre 30% 1.3 19% 64% 5% 12%
Terry Palmer 29% 1.5 25% 62% 5% 8%
Paul Stansel 28% 1.5 18% 77% 2% 3%
Gigi Giodani 26% 1.6 15% 81% 1% 2%
John Kerr 25% 0.7 11% 84% 2% 3%
Robin Reyes v1 23% 1.1 13% 50% 2% 35%
Bacon Man 22% 2.6 30% 69% 0% 1%
Patrick Butts v1 21% 0.8 18% 73% 4% 5%
Patrick Butts v2 20% 1.4 26% 66% 3% 6%
Harry Nguyen 20% 2.3 20% 72% 4% 4%
average 53% 2.1 24% 60% 5% 11%
25th percentile 34% 1.4 18% 54% 3% 6%
75th percentile 70% 2.5 28% 68% 6% 15%

I have also included the 25th and 75th percentiles, which indicate that half of these people were eating between:

  • 1.4 and 2.5g/kg LBM protein per day,
  • 18 and 29% energy from protein,
  • 54 and 67% energy from fat, and
  • 6 and 15% energy from net carbs.

Very few of these people are consuming anywhere near the minimum DRI levels for protein.  And the people who are the closest have some of the poorest nutrient scores.

Protein scales with activity levels

Unfortunately, simply eating protein doesn’t build muscles.  You also need to exercise to use the protein to build lean body mass (i.e. muscles).  If you’re active, you’ll need more protein for growth and repair of muscles.  If you’re sedentary you’ll need less.

There appears to be an upper limit to how much protein can be used for muscle protein synthesis (i.e. to grow and repair your muscles).  If you’re active, then it’s likely that your appetite for protein will increase to make sure you get these higher levels of protein to prevent muscle loss.

As shown in the figure below from Effects of Exercise on Dietary Protein Requirements (Lemon, 1999):[22] [23]

  • a strength athlete won’t stimulate more muscle protein synthesis by eating more than about 1.8 g/kg LBM;
  • an endurance athlete won’t trigger more muscle protein synthesis with more than around 1.4 g/kg LBM; and
  • someone who is sedentary won’t trigger more muscle protein synthesis with more than around 0.9 g/kg LBM.

So, if you are wanting to minimise energy intake while still building muscle you could use these values as a minimum protein intake.

is protein really a good source of energy?

We typically think in terms of the macronutrients, carbs, fat and protein as if they are all sources of energy.  However, there are some that argue that protein should not be considered be an energy source equivalent to carbs and fat.

Protein is critical for growth and repair of our muscles and organs and our neurotransmitters.[24]  While it is true that protein can be converted to glucose and ketones if required, the reality is that it is not easy for the body to do this![25]

The amount of energy lost in processing each macronutrient (i.e. the thermic effect of food or specific dynamic action) is shown in the table below.[26]  Compared to carbohydrate and fat, it takes a lot of energy to convert protein to glucose.  The body just doesn’t want to do it unless there is absolutely is no glucose available from any other sources.

macronutrient min max
carbohydrate 5% 15%
Protein 20% 35%
fat 5% 15%

Personally, I find that if I eat a lot of protein and not much else my appetite for carbs or fat will increase.  It seems that my body wants to use anything other than protein to replenish liver glycogen.  To quote Jason Fung:[27]

Why would your body store excess energy as fat, if it meant to burn protein as soon as the chips were down? Protein is functional tissue and has many purposes other than energy storage, whereas fat is specialised for energy storage.

Would it not make sense that you would use fat for energy instead of protein?  Why would we think Mother Nature is some kind of crazy? 

That is kind of like storing firewood for heat. But as soon as you need heat, you chop up your sofa and throw it into the fire. That is completely idiotic and that is not the way our bodies are designed to work.

oxidative priority

There is only a small capacity for protein storage in our blood stream and we waste around 25% of the energy from the protein as heat in processing it.  Hence, the body typically doesn’t drive us to overeat protein, but it can be used for fuel if there is nothing else to burn.   It makes sense that protein sends a strong satiety signal back to our brain once we have eaten as much as we can use.

It’s also useful to look at protein in terms of oxidative priority.  Craig Emmerich from mariamindbodyhealth.com has prepared the below refinement of Ray Cronise’s oxidative priority chart[28] (see Oxidative Priority, Meal Frequency, and the Energy Economy of Food and Activity: Implications for Longevity, Obesity, and Cardiometabolic Disease) by adding in ketones.

What this means is:

  1. The body will prioritise clearance of alcohol because there is no storage system for it.
  2. Similarly, the body will look to clear ketones from the system because there is minimal storage capacity for them in the blood.
  3. The body will look to clear protein that hasn’t been used for muscle repair and neurotransmitters for brain function.
  4. We will turn to glucose, for which we have a greater storage capacity in our liver, muscles and bloodstream.
  5. Lastly, once we have burned through all these other substrates, will we look to burn our fat, either dietary or the fat stored on our body.

So, if you want to burn body fat you need to limit alcohol, exogenous ketones, protein, carbohydrate and dietary fat.

Oxidative priority versus insulin load

I think Cronise’s oxidative priority concept is another way to look at the insulin load of our diet.

insulin load = carbohydrates – fibre + 0.56 * protein

Our body uses insulin to keep glycogen stored in our liver and fat in our adipose cells until the other fuels are used up.  There is no point in going out of our way to consume excessive protein because it takes more effort to burn through before we can get to the fat on our plate or our belly.   However, it is logical that our appetite switches off once we get enough protein because there is no room to store excess protein and it’s hard work to burn it.

but what about mTOR?

mTOR (mammalian target of rapamycin) controls our fuel flow and our appetite.  Similar to insulin and insulin-like growth factor (IGF-1), mTOR promotes growth.  Growth is good if we are a baby or a teenager.  But some people grow too much.

There is a limited number of times we can turn over our cells in our lifetime.  Constant periods of plenty without periods of restriction leads to continued growth of unwanted things like cancer.

Dr Ron Rosedale is a proponent of limiting protein in an effort to extend lifespan.

There have been a number of other proponents of limitation of animal protein in the vegan circle for some time. Dr Greger’s Plant Based NutritionFacts.org recommends limitation of methionine, leucine and isoleucine.

Dr Steven Gundry recommends a grain free high fat version of the protein restricted approach.

One option in response to this theory is to consistently restrict protein to achieve long term health.  Some people try to keep their protein low to ensure that they are always in a state of autophagy or muscle breakdown and self eating.

However, I don’t think chronic intentional protein restriction is necessarily optimal.  What we are aiming for is adequate, but not excessive, energy intake (including protein) without malnutrition (i.e. vitamins, minerals, aminos and essential fatty acids).

On top of this, balanced periods of feasting and fasting will allow autophagy and growth.

Before we had refrigerators

In the days before agriculture, fertilisers from fossil fuels, and even refrigerators in our homes (less than 100 years ago) our environment would enforce periods of growth and period of famine.

These days, we can source cheap food to keep on growing 24/7, 365 days a year.   We have no externally enforced periods of autophagy when we can clear the old and dying proteins in our body.

If we have growth interspersed with fasting, then we give the body a chance to build muscle and use protein for repair while also giving the body a chance to clean house and purge the dying white blood cells and burgeoning cancer cells before it gets ugly.

Your body will naturally crave more protein in periods of activity and repair and less in periods of inactivity.  If your appetite isn’t working as well as you’d like it to (i.e. you have more body fat than you would like), you can force a feast / fast cycle based on managing your weight or your blood glucose levels.

Like many things in life, optimal protein intake is a balance between extremes.  More is not necessarily better.  But less is not better either.  We want our body to thrive on enough, but not too much energy while still getting the micronutrients it needs.

Too much mTOR and IGF-1 can stimulate excessive growth and cancer while too little can lead to muscle loss, which does not support health in old age.[29]   The EAR and DRI for protein actually increase for people over 70 to prevent sarcopenia.  If you are lacking lean muscle mass then there is a greater chance you will not have great insulin sensitivity in old age.

If you are suffering from sarcopenia you may fall and break your hip and never get up again.  As shown in the figure below, too much or too little IGF-1 is not good.  As with most things, it’s a balance.

protein leverage hypothesis

Protein is critical to life so our appetite typically makes sure we get enough.  “Obesity: The protein leverage hypothesis[30] suggests that we keep eating until we get enough protein.  If we are getting plenty of protein then we will stop eating when we get enough energy and protein.

In the wild, animals have an innate sense of the nutrients they need and which foods will provide those requirements, whether they be protein, energy or other micronutrients.

While it’s easy to track macronutrients and calories, I think it’s often the body’s micronutrient needs that derail our calorie restriction efforts and aspirations.

Most of the food that is available to us these days is much more deficient in micronutrients than it once was, but at the same time it is flavoured and coloured to make it appear that it has heaps more nutrition than it actually does; so we keep on eating the food that is manufactured to look and taste good, all the while not getting the micronutrients we really need from the food, so we just keep eating.

We need a range of nutrients from our food to fuel our mitochondria so that it can efficiently burn through the food we eat, and not have it sit around in the blood.[31] [32]

For instance, the figure below from Spectracell shows the nutrients that are often missing in people with diabetes.[33]  We need all these nutrients from our food to support our mitochondria to effectively produce energy from our food and stop excess glucose and fatty, fatty acids and ketones building up in our blood stream.

action steps

It’s important to meet your minimum protein intake which may be higher if you are growing, older or active.

Once you’ve met the minimum intake of protein and essential fatty acids (about 314 calories per day) you need to decide what you are going to fill the rest of your “discretionary calories” with to prevent starvation.

If you are looking for therapeutic ketosis (i.e. for cancer, epilepsy, dementia, Alzheimer’s etc) then you may want to get the majority of your energy from fat while maintaining minimum protein levels and also staying in an energy deficit (see optimal foods for therapeutic ketosis).[34] [35]

If you’re managing diabetes and not looking to lose weight you will likely want to keep your carbohydrates low and get more of your energy from fat (see optimal foods for diabetes and nutritional ketosis).

If you’re wanting to lose body fat then perhaps you can count the energy from your body as part of your daily intake and try to maximise the nutrient density of the remaining intake.  That is, maximise nutrients with the minimum amount of energy intake (see optimal foods for fat loss).

summary

  • You can get too much protein but at the same time you can get too little protein.
  • Periods of feasting and fasting are beneficial rather than targeting chronic high or low protein.
  • It’s very hard to get a good balance of micronutrients with low protein. Protein tends to come packaged with other nutrients.
  • If you focus on micronutrients (vitamins, minerals, amino acids, fatty acids) then the macronutrients (carbs, fat and protein) largely look after themselves. We will get enough, but not excessive, amounts of protein.

 

references

[1] http://www.nejm.org/doi/full/10.1056/NEJM197003192821209

[2] https://www.nrv.gov.au/nutrients/protein

[3] http://ajcn.nutrition.org/content/77/1/109.full

[4] https://www.ketogenicforums.com/t/hobbit-vs-2-keto-dudes/10641/12

[5] http://www.ketogenic-diet-resource.com/daily-protein-requirement.html

[6] https://intensivedietarymanagement.com/how-much-protein-is-excessive/

[7] http://perfecthealthdiet.com/category/nutrients/protein/

[8] https://www.ncbi.nlm.nih.gov/pubmed/11382798

[9] https://www.ncbi.nlm.nih.gov/pubmed/23867520

[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4623318/

[11] https://www.ncbi.nlm.nih.gov/pubmed/12626690

[12] http://ajcn.nutrition.org/content/99/4/891.long

[13] http://ajcn.nutrition.org/content/86/4/995.long

[14] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555150/

[15] http://apps.who.int/iris/bitstream/10665/43411/1/WHO_TRS_935_eng.pdf

[16] https://en.wikipedia.org/wiki/Essential_amino_acid

[17] http://ajcn.nutrition.org/content/87/5/1554S.full

[18] https://www.ncbi.nlm.nih.gov/pubmed/15836464

[19] http://www.sciencedirect.com/science/article/pii/S0261561417302030

[20] https://optimisingnutrition.com/2016/11/19/the-alkaline-diet-vs-acidic-ketones/

[21] https://www.youtube.com/watch?v=E44yCNpP8bs

[22] https://www.researchgate.net/publication/13445647_Effects_of_Exercise_on_Dietary_Protein_Requirements

[23] http://bayesianbodybuilding.com/the-myth-of-1glb-optimal-protein-intake-for-bodybuilders/

[24] https://www.ncbi.nlm.nih.gov/pubmed/7903674

[25] https://www.ncbi.nlm.nih.gov/m/pubmed/22215165/

[26] https://en.wikipedia.org/wiki/Specific_dynamic_action

[27] https://intensivedietarymanagement.com/fasting-and-muscle-mass-fasting-part-14/

[28] http://online.liebertpub.com/doi/pdf/10.1089/met.2016.0108

[29] https://academic.oup.com/jcem/article-lookup/doi/10.1210/jc.2011-1377

[30] http://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2005.00178.x/full

[31] http://www.simonandschuster.com.au/books/The-Dorito-Effect/Mark-Schatzker/9781476724232

[32] https://www.researchgate.net/profile/Fred_Provenza

[33] https://naturallynourishedrd.com/wp-content/uploads/2013/09/Interactive-Library-Nutrient_Correlation_Wheels-2.pdf

[34] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4263749/

[35] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4215472/

why do my blood sugars rise after a high protein meal?

Complex issues often require more detail than you can pack into a Facebook post.

One such area of confusion and controversy is gluconeogenesis and the impact of protein on blood sugar and ketosis.

2017-06-03 02.27.38.png

Some common questions that I see floating around the interwebs include:

  • If you are managing diabetes, should you avoid protein because it can convert to glucose and “kick you out of ketosis”?

Imageresultforketonesglucose

  • If you’ve dropped the carbs and protein to manage your blood sugars, should you eat “fat to satiety” or continue to add more fats until you achieve “optimal ketosis” (i.e. blood ketone levels between 1.5 and 3.0mmol/L)?