articles, nutrient density, protein, weight loss

nutritious protein sparing modified fast diet foods

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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.

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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 strongly 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 nutrient.
  • 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 a number of 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 slowdown 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 a number of comments in response to the Nutrient Optimiser analysis suggesting that the Daily Recommended Intakes (DRI) for various micronutrients are excessive because a certain 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 specific 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 require 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 certain 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 critical 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 obtain 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 harder 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 normal 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 significant 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 simply prioritising nutrient density and energy density, this scenario also prioritises a lower insulin load in view of 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 really 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 in the long-term.

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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 foods can 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 intake.
    • 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.
  • Simply 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 July 2017

articles, nutrient density, protein

how much protein is too much?

6 Comments

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.

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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/

articles, protein

why do my blood sugars rise after a high protein meal?

10 Comments

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

A number of 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)?

  • Then, if adding fat doesn’t get you into the “optimal ketosis zone”, do you need exogenous ketones to get your ketones up so you can start to lose weight?

  • And what exactly is a “well formulated ketogenic diet” anyway?

This article explores:

  • the reason that some people may see an increase in their blood sugars and a decrease in their ketones after a high protein meal,
  • what it means for their health, and
  • what they can do to optimise the metabolic health.

Protein is insulinogenic and can convert to glucose

You’re probably aware that protein can be converted to glucose via a process in the body called gluconeogenesis.

Gluconeogenesis is the process of converting another substrate (e.g. protein or fat[1]) to glucose.

  1. Gluco = glucose
  2. Neo = new
  3. Genesis = creation
  4. Gluconeogenesis = new glucose creation

As shown in the table below, all but two of the amino acids (i.e. the building blocks of protein) can be converted to glucose.  Five others can be converted to either glucose or ketones depending on the body’s requirements at the time.

Once your body has used up the protein it needs to build and repair muscle and make neurotransmitters etc any “excess protein” can be used to refill the small protein stores in the blood stream and replenish glycogen stores in the liver via gluconeogenesis.

The fact that protein can be converted to glucose is of interest to people with diabetes who go to great lengths to keep their blood sugar under control (e.g. taking medications, changing their diet, exercising, trying to lose weight etc).[2]

Someone on a very low carbohydrate diet may end up relying more on protein for glucose via gluconeogenesis.[3]  The benefit of getting more glucose from protein via gluconeogenesis rather than carbs is that it is a slow process and easier to control with measured doses of insulin compared to simple carbs which will cause more abrupt blood sugar rollercoaster.

How much insulin does protein require?

The food insulin index data[4] [5] [6] is an untapped treasure trove of data that can help us understand the impact of foods on our metabolism.   I have discussed how we can use the insulin index at length in the articles here, but have summarised some relevant observations below.

Our glucose response to carbohydrate

The food insulin index testing measured the glucose and insulin response to various foods in healthy people (i.e. non-diabetic young university students).

To calculate the glucose score or the insulin index pure glucose gets a score of 100% while everything else gets a score between zero and 100% based on the comparative glucose or insulin area under the curve response.  So we are comparing the glucose and insulin response of various foods to eating pure glucose.

As shown in the chart below, the blood glucose response of healthy people is proportional to their carbohydrate intake.  High protein meat and fish and high fat foods (butter, cream, oil) tend to have a negligible impact on glucose.

Our insulin response to carbohydrates

The story is not so simple when it comes to our insulin response to food.

As shown in the chart below, carbohydrate content of our food only partially predicts our insulin response to food.  Low fat, low carb, high protein foods elicit a significant insulin response.

As you can see in the chart below, once we account for protein we get a better prediction of our insulin response to food.  It seems we require about half as much insulin for protein as we do for carbohydrate on a gram for gram basis to metabolise protein and use it to repair our muscles and organs.

image10

But does this mean we should avoid or minimise protein for optimal diabetes management or weight loss?

Does protein really turn to chocolate cake?

Read on to find the answer.

What happens to insulin and blood sugar when we increase protein?

While protein does generate an insulin response, increasing the protein content of our food typically decreases our insulin response to food.

Increasing protein typically forces out processed carbs from our diet and improves the amount of vitamins and minerals contained in our diet.[7]

Similarly, increasing the protein content of your food will also decrease your glucose response to food.

But what about a really big protein meal?

It’s worth noting that the food insulin index testing was done using 1000 kJ or 240 calories of each food (i.e. a large snack, not really a full meal).  But what about if we ate a LOT of protein?  Wouldn’t we get a blood sugar response then?

The figure below shows the glucose response to 80g of glucose vs 180g of protein (i.e. a MASSIVE amount of protein).  While we get a rollercoaster-like blood sugar rise in response to the ingestion of glucose, blood sugar remains fairly stable in response to the large protein meal.[8] [9] [10]

So, if protein can turn to glucose, why aren’t we seeing massive glucose spike?

What is going on?

The role of insulin and glucagon in glucose control

In order to properly understand how we process protein it’s critical to understand the role of the hormones insulin and glucagon in controlling the release of glycogen release from our liver.

These terms can be confusing.  So let me spell it out.

  • The liver stores glucose in the form of glycogen in the liver.
  • Glucagon is the hormone that pushes glycogen out into the bloodstream as blood glucose.
  • Insulin is the opposing hormone that keeps glycogen stored in our liver.

When it comes to getting glucose out of the liver, glucagon is like the accelerator pedal while insulin is the brake.

When our blood glucose is elevated or we have external sources of glucose, the pancreas secretes insulin to shut off the release of glycogen from the liver until we have used up or stored the excess energy.

Insulin helps to shut off the flow of glucose from our liver and store some of the excess glucose in the blood as glycogen and, to a much lesser extent, fat (via de novo lipogenesis).  It also tells the body to start using glucose as its primary energy source in an effort to decrease it to normal levels.

We can push the glucagon pedal to extract the glycogen stores in our liver by eating less carbohydrate (i.e. low carb or keto diets), even better yet, not eating at all (aka fasting)!

High insulin levels effectively mean that we have enough fuel in our blood stream and we need to put down the fork.

While fat typically doesn’t require significant amounts of insulin to metabolise, an excess of energy from any source will cause the body to ramp up insulin to shut off the release of stored energy from the liver and the fat stores.

Glucose, insulin and glucagon response to a high carbohydrate meal

At the risk of getting a little technical, let’s look at how our hormones respond to different types of meals.

As shown in the chart abobs, when we eat a high carbohydrate meal insulin rises to stop the release of glycogen.  Meanwhile, glucagon drops to stop stimulating the release of glycogen from the liver.  When we have enough incoming glucose via our mouth we don’t need any more glucose from the liver.[11]

Glucose, insulin and glucagon response to a high protein meal

When we eat a high protein meal, both glucagon and insulin rise to maintain steady blood glucose levels while promoting the storage and use of protein to repair our muscles and organs and make neurotransmitters etc (i.e. important stuff!).

In someone with a healthy metabolism we get a balance between the the brake (insulin) and the accelerator (glucagon) on at the same time so we don’t get any glycogen released from the liver into the bloodstream to raise our blood sugar because the insulin from the protein is turning off the glucose from the liver.

This is why metabolically healthy people see a flat line blood sugar response to protein.

(You may need to read that a few times to understand it.  It’s taken a couple of years for it to sink in for me.) 

Insulin response to protein for people with diabetes

Things are different if you have diabetes.

Insulin resistance means that between our fatty liver and insulin resistant adipose tissue, things don’t work as smoothly.

While your blood sugar may rise or fall in response to protein your insulin will need to rise a lot more to metabolise the protein to build muscle and repair your organs.

Unfortunately, people who are insulin resistant may struggle to build muscle because of the insulin resistance.  Then the higher levels of insulin may drive them to store more fat in the process.[12]  Becoming insulin sensitive is important!

The chart below shows the difference in the blood glucose and insulin response to protein in a group of people who are metabolically healthy (white lines) versus people who have type 2 diabetes (yellow lines).[13]

People with diabetes may see their glucose levels drop from a high level after a large protein meal and will have a much larger insulin response due to their insulin resistance.  People with more advanced diabetes (i.e. beta cell burn out or Type 1 diabetes) may even see their blood sugar rise.  This is because their ability to produce insulin to metabolise the protein and keep glycogen in storage cannot keep up with the demand.

Drawing on the brake / accelerator analogy, it’s not necessarily protein turning into glucose in the blood stream via gluconeogenesis, but rather the glucagon kicking in and a sluggish insulin response that isn’t able to balance out the glucagon response to keep the glycogen locked away in the liver.

Healthy people will be able to balance the opposing hormonal forces of the insulin (brake) and the glucagon (accelerator), but if we are insulin resistant and / or don’t have a properly functioning pancreas (brake) we won’t be able to produce as much insulin to balance the glucagon response.

Someone who is insulin resistant has normally functioning accelerator pedal (glucagon stimulating glucose release in the blood) but a faulty brake (insulin).

Real life example

To unpack this further, let’s look at an example close to home.

The picture below is of a family meal (i.e. steak, sauerkraut, beans and broccoli) that we had when my wife Monica (who has Type 1 Diabetes) was wearing a continuous glucose meter.

The photo of the continuous glucose monitor below shows Monica’s blood sugar response after the meal which we had at about 5:30pm.  Her blood sugar rises in response to the veggies and then comes back down as the insulin kicks in.

image31.jpg

The process to bring her blood sugars back under control from the small amount of carbs in the vegies takes about two hours.

But over the next twelve hours Monica’s blood sugar level drifts up as the insulin dose goes to work as she metabolises the protein.  For all intents and purposes though it looks like the protein is turning to glucose in her blood!

image24.jpg

This is not a one off.  We’ve seen this blood glucose response regularly.

Many people with type 1 diabetes know they need to dose with adequate insulin for protein.  Once you work out how to reduce simple carbs, working out how to dose for protein is the next frontier of good insulin management. It’s complex and sometimes confusing.

More insulin or less protein?

So, what is the problem here?  Why are Monica’s blood sugars rising?

Is it too much protein?

Or not enough insulin (i.e. because she has type 1 diabetes)?

I think the best way to explain the rise in blood sugars is that there is not enough insulin to keep the glycogen locked away in her liver and metabolise the protein to build muscle and repair her organs at the same time.

Meanwhile, the glycogen pedal is pushed down as it normally would be in response to protein which is driving the glucose up in her bloodstream.

There is just not enough insulin in the gas tank (pancreas) to do everything that needs to be done.

So, if Monica had a choice, should she:

  • A. Keep her blood sugars stable and stop metabolising protein to repair her muscles and organs,
  • B.  Metabolise protein to build her muscles and repair her organs while letting her blood sugars drift up, or
  • C. Both of the above.

Personally, I think the correct answer is C.

While it’s probably not wise to go hog-wild with protein supplements and powders if you have diabetes, as detailed in this article, swinging to the other extreme to target minimal protein levels is a sure way to end up with a poor nutritional outcome.

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 amounts to build lean muscle mass given that higher levels of gluconeogenesis may cause more protein loss to glucose due to their insulin resistance.

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 (or low carb).

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 (12,34).

It might be predicted that the result of higher rates of hepatic gluconeogenesis will be an INCREASED requirement for protein in the diet.

A lot of my early motivation in developing the Optimising Nutrition blog was to understand which foods provoked the least insulin response and how to more accurately calculate insulin dosing for people with diabetes to help Monica get off the blood glucose rollercoaster.

Like Ted Naiman, I thought if we reduced the insulin load from our food (including minimising protein) we would have a pretty good chance of losing a lot of weight (just like someone with uncontrolled type 1 diabetes).

I no longer think we need to restrict protein to optimise insulin resistance.  However, there’s no need to go to the other extreme and binge on protein.   Worrying about getting too little or too much protein is largely irrelevant.  We will get enough protein when we eat a nutritious diet.  Left to its own devices, our appetite typically does a good job of seeking out adequate protein to suit our current needs.

Meanwhile actively aiming to minimise protein will make it harder to maintain lean muscle mass which is critical to glucose disposal and insulin sensitivity.

If you are seeing your blood sugar levels rise due to protein it is likely due to inability to produce enough insulin rather than too much protein.

Basal and bolus insulin

One option to minimise the negative effects of excess insulin is to focus on minimizing the insulin load of our diet and eat only high fat foods that have a low proportion of insulinogenic calories (i.e. ones towards the bottom left of this chart).

If you are highly insulin resistant and obese this will work like magic, at least for a little while.

People who suddenly stop eating processed junk carbs and eat more fat often find that their appetite plummets as the insulin demand of their food drops and they are more easily able to access their own body fat.[14] [15]

But this is only part of the story.  Again, we can learn a lot about insulin from people with Type 1 diabetes who have to manually manage their insulin dose.

In diabetes management there are two types of insulin doses:

  1. basal insulin, and
  2. bolus insulin.

The bolus insulin is the insulin for the food we eat.

The basal insulin is a steady flow of insulin that is required throughout the day and night.

Without the basal insulin, we would disintegrate into uncontrolled gluconeogenesis and ketoacidosis (e.g. uncontrolled type 1 diabetes).

In a person eating a typical western diet around half the insulin given in a day is for the food and half is basal insulin. The chart below shows the daily insulin dose of a person with type 1 diabetes eating a standard diet.  The white component is the basal and the black is the bolus for their food.

In someone following a low carb diet only around 30% of the insulin is for the food and 70% is basal insulin as shown below in my wife Monica’s daily insulin dose shown below.

daily insulin.jpg

We can only reduce our insulin requirements marginally by changing our diet.   We always need basal insulin.  If we’re insulin resistant we’ll need more.

Like caffeine or alcohol, we become more sensitive to insulin from our diet.  As we reduce the insulin load of our diet our insulin sensitivity will improve.

But not everyone who follows a low carb diet instantly turns into a super athlete.  There has to be more to the story.

How to improve your basal insulin sensitivity

In addition to modifying our diet, we can also improve our blood glucose control by maximizing our body’s ability to dispose of glucose without relying on insulin (i.e. non-insulin mediated glucose updated).  We improve our insulin sensitivity and our ability to use glucose by building more lean muscle mass.

I used to think that if we just dropped the insulin load of our diet down far enough we would be able to lose weight, a bit like someone with uncontrolled type 1 diabetes.  But now I understand that there will always be enough basal insulin in our system to store excess energy (regardless of the source) and stop our liver from releasing stored energy.

While a diabetic can reduce their insulin requirements for food by eating food with lots of fat, they can actually end up insulin resistant and need more basal insulin if they drive over abundance of energy, regardless of whether it’s from protein, fat or carbs.[16]

While ketones can rise to quite high levels when fasting (which is great), I fear that some people are chasing high ketone levels with lots of dietary fat and the excess energy may lead to insulin resistance in the long term.

Dr Bernstein’s approach

The approach recommended by Dr Bernstein (who has type 1 diabetes himself) is typically lower in carbs, adequate protein (depending on whether you are a growing child) and moderate in fat.

Even at 83, Dr B feels it is important to maintain lean muscle mass through regular exercise to maximise his insulin sensitivity.

Will too much protein “kick me out of ketosis”?

While the ketogenic diet is becoming popular I think most people who are interested in it do not necessarily require therapeutic ketosis, but rather are chasing weight loss or blood sugar control / diabetes management.

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If you are managing a condition that benefits from high levels of ketosis (e.g. epilepsy, dementia, cancer, traumatic brain injury, Alzheimer’s) then limiting protein may be necessary to ensure constantly elevated ketone levels and reduce insulin to avoid driving growth in tumour cells and cancer.  

Giving the burgeoning interest in the ketogenic dietary approach I think it’s important to understand the difference between exogenous ketosis and endogenous ketosis.

  • Endogenous ketosis occurs when a person eats less than the body needs to maintain energy homeostasis and we are forced to up the glycogen in our liver and then our body fat to make up the difference.
  • Exogenous ketosis (or nutritional ketosis) occurs when we eat lots of  dietary fat (or take exogenous ketones) and we see blood ketones (beta hydroxybutyrate) build up in the blood. We are burning dietary fat for fuel.

Higher levels of ketones in the blood are an indication that you are eating more fat than you are burning.  Having some level of blood ketones is an indication that your insulin is low, but whether your blood ketones are high or low should not be a major cause for concern as long as your blood glucose levels are also low.  Unless we are doing a long term fast, we will all be somewhere on the spectrum between exogenous and endogenous ketosis.

Keep in mind though that most of the really good stuff that we attribute to “ketosis” and the “ketogenic diet” occurs when we are in endogenous ketosis (i.e.  when fat is coming from our body, not our plate or coffee cup).

As detailed in the popular article What are Optimal Ketone and Blood Sugar Levels in Ketosis? it seems that lower levels of total energy (i.e. towards the left of this the chart below) is a better place to be, particularly if we are chasing weight loss or diabetes management.

Our blood ketones may not be as high when we are in endogenous ketosis, but that’s OK because most of the good stuff happens in a low energy state.  

Endogenous ketosis Exogenous ketosis
Low total energy (i.e. blood glucose + blood ketones + free fatty acids) High total energy (i.e. blood glucose + blood ketones + free fatty acids)
Stored energy taken from body fat for fuel Ingested energy used preferentially as fuel
Stable ketone production all day Sharp rise of ketones for a short duration.  Need to keep adding fat or exogenous ketones to maintain elevated ketones.
Insulin levels are low which allows release of glucagon from our liver and fat stores Insulin levels increase to hold glycogen in liver and fat in adipose tissue
Mitochondrial biogenesis, autophagy, increase in NAD+, increase in SIRT1 Mitochondrial energy overload, autophagy turned off, decrease in NAD+
Body fat and liver glycogen used for fuel Liver glycogen refilled and excess energy in the bloodstream stored as fat.

Summary

  • Gluconeogenesis is the creation of new glucose (generally from protein).
  • Protein requires about half as much insulin as carbohydrate to metabolise.
  • Increasing protein intake will generally improve our blood glucose and insulin levels.  Protein forces out processed carbohydrates, increasing the nutritional quality of our diet and helps us to build muscle which in turn burns glucose more efficiently.
  • In a metabolically healthy person glucagon balances the insulin response to protein so we see a flat line blood sugar response to even a large protein meal.
  • If you cannot produce enough insulin you may see glucose rise as your body tries to metabolise the protein and keep the energy stored in the liver at the same time.
  • The insulin for the food we eat (bolus) represents less than half of our daily insulin demand. We can improve our basal insulin sensitivity by building lean muscle mass and improving mitochondrial function via a nutrient dense diet.
  • If we are aiming for weight loss and health then low blood sugars and low ketones will be more desirable rather than chasing high ketone levels via exogenous ketosis.

references

[1] http://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1002116

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636610/

[3] https://optimisingnutrition.com/2015/06/04/the-goldilocks-glucose-zone/

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

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

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

[7] https://optimisingnutrition.com/2017/05/27/is-there-a-relationship-between-macronutrients-and-diet-quality/

[8] https://www.ncbi.nlm.nih.gov/pubmed/16694439

[9] http://caloriesproper.com/dietary-protein-does-not-negatively-impact-blood-glucose-control/beef-vs-glucose/

[10] http://www.ketotic.org/2013/01/protein-gluconeogenesis-and-blood-sugar.html#¹

[11] https://books.google.com.au/books?id=3FNYdShrCwIC&printsec=frontcover&dq=marks+basic+medical+biochemistry&hl=en&sa=X&ei=-ctaVcivOJfq8AXL84CAAw&redir_esc=y#v=onepage&q=glucagon&f=false

[12] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4997013/

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

[14] https://docmuscles.com/

[15] https://optimisingnutrition.com/2017/01/15/how-optimize-your-diet-for-your-insulin-resistance/

[16] https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/1743-7075-11-23

articles, fat, fibre, nutrient density, protein

is there a relationship between macronutrients and diet quality?

7 Comments

Q:  To achieve optimal health, diabetes control and longevity you should:

  • Eat more fat to burn your body fat.
  • Follow a Protein Sparing Modified Fast (PSMF).
  • Eat more protein and lift heavy.
  • Drink Bulletproof Coffee.
  • Fast more.
  • Decrease protein and eat more fat bombs.
  • Take exogenous ketones, butter and MCT oil to boost your blood ketones.
  • Eat only plants.
  • Eat no plants.
  • All of the above.
  • None of the above.
  • I give up! All you ‘diet gurus’ can’t agree.  I’m going back to Maccas where things are simple!

Although many of these answers are contradictory, all are ‘correct’ depending on which low carb / keto group(s) you belong to.  It can be confusing out there on the interwebs!

Image result for confusing

For the last two years I’ve been working to refine our ability to quantitatively define and optimise our food quality (a.k.a. nutrient density).

At the start of 2017, I developed the Nutrient Optimiser and have since run detailed macronutrient and micronutrients analyses for more than forty people, all with different starting points and with different goals.

2017-05-23

With all the conflicting advice out there and my personal quest to manage diabetes while maximising nutrient density, I wondered what my nutrient analysis tools might be able to tell us about the relationship between macronutrients and micronutrients to provide some clarity to the circular debates that I see so often online.

I’m never sure where these articles will end up when I start the analysis.  And this one is certainly interesting!

The analysis suggests that a nutrient dense diet is typically not low in protein.  However just focusing on increasing protein won’t necessarily lead to a nutrient dense outcome.

We get a much better outcome when we focus on the harder-to-find micronutrients (i.e. vitamins, minerals and essential fatty acids).  From there we can tweak the nutrient dense template to suit our goals (e.g. weight loss, diabetes control, muscle gain, athletic performance or therapeutic ketosis).

Nutrient density

Let’s quickly look at what we mean by ‘nutrient density’ and how we can quantify it.

All foods

The chart below shows the nutrients provided by the 8,000 foods in the USDA database in terms of the percentage of the Daily Recommended Intake (DRI) if you ate just a little bit of all of them.

It’s easy to meet the recommended minimum intake of the micronutrients shown at the bottom of the chart (e.g. vitamin B12 and most of the amino acids) (at least if you are eating animal products).

However, you really have to go out of your way to get adequate amounts of the nutrients at the top of the chart (e.g. omega 3, vitamin D, choline, vitamin E, calcium, manganese and magnesium).

The most nutrient dense foods

The chart below shows the micronutrients provided by the most nutrient dense foods.  When we focus on foods that contain more of the harder-to-find nutrients we can get a massive boost in all the micronutrients.

Why should we pursue a nutrient dense diet?

With adequate amounts of nutrients being provided by the food we eat there is a good chance we will be able to satisfy our cravings with less energy.

Obtaining adequate levels of all the micronutrients will ensure that we have what we need to drive our mitochondria at full power rather than limping along.  We will feel energised and may find that our appetite turns off sooner and we will be less likely to overeat and get fat.[1] [2]  [3] [4] [5] [6] [7] [8] [9] [10] [11]

The chart below shows a comparison of the most nutrient dense 10% of the foods available compared to all the foods in the USDA database.  We get a significant improvement in our food quality by prioritising more nutrient dense foods.

Which nutrients do we need to worry about?

After a ton of trial and error and systems refinement (and some robust debates with Ray Cronise) I finally figured out that maximising nutrient density works best when we only focus on boosting the nutrients that are harder to obtain.

The nutrients listed below tend to be generally harder to get in adequate quantities:

  • Alpha-linolenic acid
  • EPA + DHA
  • Choline
  • Vitamin D
  • Vitamin E
  • Calcium
  • Magnesium
  • Potassium
  • Phosphorus
  • Zinc
  • Thiamine
  • Pantothenic acid
  • Niacin
  • Manganese
  • Folate
  • Selenium

Which nutrients are easier to find?

Listed below are the micronutrients that we don’t need to prioritise because they are fairly easy to get enough of:

  • Leucine
  • Valine
  • Sodium
  • Methionine
  • Isoleucine
  • Tyrosine
  • Riboflavin
  • Lysine
  • Vitamin B-6
  • Histidine
  • Threonine
  • Phenylalanine
  • Tryptophan
  • Iron
  • Vitamin C
  • Copper
  • Vitamin A
  • Vitamin B-12
  • Vitamin K

I have intentionally left out all the amino acids (i.e. protein) from the prioritisation because, as you will see below, it’s easy to get enough protein when we focus on the vitamins, minerals and essential fatty acids.

Can you get too much of a good thing?

As a general rule it’s hard to get excess micronutrients from real food, but it is possible.

  • While we can get more than thirty times the DRI for vitamin K from a nutrient dense diet there is no upper toxicity level of toxicity for vitamin K[12] [13] from natural sources.  However you can get too much menadione which is used as a vitamin K supplement.[14] [15]
  • We can get eighteen times the DRI for vitamin B12 from a nutrient dense diet, however again, there is no upper limit established for B12.[16] [17]
  • We can get seventeen times the DRI for Vitamin A from a nutrient dense diet. It is possible to get vitamin A toxicity, though again this typically occurs from supplementation.[18] [19]  There are some reports of Hypervitaminosis A from explorers gorging on polar bear liver, but this is not likely to be a common occurance.[20] [21]
  • We can get around twelve times the DRI for copper from a nutrient dense diet which is around the upper limit.  Though these high levels are unlikely to occur without high liver consumption which is not common.
  • A nutrient dense diet can provide around fifteen times the DRI for vitamin C however the upper limit is more than 20 times the DRI.[22] [23] Excessive vitamin C supplementation usually causes diarrhea, so it’s largely a self limiting situation.
  • A nutrient dense diet will provide around ten times the DRI for iron while the upper limit is set at around six times the DRI. Many women are iron deficient while many men have hemochromatosis which is excess iron storage.  Liver, mushroom, seaweed and spices are the highest sources of iron.  It’s useful to understand your current iron status to know whether you need more or less iron or should even be considering donating blood.
  • It is quite easy to get more than the DRI for amino acids. While high protein diets do not cause kidney disease in healthy people there is no need to chase excess super high levels of protein.[24]   And just like liver, most people will struggle to eat excessive amounts.

So yes, it is possible to get excessive levels of some micronutrients, though generally not a concern unless you are eating a LOT of liver or supplementing with synthetic nutrients.

The chart below shows the nutrient profile of Amy who is following a zero carb diet with a lot of organ meats.  While she is generally getting high levels of most nutrients, she is still not meeting the DRI for a number of vitamins and minerals that are typically found in plant foods (e.g. vitamin K1, calcium, manganese, vitamin E, magnesium and potassium).

At the other extreme we have David who is eating a plant based diet that has plenty of vitamins and minerals but less amino acids.  He knows he needs to supplement with vitamin B12 and vitamin D which are hard to get from a purely plant based diet.

When it comes to nutrient density I often see arguments around whether or not the daily recommended intake levels are correct and whether they might vary for different people with different dietary approaches and whether or not nutrients from plant or animal based food are more bioavailable.

While I think these are definitely under researched areas I think these discussions are not so relevant when we’re orders of magnitude above or below the DRI values.  We need to identify the full range of foods, from whatever source, that will provide the nutrients that we’re not getting enough.  We can then choose from within those to suit our tastes and preferences.  Our appetite can be a pretty good guide once we eliminate the processed hyper palatable nutrient poor foods that our willpower is no match for.

There is plenty of discussion about excess protein or excess calories.  While it’s true that excess is typically not good, I think it’s more valuable to focus on eating foods that contain more of the nutrients that we are currently not getting enough of.   When we’re eating nutrient dense whole foods we’re less likely to need to consciously worry about calories, protein, fat, carbs, sugar, fibre or whatever.

Is there any relationship between macronutrients and nutrient density?

While I don’t see a lot of discussion about nutrient density or food quality, there is seemingly endless debate in social media in low carb and keto circles around macronutrients.  People are often very passionate about eating more or less protein, carbs, fat and fibre.

Perhaps this is because macronutrients are reasonably easy to track and understand.  Or maybe it is because the previous approach hasn’t worked, so they swing to the other extreme.

We’ve been told for so long that fat is bad and now people are realising that it’s not as bad as they were told, so they swing to the other extreme.  Now fat can do no wrong.

Meanwhile, there are plenty of people who stick to fat being bad and wanting to avoid it.

Different people have different perspectives on the multifaceted topic of nutrition.

But is there really any value gained by focusing on primarily on macronutrients?  Will it improve our food quality or the adequacy of the various essential micronutrients?

To understand whether there is any useful relationship between the various macros and micronutrient adequacy I have plotted the various macronutrients versus the nutrient density score for the 8,000 foods in the USDA foods database.

Note: In this analysis a high nutrient density score means that a particular food has a relatively large amount of the harder-to-find nutrients listed above.  

Protein versus nutrients density

There is a lot of debate about protein and whether we should be getting more or less of it.

The chart below shows the nutrient density score for the harder-to-find vitamins, minerals and essential fatty acids vs protein (%).

2017-05-28 (9).png

Although amino acids have not included in the nutrient density score it appears that the more nutrient dense foods have more protein.  Conversely, foods with less protein have less of the nutrients that are harder to find.

It seems that if we avoid protein we will end up with less nutrients overall.  While if we focus on getting the nutrients that are harder to find we will get enough protein.

However, as they say, correlation does not equal causation.  There is a lot of scatter in this chart.  In this case the correlation (R2) of this relationship is 0.31.

This analysis makes me wonder if the studies that the benefits from increased protein are not at least in part from, not just getting adequate amino acids, but the increased levels of the other micronutrients that often come along with protein.

It’s hard to separate good nutrition and protein.

Fat versus nutrient density

The chart below shows the nutrient density score versus the percentage of calories from fat.

2017-05-28

The first thing to point out here is that there is a massive amount of scatter and a low degree of correlation between fat and micronutrients (R2 = 0.06).

However, it does seem that very high fat foods contain less of the harder-to-find nutrients.

Meanwhile at the other extreme very low fat foods can either be nutrient poor (e.g. sugar and processed grains which would be at the bottom left of this chart) or very nutrient dense (e.g. non-starchy vegetables which would be at the top right of this chart).

If we run a trend line through all these foods we see that the highest nutrient density occurs at around 30% calories from fat.

The reality is that not many people live primarily on high nutrient density low fat foods at the top left corner of this chart. People avoiding fat will often slip into the bottom left of this chart and resort to the low fat processed grains and sugars to get enough energy to get through the day.

Sugar versus nutrient density

There is currently a lot of focus on sugar as the primary culprit for our poor health.  Gary Taubes and Damon Gameau are down on sugar while Robert Lustig is leading the charge against fructose or fruit sugar.

2017-05-28 (1)

This analysis suggests that foods with more sugar have a poorer nutrient density, though it’s hard to make sense of this unless we differentiate between added refined sugar and naturally occurring sugar in plant based foods that come with a ton of other nutrients.  However, low sugar content does not necessarily guarantee excellent nutrient density.

Energy density versus nutrient density

Energy density is the amount of energy we get per gram of food.

2017-05-28 (2).png

Minimally processed foods contain more water and fibre and thus have a lower energy density but also tend to have a higher nutrient density.

Meanwhile, processed foods that are shelf stable and easy to transport typically have less water and fibre and more preservatives.

While lower energy density foods have a higher nutrient density, most people won’t survive long on a diet of only lettuce, broccoli and celery.  They will need some more energy dense foods to survive.

However, if you are looking to lose weight in a hurry while still getting the nutrients you need, focusing on lower energy density foods might not be a bad place to start.

Most people agree that eating more veggies will be better for their health, but the unfortunate reality is that it takes some time and money to prepare the food yourself rather than reaching for a quick and cheap energy hit with minimal effort.

Net carbs versus nutrient density

Foods with more digestible carbohydrates typically have a lower nutrient density.

2017-05-28 (4).png

However, simply going low carb doesn’t guarantee that we maximise nutrient density  There is a range of high and low nutrient density foods at the low carb end.

Whether or not you carbs are nutrient dense will likely depend more on whether they are highly processed or in their natural form, and will likely make a bigger contribution to their nutrient density than the quantity of carbs.

Fibre

Higher fibre foods contain more nutrients.  However, we can’t just add fibre supplements to maximise nutrient density.  Plant based whole foods that also happen to have heaps of fibre that provide us with more higher levels of nutrition.

2017-05-28 (5).png

Insulinogenic calories

The proportion of insulinogenic calories is the proportion of the food we eat that requires insulin to metabolise.

2017-05-28 (7).png

On the right hand side of the chart, highly processed foods with minimal protein and fat typically don’t provide a lot of the harder-to-find nutrients.

Meanwhile on the left hand side of the chart, foods with minimal fibre, carbs and protein are also less nutritious.

If we plot a trendline it appears that the maximum nutrient density occurs at around 50% insulinogenic calories.

If you are already insulin resistant you may want to steer your dietary ship to the left with a lower insulin load diet to the point that your pancreas can keep up and maintain normal blood sugars.  Meanwhile if you’re fit and insulin sensitive you will be able to have more leeway when it comes to macros and insulin load.

Summary

So what to make of all this?  Which of these parameters has the best correlation with food quality or nutrient density?  The table below shows the various parameters sorted by their correlation (R2) with their nutrient density score.

parameter correlation comment
protein 0.32 Nutrient dense foods tend to have more protein.
energy density 0.15 Lower energy density foods are typically more nutrient dense.
net carbs 0.12 Foods with more net carbs are typically less nutritious.
insulinogenic 0.11 Nutrient density peaks at around 50% insulinogenic calories.  Extremes are not optimal.
fibre 0.08 High fibre foods are often more nutritious.
fat 0.07 Nutrient density peaks at around 30% fat.
sugar 0.04 High sugar content correlates with low nutrient density

It seems that if we want to optimise the quality of our diet we should:

  1. Focus on the foods that contain the harder-to-find nutrients.
  2. Not actively avoid protein.
  3. Chose lower energy density foods when we can.
  4. Avoid foods that are largely digestible carbs with minimal fibre (e.g. processed grains and sugars).
  5. Chose moderately insulinogenic foods without swinging to either extreme (though we should err on the less insulinogenic side if we already have diabetes).

Meanwhile, sugar, fat and fibre, aren’t spectacular predictors of nutrition.

2017-05-28 03.41.23.png

chasing nutrients vs chasing macros

So, if protein is good, more is better, right?   Bring me the bulk tub of protein powder!

Not so fast.  It is important to understand the difference between emphasising:

  • all nutrients,
  • protein,
  • less insulinogenic foods, and
  • harder-to-find nutrients.

Maximise all nutrients

The chart below shows what happens to the micronutrient profile when we simply maximise all nutrients.

The amino acids are through the roof (69% protein) because aminos are easy to find in our food system, but we’re still lacking in many of the harder to get nutrients.

Maximise protein

If nutrient density correlates with protein then it makes some sense to prioritise protein.    Doesn’t it?

The chart below shows what happens to the nutrient profile if we sort the USDA foods database by % protein.  It seems that if we simply focus on protein we get a poor vitamin and mineral profile.

Minimising protein and maximising fat

Minimising protein and carbs while maximising fat is all the rage in the keto scene.  Unfortunately, a very low insulin load diet is not a high nutrient density approach as we can see from the chart below.  While we get adequate protein (15%), the vitamin and mineral profile is poor.   With 80% of our energy coming from fat we are deficient in about half the micronutrients.

Perhaps a very high fat therapeutic ketogenic approach should be reserved for special circumstances and extra attention given to the nutrients you won’t be able to get from your food?

Prioritising the harder to find nutrients

The chart below shows the outcome when we focus the harder to find nutrients (excluding amino acids).  We get adequate quantities of all the micronutrients and still plenty of protein.

Learnings from the Nutrient Optimiser analysis

It’s one thing to look theoretically in a database of individual foods.  But it’s another to look at what people are eating in real life.  Next, I’m going to share what I’ve learned from analysing a lot of different people’s food logs in the Nutrient Optimiser.

The nutrient density score

But first, I need to introduce you to the Nutrient Density Score.

The chart below shows Rhonda Patrick’s nutrient analysis.  Rhonda’s diet is not particularly extreme in anything other than nutrients.

Rhonda would score 100% if she could achieve 200% of the DRI for the hardest to hardest to find lower half of the nutrients.  However, because she doesn’t achieve 200% with all of the lesser scoring half of the nutrients she only gets a Nutrient Density Score of 81.3%.

For reference, if we add a little bit of all the foods in in the USDA database we would get a nutrient density score of 63% .  The most nutrient dense 10% of the foods in the USDA database will give us a nutrient density score of 93%.  Even Rhonda has some room for improvement.

By contrast, the chart below shows Patrick’s nutrient density score which comes in at only 21%. Patrick is following a very high fat keto approach even though his blood sugars are great and he doesn’t appear to be insulin resistant, just obese.

With so many of his micronutrients being nowhere near the DRI vales Patrick will need to eat a lot more of his current diet to meet the daily recommended intake for most of the nutrients.

There is a good chance that that Patrick will be craving more food to obtain the nutrients that he needs to get through the day.  Even though he is trying to lose weight, he might end up overeating more calories using his current diet than if he spent a week eating with Rhonda.

The table below shows the nutrient density score for more than forty Nutrient Optimiser analyses that I’ve run to date along with:

  • protein (g/kg LBM),
  • protein (%)
  • fat (%)
  • fibre (%)
  • net carbs (%).

I encourage you to click on each of the names below to review their nutrient analysis to see what they are and aren’t eating to get these scores.

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% 1.0 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% 2.0 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%
Andy Mant v2 70% 3.0 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%
Ingunn Lovik 62% 1.5 21% 70% 1% 8%
Sophia Thom 62% 1.1 24% 65% 4% 7%
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 Fornaciari 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%
Balin Jones 43% 5.0 26% 66% 3% 5%
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%
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%

In the charts below we’ll quickly look at the relationship between the macros and their nutrient score.

Protein

This chart shows the relationship between protein intake and each person’s nutrient density score.  The average protein intake for this range of people following a low carb or keto diet is 2.1g/kg LBM or 23% of energy.

On the top left corner of the chart we have David who is following a plant based diet and intentionally getting lower levels of protein but also maximising vitamins and minerals from plant based foods.

On the bottom left we have a number of people following a therapeutic ketogenic diet targeting low protein and high fat.

As long as you are not trying to target low protein and high fat to generate higher blood ketones then it doesn’t seem to matter what your protein intake is.  Most people get enough protein to support their activity levels.

The chart below shows the nutrient density score versus protein (%).  Again, it seems that it’s hard to get high levels of nutrients if you are targeting minimal protein levels.

% insulinogenic

The story is similar with insulin load.  Reducing the insulin load of your diet to the point that your blood sugars normalise is a great idea, but less is not necessarily better.  We want to avoid really high insulin levels but not drive it so low that we don’t have enough nutrients to repair our muscles and organs.

Fat

High levels of fat do not guarantee high levels of nutrition.

Net carbs

It’s good to reduce the carbohydrate load of your diet to normalise your blood glucose levels, but again minimising is not necessarily the best idea and may be unnecessary if you are not managing diabetes.

Higher levels of isn’t necessarily bad either when it comes to nutrient density.  On the top right of the chart we have David who is striving for a nutrient dense plant based diet with about 35% net carbs while for contrast we have Robin’s baseline junk food diet which also has about 35% net carbs which has about the same nutrient density score as the very high fat therapeutic keto dietary approaches on the bottom left of the chart.

Fibre

Higher levels of fibre typically correlate with more nutrition (although you can get heaps of nutrients from shellfish and organ meats with minimal fibre intake).

Summary

  • A nutrient dense diet is not low in protein; however focusing on protein won’t necessarily guarantee great nutrition.
  • Foods with a lower energy density are often more nutrient dense. To maintain our body weight and growth we will need to add more energy dense foods (i.e. more non-fibre carb and / or fat).  Meanwhile, dialling back the energy density and forcing your body to use your stored body fat can be a good strategy for weight loss.
  • Reducing your carb intake or the insulin load of your diet can be useful if you are managing diabetes. However less is not necessarily better.
  • For the most part ensuring you are getting the harder-to-find micronutrients will maximising your diet quality without going to macronutrient extremes.

references

[1] https://www.youtube.com/watch?v=rYXF0l18ciI

[2] https://www.youtube.com/watch?v=ncVJfZZ7bTM

[3] https://www.youtube.com/watch?v=ZjUgX91VZpk

[4] http://perfecthealthdiet.com/2011/02/perfect-health-diet-weight-loss-version/

[5] https://www.ncbi.nlm.nih.gov/pubmed/18469287

[6] https://www.ncbi.nlm.nih.gov/pubmed/19785688

[7] http://www.tandfonline.com/doi/abs/10.1080/13590840220143062?journalCode=ijne20&

[8] https://www.ncbi.nlm.nih.gov/pubmed/19263591

[9] http://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2007.00465.x/abstract

[10] https://www.ncbi.nlm.nih.gov/pubmed/20142823

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

[12] http://www.consumerlab.com/RDAs/#VitaminK

[13] http://www.consumerlab.com/RDAs/#VitaminK

[14] https://en.wikipedia.org/wiki/Menadione

[15] https://www.amazon.com/Nutrient-Bible-Henry-Osiecki/dp/1875239545

[16] http://www.consumerlab.com/RDAs/#B12

[17] https://www.amazon.com/Nutrient-Bible-Henry-Osiecki/dp/1875239545

[18] http://www.mayoclinic.org/drugs-supplements/vitamin-a/safety/hrb-20060201

[19] http://www.consumerlab.com/RDAs/

[20] https://www.121dietitian.com/never-eat-a-polar-bears-liver/

[21] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1257872/

[22] http://www.consumerlab.com/RDAs/#VitaminC

[23] https://www.amazon.com/Nutrient-Bible-Henry-Osiecki/dp/1875239545

[24] https://chriskresser.com/do-high-protein-diets-cause-kidney-disease-and-cancer/

articles, nutrient density

personalised nutrition… how to tweak the moving parts

2 Comments

There are a number of moving parts when it comes to optimising nutrition to suit your personal situation and goals.

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General nutritional recommendations are standardised for simplicity.    However simple and standard doesn’t always work for everyone, particularly if you aren’t average, or don’t want to be average.

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Just like people come in different shapes and sizes, their nutritional requirements vary widely depending on our situation and goals.

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The Nutrient Optimiser is a moderately sophisticated tool to optimise food choices to suit different people with different goals.  However, I don’t want it to be a black box. Ideally I would like people to understand the inputs and how best to refine their nutrition to suit their goals.

The problem is black boxes is you get what you put in.  If you understand the inputs you’ll have a better chance of getting the output you’re after.

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This article discusses the various parameters that the Nutrient Optimiser manages.    Even if you’re not a user, it may be of interest to see how you can truly personalise your nutrition.  If you are already using the Nutrient Optimiser this article will help you understand how the algorithm uses various parameters to determine the optimal foods for you.

Multicriteria analysis

The first thing to understanding is the parameters used in the multi criteria analysis which is at the heart of the Nutrient Optimiser algorithm.  The image below illustrates the three main dials that you can adjust in the algorithm:

  • insulin load,
  • nutrient density, and
  • energy density.

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A multi criteria analysis is a way to combine a number of priorities.

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You do it all the time.  You want to have money in the bank but you also want to wear clothes and live under a roof.  So you balance these priorities depending on your goals.  You like to look and feel good but you also like to eat treats “occasionally”.  So you balance these priorities.

You want to have the proverbial cake and eat it too.  We make compromises all the time in life.  Living at the extremes is not always healthy or optimal.

I have written at length on the blog about the three key parameters of the system.  The pros and cons of having the various parameters at either extreme are highlighted in the table below.

Parameter Too high Too low
Insulin load Very high insulinogenic processed junk food that drives a blood glucose roller coaster. Super high fat therapeutic ketogenic foods do not provide high levels of the broad range of various essential vitamins and minerals.
Nutrient density Very high nutrient per calorie foods are also very low energy density.  For someone who is active and not looking to lose weight the most nutrient dense foods may not contain enough energy to provide satiety and prevent excessive fat loss. Low nutrient density processed junk food leads to a lack of satiety (nutrient hunger), overeating and a whole host of other health issues.
Energy density Energy dense foods are ideal for someone who is very active and looking to replenish energy, though not necessarily for someone who is less active or looking to lose weight. Low energy density foods are very bulky and hard to get enough energy  to maintain weight if you’re very active.

 

As you can see, these three parameters are important to different people to different degrees for different people.  The table below shows the ‘pre-set values’ in the system that have been found to work well for different goals.  More experienced users of the Nutrient Optimiser may want to tweak these values to refine the results to further suit their preferences.

approach insulin load nutrient density energy density total (absolute)
bulking -20% 60% -20% 100%
nutrient dense maintenance 20% 70% 10% 100%
weight loss (insulin resistant) 5% 70% 25% 100%
weight loss (insulin sensitive) 0 85% 15% 100%
therapeutic ketosis 15% 85% 0% 100%
diabetes and nutritional ketosis 10% 90% 0% 100%

You may have noticed that some of the parameters are negative (e.g. insulin load and energy density for the bulking approach).

While many people are eating too much, some athletes want to bulk up and / or get more energy “down the pie hole” to support their amazing feats of endurance.

Someone who is insulin resistant will want to minimise the insulin load of their diet, bodybuilders often want food to spike insulin around workouts to promote growth.  If you turn the nutrient density parameter negative you’ll get a list of processed junk food that you see in the supermarket aisles.

Adapting the system as you progress

People would ideally use these value as a starting point and refine them to suit your goals as you see fit and as you get fit.

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Someone who starts out with  diabetes, is on three medications and hundreds of units of insulin may need to start on the high fat therapeutic keto approach to reduce the insulin load of their diet.

Someone like this who is looking to progressively refine their diet would come back and re-run the Nutrient Optimiser every two to four weeks to see their new dietary recommendations and refinements.  Through continual, gentle, non-judgemental and anonymous guidance (with the support of the Nutrient Optimiser Facebook group community as required) they would be able to progressively refine their diet.

In time, their blood glucose would come down with lower insulin load foods.  But then they still might want to lose weight so they would start to prioritise lower energy density foods rather than low insulin foods so much.  Then as their weight came closer to optimal and they were more active they might swing back to some focus on insulin load to enable them to have a more nutrient dense suit of foods.

Where do I start?

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While there are a lot of parameters you can use, your average glucose levels and waist : height ratio is a pretty good starting place as shown in the table below.

A higher fat / ketogenic / low carb approach typically works really well for people who have elevated blood glucose and elevated insulin levels.  However, as blood glucose control and improved insulin sensitivity kicks in but you still need to lose weight energy density and nutrient density become more important.

The table below will give you a guide on which approach might be most appropriate based on your current weight blood glucose levels and body fat levels.

approach average glucose waist : height
(mg/dL) (mmol/L)
therapeutic ketosis > 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 > 0.5
weight loss (insulin sensitive) < 97 < 5.4 > 0.5
bulking < 97 < 5.4 < 0.5
nutrient dense maintenance < 97 < 5.4 < 0.5

 

Food preferences

There are a plethora of different approaches to choosing foods.  Some of these are based around avoiding allergens (autoimmune, lactose intolerant, nut allergy etc) or digestive issues (zero carb, low fodmap).  Some are based on religious belief systems (e.g. vegetarian).

Although the ideal approach is going to be to prioritise the most nutrient dense foods available, we have also created options to suit your preferences.

The recommended foods list will be based on the remaining top 10% foods.   Noting your preferences up front will save you sifting through a long list of foods that you may not want to eat.

option details
most nutrient dense No limitations
zero carb Eliminates vegetables, fruit, grains and any non-animal based sources of carbohydrate.
vegan / plant based No animal products or animal derived products such as dairy or eggs.
vegetarian No animal products but includes eggs and
paleo No grains, dairy or processed foods.
pescatarian Vegetarian plus seafood
gluten intolerant No grain products
nut allergy Excludes nuts
no salicylates  
no organ meats Excludes organ meats.
no offall  

Should I log my supplements?

No!

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But why not?

The goal of the Nutrient Optimiser is to identify nutrient deficiencies and whole foods to fill them.  If you don’t manage to fill the gaps, then you will know which nutrient you might need to supplement.

There is a credible line of thinking that the reason that many processed foods are fortified with B vitamins and the like is that we would find these foods unpalatable and lose our appetite without the fortification.[1] [2] [3] [4] [5]  With fortification, we associate these otherwise nutrient devoid processed foods with essential vitamins and hence we are happy to keep eating them.  Unfortunately, they don’t also contain the full range range of beneficial nutrients that whole foods possess (i.e. essential, non-essential and the ones that we haven’t discovered yet) so fortified foods are unlikely to lead to optimal health.

If you are taking a ton of supplements then you may be able to continue to happily eat large quantities of nutrient poor processed food that you would otherwise lose your taste for.  If you cut back to foods that don’t need to be fortified or flavoured to make up for their nutritional deficiencies you will be able to hear your appetite again and let it guide you to whole foods that contain the nutrients you need at a particular point in time.

Regardless of whether this narrative is correct I think it’s safer to get your nutrients from real food.  Supplements supplement.  They shouldn’t be the foundation.

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If you still can’t quite cover off on the nutrients you need from real food, you can supplement in a targeted manner once you’ve got the foundation of whole foods in place.

Micronutrients

The Nutrient Optimiser compares the nutrients you are getting to the recommended daily allowance (RDA) or daily recommended intake (DRI).  Different RDA / DRIs are commonly given for different situations including  whether you are male or female and if you are pregnant or breastfeeding.

Recommended micronutrient levels for men are typically greater than those for women (other than iron, which is greater for women).  Levels of micronutrients during pregnancy and breastfeeding are greater for obvious reasons.  These values (for adults) are included in the Nutrient Optimiser.

You may have blood tests that indicate you are deficient or sufficient in particular nutrients.  You may also be able to use tools like the Organic Acids Test or the NutrEval test to identify any nutrient deficiencies that you need to prioritise.

If you have this data you can override the recommendations from your food log to focus the nutrients you know you are low in.  For example you may have blood tests that you are getting a lot of vitamin D from the sun so you could decrease your dietary targets or you may have blood tests that suggest you are low in iron due to poor absorption so you can increase your dietary targets.

The daily recommended intake levels for vitamins, minerals and essential fatty acids are shown in the table below.  Keep in mind that these are the recommended minimum levels to prevent the diseases of malnutrition.  There is generally no harm in being above these levels in a particular nutrient if you are getting it from real food.  However if a certain nutrient is super high there is a chance that you are neglecting other nutrients.

Vitamin men women pregnant breastfeeding
B1 (Thiamine) (mg) 1.2 1.1 1.4 1.4
B12 (Cobalamin) (µg) 2.4 2.4 2.6 2.8
B2 (Riboflavin) (mg) 1.3 1 1.4 1.6
B3 (Niacin) (mg) 16 14 18 17
B5 (Pantothenic Acid) (mg) 5 5 6 6
B6 (Pyridoxine) (mg) 1.3 1.2 1.9 2
Folate (µg) 400 400 600 500
Vitamin A (IU) 3000 3000 3000 3000
Vitamin C (mg) 90 75 85 120
Vitamin D (IU) 600 600 600 600
Vitamin E (mg) 15 15 15 19
Vitamin K (µg) 120 90 90 90
Calcium (mg) 1000 1300 1000 1000
Copper (mg) 0.8 0.8 1 1
Iron (mg) 8 18 27 10
Magnesium (mg) 400 310 350 310
Manganese (mg) 5.5 5 5 5
Phosphorus (mg) 1000 1000 1000 1000
Potassium (mg) 3800 2800 2800 3200
Selenium (µg) 55 55 60 70
Sodium (mg) 460 460 460 460
Zinc (mg) 11 9 11 12
Omega-3 (g) 1.6 1.1 1.4 1.3

Amino acids

There is a lot of passion around the topic of optimal protein levels.

I think the long and short of it is that if you focus on getting the harder to find nutrients you won’t need to worry too much protein.  However if you focus on getting particularly high or low levels of protein you will risk missing out on getting adequate vitamins and minerals.

However, unless you’re actively trying to avoid protein you will likely be getting enough.  Conversely, unless you’re trying to hammer down to get extra protein with powders, you will find it hard to get too much protein whole foods.

As long as you’re not living exclusively off hyperpalatable processed foods I think you can generally trust your appetite to make sure you’re getting enough protein.  People who are active and working out will need more protein to support muscle growth and recover.  People who are sedentary will need less protein (as well as fat and carbs).

The Nutrient Optimiser takes your weight and LBM into account to tell you how you’re positioned against normal healthy protein intake levels which are noted in the table below.

Scenario % calories g/kg LBM
minimum (starvation) 6% 0.4
RDI/sedentary 11% 0.8
typical 16% 1.2
strength athlete 24% 1.8
maximum 35% 2.7

To take things another step further, the Nutrient Optimiser also looks at the adequacy of the individual amino acids.  If you’re following a lower carb or paleo approach these are likely to be adequate.  If you’re vegan, fasting or aiming for therapeutic ketosis, the Nutrient Optimiser may encourage you to seek our more of specific amino acids if you’re not getting enough.  Although typically most people get enough of the amino acids unless they are actively trying to avoid protein.

The table below shows the minimum daily requirement of the various essential amino acids in terms of milligrams per kilogram of body weight as well as for someone who is 70kg and 100kg.  These target levels have been included in the Nutrient Optimiser based on your total body weight.  If you are deficient in any of these individual amino acids the Nutrient Optimiser will highlight foods that will fill the gaps.  The Nutrient Optimiser also checks to make sure you’re getting enough protein overall based on your lean body mass.

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

Common micronutrient deficiencies

Managing micronutrients is a bit of a moving feast.  You could run a reasonable argument that the various daily recommended intakes (DRI) are based on limited knowledge and understanding.  Realistically in the early stages of understanding nutrients and how they work in our body.

For this reason, the Nutrient Optimiser doesn’t try to hit the DRI for every single nutrient.  That would be unrealistic with real food (chemical concoctions like Soylent or other meal replacement products, might get closer, but who knows what you’ll be missing out on if you only get what we currently understand to be the essential nutrients).  Instead we want to highlight the nutrients that you are currently getting in smaller quantities and help you focus on the foods that contain more of those harder to find nutrients.

The chart below shows common micronutrient deficiencies.  The majority of people are not getting adequate amounts of vitamin D, vitamin E, magnesium, calcium, vitamin A and zinc.  However your situation will be unique.

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The Nutrient Optimiser will progressively train you to incorporate new foods and rebalance your diet to fill your nutritional gaps.  When you get to the point that most of your nutrient requirements meet the minimum from real food you might just find your appetite and cravings for particular nutrients start to diminish.

If you’re interested in checking out how the Nutrient Optimiser has worked for a number of other people check out the Nutrient Optimiser Facebook Page or the Nutrient Optimiser site for more details on the tool and how to be involved.

2017-05-23

 

references

[1] http://freetheanimal.com/2015/10/fortification-obesity-refinements.html

[2] http://freetheanimal.com/2015/06/enrichment-theory-everything.html

[3] http://freetheanimal.com/2016/05/enrichment-promotes-everything.html

[4] http://www.audible.com.au/pd/Health-Personal-Development/The-Dorito-Effect-Audiobook/B00WVLVT0Q

[5] https://www.amazon.com/Dorito-Effect-Surprising-Truth-Flavor/dp/1476724237

articles, ketosis, therapeutic ketosis

are ketones insulinogenic and does it matter?

17 Comments

There has been a lot of hype around the interwebs lately about exogenous ketones and whether they are health promoting, particularly for people with conditions that relate to excess insulin such as diabetes, traumatic brain injury, Alzheimer’s, cancer, epilepsy, obesity etc.

exogenous ketone are trendy
exogenous ketones, Pruvit and Keto//OS are becoming trendy.

Exogenous ketones are becoming trendy, particularly in the low carb scene!

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A couple of people recently asked me whether I thought exogenous ketones are insulinogenic.

Roger Unger’s 1964 paper the Hypoglycemic Action of Ketones.  Evidence for a Stimulatory Feedback of Ketones on the Pancreatic Beta Cells[1] indicates that ketone levels are controlled by insulin and that ketones suppress lipolysis:

Ketone bodies have effects on insulin and glucagon secretions that potentially contribute to the control of the rate of their own formation because of antilipolytic and lipolytic hormones, respectively.  Ketones also have a direct inhibitory effect on lipolysis in adipose tissue.[2]

It seems that exogenous ketones are indeed insulinogenic to some degree.

But how do we test this hypothesis to find out whether they are just slightly insulinogenic like fats or more insulinogenic like carbohydrates?

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how to test the insulin response to exogenous ketones in someone with Type 1 Diabetes

If someone with Type 1 Diabetes stops taking their insulin both their blood glucose levels and blood ketones spiral out of control as they slip into ketoacidosis[3] which can be dangerous and fatal before very long without exogenous insulin injection.[4]   In metabolically healthy people,  high levels of ketones suppress mobilisation of body fat (lipolysis).[5]

In someone with Type 1 Diabetes, taking exogenous insulin brings both ketones and blood glucose under control.  So, based on what we see in people with Type 1 Diabetes, it seems logical that exogenous ketones would provoke an insulin response to keep ketones and glucose under control.

One way to test whether exogenous ketones are insulinogenic would be to have a Type 1 Diabetic to take a significant amount of exogenous ketones and monitor how much additional insulin they need to keep the continuous blood glucose monitor stable with the same amount of calories in glucose.

I initially became interested in exogenous ketones after hearing a number of podcasts with Patrick Arnold and Dominic D’Agostino thinking that it may be a useful alternative source of energy that does not rely on insulin for my wife, who has Type 1 Diabetes.  However, the one time she tried it resulted in such bad gut distress she never touched it again.  So scratch that n = 1.

food insulin index testing with exogenous ketones

Another way to test whether exogenous ketones are insulinogenic would be to run a food insulin index test[6] [7] using ketones rather than food.  This would involve giving 1000kJ of exogenous BHB (e.g. 48g of KetoCaNa) and measuring the insulin response over two or three hours.

The chart below compares the results of previous food insulin index tests undertaken for different foods.[8]   Comparing the area under the curve insulin response for the exogenous ketones to the insulin area under the curve for glucose would give you the insulin index for exogenous beta hydroxybutyrate.

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I am surprised that the companies marketing exogenous ketones to people with metabolic issues, as part of their due diligence, haven’t already done this testing to understand to what degree exogenous ketones are insulinogenic.

but wait, the food insulin index testing with exogenous ketones has already been done!

Then I came across this figure in a paper, Nutritional Ketosis Alters Fuel Preference and Thereby Endurance Performance in Athletes (Cox et al, 2016)[9],  where they have effectively done the food insulin index testing with exogenous ketones.

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Thirty-nine athletes took an isocaloric dose of ketone esters, carbs and fat in three different sessions. In the chart on the right (G) we can see that the ketones provoked about half the insulin response compared to the carbohydrate drink.  This test is different to normal food insulin index testing in that the participants started to exercise ten minutes after taking the drinks (i.e. at T = 0) at which point insulin and glucose start to decline.

updated insulin load formula, including exogenous ketones

The chart below shows the relationship between the food we eat and our insulin response based on the previous food insulin index testing.

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In lieu of more thorough food insulin index testing, I think we can update the insulin load calculation formula to:

insulin load = carbohydrate – fibre + 0.56 * protein – 0.725 * fructose + 0.5 * exogenous ketones

It appears that exogenous ketones provide about half the insulinogenic impact of carbohydrates (i.e. about the same as protein).


So, if you’re avoiding protein because of its impact on insulin, should you also consider exogenous ketones for the same reason?

Exogenous ketones stimulate insulin, but BHB also inhibits lipolysis directly via the nicotinic acid receptor PUMA-G in adipose.[10]

While exogenous ketones may be equally as insulinogenic as protein, they’ll also be a counterproductive use of insulin.

Whereas the insulin response to protein is a positive use of insulin to build and repair muscle, with exogenous ketones, insulin simply reduces oxidation of other fuels to allow ketones to be burned.

Exogenous ketones displace the burning of other substrates.  You know what else displaces the burning of other substrates?  Glucose. Carbs reduce the amount of fat you burn. Similarly, exogenous ketones displace both fat and carbs/glucose.

That’s a double whammy in the wrong direction! Substrate competition is key.

Mike Julian

total energy = glucose + ketones

In a healthy metabolism, endogenous ketones are generated as fat stores are mobilised to compensate for a decreased energy availability from glucose.  When glucose is not available, ketones come to the rescue to ensure survival.

If you’re insulin resistant, you might have trouble releasing free fatty acids due to the high levels of insulin circulating in your bloodstream.  This inability to access your own fat stores will reduce your ability to create ketones and likely lead you to be more hungry and eat more than you otherwise would if you were insulin sensitive.  If you are insulin sensitive you can more easily access your own body fat stores.

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This chart demonstrates the concept of total energy (i.e. glucose + ketones) using more than a three thousand combined ketone and glucose readings from people following a low carb/keto lifestyle.  Other than in the extremes of extended fasts or major feasting, the body seems to use insulin to maintain a homoeostasis of around 5 to 6 mmol/L of total energy in the blood.

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On the left-hand side of the chart, when our blood glucose levels drop, we get a rise in ketones, but an increase in autophagy and all the good stuff that comes with fasting and ketosis.

On the right-hand side of the chart, when we drive our total energy high with excess energy (be it from processed carbs, Bulletproof Coffee, or exogenous ketones) the body releases insulin to stop stored body fat and glucose being released into our bloodstream.

People with the highest levels of metabolic health tend to walk around with a lower total energy in their bloodstream.  It seems you don’t need to buffer lots of energy in the blood if you can easily mobilise body fat and glycogen stores quickly when required.

Having high levels of energy sitting around in the blood stream is far from ideal and leads to glycation in the case of high blood glucose levels and oxidation in the case of free fatty acids.

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The total energy concept also seems to hold up with laboratory testing in rat pancreas islet cells, where exogenous ketone bodies promoted insulin secretion when there was greater than 5.0 mmol/L of glucose.[11]

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It appears that if your blood glucose levels are greater than 5.0 mmol/L (or 90 mg/dL), then exogenous ketones will be insulinogenic (at least if you’re a rat, but we have no reason to believe this wouldn’t occur in humans as well).

So if your blood glucose levels are greater than 5.0mmol/L (or 90 mg/dL),  then those expensive exogenous ketones will be working just like a quick burning insulinogenic fuel, just like a dose of carbs.

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do exogenous ketones “help” with fasting?

If exogenous ketones raise insulin and reduce blood glucose, then where does the glucose go?  It gets stuffed back into the liver. 

Think about all of these people who fast with the intent of depleting liver glycogen but drinking Keto/OS. They’re literally preserving glycogen stores! No wonder we were seeing whacky glucose and ketone response to fasting with exogenous ketones.

Instead of the normal trajectory of a fast that would result in depleted liver glycogen we see exogenous ketones keeps this from happening, so you would get purges of glucose out of the liver throughout the fast when people were fasting using exogenous ketones.”

Mike Julian

Let’s take a quick look at what Mike means by “the normal trajectory of glucose”.    In the chart below, we can see that blood glucose levels drop and ketone increase in four people.

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Where things get interesting is when you step look at the longer-term glucose and ketone trajectory of the fourth person who was taking exogenous ketones during the fast.

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What’s causing this anomaly in glucose and ketone response?   Is it a unique level of insulin resistance, or could this simply be explained by the use of exogenous ketones which are down regulating release of free fatty acids and endogenous ketone production?

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One theory is that exogenous ketones are switching off lipolysis, which drives the liver to release more glucose and ramp up gluconeogenesis to fuel the system during fasting?

The glucose : ketone index is the measure that Dr  Thomas Seyfried encouragescancer patients to use during a fast to measure its therapeutic effect.  The lower the better.  For most people the GKI continues to drop during extended fasting, but in this case the GKI dropped and then starts to rise over time when taking exogenous ketones.

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I would like to see some more thorough studies to understand if this is typical in people taking exogenous ketones during extended fasting.  It’s not conclusive, but n = 1s are useful to build a hypothesis that can be tested in a more controlled environment.

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oxidative priority

Ray Cronise and David Sinclair recently published an intriguing article, Oxidative Priority, Meal Frequency, and the Energy Economy of Food and Activity: Implications for Longevity, Obesity, and Cardiometabolic Disease (2016)[12] where they detailed the basis for the oxidative priority of different fuel substrates.

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  1. Alcohol will be burned first because the body has limited storage capacity for it. It sees it as a toxin that needs to be cleared.
  2. Protein will be burned second because you can only store a few hundred calories worth of amino acids in the bloodstream (though I think most people struggle to overeat protein when from whole food sources).
  3. Carbohydrate will then be burned before we can access our virtually unlimited stores of body fat.

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So, I think it would be logical that exogenous ketones would be first in line (before or just after alcohol) to be burned off because the body has no way of storing the exogenous ketones other than circulating in the blood stream.

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So, it seems that exogenous ketones neither lower insulin nor promote fat burning.  They’re just another fuel that will be burned before the fat on your bum and your belly.

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do exogenous ketones boost exercise performance?

Exogenous ketones in sports performance is an interesting area of research.  Rumour has it the Tour de France cyclists and British Olympic rowers are using ketone ester drinks (though it’s worth noting that the people spreading these rumours are selling the ketone esters).[13]

Some people use exogenous ketones as a preworkout, like caffeine, to give them a cognitive boost.  Research by Richard Veech and Kieren Clarke suggests that there may be a small athletic boost if you provide both exogenous ketones and exogenous glucose at the same time to provide a “dual fuel”.[14] [15]  This situation provides a fuel oversupply that would force the body to burn off the excess fuel quickly.

Dr Mike T Nelson suggest that driving a chronic energy surplus from high ketones and high glucose might be problematic in the long term as there is no precedent in nature for this condition.[16]

I have dabbled with exogenous ketones (i.e. KetoCaNa, Pruvit and the Ketone Aid ketone ester).  The chart below shows  how my blood ketones rose to 3.5mmol/L and then back down to normal levels after about 3 hours.  Note how my body tries to remove the excess energy from the blood stream and bring the total energy back down to around 5.0mmol/L.

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I didn’t find a massive boost in performance in my workouts with any of the ketone products.  My best performance is when I was fasted without supplementation and it seems I could easily access my fat stores and breath more effortlessly.

I’m far from a high level athlete, but when I perform at my best cycling or in my kettlebell workouts, my breathing seems effortless and my time to exhaustion increases.   When we are insulin sensitive and / or don’t have excess glucose in our system and burn more fat for fuel we use less oxygen than when we burn glucose for energy.[17]  That reduction in oxygen usage is critical to make sure you don’t get out of breath and fatigue.  It seems that too much exogenous ketones or glucose in the system will mean that we’re less reliant on burning our own body fat.

I think the future of exogenous ketones in athletic performance will revolve around finding the right dose to boost ketones enough to get a performance benefit, without switching off lipolysis, which is where the real performance powerhouse lies.   If you put in so much fuel in line in front of your virtually unlimited fat stores, then you may risk gassing out because you can’t access your fat stores as easily.

Perhaps someone who is a normal carb burner might benefit from having ketones raised to the 3 or 4 mmol/L range, while someone who is more fat adapted might benefit more with ketones in the 1 to 2 mmol/L range so as to get a dual fuel boost without switching off fat burning?

It’s still early days.  Time and more experimentation will tell.

does it matter?

If you’re metabolically healthy and you enjoy the brain buzz of exogenous ketones more than alcohol or caffeine and want to use exogenous ketones as a pre-workout, then I say go your hardest if you can afford it.

However, if you are looking for improvements in your metabolic health or magical weight, I think you should be cautious.

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Companies like Ketopia are marketing exogenous ketones as a “bridge” through the keto flu, which I think is a more ethical approach (although many people say you can eliminate the ‘keto flu’ with good mineral supplementation).

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But you probably haven’t heard of Ketopia, because selling seven days’ worth of exogenous ketones isn’t a great business model in comparison to getting people to sign up for an ongoing subscription as a distributor buying thousands of dollars of ‘inventory’ up front so they can take it… Every.  Single.  Day.

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Perhaps when exogenous ketones are no longer the realm of overhyped multi level marketing campaigns people will be able to experiment with exogenous ketones and find whether they live up to any of the claims and are indeed worth the money?  This is starting to happen now with Julian Baker’s InstaKetones coming in at about one sixth of the price of Pruvit’s products.

If you’re using exogenous ketones with the hope of reducing insulin levels or reversing metabolic disease (e.g. Type 2, cancer, Alzheimer’s, obesity), then maybe think again.  Exogenous ketones may alleviate your symptoms while they’re in your system (about 2 hours), but I fear they might worsen the conditions that people are using them for in the hope of improved metabolic health.

Mike Sheridan’s article in T-Nation makes a number of excellent points:

Ketones may be depressing dieters’ hunger and giving them a hit of energy and cognitive enhancement, but it’s INHIBITING their ability to burn fat, providing zero nourishment, and doing nothing for their metabolic health. There’s an assortment of evidence suggesting that it’s probably making things worse.

Think of exogenous ketones kind of like alcohol. When they’re consumed, everything is stored and nothing else is burned. So any lipolysis (fat burning) that would be taking place is halted; any glucose and fatty acids in your blood that were circulating are stored; and the ingested ketones are burned until there aren’t any left.

But suggesting individuals already fasting, restricting calories, or cutting carbs will get anything other than a brain buzz is misleading. And to serve up exogenous ketones to an obese, insulin-resistant general population with promises of fat-burning and disease prevention is potentially damaging.

Sure, it might suppress hunger and give a damaged brain a useable fuel source, but what happens when pre-diabetic Pete starts adding ketones to his glucose-rich blood? Or anaerobic Andy continues reloading with the same amount of carbs post-workout even though the liver glycogen he normally burns during his sessions is now suppressed?[18]

Sure, exogenous ketones might provide energy to the muscles or brain cells of someone with Type 2 or Alzheimer’s who can’t use glucose well because of decades of hyperinsulinemia.  But, if someone already has super high glucose and insulin levels, will they worsen the condition by chasing high ketone levels with large doses of insulinogenic exogenous ketones?

If someone is trying to shrink their brain tumour by reducing growth stimulating insulin, will ingesting large amounts of exogenous insulinogenic ketones accelerate growth in the brain tumors?  Recent studies suggest that this may in fact be the case.[19]

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At the current rate, it looks like we will be able to confirm the long term effects of exogenous ketones sooner rather than later.


But by then, the people running the MLMs will have driven off into the sunset and be on to another scheme.

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good news… endogenous ketones for free!

The good news is that all the benefits of endogenous ketosis is freely available risk free!  It’s not easy, but you can get the benefits of ketosis (e.g. autophagy, apoptosis, increased NAD+, mitogenesis etc) by keeping the insulin load of your normal diet down to the point that you can maintain normal blood glucose and insulin levels, then occasionally you can push the time between meals than usual in order to derive some extra benefits (i.e. intermittent fasting).

 

references

[1] https://www.dropbox.com/s/287bftreipfpf29/jcinvest00459-0078.pdf?dl=0

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC441933/

[3] http://www.webmd.com/diabetes/type-1-diabetes-guide/ketoacidosis

[4] http://www.webmd.com/diabetes/tc/diabetic-ketoacidosis-dka-topic-overview#1

[5] https://www.dropbox.com/s/hnycwc6b5pw37hr/Inhibition%20of%20Ketogenesis%20by%20Ketone%20Bodies%20in%20Fasting%20Humans.pdf?dl=0

[6] http://ajcn.nutrition.org/content/66/5/1264.abstract

[7] http://ses.library.usyd.edu.au/handle/2123/11945

[8] http://ajcn.nutrition.org/content/90/4/986.short

[9] https://www.ncbi.nlm.nih.gov/pubmed/27475046

[10] https://www.dropbox.com/s/j66y3osyasvq3b3/KETONES%20and%20NICOTINIC%20ACID%20receptor.pdf?dl=0

[11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1152056/

[12] https://www.ncbi.nlm.nih.gov/pubmed/27869525

[13] http://www.nutraingredients.com/Markets-and-Trends/Ketones-get-rough-ride-at-Tour-de-France

[14] http://journals.lww.com/acsm-msse/Abstract/publishahead/A_Ketone_Ester_Drink_Increases_Postexercise_Muscle.97232.aspx

[15] http://www.nourishbalancethrive.com/blog/2016/10/10/instant-ketosis-04-62mm-30-minutes/

[16] http://www.nourishbalancethrive.com/podcasts/nourish-balance-thrive/high-ketones-and-carbs-same-time-great-performance/

[17] http://www.freemocean.com/2017/02/22/oxygen-and-your-dna/

[18] https://www.t-nation.com/diet-fat-loss/avoid-this-ketogenic-rip-off

[19] https://link.springer.com/article/10.1186/s40170-017-0166-z

 

post updated July 2017

recipes, smoothies

chocolate orange smoothie

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This recipe is from Carrie Brown’s Eat Smarter! Smoothies and Sides.  While not particularly low carb due to the orange, it packs a solid amount of nutrients.

ingredients

  • 1 cup / 8 fl oz. unsweetened coconut
  • milk ⅔ cup / 2 oz. / 55g powdered egg white
  • 1 oz. / 30 g unsweetened cocoa powder
  • 2 oranges, take zest from one orange before peeling
  • ½ tsp. sea salt
  • ½ tsp. orange essence
  • 1 head Romaine lettuce
  • Xylitol as needed to sweeten
  • ½ tsp. guar gum

directions

  1. Place ingredients in the blender in the order listed, except guar gum.
  2. Blend on high until completely smooth.
  3. Tap the guar gum through the hole in the blender lid while the blender is still running and blend for 5 seconds.

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The micronutrient breakdown is shown below indicating that it does quite well in terms of vitamins, minerals and protein.

2016-11-19-20

The table below shows the nutritional data per 500 calorie serving.

net carbs insulin load carb insulin fat protein fibre
27g 56g 48% 16% 53g 26g
athletes, calorie density, nutrient density

high nutrient density, high energy density foods for athletes

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If you’re an athlete, the “problem” with nutrient dense foods like non-starchy vegetables and organ meats is that it can be hard to get enough fuel to support your activity.

Foods designed for athletes are energy dense but are not nutrient dense but rather are fast burning foods that don’t contain a lot of essential nutrients.  These foods may provide fuel for the short term, but they can lead to gut distress in the short term and as well as inflammation and insulin resistance in the long term.

To overcome these problems, this list of foods has been designed to be both nutrient dense and energy dense to ensure someone who is very active can get enough fuel while maximising nutrient density as much as possible.

energy density

The energy density of the foods listed below comes out at 367 calories per 100g compared to 231 calories per 100g for all foods in the USDA foods database.  They will contain enough energy to fuel an active life without spending all day chewing or overfilling your stomach.

macronutrients

From a macronutrient perspective these foods will provide you with:

  • more protein for muscle recovery,
  • more fat to provide energy,
  • more fibre due to the lower level of processing, and
  • less non-fibre carbohydrates which will normalise blood glucose levels while still providing some glucose for explosive power.

micronutrients

The chart below shows that these foods are quite nutrient dense, with all of the nutrients achieving greater than the daily recommended intake.

nutrient dense, energy dense foods for athletes

Listed below are the top 10% of the foods using this ranking including:

  • nutrient density score (ND)
  • energy density (calories/100g) and
  • their multi criteria analysis score (MCA).

vegetables

While the vegetables and spices in this list aren’t particularly energy dense they will ensure that you get the vitamins and minerals you need to perform at your best.  The lower energy density vegetables have been removed because they won’t be that helpful fueling for race day.

food ND calories/100g MCA
spinach 17 23 1.6
yeast extract spread 11 185 1.4
seaweed (wakame) 13 45 1.3
portabella mushrooms 13 29 1.2
shiitake mushrooms 7 296 1.1
broccoli (sulforaphane) 11 35 1.0
shiitake mushroom 11 39 1.0
seaweed (kelp) 10 43 0.8
cauliflower 9 25 0.7

seafood

Seafood packs some nutrient density and energy density at the same time.

food ND calories/100g MCA
cod 13 290 1.9
crab 14 83 1.4
anchovy 10 210 1.3
salmon 11 156 1.3
lobster 13 89 1.3
fish roe 11 143 1.3
caviar 8 264 1.2
halibut 11 111 1.2
trout 10 168 1.2
sturgeon 10 135 1.1
crayfish 11 82 1.1
pollock 10 111 1.0
oyster 10 102 1.0
shrimp 10 119 1.0
haddock 9 116 0.9
rockfish 9 109 0.9
sardine 7 208 0.9
octopus 8 164 0.9
flounder 9 86 0.8
white fish 9 108 0.8
perch 8 96 0.8
mackerel 4 305 0.7
whiting 7 116 0.7
herring 5 217 0.7
tuna 6 184 0.7
clam 6 142 0.6
scallop 7 111 0.6

eggs and dairy

Eggs are nutritionally excellent.  Butter has plenty of energy.

food ND calories/100g MCA
egg yolk 6 275 0.9
butter -5 718 0.7
whole egg 5 143 0.5

fats and oils

Fats and oils don’t contain a broad range of micronutrients, but they’re a great way to fuel without excessively raising your blood glucose or insulin too.  From an inflammatory perspective, they’re going to be better than process grains and glucose for fueling as well as keeping insulin levels low to enable you to access your fat stores during endurance activities.

food ND calories/100g MCA
grapeseed oil -4 884 1.3
peanut oil -5 884 1.1
olive oil -6 884 1.1
soybean oil -6 884 1.1
beef tallow -6 902 1.1
duck fat -6 882 1.1
soy oil -6 884 1.1
lard -6 902 1.1
coconut oil -7 892 1.0
walnut oil -7 884 1.0
palm kernel oil -6 862 1.0
mayonnaise -4 717 0.8

grains and cereals

The more nutrient dense bran component of wheat makes the cut, however, the more processed and more popular grains don’t make the list. Many people find use the “train low, race high” approach to be useful to ensure you are fat adapted through fasted or low glycogen training but have some glucose in the system for explosive bursts on race day.

food ND calories/100g MCA
wheat bran 10 216 1.3
baker’s yeast 12 105 1.2
oat bran 5 246 0.8

legumes

Legumes are moderately nutrient dense and have a higher energy density than most vegetables.  Properly prepared legumes can be a cost effective way of getting energy and nutrients, though not everyone’s gut handles them well.

food ND calories/100g MCA
peanut butter 1 593 1.1
soybeans 2 446 0.9
peanuts -1 599 0.9
cowpeas 2 336 0.6
black beans 1 341 0.5
broad beans 1 341 0.5

nuts and seeds

Nuts and seeds are a great way to get some energy in, though they’re not as high in the harder to find nutrients.

food ND calories/100g MCA
sunflower seeds 4 546 1.4
pumpkin seeds 1 559 1.1
almond butter 0 614 1.1
almonds 0 607 1.0
pine nuts -2 673 1.0
walnuts -1 619 1.0
brazil nuts -2 659 1.0
flax seed 1 534 1.0
sesame seeds -2 631 0.9
sesame butter -1 586 0.9
hazelnuts -2 629 0.9
macadamia nuts -4 718 0.8
pecans -4 691 0.8
cashews -2 580 0.7
pistachio nuts -2 569 0.7

animal products

Organ meats also do well in terms of nutrient density.  Fattier cuts of meat will pack some more energy.

food ND calories/100g MCA
lamb liver 12 168 1.4
veal liver 10 192 1.2
ham (lean only) 11 113 1.2
lamb kidney 11 112 1.2
beef liver 9 175 1.1
chicken liver 9 172 1.1
turkey liver 9 189 1.0
pork chop 8 172 0.9
chicken breast 8 148 0.9
pork liver 7 165 0.8
beef kidney 7 157 0.8
pork shoulder 7 162 0.7
veal 7 151 0.7
leg ham 6 165 0.7
ground pork 6 185 0.7
lean beef 7 149 0.7
sirloin steak 5 177 0.6

 

post updated July 2017

articles, carbohydrates, fat, nutrient density, protein

micronutrients at macronutrient extremes

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In the previous article, Which Nutrients is YOUR Diet Missing?, we looked at the micronutrients that you might be lacking when following popular dietary strategies such as vegan, Paleo, keto, or zero carb.

As a follow-up, I thought it would be interesting to look at the effect on essential micronutrients if we define our dietary approach in terms of macronutrient extremes such as low carb, high fat, high protein, high carb, or low protein.

Humans tend to think in extreme terms.  It’s easy to follow a binary approach to nutrition, but which, if any, of these are the most useful in terms of maximising the nutrition provided by our diet?

For most of my life, best practice nutrition has been defined by a fear of fat which spawned the low-fat processed food era.

And because protein is necessary for muscle growth, more must be better?

But protein is also insulinogenic, so less protein must be good.  Right?

And then of course there is low carb, which has been popular since the appearance of the Atkins diet appeared in the early 1970s.

atkins.jpg

But then there are a good number of people who still define their diet as being high carb.

Banana-girl-.jpg

All of them seem to be similarly zealous about their all-or-nothing approach.

But are any of these macronutrient extreme approaches beneficial?  And if so, which one leads us to the optimal selection of nutritious foods that will lead to health, happiness, optimal weight, and longevity?

why bother with nutrient density?

The premise of nutrient density is that we want to maximise the quantity of essential micronutrients that we need to support our bodily functions while not overdoing energy intake.

Micronutrient dense foods allow us to obtain adequate nutrition with fewer calories.  Then, with our nutrients accounted for, higher micronutrient density might just lead to higher satiety levels, reduced appetite, reduced food intake and optimal body fat levels.

At the other extreme, if we consume fewer foods with a lower nutrient density, we will likely end up needing to consume more food to obtain the nutrients we need to survive and thrive.  If our appetite drives us to keep on eating until we obtain the nutrients we need, we may end up having to consume too much energy and and end up storing unwanted energy as fat.

macronutrient comparison

In this post, we’ll look at the micronutrients provided by the highest-ranking foods when we sort the eight thousand foods in the USDA database by the most and least fat, protein, and carbs.

Approach % protein % fat % net carbs % fibre
high fat 14% 82% 3% 1%
low net carbs 33% 67% 0% 0%
most nutrient dense 49% 19% 20% 12%
high protein 77% 22% 1% 0%
least nutrient dense 7% 32% 59% 2%
low protein 1% 27% 68% 3%
low fat 8% 1% 84% 7%
high net carbs 3% 2% 92% 2%

This chart shows the macronutrient split for these extreme approaches.

fat

While low carb is still in the lead in terms of internet searches (as shown in the Google Trends data below), the ketogenic diet is becoming pretty popular these days.

The chart below shows the nutrients provided by 2000 calories of the fattiest foods.  Nutrients are expressed in terms of the percentage of the daily recommended intake (DRI), for each nutrient, per 2000 calories (i.e. a typical daily intake).

While we achieve adequate amounts of about half of the essential micronutrients with a therapeutic ketogenic diet, we may need to consider supplementing some of the harder to obtain nutrients such as vitamin C[1], vitamin D, potassium, choline, vitamin K, and magnesium.

Looking at things from the other extreme, a low-fat diet will give you a ton of vitamin C, sodium, manganese, and iron.  However, it will be harder to obtain adequate quantities of the twenty-one essential nutrients, particularly essential fatty acids.

saturated fat

These days, the US Dietary Guidelines have lifted their limit on fat and cholesterol but retained their limitation on saturated fat.  Saturated fat and trans fats remain the two nutrients that we are advised to avoid.

The chart below shows the outcome when we avoid saturated fat.  The top 10% of foods with the lowest saturated fat are lacking (i.e. < 100% DRI) in nineteen essential nutrients.

At the other extreme, foods with the most saturated fat are slightly better with seventeen essential micronutrients lacking.

As discussed in the ‘What about Saturated Fat?’ article, I think saturated fat is neither a concern nor a priority.  Saturated fat a great clean-burning fuel, but there’s no need for us to make up for the last four decades of avoidance by suddenly binging on it.

The chart below shows a comparison of the nutrient density of the quartiles of saturated fat in terms of percentage of energy.  It seems that the foods with moderate levels of saturated fat that are the most nutrient dense.

protein

Once you move past the fear of fat, the next hot topic is optimal protein levels.

The ‘high protein bros’ recommend more protein for muscle growth and satiety, while many in the low carb/keto community target lower protein levels for longevity and ketosis through minimising insulin and mTOR signalling.[2]

As shown in the chart below, when rank foods to minimise protein, we end up with only four essential nutrients meeting the recommended daily guidelines to prevent malnutrition.

At the other extreme, if we prioritise protein we end up with ten nutrients that we fall short of.  The other twenty-six essential nutrients meet the minimum recommended levels.

Not only does protein contain essential amino acids, this analysis indicates that higher protein foods generally come bundled with high amounts of vitamins and minerals, such as vitamin B-12, selenium, vitamin B-6, riboflavin and copper.

It’s one thing to talk about targeting the minimum daily protein that you can get away with if you are looking to preserve muscle in fasting or extreme calorie deprivation during long term weight loss.  It’s a whole different discussion if you’re looking to minimise protein while making up the rest of your daily energy intake with fats or carbs!

carbohydrates

The chart below shows the nutrients we obtain if we maximise energy from non-fibre digestible carbohydrates (i.e. net carbs).  This high carb approach provides adequate amounts of twelve of the essential nutrients, while still being inadequate in twenty-four essential nutrients.

The chart below shows that low carb performs better than high carb, only falling short in sixteen essential micronutrients.

One of the benefits of a low carb approach, is that it often forces the elimination of many processed foods that fill the supermarket shelves to satisfy the demand for low fat foods driven by the admonition by the for the last four decades by the ruling dietary establishment to minimise fat.

A nutrient dense diet contains less non-fibre carb than the typical diet, but some people will do better, at least for a while, on a carb restricted diet.  Another major benefit of low carb is for insulin resistant people when they can lower their blood glucose and insulin levels on a carb restricted diet.  Many people find it easier to lose excess body fat once they have restored their insulin sensitivity.

nutrient density

You’re probably wondering where all these analyses are headed.

With all of these extreme approaches being so deficient in many micronutrients, you must be thinking “I hope there is a happy ending to this story, and soon.”

The good news is that we can manipulate our food selection to maximise micronutrients.  But first, here’s something to scare you even more.

The chart below shows the outcome when we minimise the harder-to-find nutrients.  This low nutrient density approach ends up being adequate in only three essential nutrients: sodium, vitamin C and iron.

The good news is shown in the chart below, which quantifies the nutrients provided by the most nutrient dense foods when we prioritise for the harder to find nutrients.  Alpha linolenic acid (found mainly in nuts and seeds) is hard to come by in adequate quantities, however we can obtain the daily recommended intake of all the other nutrients when we prioritise the harder to find micronutrients.

comparison of nutrients adequate

It’s a little hard to present and digest this analysis clearly.  There is no agreed protocol to compare the nutrient density foods.  So I’ve tried to summarise it in a number of different ways to allow you to draw your own conclusions.

Firstly, the chart below shows the number of nutrients that each macronutrient extreme is adequate in, from the most nutrient dense at the top to the least nutrient dense at the bottom.

The chart below shows a stacked bar chart of the various nutrients in terms of % DRI.  It’s like we have added up all the above charts for each nutrient and stacked them on top of each other.  This chart demonstrates that there is a is a massive difference between the most nutrient dense and least nutrient dense approaches.  If you’re foods that have a lower nutrient density you might just be hungrier compared to if you are eating the same number of calorie of the most nutrient dense foods which will much more effectively provide you with your essential micronutrients.

But  we needn’t be too concerned about the micronutrients that are easy to obtain.  What we really care about is the nutrients that are harder to obtain.  The chart below shows the sum of the eighteen nutrients that are harder to obtain for each extreme approach.

application

It seems that thinking in terms of macronutrient extremes has some usefulness.  However, focusing on micronutrient density seems to provide an order of magnitude improvement in the level of actual nutrients provided by our food.

Maybe it’s time for a new trend?

The ‘problem’ with nutrient dense foods is that that they are so lean and contain so much fibre that it can be hard to consume enough calories to maintain weight.  You’ll just be too full!

If you are insulin sensitive and not looking to lose weight, then you could consider adding some more ‘Paleo friendly’ carbs such as beets, squash, yams, and sweet potatoes, and/or some fattier cuts of meat to fuel your activity.  If you are insulin resistant, you may need to add some fattier (but still relatively nutrient dense) foods to maintain your weight while also keeping your blood glucose and insulin levels in check.

Perhaps micronutrient density is the most important parameter to pursue in our diet.  Then with that cornerstone in place we can personalise our nutritional approach to suit our goals (e.g. weight loss, ketosis, athletic performance or healthy maintenance).

The various food lists in the table below are designed with micronutrient density as the main priority, but also consider insulin load and energy density to suit different goals.

approach average glucose waist : height
(mg/dL) (mmol/L)
therapeutic ketosis > 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 > 0.5
weight loss (insulin sensitive) < 97 < 5.4 > 0.5
bulking < 97 < 5.4 < 0.5
nutrient dense maintenance < 97 < 5.4 < 0.5

personalisation

In the end, no one sticks to an optimal list of foods that perfectly balances their diet 100% of the time.

I’ve been working on a system that will give you feedback on YOUR current diet, identify which nutrients you are currently lacking, and which supplements or real whole foods you may need to add or subtract to optimise your nutrition.  Most people don’t eat perfectly all the time, but we could all use some help moving forward towards optimal.

Check out the Nutrient Optimiser page for more details.

 

notes

[1] There is a strong case for the idea that the DRI for vitamin C could be relaxed for a diet with lower glucose.  See http://breaknutrition.com/ketogenic-diet-vitamin-c-101/ and http://orthomolecular.org/library/jom/2005/pdf/2005-v20n03-p179.pdf

[2] Check out this video by Ron Rosedale for an overview of the topic of protein, mTOR signalling and longevity.  https://www.youtube.com/watch?v=xtZ0LqUBySQ

articles, nutrient density, therapeutic ketosis, vegan, weight loss, zero carb

which nutrients is YOUR diet missing?  

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I recently took a look at which nutrients might be missing from various popular dietary approaches in preparation for a recent on nutrient density.  At a population level, the chart below shows the proportion of the US population that are deficient in various micronutrients.  Many people are not getting enough vitamin D, vitamin E, magnesium, calcium, etc.

While your body hasn’t read the World Health Organisation’s reports on the Daily Recommended Intake of the various essential nutrients,[1] it’s likely that your appetite will drive you to seek out the nutrients that are lacking.  If we are deficient in something that is required the body kicks in “nutrient hunger” and cravings that will make sure it gets what it needs.[2] [3] [4]

If you work hard to restrict your food intake to a certain dietary approach, but the body doesn’t receive the nutrients it needs, it may slow down and not function at full capacity.   By contrast, adequate nutrition, without too much energy, slows many of the modern diseases of aging such as diabetes, Alzheimer’s and cancer and improves your chance of living healthfully to a ripe old age.[5]

USDA foods database

The chart below shows the nutrients that are both easiest and hardest to obtain from the eight thousand foods in the USDA foods database.  At the bottom of this plot we have iron, various amino acids, and vitamin C, all of which are easy to obtain in adequate quantities.

However, at the top of the chart, we can see that it is much harder to obtain adequate quantities of six essential nutrients (omega 3 fatty acids, vitamin D, choline, vitamin E, and potassium).  We would obtain sufficient quantities of all the other essential nutrients if we ate just a little of each of the foods in the USDA food database.

If we want to maximise nutrient density, it makes sense to prioritise foods that contain more of the harder-to-obtain nutrients.  The chart below shows the nutrients for the top 10% of the 8000 foods in the USDA database (blue bars) when we prioritise for those.  Not only do we get an increase in the more difficult to obtain nutrients, we also get a massive boost in all nutrients.  Rather than being inadequate in six nutrients, we are now lacking only one (alpha-Linolenic acid, an Omega 3 fatty acid).

Limiting our food selection to the most nutrient dense foods makes it easier for us to consume the required nutrients without excessive energy, which is ideal if we are trying to lose fat or reduce calorie intake to slow the diseases of ageing.[6] [7]  Nutrient density becomes even more important if you’re fasting or restricting calories to achieve long term weight loss.

Optimising nutrient density

If you’re reading this, then you’re likely aware that there is a wide variety of dietary approaches that people follow to optimise their health depending on their preferences and beliefs.

I’ve tried to turn many of these beliefs about nutrition into a quantitative algorithm that we can use to evaluate and compare these approaches, and make sure we’re getting the outcome we want (e.g. low insulin, blood glucose control, nutrient density, or low/high energy density).

After testing a number of options, the three quantitative parameters that I have found the three parameters that are most useful are:

  • insulin load,
  • nutrient density, and
  • energy density.

My aim in this post is to show how considering nutrient density can improve various dietary approaches, from therapeutic ketogenic, vegan, paleo, and low fat.   This post highlights which nutrients you will most likely be lacking with each of the different nutritional approaches, which foods you can use to fill these nutritional gaps, and perhaps which supplements you may need if you are still looking for some added nutritional insurance.

There’s been a lot of talk lately by Taubes[8] and Lustig[9] about how bad sugar and fructose are, but I think these nutritive sweeteners are just extreme examples of nutrient poor foods that are highly insulinogenic and energy dense.  At the other end of the spectrum, we have foods like liver, broccoli, and spinach.  Everything else is somewhere in the middle and will support or work against your goals, whatever they may be, to different degrees.

My aim here is to help you see where each of these foods sits on that continuum and use this information to help you refine your food choices to reach your personal goals.

Therapeutic ketogenic diet

Let’s start with the therapeutic ketogenic dietary approach.   I have previously noted that a number of the issues and concerns with the ketogenic diet seem to relate to being able to obtain essential nutrients rather than consuming excessive levels of fat.[10] [11] [12]  On one hand, I’m excited that the concepts of insulin load and percentage of insulinogenic calories have been helpful for people with chronic conditions such as epilepsy, cancer, dementia, Alzheimer’s etc.  However, I think there is a risk their ultra-high fat diet will not contain the nutrients which are critically important for mitochondrial function and energy production.

The chart below shows the vitamins and minerals provided by a therapeutic ketogenic dietary approach if we simply prioritise for low insulin load (red bars)[13] in comparison to the average of all foods in the USDA database (orange bars).  If you don’t pay attention to nutrient density a therapeutic ketogenic diet can provide lower levels of nutrition.

As shown in the chart below if we ate a little of all the foods in the USDA database, we would be deficient in six essential nutrients, whereas if we follow a therapeutic ketogenic diet, we will likely be lacking in ten essential nutrients.

The chart below shows the effect of how thinking in terms of nutrient density can improve the therapeutic ketogenic dietary approach (blue bars) compared to prioritising for insulin load only (red bars).  All nutrients are boosted, particularly the harder to obtain ones.

While lots of people find that higher fat whole foods are hard to overeat, there are still some hyper palatable high fat foods that go down easily.  We talk about eating “fat to satiety”, but what happens when nutrient hunger kicks in and your body is craving more potassium, magnesium, calcium, or one of the other nutrients that are harder to obtain in a very high fat dietary approach?  If you keep on consuming large amounts of processed fats that don’t contain the nutrients you require, your appetite may not automatically turn off before you’ve consumed a lot of excess energy!

Low carb

The chart below shows the boost in nutrients when we consider nutrient density combined with a low carbohydrate approach.  It appears that, based on this analysis, that without a focus on nutrient density, a low carbohydrate diet is likely to be deficient in folate, vitamin D, choline, potassium, magnesium, pantothenic acid, calcium, vitamin E and manganese.  With a focus on nutrient dense foods, a low carb diet provides adequate amounts of the majority of nutrients.

Weight loss (insulin sensitive)

The weight loss approach is intended for people who are insulin sensitive but still have excess body fat to lose.  Foods with a lower energy density (e.g. spinach, broccoli cucumber, celery, lettuce etc) typically are harder to overeat because they are bulky.

This approach doesn’t pay any attention to insulin load because it is assumed that people using this approach are not insulin resistant and are able to maintain good blood glucose levels.  Practically, it’s also difficult to achieve a really high insulin load with these foods because they do not contain a large amount of processed carbs and are hard to overeat.

Without consideration of nutrient density, the essential fatty acids tend to be low along with vitamin B-12, choline, and tyrosine.  However, once we factor in nutrient density all these nutrients dramatically improve.

This approach may not be viable for long term maintenance due to the extremely low energy density which would make it hard to get in enough energy.  However, in the short term, it may be appropriate for a period of substantial energy restriction, and will provide maximum nutrition with a minimum amount of energy.

Zero carb

Getting adequate protein on a zero-carb approach is not a problem.  However, unless there is a major focus on organ meats, there are a large number of vitamins and minerals, such as   vitamin K, manganese, vitamin C, vitamin E, vitamin D, potassium, magnesium and calcium that may be worth supplementing.

Vegan

At the other extreme, the chart shows the nutritional analysis of the vegan diet.  The main deficiencies in a vegan approach are omega 3s and vitamin B-12, which are hard to obtain without animal products.  It may be prudent for vegans to consider fish oil supplementation and B-12 injections, or alternatively adding some seafood occasionally.

While it appears possible to obtain the recommended levels of protein, it’s hard to get very high levels of it.    If you are insulin resistant, the fat levels can be increased using added coconut products and nuts.

Higher insulin load foods for bulking

The bulking approach is designed for people who are looking to gain strength and size by combining nutrient density with more calories and insulin load.  Without consideration of nutrient density, a high insulin load means very low nutrient density foods.  However, once we factor in nutrient density, we get a range of highly nutritious foods that may be helpful if you want to gain size and strength, while still maximising health and nutrition.

Paleo

The chart below shows the nutrients provided by the Paleo approach (i.e. no processed foods, dairy or grains) both with and without consideration of nutrient density.  While ‘going Paleo’ eliminates many of the nutrient-poor processed food, it appears to be beneficial to also consider nutrient density as well in addition.

What does this all mean?

So, how do we decide which approach is best?  Unfortunately, it’s not straightforward so I’ll look at this a number of ways.

What we ideally want is to identify the foods that will provide us with high amounts of all of the nutrients.   The blue bars in the chart below represents the average of the % daily recommended intake of all the nutrients in the various approaches evaluated above, without considering nutrient density.  The orange bars represent the average minus 0.5 x the standard deviation which is a measure of reliability.  The higher the reliability the more consistent and high are the nutrients over all.

This chart shows that, in comparison to the other approaches, Paleo foods have a high and consistent level of nutrients; while the vegan and low energy density weight loss foods have high levels of some individual nutrients, but low levels of some others.  Without consideration of nutrient density, the high insulin, low carb and zero carb approaches are a bit lacking in nutrients.

Things become a little more interesting once we factor in nutrient density.  The vegan, therapeutic keto, low carb and zero carb approaches do poorly against the paleo, higher insulin load, most nutrient dense of all foods, and the lower energy density weight loss foods.

Many people will benefit on a high fat therapeutic ketogenic dietary approach, at least until their blood glucose and insulin levels normalise.  However, in time, it may be beneficial to transition to more nutrient dense foods to continue their journey towards optimal health.

As detailed in the ‘how to optimise your diet for insulin resistance’ article, I think you should eat the most nutrient dense foods your pancreas can keep up with while maintaining good blood glucose levels.  In time, someone who is highly insulin resistant may be able to progress to a more nutrient dense and more moderate fat approach if your ultimate goal is to normalise blood glucose levels and lose weight.

Food lists

If you identify with any of these goals, you may be interested in following these food lists.   If blood glucose levels are sky high or you are managing a chronic condition such as epilepsy, cancer, Alzheimer’s or dementia, you may benefit from a higher fat therapeutic keto dietary approach, for a period.  As your glucose levels come under control, you can transition to more nutrient dense foods that will also help you to achieve your weight goals.

approach average glucose waist : height

(mg/dL)

 (mmol/L)
therapeutic ketosis

> 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

> 0.5
weight loss (insulin sensitive)

< 97

< 5.4

> 0.5
bulking

< 97

< 5.4

< 0.5
nutrient dense maintenance

< 97

< 5.4

 < 0.5

Getting even more personal

As you can see, nutrients are provided at different levels depending on the approach.  However, most people don’t follow any dietary approach strictly, so the nutrients in your diet will be different depending on your personal habits and preferences.

Rather than trying to pick up someone else’s nutrition plan, or live by a strict list, I think it’s better to refine your current habits, emphasising the good foods, minimising the bad, and progressively trying new foods that may be beneficial.

To this end, I’ve been developing a Nutrient Optimizer algorithm that can help you refine your food choices to suit your goals.  By identifying the foods you are currently eating that align most with your current goals, which ones don’t, and which new foods perhaps you should consider.

Most current nutritional advice is driven by the avoidance of fat, particularly saturated fat, and therefore ends up being next to useless.  Calorie counting apps like MyFitnessPal does nothing but count calories, which is also of limited use.  Cron-o-meter tracks your micronutrients and can recommend foods to boost a single nutrient.  However, there doesn’t seem to be anything available that will tell you which foods will help you actually correct multiple deficiencies and  achieve a diet that is truly balanced in micronutrients.

The Nutrient Optimiser also allows you to tailor the approach to your goals, such as:  therapeutic ketosis, diabetes management, weight loss or just nutrient dense maintenance.  Food preferences like vegan, pescetarian, autoimmune, or paleo can be factored in to the recommended food lists.

At the moment, the process involves manually exporting food intake data from Cron-o-meter, then analysing it in a spreadsheet to manually generate a personalised report.  I am eager to do this as a proof-of-concept for a range of people with various goals (particularly therapeutic ketosis, vegetarian, zero carb, fruitarian) to demonstrate how it works.  So, if you’re happy to have your report shared publicly, and have a couple of weeks of Cron-o-meter data, feel free to send it to me and  have your data analysed.

In time, the plan is to automate the process via an online interface and then ideally an independent mobile app.    To keep up-to-date with progress, watch this space and check out the various analysed examples on the Marty Kendall’s Nutrient Optimiser Facebook page.

Epilogue…  limitations

For completeness, I thought it would be worth mentioning a few limitations relating to calculating nutrient density…

  1. Measuring foods in terms of calories has its own limitations as different macronutrients provide different amounts of energy (ATP) in different people. Some smart friends of mine are working on calculating ATP yield for different foods based on their macronutrient content.  I’ll happily update this analysis in terms of nutrients per ATP as soon as that data is available.  Initial indications are that people who are fat-adapted are able to use fat more efficiently (i.e. less entropy/losses in metabolism) and hence require less calories to yield the same amount of energy in the body (i.e. ATP).  Hence, it appears that it is even more important for someone following a low carb or ketogenic approach to maximise nutrient density in terms of nutrients per calorie.
  2. The official dietary reference values are based on limited research.[14] Typically, they relate to the minimum amount of a nutrient to avoid disease rather than the amount required for optimal function.  They may also vary by person (e.g. someone who is more active may need more protein) and by their diet type (e.g. someone who is on a low carb diet may need less vitamin C to process the limited amount of glucose).  Hence, I think the DRI values should be seen as a minimum.  Ideally, we want to get more than the minimum while not having to ingest too much energy.  I also don’t think nutrients are meant to come as individual vitamins and minerals in a bottle.  The nutrients required to metabolise a certain food typically come packaged in whole foods, and often work synergistically.  Taking supplements or fortifying foods will always be inferior to obtaining nutrients from whole foods.
  3. Species-specific bioavailability and anti-nutrients are contentious topics. Zero carbers will tell you that nutrients in animal based foods are more bioavailable than plant based foods, while the vegans will tell you the opposite.  To date, I haven’t been able to find useful data that would enable me to quantitatively refine the nutrient data in the USDA database regarding bioavailability.  All we currently have is a measure of the nutrients contained in the food– rather than the nutrients that make it into your body after digestion.  Again, if this data ever comes to hand, I’ll eagerly update the analysis.

Overall, I don’t think these limitations make a difference in the outcomes of the analysis.  This is not an exact science and the body doesn’t operation like a rigid machine.  Calculation of nutrient density is just a way to identify the foods that contain the most raw materials with the least amount of calories that your body can work with.

referecnes

[1] http://www.who.int/nutrition/publications/nutrient/en/

[2] https://books.google.com.au/books?id=gtQyAgAAQBAJ&pg=PA185&lpg=PA185&dq=%22nutrient+hunger%22&source=bl&ots=VMRQ8EbvHx&sig=l_xJEksBS538UX3QwQNxVJBXTLw&hl=en&sa=X&ved=0ahUKEwjRj6mSs5DSAhWKyLwKHXBQAjEQ6AEIKDAC#v=onepage&q=%22nutrient%20hunger%22&f=false

[3] https://www.amazon.com/Perfect-Health-Diet-Regain-Weight/dp/1451699158

[4] https://www.amazon.com/Dorito-Effect-Surprising-Truth-Flavor/dp/1476724237

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

[6] http://ajcn.nutrition.org/content/78/3/361.full

[7] http://www.nature.com/articles/ncomms14063

[8] https://www.amazon.com/Case-Against-Sugar-Gary-Taubes/dp/0307701646

[9] https://www.youtube.com/watch?v=dBnniua6-oM

[10] https://www.thepaleomom.com/adverse-reactions-to-ketogenic-diets-caution-advised/

[11] http://ketotalk.com/2016/06/23-responding-to-the-paleo-mom-dr-sarah-ballantynes-claims-against-the-ketogenic-diet/

[12] http://www.thelivinlowcarbshow.com/shownotes/10888/868-dr-sarah-ballantyne-challenges-the-wisdom-of-low-carb-diets-for-women-2/

[13] In terms of macronutrients this high fat dietary approach comes out at 80% fat, 15% protein, 2% fibre and 3% net carbs.

[14] http://www.who.int/nutrition/publications/nutrient/en/

nutrient density optimised for diabetes, ketosis, weight loss, longevity and performance

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