ketosis… the cure for diabetes?
- A reduced insulin load diet will lead to normalised blood sugars and improved insulin sensitivity.
- A reduced insulin load diet can be achieved by reducing carbohydrates, moderating protein and choosing higher fibre foods.
- Intermittent fasting also reduces insulin load.
- Measuring your blood sugars is a simple and cost effective way to check that your metabolic health is on track.
- A diet of nutrient dense, high fibre, high fat foods is the best way to optimise nutrition and minimise the risks associated with diabetes.
how to become diabetic…
In the “good old days” there were periods of feast and famine. Food was typically eaten with the fibrous packing that it came with. In today’s modern food environment we are encouraged by the food industry (and those sponsored by it) to eat breakfast, lunch, dinner, snacks, pre-workout meals, post workout stacks, sports gels during exercise, and maybe some Gatorade to speed recovery.
Today’s food is plentiful, typically highly processed and low in fibre. Carbohydrate and sugar based foods have a long shelf life, can be transported long distances and therefore cheap. Win, win? Maybe not.
As we keep loading our bodies with simple sugars and carbohydrates our pancreas has to work overtime to produce insulin to shuttle excess sugar from the blood to your fat stores.
Over time we become insulin resistant and the pancreas can’t keep up. Once your blood sugars get high enough you will be diagnosed with “type 2 diabetes” and put on medication to improve your insulin sensitivity, for a time. If nothing changes in your food intake your insulin sensitivity will continue to deteriorate until you reach a point when you’ll need to inject insulin to keep your blood sugars down.
Injecting excessive amounts of insulin will cause you gain even more body fat. Recently we have learned that it’s not just the high blood sugars that are diabolical for your health, high levels of insulin are also toxic. 
Doesn’t sound like much of a solution does it?
…and how to reverse it
While there are many aspects to managing diabetes including stress, sleep, food quality and environmental toxins, the simplest and most effective thing you can do to achieve optimal blood sugars is to do the opposite of what caused the problem in the first place.
Listed below are the main things that cause diabetes and what we can do to reverse it.
|leads to diabetes||reverses diabetes|
|Excessive sugar and simple carbohydrates in the diet generate high insulin load||Reduce foods in your diet that require insulin |
|Constant food with no significant periods between meals when insulin levels are reduced||Create periods when your body does not have significant amounts of circulating insulin (i.e. intermittent fasting).|
Sounds simple. But it’s not easy or quick to reverse years of metabolic damage. Your body is hard-wired to retain fat so it can survive the next famine.
Worth the effort? People who have done it say yes. That’s why they’re so annoyingly passionate about it!
foods that require insulin
You’re likely already aware that foods containing carbohydrates require your pancreas to produce insulin.
- protein requires about half as much insulin as carbohydrates per gram on average,  and
- carbohydrates in the form of indigestible fibre do not require insulin. 
So if you’re trying to reduce the insulin load of your diet you should:
- limit simple processed carbohydrates that do not contain fibre,
- choose high fibre foods (such as non-starchy vegetables) to obtain vitamins and minerals while keeping net carbohydrates low, and
- back off on the protein if you’re not achieving the normalised blood sugars, weight loss or nutritional ketosis results you’re after.
Rather than simply counting carbs, you could get a bit fancy and calculate your total insulin load using this formula:
Most people will achieve nutritional ketosis with an insulin load of around 100 to 150 grams. Athletes and weight lifters will be able to tolerate more without messing up their blood sugars. Inactive people aiming for weight loss may need to reduce their insulin load further. I don’t think that it’s ideal for most people to weigh and measure their food for extended periods.
If you’re not getting the results you want then tracking your food in MyFitnessPal or something similar can be a useful in the short term to retrain your dietary habits.
measuring for ketones versus measuring blood sugar
Once you get over seeing a little drop of your own blood, measuring your own blood sugar is pretty simple and painless, and is much cheaper than measuring blood ketones. In Australia and Canada blood sugar strips are about $0.16 compared to blood ketone strips which are about $0.80.  In the US ketone strips are much more expensive, and basically unaffordable. Ketostix (which measure ketones in your urine) will typically only work for a little while until your body learns to use fat for fuel.
relationship between blood sugars and ketones
Blood sugar can be a useful way to see if you’re in ketosis. The chart below shows my blood sugars versus ketones over the last nine months or so that I’ve been trying to achieve nutritional ketosis.
Based on my n=1 experience I’ve added the ketone levels which correlates HbA1c, average blood sugar and ketones. This suggests that excellent blood sugar control for me is achieved when I’ve got ketone levels between 0.5 and 1.3mmol/L.
|HbA1c||average blood sugar||ketones|
|excellent||< 5.0||< 5.4||< 97||> 0.5|
|good||< 5.4||< 6||< 108||< 0.3|
|danger||> 6.5||7.8||> 140||< 0.3|
is more ketosis better?
The point way out to the right with a high ketone level of 2.1mmol/L and a blood sugar of 4.0mmol/L occurred after I cycled to work two days in a row on Bulletproof Coffee with a good amount of MCT oil.
In The Art and Science of Low Carbohydrate Performance  Volek and Phinney say that “light nutritional ketosis” occurs when blood ketones are between 0.5mmol/L and 1.0mmol/L and “optimal ketosis” is between 1.0mmol/L and 3.0mmol/L.
Based on the fact that an optimal blood sugar corresponds to a ketone reading of 1.3mmol/L and the low end of healthy normal blood sugars corresponds to a ketone reading of 2.1mmol/L I wonder if there is really any value in aiming for higher ketone values?
It’s interesting to note that Sami Inkenen, when rowing from the US to Hawaii on an 80% fat diet,   was only getting ketones of around 0.6mmol/L . If you’re striving for mental focus then loading up with butter, coconut oil and MCT oil to jack up your ketones might be for you.
If your aim is exercise performance or fat loss then ketones between 0.5mmol/L and 1.3mmol/L might be all you need to aim for. I also think loading up on dietary fat at the expense of getting adequate protein, vitamins and minerals may be counterproductive in the long term.
On the other end of the argument though, if you have good control of your blood sugars you should be showing some level of ketones in your blood. If you consistently measure at a ketone value of less than 0.2mmol/L then it’s likely your blood sugar is not yet optimal.
what to do?
If you find this interesting and want to experiment I recommend that you buy a blood glucose metre and track your blood sugars for a while. I enter my results into a spreadsheet and look at the average of the past twenty results.
You can adjust your insulin load (i.e. less carbs, more fibre, moderate protein) until you achieve your target blood glucose level. As you test you’ll also notice that some foods cause your blood sugars to rise more than others. Make sure you scratch those off your “do again” list.
You might also notice as you get your blood sugars under control you will get a metallic taste in your mouth, stronger smelling urine or a different body odour. These are all signs that you’re transitioning into ketosis. These symptoms typically don’t last for too long. If at first you don’t succeed, throw in some intermittent fasting. I use bulletproof Coffee  to help me skip breakfast and sometimes lunch a couple of times a week.
Intermittent fasting is more effective than constant calorie restriction which can cause your metabolism to slow down due to conserve energy for the famine it thinks is coming.   Having extended periods when insulin levels are low allows your body to learn to use body fat for fuel.
Once you begin to reset your insulin sensitivity you might start to notice a lack of inflammation and puffiness. You may also find that you’re finally losing that stubborn weight and breaking through that dreaded plateau. You may notice you feel great and your head is clearer than it’s been for a long time. Or that that may just be my experience.
physiological insulin resistance
Some people find that as they reduce their carbohydrates that their fasting blood sugars will drift up. This has been termed ‘physiological insulin resistance’ and is where the body develops a level of insulin resistance in the muscles to prioritise glucose for the brain. For some people this can be a transitionary phase on the way to stable ketosis. It’s not thought to be something to be concerned about as it doesn’t cause elevated levels of insulin which is what can be really detrimental.
However some type 1 diabetics find it to be an issue long term and choose to increase the carbohydrates and protein in their food so they are just outside nutritional ketosis to reduce this effect.
My experience is that during this phase my post meal blood sugars were great even though the fasting blood sugars were higher than optimal. As I continued to persist with more fat and added some intermittent fasting this went away and I was able to achieve lower fasting blood sugars.
Particularly during this time it is important to keep an eye on your average blood sugar (i.e. both fasting and after meals) and make sure it’s under 5.4mmol/L (100mg/dL).
can you eat too much fat?
The fear of fat has forced people to eat more simple carbohydrates which has led to the diabetes epidemic. I analysed a number of dietary scenarios to see if there is any truth to the fear that low carbohydrate diets do not provide adequate nutrition and that you need your “heart healthy whole grains” to achieve optimal health, provide enough sugar for the brain, support growth in children etc. While a grain-based diet can be cheaper, my analysis suggest that a high fat diet that focuses on high fibre, high nutrient density, non-starchy vegetables is better in terms of the nutrition it provides and managing insulin demand.
The optimal diet to balance vitamins and minerals, amino acids and insulin load appears to contain between sixty and eighty percent calories from fat. It is possible to meet the recommended daily intake for most vitamins and minerals with 80% of calories coming from fat.
At the other end of the scale, higher levels of carbs may leave you storing more fat than you want to due to high insulin levels.
which foods are optimal?
What foods are optimal? It all depends on your unique situation, goals and even finances.
I have developed a system to prioritise food choices based on the insulin properties of various foods as well as a range of other factors including:
- nutrient density per calorie,
- fibre per calorie,
- nutrient density per dollar,
- calorie density per weight, and
- calories per dollar.
The list of foods below is a summary of the highest ranking foods using the weighting shown below in order to identify low insulin, high nutrient density food choices will lead to improved blood sugar control, mood, mental clarity, weight loss and overall health.
|ND / calorie||fibre / calorie||ND / $||ND / weight||insulinogenic (%)||calorie / 100g||$ / calorie|
Next time you’re wanting a nutritious meal that will push you into ketosis or lower your blood sugars you could consider some of these foods.
I’ve also developed this ‘cheat sheet’ using this approach to highlight optimal food choices depending, whether they be reducing insulin, weight loss or athletic performance. Why not print it out and stick it to your fridge as a reminder of your optimal foods or to inspire your next shopping expedition?
- turnip greens
- coriander (cilantro)
- peppers / capsicum
- mustard greens
- Swiss chard
- Brussel sprouts
- coconut oil
- olive oil
- fish oil
- flaxseed oil
- whole egg
- goat cheese
- goat cheese
- parmesan cheese
- cream cheese
- blue cheese
- Colby cheese
- Swiss cheese
- edam cheese
- cottage cheese
- brazil nuts
- sunflower seeds
- pumpkin seeds
- macadamia nuts
- pine nuts
- coconut milk
- coconut meat
- pistachio nuts
- organ means (liver, kidney, heart etc)
- beef sausage
- ground beef
- beef steak
In the next article we’ll look at which foods are optimal for weight loss by prioritising low calorie density, high fibre high nutrient density foods that will also help stabilise your blood sugars.
 Some anecdotal evidence and studies such as http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342171/pdf/IJE2015-216918.pdf indicate that it’s the protein in excess of the body’s needs for muscle growth and repair that gets turned to glucose and requires insulin.