the cost of going low carb

  • Analysis of the USDA Cost of Food at Home database shows that fat is the cheapest macronutrient.
  • Protein is the most expensive macronutrient, however a reduced carbohydrate diet does not necessarily require an increase in protein.
  • Reducing the amount of carbohydrate and increasing the amount of fat in your diet is the most effective way to reduce your grocery bill.

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One of the common concerns about eating differently from the norm is that it will be more expensive.

Apparently one of the reasons for the relatively low Recommended Daily Intake for protein of 0.8g/kg is that many people can’t afford to eat more protein. [1]  One of the common criticisms of Paleo or the Banting Diet (LCHF) is that it will be too expensive due to the extra protein. [2]

To see if these concerns were valid I thought it would be interesting to see what the data has can tell us about the relative cost the three macronutrients, protein, carbohydrate and fat.

protein

The chart below shows the cost per calorie versus the percentage of protein in the thousand or so foods in the USDA Cost of Food at Home database. [3]

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Protein is indeed the most expensive of the three macronutrients.  As you move to the right in the chart you can see that your weekly grocery bill will increase.

Average intake of both protein and fat in the United States decreased between 1971 and 2004, with an overall increase in carbohydrate. [4]

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While from a nutritional point of view there area lot of good reasons for people to eat higher levels of protein, a low carbohydrate diet is not necessarily high in protein.

People aiming for therapeutic ketosis may aim for lower amounts of protein to minimise insulin.

Tim Noakes’ Banting diet recommends that people get between 20 and 30% of their calories from protein.  He says that those with diabetes and / or insulin resistance issues should aim for the lower end of this range, while people who are active and healthy can aim for higher amounts.  [5]

Practically it is difficult to eat much more than 30% to 35% protein from real foods.

The table below shows the relative change in cost if we were to increase our protein from current average levels back to 1970s levels, or to moderate levels such as the Mediterranean diet or even the higher protein Atkins approach.

scenario % protein cost ($/kcal) change
2004 average 14.7% 4.67
1970 average 16.9% 4.83 +3%
Mediterranean 20% 5.06 +8%
Atkins 30% 5.79 +24%

As shown in the table below, the most expensive high protein foods tend to be seafood.  For reference, the average cost of food across the more than one thousand foods in the database is $5.37/kcal.

food cost ($/kcal)
crayfish 26
spinach 26
crab 24
spirulina 23
lobster 22
scallops 17
clam 16
haddock 16
cod 15

While protein can be expensive there are some low cost high protein options available.

food cost ($/kcal)
whole egg 1.70
ground turkey 2.13
beef liver 2.81
chicken heart 2.94
cottage cheese 3.58
pork 3.59
chicken liver 3.81
ham 4.10

If you are willing to try organ meats you might get them even cheaper as they are often discarded.   The cheaper organ meats also typically have a much higher nutrient density than the more popular muscle meats or even fruits or vegetables.

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carbohydrates

You often hear the term ‘cheap carbohydrates’, but does this mean that a diet of processed grains and sugars is the most economical way to fill your shopping trolley?

While sugar and corn starch are very cheap food ingredients per calorie, the analysis of the data suggest that a higher carbohydrate diet is actually more expensive overall.

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The cheaper high high carbohydrate foods tend to be processed and calorie dense.   While the most expensive high carbohydrate foods tend to be natural foods that have a much lower calorie density. The table below shows that someone switching from a typical western diet to a reduced carbohydrate diet could make some significant savings.

scenario % carbohydrate cost ($/kcal) change
2004 average 51% 5.57
1970 average 45% 5.37 -4%
low carb 30% 4.77 -14%
ketogenic 5% 3.80 -32%

fat

So if increasing the proportion of protein and carbohydrate both increase the cost of our food bill then what makes it cheaper?  Yes it’s the other macronutrient, fat.

Increasing the proportion of fat in your diet while decreasing the carbohydrates will make your meals tastier, gentler on your blood glucose and cheaper.  Not to mention the fact that people typically spontaneously consume less calories when they consume less carbohydrates.

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You may pay a premium for coconut oil, butter or olive oil relative to corn oil which is the cheapest food ingredient, however these fats are still much cheaper than the other macronutrients.

food cost ($/kcal)
corn oil 0.20
coconut oil 0.31
chicken fat 0.86
butter 1.10
bacon fat 1.12
coconut milk 1.15
cream cheese 1.76
sesame oil 2.00
cream 2.81
olive oil 2.81

It appears that the it’s the very cheapest ingredients that are so prevalent in processed foods – sugar, corn starch, corn oil, high fructose corn syrup.  Regardless of cost you’re always going to have to make a value judgement on the nutritional value of your food.

summary

Increasing the protein content of your diet will increase your grocery bill marginally.

While higher levels of protein may be ideal for people who are healthy and active, LCHF is not necessarily high protein, particularly for those who struggle to regulate their blood glucose levels.

The LCHF approach, with its combination of moderate protein, lower carbohydrates and high fat provides an optimal solution with respect to blood glucose management, nutrition and cost.

references

[1] https://www.facebook.com/physiquescienceradio/posts/378943502302499

[2] http://talkfeed.co.za/lchf-diet-on-a-budget/

[3] http://www.cnpp.usda.gov/USDAFoodPlansCostofFood

[4] http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9146789&fileId=S1368980012005423

[5] http://www.biznews.com/health/2015/01/19/complete-idiots-guide-tim-noakes-diet-banting-lchf/

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bacon, eggs, avocado and spinach

This is a pretty incredible combination of superfoods and a taste sensation in your mouth.

As you can see from the NutrientData plot below the nutrients are spectacular with every nutrient and mineral covered and the amino acid score is also very high.

Even though there are 13% carbs most of them (12g out of 17g total carbs) are fibre from the spinach and avocado.

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The table below shows the stats for a 500 calorie serving size.

net carbs

insulin load carb insulin fat protein

fibre

4g 18g 35% 83% 66%

12g

 

 

eggs benedict

This photo is of our favourite breakfast from our holiday in Vanuatu over Christmas – Eggs Benedict, no bread.  So yum!

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The nutritional analysis is of Dave Aspery’s “Bulletproof Benedict” from his Bulletproof Diet Book and involves lots of spinach, butter, eggs and avocado.

It does very well on both the protein score as well as the insulin score having only 3g of net carbs after you account for all indigestible the fibre in the spinach and avocado.

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Overall a very nutritious and delicious low carb meal that ranks number one for diabetes and nutritional ketosis.

The nutritional analysis above is for a larger batch while the table below shows the data for a 500 calorie serving.

net carbs

insulin load carb insulin fat protein fibre
3g 8g 34% 83% 8%

8g

Dave Asprey’s recipe doesn’t include bacon, but if we add some in we get an increase in the protein and a sight decrease in the nutrient score.  The net carbs goes down thought the overall insulin load goes up with the increased protein.  Either way a great option for people trying to manage their blood sugars and optimise their nutrition.

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Details for a 500 calorie serving are below.

net carbs

insulin load carb insulin fat protein fibre
2g 11g 21% 80% 13%

6g

optimal ketone and blood sugar levels for ketosis

I have seen a lot of interest and confusion recently from people following a ketogenic about ideal ketone and blood sugar levels.

This article reviews blood ketone (BHB), breath ketone (acetone) and blood sugar data from a large number of people who are following a low carb or ketogenic diet to understand what normal and optimal really look like.

This data will to help us fine tune our diet and lifestyle to suit our goals whether they be weight loss, diabetes management, therapeutic keto or athletic performance.

low carb diets reduce blood glucose levels

Many people initiate a low carb diet to manage their blood glucose levels, insulin resistance or diabetes.  As shown in the chart below, foods with less carbohydrate tend to have a smaller impact on our blood sugar.[1] [2] [3]

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While not typically recommended by dieticians and diabetes associations, it would appear that, if you are insulin resistant, have prediabetes, or diabetes (Type 1 or Type 2) it make sense to reduce the carbohydrates in your diet to the point where you can achieve the blood glucose levels of a metabolically healthy person.

what are optimal blood sugar levels?

By mainstream standards “normal” blood sugar regulation is defined as having a HbA1c of less than 6.0%.  “Prediabetes” is diagnosed when you have a HbA1c between 6.0 and 6.4%, while Type 2 diabetes is diagnosed when you have a HbA1c of greater than 6.4%.  However, as you can see from the charts below, this definition of “normal” is far from optimal.

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By the time you have “prediabetes” with a HbA1c of greater than 6.0% you are at risk of many of the most common western diseases of aging and causes of death (i.e. heart disease, stroke, Parkinson’s, Alzheimer’s and cancer).[4] [5]

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So, if you’re interested in optimal rather than that what currently passes for “normal” health, the table below shows some suggested HbA1c and average blood sugar targets for optimal health and longevity.

risk level

HbA1c

average blood sugar

(%)

(mmol/L)

(mg/dL)

optimal

4.5

4.6

83

excellent

< 5.0

< 5.4

< 97

good

< 5.4

< 6.0

< 108

danger

> 6.5

> 7.8

> 140

ketosis vs hyperinsulinemia

While high glucose levels are bad news in and of themselves (glucose toxicity and excessive glycation), high blood sugars typically go hand in hand with high insulin levels which are also bad news.[6] [7] [8]

A metabolically healthy person will store excess energy in their fat cells for easy access when required later.  But if we continue to fill our fat cells with excess energy, you will get to the point where they cannot expand to accept any more energy.  It is at this point that our adipose tissue becomes insulin resistant.  Ted Naiman does an excellent job explaining this.

The good news is that insulin resistance will slow the expansion of our fat cells (the excess energy can’t get in as easily).  The bad news is that the excess energy will be re-directed to the parts of our body that are more insulin sensitive such as our liver, pancreas, heart, brain and other vital organs.  Our pancreas will work overtime secreting more insulin to try to keep the energy in the liver as well as put it back into storage.

High insulin levels mean that we will find it harder to release energy from our fat stores when we go without food.[9]  Without easy access to our body fat stores, we will be driven by our appetite to eat again sooner.  Someone who is insulin resistant is more likely to become obese because their chronically elevated insulin levels will drive them to eat more often because, without easy access to their fat stores, they feel bad without a constant flow of glucose for energy.

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Fasting insulin levels in healthy populations range between 2 to 6 mIU/L.[10] [11] [12]  The average insulin levels in western populations are 8.6 mIU/L.   Meanwhile, the official reference range for “normal” fasting insulin is less than 25 mIU/L.[13] [14]

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Given that the western world is going through a crisis of metabolic health, it is probably safe to say that, similar to the “normal” blood glucose levels, this cut off for insulin levels is also far from optimal.

how to manage your dietary insulin load

To help manage your insulin levels and blood sugar you can tailor the insulin load of your diet to suit your current level of insulin resistance.   As shown in the chart below, our insulin response to the food we eat is proportional the net carbs plus about half the protein it contains.

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Reducing the insulin load of your diet can help to reduce your insulin and blood sugar levels to the point where your pancreas and insulin resistance levels can keep up.  When our insulin levels are low, we can access our body fat for fuel, either from our body or our food.  We then see the ketone levels in our blood rise.  At this point we are deemed to be “in ketosis”.

A person with type 1 diabetes (like my wife Monica) is not able to produce enough insulin.  Without exogenous insulin injections they will see both their blood glucose and blood ketones rise to very high levels.  This is called ketoacidosis which is a dangerous state that requires exogenous insulin as soon as possible to prevent their body from falling apart.

Without insulin people with type 1 diabetes are unable to metabolise glucose and turn to their muscles for energy.  As shown in the image below of JL, one of the first children with type 1 diabetes to receive insulin, they quickly regain weight.

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It’s important to find the right balance of insulin.  Lowish blood ketones with healthy blood glucose levels is a normal healthy state where your body fat can more easily be accessed for fuel.

People who switch to a low carb dietary approach often find that their blood glucose and insulin levels plummet and they are not hungry because excess excessive amounts of energy can now flow out of storage (a little bit like someone with uncontrolled type 1 diabetes.

However the problem with a very low insulin load dietary approach (e.g. very high fat therapeutic ketogenic diet), is that it may not contain enough of the vitamins and minerals that you need for optimal function and avoid nutrient cravings in the long term.  High fat foods also have a high energy density which can make it hard for some people to control portion sizes if their goal is weight loss.

blood glucose and ketones in fasting

When we go without food, our blood glucose levels will decrease as the glucose in our bloodstream and liver (glycogen) are used up.  The body then turns to our fat stores and our liver converts them into ketones for use.  This is termed “endogenous ketosis” (endogenous = originating from within an organism).

The chart below shows my blood sugar and blood ketone (BHB) during a recent seven day fast.  You can see that as glucose levels decrease, ketone levels rise.

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As explained by Dr David Sinclair in the video below, there are a ton of beneficial things that occur during endogenous ketosis such as autophagy, mitogenesis, mitophagy, upregulation of SIRT1 and increase of NAD+).  Ketones also increase during this low energy state to keep the brain and muscles well fuelled.  However, while ketones are present, they are not necessarily the cause of these benefits that are often associated with ketosis.

At the time these blood sugar and ketone readings were taken I had just started taking a mix of potassium, magnesium and calcium which seems to have helped to rebalance a higher acidity that seems to be typical in people on a low carb diet approach (see the The Alkaline Diet vs Acidic Ketones article).   Rebalancing these minerals seems to be part of the reason that my ketone levels went so high and I didn’t feel the need to eat.  I have done a range of fasts since and haven’t been able to achieve such high ketone levels.   It seems that there was a build up that was release and now I have reached a new equilibrium where I have adjusted to burning the ketones more effectively.  This experience made me wonder what optimal ketone and blood sugars should really be in the fed and fasted states.

You can see that the sum of glucose and ketones continues to increase during fasting.  I have termed the sum of glucose and ketone as “total energy” (i.e. glucose + ketones).  Often in fasting it seems that the body will let the total energy in the blood go quite high.  This enables you to be on a state of very high alert ready to find food to survive.  It feels great and I typically feel at my sharpest after not eating for a few days.

what should your blood sugars and ketone levels be in ketosis?

The ketogenic diet is still evolving and fertile area of research.  Even Keto Clarity co-author Eric Westman recently admitted that there is still a lack of clarity around what your ketone levels should be.[15]

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The chart below shows the ‘optimal ketone zone’ from Volek and Phinney’s Art and Science of Low Carb Living which is typically referred to as the ultimate guide to optimal ketone values.  The problem, however, is that it is difficult for most people to achieve “optimal ketone levels” (i.e. 1.5 to 3.0mmol/L) without fasting for a number of days or making a special effort to eat a lot of additional dietary fat (which may be counterproductive if you’re trying to lose weight).

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Recently, I had the privilege of having Steve Phinney (pictured below in our kitchen making his famous blue cheese dressing) stay at our place for a night when he spoke at a Low Carb Down Under event in Brisbane.  I quizzed Steve about the background to this optimal ketosis chart.  He said it was based on the blood ketone levels of participants in two studies.  One was with cyclists who had adapted to ketosis over a period of six weeks and another ketogenic weight loss study.  In both cases these ‘optimal ketone levels’ (i.e. between 1.5 to 3.0mmol/L) were observed in people who had recently transitioned into a state of nutritional ketosis.  

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Since the publication of this chart in the Art and Science books, Phinney has noted that well trained athletes who are long term fat adapted (e.g. the athletes in the FASTER study) actually show lower levels of ketones than might be expected.

Over time, many people, particularly metabolically healthy athletes, move beyond the ‘keto adaption’ phase and are able to utilise fat as fuel even more efficiently and their ketone levels reduce further.

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Urine ketone strips are often considered to be of limited usefulness due to the fact that the body stops excreting ketones as it learns to use them.  Could it be a similar situation with blood ketones (BHB), albeit over a longer period of time?

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As our blood glucose levels decrease, our ketones increase to balance out the fuel deficit.   When we have less glucose available our insulin levels go down, more fat is burned and blood ketone levels rise.

The chart below shows the sum of the blood glucose and ketones (i.e. total energy) from nearly three thousand data points from a broad range of people following a low carb or ketogenic dietary approach.

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[note: I initially pooled a range of data from myself and a number of people on the Optimal Ketogenic Living (OKL)  Facebook group.  After sharing this data initially a number of other people sent me their data.  Later, Michel Lundell from Ketonix agreed to share a very large set of anonymised data for me to analyse.]

On the left hand side of the chart, we have a low energy situation where insulin levels are low.  The body will be drawing on stored body fat for fuel to meet the shortfall and weight loss will occur.

On the right hand end of the chart, we have a high energy situation from both glucose and ketones.  This high energy situation causes the pancreas to secrete insulin to control lipolysis (i.e. the release of fat from storage) because there is more than enough energy floating around in the blood.

It’s a slight oversimplification to say that the left hand side of the chart is endogenous ketosis (which is good) and the right is exogenous ketosis (which is bad).  As we can see from my example above, we can have very high ketone levels in extended fasting.  However, I think it’s important to differentiate exogenous from endogenous ketosis.

Endogenous ketosis, the process of mobilising your own body fat stores for fuel, is where the good stuff happens.   Exogenous ketosis is where we force additional fat into the system to elevate the ketone levels in our blood.

We may or may not see high blood ketone levels when we go without food for a long period, but replicating this with high levels of exogenous ketones of an oversupply of dietary fat is not the same even though both situation are called ketosis.

Based on this data it seems the body tries to maintain a blood glucose level of around 4.9mmol/L and a blood ketone level (BHB) of around 1.5mmol/L.  The table below shows this data in terms of average as well as the 25th percentile and 75th percentile points (i.e. 50% of the values fit between the 25th and 75th percentiles).

 

ketones (mmol/L)

BG (mmol/L)

BG (mg/dL)

HbA1c

GKI

BrAc

total energy (mmol/L)

25th

0.6

4.2

76

4.3

1.8

46

3.4

average

1.5

4.9

89

4.7

7.3

56

6.4

75th

2.1

5.6

101

5.1

14

66

12.9

blood glucose and ketone levels during exogenous ketosis

Some people come to low carb or keto for therapeutic purposes (i.e. to manage chronic conditions such as cancer, epilepsy, traumatic brain injury or dementia).  These people will benefit from high ketone levels to feed the brain when glucose cannot be processed due to high levels of insulin resistance.

Most people however do not require this degree of therapeutic ketosis, particularly if managing insulin resistance or obesity is the key priority.  People using low carb to manage diabetes or weight loss goals may end up driving excess energy consumption and a lower than necessary nutrient density, both of which may be counter productive.

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People following a therapeutic ketogenic diet may be fuelling up with MCT oils to achieve high ketone levels and low glucose : ketone index values (GKI) value for therapeutic purposes.  Others will target high levels of ketones for brain performance.  Others will load up on exogenous ketones and glucose to ‘dual fuel’ the system for athletic performance.

One of the benefits of a low carb or keto diet is that it tends to eliminate a lot of hyperpalatable processed foods, and lowers insulin levels which help many people normalise their appetite and eat less.  The danger, however, with trying to drive exogenous ketosis is that it will lead to an energy excess situation which will drive insulin to remove excess energy from your bloodstream, which can worsen insulin resistance.

Even though we are getting most of our energy from fat rather than carbs, the body will still try to bring the total energy back towards optimal levels using insulin, and stop the release of stored glycogen and body fat until you have used up the energy in your blood from your food.  This is why Thomas Seyfried and Dominic D’Agostino talk about the benefits of a calorie restricted ketogenic diet. [16] [17] [18]

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blood glucose and ketone levels for weight loss and endogenous ketosis

Many people embark on a ketogenic dietary approach to manage their diabetes and achieve long term weight loss.  They want lower insulin levels to enable them to burn more body fat for long term insulin sensitivity and health.

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On the left hand side of the total energy chart below we have a situation where we are generating endogenous ketosis, meaning that our own body fat is being burned for fuel.  With a lower total energy level in our blood, our body needs to pull fat from our body fat stores as well as use up the excess stored fat and old proteins in our liver, pancreas, brain and other vital organs (i.e. autophagy).

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In order to understand what all this means I have divided the three thousand data points into five quintiles, from lowest to highest total energy.  For each quintile I have calculated the average, 25th percentile and 75th percentile blood ketone (BHB) value.  Have of the ketone values will fit between the 25th and 75th percentile values.

optimal ketosis

The table below shows this data numerically.  I think the key takeaway is that the lowest blood sugar levels are associated with lower ketone levels and a lower total energy.

quintile

average BG (mmol/L)

BG (mg/dL)

ketones (mmol/L)

total energy (mmol/L)

25th

average

75th

1

4.5

80

0.3

0.6

0.7

5.0

2

4.9

88

0.4

0.8

1.1

5.7

3

5.1

92

0.6

1.1

1.5

6.2

4

5.1

92

1.2

1.8

2.3

6.9

5

5.1

91 2.2

3.2

4.0

8.3

In the discussion above we see that the lowest risk of the modern diseases of aging and metabolic health occurs when we have a HbA1c of less than 5%.  Further Dr Richard Bernstein recommends says that a blood glucose of 83 mg/dL or 4.6 mmol/L is optimal.  So it seems that as a general rule (maybe other than when we are fasting or aiming for therapeutic ketosis) that being somewhere to the left of this chart is optimal.

You may not always be able to live at a very low total energy level, but as you fast or increase the spacing between your meals your total energy levels will decrease and you will get all the positive benefits of fasting.  The articles How to Use Your Blood Sugar Meter as a Fuel Gauge and How to Use Your Bathroom Scale as a Fuel Gauge can help you use objective measures to refine your balance between feasting and fasting to achieve your goals.

You don’t achieve optimal ketone levels by adding fat with super high ketone levels, but rather by managing your energy balance, carbohydrate intake, and meal timing so you can dip into endogenous ketosis on a regular basis through fasting.  When you do eat, you should try to maximise nutrient density to ensure you get the nutrients you need without needing to overeat.  Your blood ketone levels will decrease when you are using insulin to build and repair your muscles.  When you stop eating for a while you will see them rise again as fat flows out of storage.

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Anecdotally it seems that people who are very physically fit may find they have lower blood ketone levels.  Lower blood ketone levels (say greater than or equal to 0.2mmol/L) with low blood glucose levels seems to be a healthy place to be.

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In fact, you could even save your money on testing ketones and just focus on making sure your blood sugars are closer to optimal.

is it the ketones or NAD+ that is really doing the good stuff?

A smart friend of mine, Robert Miller, has been influencing my thinking recently around ketones.  His theory is that the benefits that people attribute to ketones are actually largely due to an increase in nicotinamide adenine dinucleotide (NAD+).[19] [20]  Adequate levels of NAD are critical to moving energy around our body, from our food to our mitochondria.[21]

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NAD+ declines with age, increases in fasting, during ketogenic diet or during exercise.  When NAD+ rises, SIRT1 helps our body to repair and improve our insulin resistance.[22]  Our NAD+/NADH balance is critical to controlling our appetite and telling the body whether we need more fuel, or if it’s time to tap into our body fat stores.

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We can increase our circulating levels of NAD+ by eating a nutrient dense diet, particularly with adequate niacin (vitamin B3).[23]  There are also a range of NAD+ supplements that seem to have positive benefits for a lot of people.  Nicotinamide Riboside is a close precursor to NAD+ which can be helpful for people who struggle to make NAD+ directly from food.

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However, Nicotinic Acid (i.e. full flush niacin) is a much cheaper supplement that will work just as well for most people.

NAD+ is a fascinating rabbit hole if you want to do some research, but for now let’s say that it’s important to have adequate NAD+ to enable your mitochondria to convert the food you eat to energy rather than having it back up in your body.

what about breath ketones (acetone)?

You will likely be aware that three separate types of ketone bodies:

  1. acetone (breath ketones),
  2. acetoacetic acid, and
  3. beta-hydroxybutyric acid (BHB in the blood).

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Fatty acids come to the liver either from our food or lipolysis (mobilisation of fat from our body) and converted to acetoacetate.   We have no way to directly measure acetoacetate, only BHB in the blood and acetone in the breath.

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The Ketonix is a device that you blow into that measures the acetone which is akin to an exhaust that is released when you burn acetoacetate.  Special thanks to Michel Lundell from Ketonix for sharing the data and Alessandro Ferretti and Weikko Jaross for helping to crunch the numbers.

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Blood ketones (BHB) are the most well known form of ketone bodies.  There is some relationship blood ketones and breath ketones but it is not direct.  The chart below is from a study Measuring Breath Acetone for Monitoring Fat Loss: Review (Anderson, 2015)[24] which states

“Endogenous acetone production is a by-product of the fat metabolism process… Breath acetone concentration (BrAc) has been shown to correlate with the rate of fat loss in healthy individuals…  A strong correlation exists between increased BrAce and the rate of fat loss.”  

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The Ketonix data shows a similar relationship but a lot of scatter!  Most people at this point throw in the towel and go back to blood ketones (BHB) which appear to be more reliable, but it’s important to note that breath acetone is a stronger marker of burning ketones for fuel, not just buffering energy in the blood.

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What I’m trying to illustrate with the dodgy clipart is that having high levels of blood ketones and low levels of breath acetone appears to be a sign that you are not actually metabolising the fat you’re eating.

By contrast, a high level of breath acetone with a low level of blood ketones (BHB) and low blood glucose may be a sign that you are very effectively burning the fat you eat.

If you had a choice, I think it’s better to have high breath acetone (BrAce) and lower blood ketones (BHB) (which would indicate that you were efficient at burning fat) than high BHB and low BrAc (which would indicate that you were good at eating fat but not necessarily burning fat).

The figure below shows BHB vs BrAc for the different purposes that people nominate for using the Ketonix.  What we see is that people with diabetes (red trend line) have both higher blood glucose and higher blood ketone (BHB) levels (i.e. higher total energy).   Fuelling the mitochondria with the right nutrients that increase NAD+ will both help to burn off the excess energy and manage appetite through the NAD+/NADH ratio.

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The second law of thermodynamics states that the total entropy (chaos) of an isolated system can only increase over time.  The total energy concept is novel, but it seems that an organism that is aging will decay and not be able it’s energy packed in storage but rather we will see increasing levels of energy floating around in the blood stream.

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the glucose : ketone index (GKI)

The glucose : ketone index (GKI) was developed by Dr Thomas Seyfried[25] and is defined in The glucose ketone index calculator: a simple tool to monitor therapeutic efficacy for metabolic management of brain cancer.

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The GKI simply the glucose value divided by the ketone value taken at the same time, both converted to mmol/L.  If you are using US based mg/dL units you will need to divide you glucose measurement by 18.

For example, if your blood glucose is 108 mg/dL and your blood ketones are 0.5mmol/L, GKI = blood glucose / ketone = (108 mg/dL / 18) / 0.5 = 6 mmol/L / 0.5mmol/L = 12.

Seyfried suggests that when glucose to ketone ratio (GKI) is low, they are metabolically healthy and “fat adapted”.  The GKI is a proxy for insulin without needing a blood test.

Seyfried’s goal for cancer patients using a therapeutic ketogenic diet is to have a GKI of less than 1.0.  Patients with chronic disease like cancer typically have glucose to ketone index values of 50 or more.

For most people who are not trying to slow cancer growth or combat epilepsy through a ketogenic diet, anything under 10 outside the influence of a meal is considered to be a “low insulin condition”.  This is indicative that you are not significantly insulin resistant.

The lot below shows how the GKI changes with fasting in four different people (Simon Saunders from Keto Island, RD Dikeman, Jimmy Moore and myself).

image

HOMA-IR

Another popular measurement of insulin resistance is the HOMA-IR[26] [27] (Homeostatic Model Assessment of Insulin Resistance).  The HOMA-IR is the amount of insulin required to keep your blood glucose at a certain level and is calculated by multiplying your insulin level (in mU/L) by glucose level (in mg/dL).[28]

The healthy range for HOMA-IR is 0.5–1.4.  Less than 1.0 means you are insulin-sensitive which is optimal.  Above 1.9 indicates early insulin resistance.  Above 2.9 indicates significant insulin resistance.

The Kraft insulin assay test

The Kraft Insulin Assay was by Joseph Kraft and involves measuring the insulin response to a 75 or 100g glucose load over a number of hours.  The blue line in the chart below shows the normal glucose response while the other response curves are deemed to be different degrees of hyperinsulinemia.  Looking at our insulin response can give us an insight into the risk of metabolic diseases much earlier than other methods that only measure glucose.

image

The great thing about the Kraft test is that it measures our dynamic insulin response to food rather than blood sugar at a single point in time.  The bad thing about the test is that it requires someone to sit in a lab for five hours and with numerous blood draws, hence the test is expensive and not commonly done.

the glucose vs ketone gradient

Finally, I wanted to introduce a new method of quantifying your insulin resistance by looking at ketones vs glucose.

The real problem with all of these measurements of insulin resistance, other than the Kraft Insulin Assay, is that they only tell you about your insulin resistance at a single point in time, not how you dynamically respond to food..

I think the more interesting and perhaps the most important question is how you respond to not eating.   Our appetite usually wins out over our conscious effort to control intake whether it be calorie counting or intermittent fasting / feasting.

What really matters is how easily you can go without food before you have to eat again.  This is likely to be the biggest influence on your likelihood to overeat, gain weight and increase your risk of metabolic disease.

The good news is that you can test your glucose : ketone gradient at home with a blood glucose and ketone meter relatively inexpensively.   The bad news is that you will have to fast for a while to get a meaningful result.

The chart below shows the three thousand ketone and glucose data points from a range of different people who are generally following a low carb dietary approach.  I think for optimal metabolic health we want our glucose levels to be reasonably low.  When we go without food, we ideally want our insulin levels to be low enough so that our body fat stores kick in easily and we will see our ketone levels increase without our blood glucose levels plummeting too much.

image

Where this data gets more interesting is when we look at the relationship between glucose and ketones for individual people.  We see that each person has a unique relationship between their glucose and ketone values.

image

Some of the lines are steeper than others, indicating that they find it harder to release their stored body fat when they go without food.  And when you follow the lines to the y-axis, they have different ‘glucose intercepts’ meaning that they have higher glucose levels when they are eating and have low ketone values.

Our glucose : ketone gradient can change as our metabolic health improves.  The chart below shows my glucose : ketone plot during two different periods.   The orange dots in this chart shows the relationship between glucose a couple of years ago when I first started trying to understand the ketogenic diet.  I was inflamed, tubby and insulin resistant.  The blue dots show the relationship between my glucose and ketones during the recent fast where my blood glucose levels were lower and I could more easily access my body fat for fuel to manage my appetite.

image

There are two separate components to the glucose : ketone gradient measurements:

  • an intercept on the y axis which represents our average glucose when our ketones are zero), and
  • a gradient which represents how easily we release ketones when our blood glucose drops).

The chart below shows the glucose : ketone relationship for different states of metabolic health.  Someone who has full blown Type 2 diabetes will have very high glucose levels but struggle to release fat from storage when they go without food.  They will be compelled to eat again soon.  Someone with pre-diabetes will have a lower intercept and a flatter slope.

image

The mild insulin resistant line is based on my orange points in the chart above when I was mildly insulin resistant and heading for pre-diabetes.  The red line is based on RD Dikeman’s data (pictured below) who runs the Type One  GRIT Facebook Group.  Since his son was diagnosed with Type 1 whole family have been strictly low carb for the last four years.  RD says his ketones used to be 2.0 mmol/L, then 1.0 mmol/L but now all four family members have dropped down to 0.2 or 0.3mmol/L.   However, when he goes a long time without food his ketone levels increase quite easily to compensate for the lack of food intake.

image

If you want to try calculating your own glucose : ketone gradient you can fast for a few days and periodically test your glucose and ketone values at the same time.  You can then plot the values in an Excel sheet and run a linear trend line to find the gradient and intercept.  The reference values for the different states of metabolic health are shown below.

 metabolic health level

intercept (mmol/L)

gradient

type 2 diabetes

13

-40

prediabetes

9

-10

insulin resistant

6

-1

metabolically healthy

4.5

-0.3

You can then use your understanding of your level of insulin resistance to refine your dietary choices to optimise your blood glucose and insulin levels using the dietary approaches noted in the table below.  As your blood glucose levels stabilise, you can start to focus on more nutrient dense food to maximise the nutrients per calorie if your goal is weight loss.

approach

HbA1c

average glucose

waist : height

(mg/dL)

(mmol/L)

therapeutic ketosis

> 6.5

> 140

> 7.8

diabetes and nutritional ketosis

5.4 to 6.4

108 to 140

6.0 to 7.8

weight loss (insulin resistant)

5.1 to 5.4

100 to 108

5.4 to 6.0

> 0.5

weight loss (insulin sensitive)

< 5.1

< 97

< 5.4

> 0.5

bulking

< 5.1

< 97

< 5.4

< 0.5

nutrient dense maintenance

< 5.1

< 97

< 5.4

< 0.5

If you really want to fine tune your nutrition, you can use the Nutrient Optimiser to make sure you’re getting a good balance of all the harder-to-find micronutrients while also maintaining great blood glucose and insulin levels.

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summary

  • Metabolic related diseases such as heart disease, cancer, stroke, diabetes, Alzheimer’s disease, kidney disease are the major causes of death.
  • People with the best metabolic health (i.e. low HbA1c, insulin and blood sugar levels) have the lowest risk of dying from these common western diseases of aging.
  • Keeping your processed and starchy carbohydrates low will help to keep your blood glucose and insulin levels and reduce your risk of obesity.
  • When we fast, our glucose levels decrease and ketones increase to maintain our energy levels.
  • People who are metabolically healthy and insulin sensitive typically have a lower level of total energy (i.e. glucose + ketones) in their bloodstream.
  • We can mimic the rise in ketones with added fats or exogenous ketones that we see in fasting, however the real benefits occur when the body is forced to draw on its own stored energy and we experience autophagy, upregulation of SIRT1, and a rise in NAD+.
  • The benefits that we generally attribute to ketones may also be due to increased NAD+ levels which occur in fasting and / or with a nutrient dense diet.
  • We can only measure beta hydroxybutyrate (in the blood) and acetone (in the breath). We can think the BHB as a buffer ready for use, and acetone as the exhaust showing that the ketones have been burned for fuel.  Higher levels of fat burning with a lower need for buffering is a better place to be than a high buffer in the blood and minimal fat burning.
  • We can measure our insulin resistance a number of ways to understand how we may need to modify our diet such HOMA-IR, the glucose : ketone index or the Kraft insulin assay.
  • The glucose : ketone gradient is a novel method of measuring your typical glucose level when you are eating, as well as showing how easily you release body fat stores during fasting. The glucose : ketone index will give you an indication of your insulin resistance as well as tell you how hard it will be for you to go without food.  If you can’t access your body fat for fuel you will be more likely to be driven by your appetite to overeat.

post last updated May 2017

references

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

[2] https://www.researchgate.net/profile/Peter_Petocz/publication/13872119_Holt_SHA_Brand_Miller_JC_Petocz_P_An_insulin_index_of_foods_the_insulin_demand_generated_by_1000-kJ_portions_of_common_foods_Am_J_Clin_Nutr_66_1264-1276/links/00b495189da41714fa000000.pdf/download?version=vs

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

[4] http://www.cardiab.com/content/12/1/164

[5] http://www.nejm.org/medicine-and-society-data-watch

[6] https://intensivedietarymanagement.com/tag/hormonal-obesity-theory/

[7] http://carbsanity.blogspot.com.au/2011/09/24hr-profiles-insulin-secretion.html

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC329588/

[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC329589/

[10] http://wholehealthsource.blogspot.com.au/2009/12/whats-ideal-fasting-insulin-level.html

[11] https://www.ncbi.nlm.nih.gov/pubmed/11994907

[12] https://www.ncbi.nlm.nih.gov/pubmed/10535381

[13] http://emedicine.medscape.com/article/2089224-overview

[14] http://www.newhealthadvisor.com/Normal-Insulin-Levels.html

[15] https://www.facebook.com/AdaptYourLife/videos/vb.1608140252761871/1899686180273942/?type=2&theater

[16] http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0115147

[17] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819381/

[18] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819381/

[19]

[20] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852209/

[21] http://www.ketoisland.com/blog/all-aboard-nad/

[22] https://selfhacked.com/2015/09/06/nad-and-sirt1-their-role-in-chronic-health-issues/

[23] http://mitofuel.co.za/mitofuel/

[24] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737348/

[25] https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/s12986-015-0009-2

[26] http://care.diabetesjournals.org/content/24/2/362

[27] https://en.wikipedia.org/wiki/Homeostatic_model_assessment

[28] http://www.thebloodcode.com/homa-ir-calculator/

superfoods for therapeutic ketosis

A therapeutic ketogenic diet has a very low insulin load from non-fibre carbohydrates and a higher amount of dietary fat to achieve higher ketone to manage chronic conditions such as cancer, epilepsy, alzheimer’s, dementia etc.

The chart below shows our insulin response versus insulin load which considered fibre and protein as well as carbohydrates.  People wanting to following a ketogenic diet should eat foods towards to the bottom left of this chart.

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We can quantify the insulin load using the following formula:

insulin load = total carbohydrates – fibre + 0.56 x protein

The foods listed below have a very low insulin load while still maximising nutrient density (ND) as much as possible.  Also included in the table are the nutrient density score, percentage of insulinogenic calories, insulin load and energy density.

nuts, seeds and legumes

26765969aae6926f

food ND insulin load (g/100g) calories/100g MCA
coconut milk -5 5 230 1.5
flax seed 0 16 534 1.5
coconut cream -6 7 330 1.5
pecans -5 12 691 1.5
macadamia nuts -5 12 718 1.5
brazil nuts -2 16 659 1.5
sesame seeds -2 17 631 1.4
sunflower seeds 3 22 546 1.4
hazelnuts -2 17 629 1.4
coconut meat -6 9 354 1.4
pine nuts -2 21 673 1.4
walnuts -1 22 619 1.3
almonds -1 25 607 1.3
peanut butter 1 27 593 1.3
almond butter -1 26 614 1.3
pumpkin seeds 2 29 559 1.2
peanuts -1 29 599 1.2
butternuts -3 28 612 1.2
sesame butter -1 33 586 1.1
pistachio nuts -2 34 569 1.0

seafood and animal products

7450703_orig

food ND insulin load (g/100g) calories/100g MCA
mackerel 1 10 305 1.5
sweetbread -3 9 318 1.4
bacon -4 11 417 1.4
liver sausage -3 10 331 1.4
bologna -6 9 310 1.4
bratwurst -1 13 333 1.3
pepperoni -4 16 504 1.3
beef brains 3 8 151 1.3
kielbasa -3 12 325 1.3
blood sausage -5 13 379 1.3
knackwurst -4 12 307 1.3
liver pate -4 13 319 1.3
pork ribs -2 16 361 1.3
salami -1 17 378 1.2
frankfurter -4 12 290 1.2
turkey bacon -2 11 226 1.2
beef sausage -3 15 332 1.2
duck -3 15 337 1.2
chorizo -3 19 455 1.2
meatballs -3 14 286 1.2
lamb rib -2 17 361 1.2
pork sausage -2 16 325 1.2
lamb brains 4 10 154 1.2
headcheese -4 8 157 1.2
turkey -2 21 414 1.1
pork sausage 1 13 217 1.1
cisco 4 13 177 1.1
caviar 9 23 264 1.0
bologna -2 11 172 1.0
ground turkey 4 19 258 1.0
T-bone steak -1 19 294 1.0
turkey drumstick (with skin) -1 15 221 1.0
ham -0 11 149 0.9
chicken liver pate 5 17 201 0.9

vegetables, fruit and spices

spanish-olives

food ND insulin load (g/100g) calories/100g MCA
alfalfa 15 1 23 1.8
olives -5 1 145 1.8
endive 18 1 17 1.7
avocado -1 3 160 1.7
chicory greens 16 2 23 1.7
curry powder 5 14 325 1.6
escarole 14 1 19 1.6
coriander 15 2 23 1.4
poppy seeds 2 23 525 1.3
paprika 8 26 282 1.3
beet greens 12 2 22 1.2
sage 5 26 315 1.1
blackberries 2 3 43 1.1
caraway seed 3 28 333 1.1
zucchini 14 2 17 1.0
mustard greens 9 3 27 1.0
marjoram 5 27 271 1.0
mustard seed 2 37 508 1.0
banana pepper 8 3 27 1.0
eggplant 6 3 25 1.0
raspberries 0 4 52 1.0
collards 8 4 33 1.0
thyme 7 31 276 0.9
nutmeg -5 32 525 0.9
cloves 7 35 274 0.9

eggs and dairy

dairy20and20eggs

food ND insulin load (g/100g) calories/100g MCA
cream -5 5 340 1.6
butter -6 3 718 1.6
egg yolk 5 12 275 1.4
sour cream -4 6 198 1.4
cream cheese -5 10 350 1.4
limburger cheese -1 15 327 1.2
camembert -1 16 300 1.2
cheddar cheese -1 20 410 1.2
brie -3 16 334 1.2
feta cheese -1 15 264 1.2
blue cheese -1 19 353 1.1
Monterey cheese -2 19 373 1.1
muenster cheese -2 19 368 1.1
goat cheese -3 14 264 1.1
Swiss cheese -0 22 393 1.1
whole egg 6 10 143 1.1
gruyere cheese -1 23 413 1.1
Colby -2 20 394 1.1
edam cheese -1 21 357 1.1
gouda cheese -1 21 356 1.1
ricotta -2 12 174 1.0

nutrient density

The chart below shows the nutrition provided by this high fat approach.  The therapeutic ketogenic dietary approach does not provide the DRI levels of:

  • tyrosine,
  • phosphorus,
  • alpha linolenic acid,
  • threonine,
  • vitamin A,
  • copper,
  • vitamin K,
  • riboflavin,
  • selenium, and
  • lysine.

Hence this style of therapeutic approach is idea for a shorter term intervention with a higher nutrient density approach being adopted when possible.

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other dietary approaches

The table below contains links to separate blog posts and printable .pdfs detailing optimal foods for a range of dietary approaches (sorted from most to least nutrient dense) that may be of interest depending on your situation and goals.   You can print them out to stick to your fridge or take on your next shopping expedition for some inspiration.

dietary approach printable .pdf
weight loss (insulin sensitive) download
autoimmune (nutrient dense) download
alkaline foods download
nutrient dense bulking download
nutrient dense (maintenance) download
weight loss (insulin resistant) download
autoimmune (diabetes friendly) download
zero carb download
diabetes and nutritional ketosis download
vegan (nutrient dense) download
vegan (diabetic friendly) download
therapeutic ketosis download
avoid download

If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help identify the optimal dietary approach for you.

image02

post last updated April 2017

the therapeutic ketogenic diet

A therapeutic ketogenic diet can be helpful for a range of chronic health conditions such as cancer, epilepsy, Alzheimer’s disease or dementia.

Domonic D’Agostino is doing interesting research into the possible uses for ketosis, both through diet and supplementation.  His initial funding was from the US Military to research the applications of ketosis for navy seal divers in order to avoid oxygen toxicity seizures.

He has continued this research into how ketosis can starve cancer and be used in conjunction with normal treatments to aid recovery from chemotherapy and slow tumour growth. [1]  His more recent research demonstrates that body builders can maximise their power to weight ratio and recovery using a ketogenic approach.

Dr Mary Newport has received a lot of coverage after treating her husband’s advanced Alzheimer’s with coconut oil. [2]

Terry Whals is undertaking clinical trials of her high nutrient density ketogenic diet that has worked to reverse her own multiple sclerosis.[3]

The ketogenic diet for epilepsy has made a resurgence since director Jim Abrahams [4] found success with the ketogenic diet for his son Charlie and then made a movie of his experience. [5]

The Charlie Foundation (with partner site ketocook.com) supports families working to use a ketogenic dietary approach to manage epileptic seizures. [6]

Jimmy Moore’s Keto Clarity [7] spends three chapters profiling the various conditions that the ketogenic diet has been claimed to be beneficial for.

  • Solid science (chapter 16)
    • Epilepsy
    • Diabetes mellitus
    • Weight loss
    • Polycystic ovary syndrome (PCOS)
    • Irritable bowel syndrome (IBS)
    • GERD and heartburn
    • Non-alcoholic fatty liver disease (NAFLD)
  • Good evidence (chapter 17)
    • Alzheimer’s disease
    • Parkinson’s disease
    • Dementia
    • Schizophrenia, bipolar and other mental illnesses
    • Narcolepsy and other sleep disorders
    • Exercise performance
  • Emerging areas (chapter 18)
    • Cancer
    • Fibromyalgia
    • Chronic pain
    • Migraines
    • Traumatic brain injury
    • Stroke
    • Gum disease and tooth decay
    • Acne
    • Eyesight
    • Amyotrophic lateral sclerosis (ALS)
    • Multiple sclerosis (MS) and Huntington’s disease
    • Aging
    • Kidney disease
    • Restless leg syndrome (RLS)
    • Arthritis
    • Alopecia and hair loss
    • GLUT1 deficiency syndrome

The therapeutic ketogenic diet is similar to the LCHF approach but takes it one step further, with net carbs typically restricted to 25g per day (or sometimes less) and protein restricted to the minimum necessary for muscle repair.

People trying to slow or reverse cancer growth or stop seizures will often also resort to more aggressive measures including supplementing with larger amounts of butter, coconut oil, MCT oils and ketone salts to drive their ketones to higher levels (i.e. 1.5 to 3.0mmol/L).

I figured we could use the food ranking system to prioritise foods with a low insulinogenic load over and above nutrition or the other parameters.

The table below shows the weighting I have used for this ranking.  Still considering nutrient density, cost and calorie density will help to optimise these other elements of nutrition even though we are primarily targeting a low insulin load.

ND / cal fibre / cal ND / $ ND / weight insulinogenic (%) cal / 100g $ / cal
5% 5% 5% 5% 70% 5% 5%

I have also used a filter using Wilders’ formula to show only foods that have a ratio of ketogenic to anti ketogenic calories greater than 1.5.  This is the commonly accepted parameter in therapeutic ketosis circles to determine whether a food or a meal is sufficiently ketogenic.

You could also use this calculator to check the percentage of insulinogenic calories of your food.  If you’re aiming for therapeutic ketosis you’ll probably need to have an overall average of less than 15% and any individual food should ideally have a percentage of insulinogenic calories less than 25%.

The resultant foods are listed below.  This approach will obviously prioritise liberal use of fats and oils along with higher fat dairy products and meats.

Not all of the vegetables have a Wilder’s ketogenic ratio greater than 1.5 but it would still be desirable to include adequate vegetables for nutrition as long as they give they fit your tolerances whether they be net carbs, ketones or something else.

Someone using this approach may choose to supplement vitamins and minerals or use organ meats to achieve their nutrition in order to minimise carbohydrates from the vegetables.

People battling chronic illnesses also often have allergies that will mean that they further need to refine this list.

insulin vitamins & minerals protein fibre calorie density
70% 10% 10% 5% 5%

I hope that these lists will be useful for people who need to maximise ketosis for therapeutic purposes, as well as possibly others with diabetes, insulin resistance or people looking to lose weight who want to use a more aggressive approach for a period.

fats and oils

  • butter
  • coconut oil
  • olive oil
  • fish oil
  • flax seed oil
  • lard
  • bacon grease

nuts, seeds & legumes

  • Brazil nuts
  • pecan nuts
  • peanuts
  • Macadamia nuts
  • sunflower seeds
  • coconut milk
  • pine nuts
  • almonds
  • coconut meat
  • almond butter
  • pumpkin seeds
  • almonds
  • pistachio nuts

fruit

  • avocado
  • olives

dairy and egg

  • egg yolk
  • whole egg
  • cream
  • cream cheese
  • goat cheese
  • cheddar cheese
  • Monterey cheese
  • Camembert
  • Muenster cheese
  • Colby cheese
  • brie
  • blue cheese
  • Edam
  • Gruyere
  • parmesan cheese
  • feta cheese
  • mozzarella cheese
  • gouda
  • Provolone
  • Monterey cheese
  • ricotta cheese
  • cottage cheese

animal products & fish

  • polish sausage
  • link sausage
  • chorizo
  • frankfurter
  • bratwurst
  • beef sausage
  • duck
  • knackwurst
  • bacon
  • bologna
  • herring
  • ground lamb
  • chicken
  • chuck eye steak
  • sardines
  • turkey
  • chicken liver
  • anchovy
  • salmon
  • ham
  • carp
  • trout
  • clam
  • catfish
  • shrimp
  • oyster
  • squid
  • lobster
  • cod
  • haddock

vegetables

  • turnip greens
  • mustard greens
  • coriander
  • spinach
  • artichokes
  • mushrooms
  • chives
  • lettuce
  • alfalfa seeds
  • sauerkraut
  • cauliflower
  • asparagus

[this post is part of the insulin index series]

[Like what you’re reading?  Skip to the full story here.]

references

[1] https://www.youtube.com/watch?v=3fM9o72ykww

[2] https://www.youtube.com/watch?v=feyydeMFWy4

[3] https://www.youtube.com/watch?v=KLjgBLwH3Wc

[4] http://www.imdb.com/name/nm0000720/

[5] https://www.youtube.com/watch?v=HyeC9IiFKpw

[6] http://www.charliefoundation.org/

[7] http://www.amazon.com/Keto-Clarity-Definitive-Benefits-Low-Carb/dp/1628600071

egg, spinach, cheese and cream

My nine year old son was asking what he could have for breakfast that would be healthy.

This is pretty much the simplest and healthiest recipe that I could design that a nine year old can put together unsupervised.

I’m teaching him to just put some frozen spinach, eggs, cream and cheese into a microwave bowl.

Eggs are a wonderfully complete protein.  Cheese and cream add to the taste as well as adding in other proteins and fat not in the eggs.

IMG_9731

Spinach is such a great superfood with so many micronutrients while being low in net carbs due to the high fibre content.

You can add coconut oil or butter to get extra good fats into your meal to create something wonderfully indulgent, nutritious and that will be gentle on your blood sugars.

IMG_9728

If you’re short on time frozen spinach is quicker than using fresh spinach.  I figure if you’re going to skip the spinach because it takes too long to fry up, then it’s better to go with the frozen option.   I will use frozen kale sometimes too which gives a slightly different taste and texture.

If I’m cooking for the family and have bit more time I’ll do the fresh spinach in the fry pan.   If I’m putting this together for the family before we run out the door in the morning I will use some frozen spinach or kale.

IMG_9736

With only 7g net carbs and heaps of well rounded nutrition (in terms of both vitamins and minerals and amino acids) it’s pretty hard to go wrong with this for any meal.

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The stats for a 500 calorie serving are shown below.  The net carbs are low, the fibre is fairly high with the spinach and most of the insulin requirement is for the slower digesting protein rather than the carbohydrates.

net carbs insulin load carb insulin fat protein fibre
7g 25g 19% 66% 27% 7g

The more spinach the better if you want to maximise the nutrition.   The highest overall score occurs when we we use 700g of spinach.   Though this may be pushing the limits of optimising nutrition, not necessarily palatability or eating pleasure.

If you found 7g of net carbs raised your blood sugar you could certainly reduce some of the spinach, although most people find that counting net carbs in real food (rather than processed / manufactured foods) are OK (see the article fibre… net carbs or total carbs for more info)

Since working through the nutrition analysis comparing different meals, this meal has basically become our preferred go to meal, which you can make as simple or as complex as you want.  If you’re an insulin dependent diabetic you could use this as a regular meal and refine your insulin dosing based what you see on your BG metre after the meals.

I’ve run the analysis below with the kale rather than the spinach.  As much as people rave about kale, it actually does not do as well on the nutrient balance score as spinach!  Spinach scores better in both the nutrient completeness and the amino acids.  Kale also has more total carbohydrates and less fibre which makes less diabetic friendly.

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carbs insulin load carb insulin fat protein fibre
11g 28g 39% 62% 25% 5g

the food insulin index v2

It’s generally difficult for healthy people to eat too much protein.  However the fact that protein requires some insulin to metabolise is an important consideration for people who need to inject extra to keep their blood glucose levels stable.

A better understanding of the insulin response to various foods would be useful for diabetics calculating their insulin dose or even to help refine food choices to manage insulin load.

Since launching the optimising nutrition blog I have had many interesting discussions and learned a lot about protein and how it affects insulin and blood glucose.

The Most Ketogenic Diet Foods article which reviews the food insulin index data and what we can learn about our food choices has received almost 200,000 view.  Given the level of interest, I thought it would be useful to review this topic in more detail.

the food insulin index… a quick refresher

If you’ve been reading Optimising Nutrition blog you would have come across discussion of the recent food insulin index testing undertaken at the University of Sydney as detailed in Kirstine Bell’s PhD thesis Clinical Application of the Food Insulin Index to Diabetes Mellitus [1] (Sept 2014).

The primary learning from the recently expanded food insulin index data is that the carbohydrate content of a food only partially explains the insulin response.  The protein, fibre and fructose also affect our insulin response to our food.

The cluster of data points on the left-hand side of the figure below shows that:

  1. low carbohydrate, high fat foods trigger a negligible insulin response, while
  2. low carbohydrate high protein foods cause a significant insulin response.

image001

When we assume that fibre is indigestible and protein has about half the insulinogenic effect of carbohydrates we get a much better prediction of insulin response.

image002

The insulin requirement of a particular food is described better by the following formula:

insulin load = total carbohydrates – fibre + 0.56 * protein

digestion time for protein versus carbohydrates

One of the limitations of the food insulin index data is that the insulin area under the curve was measured over only three hours.  This is not a big deal for foods that are high in carbohydrates as they are generally fully digested within three hours.

However protein can take much longer to digest.  In the article The Blood Glucose, Glucagon and Insulin Response to Protein we saw that the insulin response to protein in diabetics can be even greater and over a longer period than for people who do not have diabetes.

If we were to repeat the food insulin index testing over a longer period it is likely that the measured insulin response would be significantly greater and even more-so in people with diabetes.  That is, the insulin response to protein may be greater than the 56% of the insulin response to carbohydrate indicated by the analysis of the food insulin index data if we were to measure the insulin response over a longer period.

Wilder’s ketogenic formula

Dr Russell Wilder of the Mayo Clinic was the first to coin the term ‘ketogenic diet’. [2]  Wilder developed the diet as an alternative to fasting in the treatment of epilepsy in the 1920s.

Image result for dr russell wilder

Wilder also developed the formula shown below to determine whether a diet would be ketogenic.  If the number from this calculation was greater than 1.5 (ideally greater than 2.0) then the diet would be considered to be ketogenic and appropriate for the treatment of epileptics. [3]

image003

This formula is based on the understanding that:

  • 100% of carbohydrate is glucogenic (i.e. converts to glucose),
  • 54% of protein is glucogenic,
  • 46% of protein is ketogenic, and
  • 10% of fat is glucogenic.

I had previously searched for detail of how Wilder had arrived at the 56% / 46% split for protein and only found references suggesting that the 56% glucogenic potential of protein comes from the analysis of nitrogen in the urine of dogs. [4]  However I recently came across this paper which details Wilder’s thinking in more detail.

Wilder’s conclusion that a diet needs to have more than two times the ketogenic precursors compared to glucogenic precursors is still the basis of the formulation of diets used to treat epilepsy.

According to George Cahill, Krebs also found that 57g of glucose may be derived from 100g of protein. [5]   Again, this is similar to the insulin demand for protein observed in the food insulin index tests.

carbohydrate counting

The most straight forward approach is to assume that protein has no impact on insulin or blood sugars.

Dr Richard Berstein and Dr Robert Atkins pioneered the concept of carbohydrate counting for weight loss and diabetes management in the 70s and 80s.  There have been various waves of popularity of low carbohydrate diets with many people finding success.

Carbohydrate counting alone is a reasonable approach that is likely to work for most people, particularly if they are not highly insulin resistant.

However, there are some people that reducing carbohydrates alone doesn’t work for.   The fact that protein also generates insulin suggests that managing protein as well as carbohydrates may be necessary to manage insulin levels.

thermic effect of food

You may have heard of the concept of the thermic effect of food where different foods require different amounts of energy for the digestion process.  For example, a mushroom, which has a very low calorie density and a lot of fibre and protein, may require more energy to digest than is obtained from the digestion of the mushroom.

The maximum and minimum thermic effect (also known as the specific dynamic action) for each macronutrient is shown below. [6]

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Compared to carbohydrates and fat, protein only yields between 76% and 84% of the energy per calorie ingested because of losses in digestion.  This is useful to know if you’re trying to minimise calorie intake.

As discussed in the Why We Get Fat V2 article, part of this thermic effect of food is also likely to be due to the fact that there is a significant loss of energy when we convert protein to glucose to be used as energy.  The body doesn’t like to do this other than in an emergency.

Steve Phinney’s “well formulated ketogenic diet”

One of the key observations from Steve Phinney’s well formulated ketogenic diet (WKFD) chart is that we need to strike a balance between carbohydrates and protein in order to maximise the ketogenic potential of our diet.

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You can have 30% protein and 5% carbs or 20% carbs and 10% protein and still be within the bounds of a ketogenic diet.  However if you have 30% protein and 20% carbs you will be outside the realms of a ketogenic diet because you will be producing too much glucose.

According to Nuttall and Gannon [7] the body requires between 32 and 46g per day of high quality dietary protein to maintain protein balance.  This equates to around 6 to 7% of calories in a 2000 to 2500 calorie diet being taken ‘off the top’ for growth and maintenance, with everything else potentially available as ‘excess’ protein for gluconeogenesis.  This should not be considered optimal, but simply a minimum reference point for the absolute minimum amount of protein.

Interestingly, the slope of the line along the face of Phinney’s WFKD triangle corresponds with the assumption that 7% of protein goes to muscle growth and repair (protein synthesis) with 75% of the remaining ‘excess’ protein being glucogenic.  This 75% value is in the “ball park” (although a little higher) of our previous estimate of the glucogenic potential of protein based on the analysis of the food insulin index data.

amino acid potential

We also have an understanding of which amino acids are glucogenic, which are ketogenic and which are a bit of both. [8] [9] [10]  The table below shows the various amino acids divided up on the basis of their ketogenic versus glucogenic potential and also which are essential versus non-essential. [11]

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Only two amino acids are exclusively ketogenic.  There is a handful that are both glucogenic and ketogenic.  However most of the amino acids are glycogenic, meaning that they will most likely turn into glucose if not required for protein synthesis.

According to David Bender “In  fasting  and  on  a  low  carbohydrate diet  as  much  of  the  amino  acid  carbon  as  possible  will  be  used  for gluconeogenesis, an ATP-expensive, and hence thermogenic process.” 

Hence it appears likely that in a low carbohydrate diet situation excess amino acids that fit under the “both” classification will be turned to glucose rather than ketones because the body needs the extra glucose which it is not getting from ingested carbohydrates.

Conversely, if someone is consuming a high carbohydrate diet the excess amino acids that fit into the “both” category will be converted to ketones rather than glucose because the body is getting more than enough glucose from the diet.

So, to some extent, protein is versatile depending on the body’s need. But at the same time, it is only a small portion of the amino acids that are able to do this. The fate of the majority of the amino acids is pre-destined.

the krebs cycle

The figure below shows the process of catabolism of amino acids. [12]

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I am not an organic chemist, but from what I understand this means that:

  • The amino acids Leucine and Lysine cannot be converted back to glucose as they are ketogenic;
  • Isoleucine, Tyrosine, Phenylalanine, Tryptophan, Threonine all enter into the amino acid catabolism cycle and can be used for various functions, such as muscle repair and growth, but can also be converted back into glucose if required (glucogenic) or turned into fatty acids (ketogenic); and
  • The remaining amino acids enter the cycle and can be used for a variety of functions in the body, but cannot be converted into fatty acids.  If they are not required they can be turned into glucose and potentially stored as body fat.

The majority of the amino acids obtained from the digestion of protein have the potential to be turned into glucose through gluconeogenesis.

The reason that we don’t see a sharp rise in blood glucose is partly because amino acids from digestion circulate in the blood until they are required.  Gluconeogenesis is a demand driven process.  Glucose is pulled from amino acids when there is no other source rather than pushed into the bloodstream due to ingestion of excess protein.

By contrast, glucose from carbohydrates will be used to refill glycogen stores (liver and muscle) and then find their way quickly into the bloodstream.  In most people, the amino acid stores in the blood are not saturated and hence there is plenty of capacity to store amino acids until they are required, at least if you have good insulin sensitivity and are not diabetic.

The body does need glucose, and it is fine to get it from carbohydrates or protein via gluconeogenesis.  However many people struggle to produce enough insulin and / or are insulin resistant and hence struggle to keep their blood sugars in normal range.  For these people it makes sense to reduce the insulin load their diet (the portion that requires insulin) to a point that they can maintain normal blood glucose levels.

tallying up the amino acids

I figured I could use this knowledge of the categorisations of the various amino acids to better understand how much of the proteins in the 8000 foods listed in the USDA food database are glucogenic versus ketogenic.

For each food in the USDA database I tallied up the weight of the glucogenic and ketogenic amino acids and the amino acids that fell onto the ‘both’ category and found that:

  • ketogenic amino acids make up only 12% by weight of the total protein across the 8000 foods in the database,
  • glucogenic amino acids comprise 74% of the foods, and
  • amino acids that fit in the “both” comprise 14% of the total weight of amino acids.

This means that somewhere between 78% and 89.5% of protein has the potential to turn into glucose, depending on whether you considered the amino acids in the ‘both’ column to be glucogenic or ketogenic, or somewhere in between.

For someone eating a low carbohydrate diet nearly 90% of ‘excess’ protein could be turned to glucose in the blood stream.

Why is this different to the observation from the food insulin index testing that approximately 56% of protein raises insulin?  Perhaps the following factors come into play:

  1. When we consider the glucogenic potential of the individual amino acids we are considering the maximum potential of protein if it is not first used for protein synthesis.  The amount of protein synthesis will be greater for say an athlete or a body builder, with less protein remaining for gluconeogenesis.
  2. Converting protein to glucose requires energy and hence some of the energy from ingested protein is lost in the process and hence is not converted to glucose.
  3. The insulin index testing is undertaken over only three hours. Protein takes much longer to digest and be metabolised into glucose hence the insulin index testing may underestimate the full glucogenic potential of protein.

which foods have the most ketogenic protein?

So I bet you are wondering which forms of protein have the highest amount of ketogenic protein.  Maybe not?  Well, I was, and I am going to share it with you.

The table below shows the foods from the USDA database that have the most ketogenic protein (assuming the ‘both’ amino acids are split 50/50 glucogenic / ketogenic) in terms of grams of ketogenic amino acids per 100 grams of the food.

Food ketogenic aminos ( per 100g) % ketogenic protein % insulinogenic
Seal, Bearded Alaskan 19.4g 23% 72%
Whale, Beluga 17.6g 25% 64%
Cod 16.3g 26% 68%
Seaweed, spirulina 14.2g 25% 64%
White fish 13.6g 22% 53%
Parmesan cheese 12.3g 32% 28%
Beef, sirloin 10.0g 33% 50%
Beef, ribeye 9.7g 33% 44%
Bacon 9.3g 25% 22%
Egg yolk 9.2g 27% 18%
Lamb 9.0g 25% 39%
Chicken, breast with skin 7.8g 24% 48%
Salmon 7.0g 28% 45%
Egg, whole 3.3g 26% 29%
Milk 0.9g 29% 43%

It is hard to know what to make of this list other than noting that the seal, whale and cod have the highest amounts of ketogenic protein.  Perhaps there is something about cold water animals that cause them to store more ketogenic amino acids?  This seems to align with what we see in the traditional diets of humans who may eat more fat if they are living further away from the equator but eat more carbohydrates from fruits if they live closer to the equator.

Although seal, whale and cod have high amounts of ketogenic amino acids, overall they are still quite insulinogenic.  In view of the high proportion of insulinogenic properties of some meats it is not surprising that people can thrive on a 100% meat zero carb diet because the body can get as much glucose they need from the meat.[13]  At the same time though, I’m not sure that an all meat diet can provide an optimal array of vitamins and minerals unless you are emphasising organ meats.

In view of the fact that a large amount of protein can be converted to glucose through gluconeogenesis, it seems better to focus on foods that have a lower percentage of insulinogenic calories if you are insulin resistant or do not have a fully functioning pancreas.

Rather than worrying about whether you’re eating too much protein, most people will do fine if they limit their processed grains and sugars and eating as much protein as their appetite directs them to.  If you are aiming for a therapeutic ketogenic diet to manage chronic conditions such as cancer, epilepsy or dementia, then you may want to consider moderating your protein intake to drive ketosis.

While there is no such thing as a glycemic index for protein, it also makes sense to avoid processed foods if you are after stable blood glucose levels and lasting satiety.  Unless you are a bodybuilder who is looking for a quick insulin spike it would be prudent to prioritise protein from whole foods.

summary

The table below shows a comparison of a range of glucogenic factors for protein relative to carbohydrate, summarising the discussion above.  Most of the approaches to understanding the insulinogenic portion of protein give an even higher value than suggested by the analysis of the food insulin index data.

Basis % insulinogenic Comment
Carbohydrates only 0% A lower end sensitivity assuming that no protein is converted to glucose (i.e. as per standard carbohydrate counting).
Food insulin index 56% Based on testing of > 100 foods in healthy individuals
Thermic effect of food 77% Average of additional in digestion losses minus 7%.
Wilder’s formula 54% Used in initial ketogenic formula
Krebs  / Janney 57% Based on nitrogen excretion in dogs
Glucogenic potential (min) 78% Based on summing amino acids in USDA foods database, excluding “both” aminos.
Glucogenic potential (max) 89.5% Based on summing amino acids in USDA foods database, including “both” aminos.
Steve Phinney WFKD 75% Assuming that the first 7% of calories goes to growth and repair with 75% of the remaining amino acids being glucogenic.

the most ketogenic foods… updated

I have calculated the insulinogenic potential of the foods shown in this previous article (The Most Ketogenic Diet Foods) using the following approaches:

  • carbohydrates only;
  • food insulin index data (i.e. protein is 56% insulinogenic);
  • thermic effect (i.e. protein is 77% insulinogenic); and
  • maximum glucogenic potential of the amino acids for each food (varies for each food based on data in USDA foods database).

This updated data illustrates the difference in standard carbohydrate counting and the full insulinogenic potential of the food.  While there is a range of values due to the varying amounts and types of protein overall, there is a reasonable alignment between the food insulin index (56%), thermic effect of food (77%) and maximum glucogenic potential values, particularly when we compare it to the carbohydrate only approach for the lowest carbohydrate foods.

least insulinogenic foods

food carb only (0%) FII (56%) thermic (77%) glucogenic (max)
olives 1% 4% 4% 4%
cream 3% 4% 6% 4%
pecans 2% 5% 8% 6%
Macadamia nuts 3% 5% 7% 6%
duck 0% 7% 4% 9%
pork sausage 2% 10% 19% 9%
sesame seeds 7% 7% 10% 11%
sausage 0% 9% 12% 14%
frankfurter 2% 11% 14% 14%
pepperoni 0% 10% 14% 15%
bacon 1% 16% 21% 21%
mackerel 0% 20% 28% 28%

Eggs

egg  carb only (0%) FII 56%) thermic (77%) glucogenic (max)
egg yolk 16% 15% 20% 19%
whole egg 17% 21% 23% 25%
egg white 6% 53% 71% 72%

Dairy products

Cheese

cheese carbs only (0%) FII (56%) thermic (77%) glucogenic (max)
cream cheese 5% 9% 10% 9%
brie 1% 14% 20% 18%
limburger 1% 14% 19% 18%
camembert 1% 15% 21% 19%
Monterey 1% 15% 20% 19%
cheddar 1% 15% 20% 19%
gruyere 0% 17% 23% 20%
Colby 3% 16% 21% 20%
blue 3% 16% 21% 20%
edam 2% 17% 23% 21%
gouda 2% 18% 24% 22%
feta 6% 18% 23% 22%
ricotta, whole milk 7% 21% 27% 24%
mozzarella 3% 20% 26% 26%
cream cheese, low fat 16% 25% 28% 27%
parmesan 3% 21% 27% 28%
mozzarella, skim milk 4% 26% 34% 31%
Swiss 6% 22% 27% 34%
ricotta, part skim milk 15% 33% 40% 37%
cream cheese, fat free 29% 62% 75% 72%
Swiss, low fat 8% 45% 48% 73%
cottage cheese, low fat 17% 55% 69% 86%
mozzarella, non-fat 10% 60% 79% 95%

Milk

milk carb only (0%) FII (56%) thermic (77%) % insulinogenic (max)
Full cream milk, 3.7% fat 29% 41% 41% 43%
Human milk 40% 43% 44% 43%
Skim milk, 1% fat 47% 65% 72% 69%
Chocolate milk, low fat 63% 72% 76% 70%

Yogurt

yogurt carb only (0%) FII (56%) thermic (77%) % insulinogenic (max)
plain, whole milk 30% 42% 48% 46%
Plain, low fat 44% 63% 70% 68%
fruit, low fat 71% 81% 85% 83%
plain, skim milk 55% 78% 87% 85%
fruit, non-fat 70% 90% 97% 96%

Fruits

fruit carb only (0%) FII (56%) thermic (77%) % insulinogenic (max)
olives 1% 3% 4% 4%
avocados 4% 8% 9% 7%
raspberries 42% 42% 51% 45%
blackberries 40% 42% 53% 47%
strawberries 70% 75% 76% 69%
oranges 77% 81% 83% 76%
apples 88% 89% 89% 81%
bananas 91% 91% 95% 86%

Vegetables

vegetable carb only (0%) FII (56%) thermic (77%) % insulinogenic (max)
endive 6% 22% 29% 24%
dock 5% 27% 33% 27%
mustard greens 7% 61% 43% 34%
asparagus 36% 60% 69% 34%
artichoke 22% 35% 39% 38%
sauerkraut 30% 41% 45% 40%
broccoli 3% 35% 47% 42%
lettuce 28% 44% 50% 42%
coriander 15% 36% 44% 43%
chrysanthemum leaves 0% 32% 43% 44%
alfalfa 3% 42% 57% 47%
parsley 34% 52% 59% 48%
cauliflower 32% 50% 56% 48%
spinach 24% 53% 63% 50%
bamboo shoots 19% 50% 62% 51%
mushroom 31% 56% 66% 55%
turnip 17% 30% 34% 62%
onions 78% 85% 88% 82%

Nuts, seeds and legumes

nuts, seeds legumes carbs only (0%) FII (56%) thermic (77%) % insulinogenic (max)
pecans  2% 5%  10% 5%
Macadamia  3% 5%  6% 6%
coconut meat  7% 6%  10% 7%
coconut cream  6% 7% 9% 8%
coconut milk  6% 7% 9% 8%
Brazil nuts  3% 7% 10% 9%
flax seed  1% 8% 12% 11%
walnuts  4% 9%  11% 11%
pine nuts  5% 9%  11% 11%
sesame butter (tahini)  6% 11% 15% 14%
sesame seeds  0% 12% 10% 15%
chia seeds  6% 13% 17% 16%
peanuts  4% 13%  19% 18%
sunflower seeds  9% 14% 19% 18%
pumpkin seeds  6% 14% 22% 19%
pistachio nuts  12% 19%  23% 22%
cashew butter  21% 22% 29% 25%
almonds  7% 13% 18% 17&

Fish

fish carbs only (0%) FII (56%) thermic (77%) % insulinogenic (max)
Tuna 0% 32% 44% 44%
Mackerel 0% 33% 46% 25%
Herring 0% 19% 26% 25%
Salmon 0% 24% 33% 34%
Sardine 0% 26% 36% 36%
Anchovy 0% 31% 42% 42%
Swordfish 0% 31% 42% 42%
Trout 0% 31% 44% 43%
Carp 0% 32% 43% 43%
Yellowtail 0% 36% 49% 49%
Bass 0% 37% 51% 51%
Mullet 0% 37% 51% 51%
Squid 18% 41% 49% 51%
Abalone 23% 47% 55% 57%
Monkfish 0% 44% 59% 60%
Halibut 0% 47% 24% 61%
Mussel 17% 49% 60% 62%
Oyster 21% 46% 56% 63%
Crab 0% 48% 66% 65%
Shrimp 5% 48% 64% 65%
Hadock 0% 51% 68% 66%
Perch 0% 49% 65% 67%
Clam 14% 56% 67% 71%
Scallop 19% 59% 76% 80%

Meat

meat carbs only (0%) FII (56%) thermic (77%) % insulinogenic (max)
Bologna 6% 12% 17% 14%
Frankfurter 2% 11% 14% 14%
Duck 0% 14% 17% 17%
Chorizo 2% 15% 18% 17%
Beef, ribeye 0% 15% 26% 21%
Bacon 1% 15% 21% 21%
Pork, ham 6% 17% 38% 22%
Pork, blade, hocks & shoulder 31% 23% 42% 31%
Turkey 0% 23% 29% 32%
Lamb mince 0% 24% 27% 34%
Chicken 0% 24% 34% 34%

post last updated May 2017

references

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

[2] http://www.thepaleomom.com/2015/05/adverse-reactions-to-ketogenic-diets-caution-advised.html

[3] http://perfecthealthdiet.com/2011/02/ketogenic-diets-i-ways-to-make-a-diet-ketogenic/

[4] https://books.google.com.au/books?id=SqzMBQAAQBAJ&pg=PA245&dq=Krebs+1964+The+metabolic+fate+of+amino+acids.&source=gbs_toc_r&cad=4#v=onepage&q&f=false

[5] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC292907/pdf/jcinvest00272-0077.pdf – Cahill references a 1964 paper by Krebs in this paper but I can’t find the original paper.

[6] http://en.wikipedia.org/wiki/Specific_dynamic_action

[7] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636610/

[8] http://en.wikipedia.org/wiki/Glucogenic_amino_acid

[9] http://en.wikipedia.org/wiki/Ketogenic_amino_acid

[10] https://www.dropbox.com/s/4dkl03mz2fci71v/The%20metabolism%20of%20%E2%80%9Csurplus%E2%80%9D%20amino%20acids.pdf?dl=0

[11] http://www.medschool.lsuhsc.edu/biochemistry/Courses/Biochemistry201/Desai/Amino%20Acid%20Metabolism%20I%2010-14-08.pdf

[12] http://en.wikipedia.org/wiki/Gluconeogenesis

[13] http://zerocarbzen.com/2015/03/09/zero-carb-interview-the-andersen-family/

why is good blood glucose control so important?

When my wife Monica was diagnosed with type 1 diabetes at ten she was advised to eat at least 130g of carbohydrates with every meal.

The insulin dose was kept fixed to cover this fixed amount of carbohydrates.  If she went low she had to eat more carbs to bring her blood glucose back up.

Welcome to the everyday blood sugar roller coaster that takes over your life when you have diabetes!

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It wasn’t till after we were married in 2002 and started thinking about having kids that she found a doctor with an interest in diabetes who told her that she could tailor her insulin dose to what she wanted to eat.

Up until this time even the visits to the endocrinologist were to get more scripts for insulin and thyroid medication.  No useful advice was provided about how to manage diabetes.

It’s amazing that the concept of carbohydrate counting was new and shiny in 2003 when Richard Bernstein developed the concepts back in 1970s!

Today, the standard of care for diabetes seems to have incorporated Bernstein’s carbohydrate counting, however the nutritionists and diabetes associations still advises that diabetics should not have to deprive themselves of any food in the pursuit of health.  And like everyone else, they should eat a diet full of “healthy whole grains”.

It wasn’t until we discovered Paleo and then low carb through family members and social media that she found that she could improve blood sugar control through diet.

More recently by refining our diet to prioritise low insulin load, high fibre and high nutrient density foods I’m pleased to say that she has been able to find another level of improved blood sugar control, increased energy and reduced depression and anxiety that so often comes with blood sugar dis-regulation.

Real-Food-Pyramid1 (1)

It is still not easy and we are still learning, however she is now able to enjoy working as a supply teacher rather than just getting through the morning and needing to sleep during the afternoon before picking up the kids from school.

Her big regret is that she did not discover this earlier, which would have saved her from spending decades living in a fog with limited energy.

The chart below shows the difference diet can make in the management of blood glucose, particularly for a type 1 diabetic (notice that these plots are only two months apart!).  People who find success with this dietary approach find a substantial improvement in quality of life and their state of well being that makes it well worth the effort.

image017

Below is a recent post on the TYPEONEGRIT Facebook group from a mother of a type 1 diabetic child describing their interaction with her health care team.  It’s still not simple to go against the main stream dietary advice.

We had our team meeting today to discuss LCHF…  they are so terrified of this, even though we have great BG readings, behaviour improvements and learning improvements (noted by us, family, friends and his school) which they didn’t even acknowledge.

The nutritionist is concerned that he won’t be getting the micronutrients that only come from grains and the higher carb vegetables (grains are fortified), then her concern was the B vitamins 1, 3 and 6. 

Then the concern about Iron (what?! have you seen the meat and spinach listed?). Then it was calcium and magnesium (clearly they don’t have a clue about LCHF).

They said they are afraid this diet may cause future developmental harm. We said your diet WILL cause future harm and way more than developmental. Back and forth and on it went. We addressed their concerns with peer reviewed research, and respect to their limited knowledge.

We will be an open book and comply because I want them to learn that T1D care can be so much better than it has been up to now, and pave the way for the next families that wishes to do LCHF.

They will check for vitamins and minerals at his 3 month blood work (again special for our case, which we have to pay for).

The good news here is that after running an intense battery of tests they decided to use this child as Canada’s first case study in LCHF paediatrics for the management of type 1 diabetes.

This post inspired me to run some numbers on a range of diets to see whether there was any issue with the nutritional content of higher fat diets.   It turns out that diets with higher levels of fat can be very nutritious while the grain based diet that everyone is recommended does very poorly, particularly when you take the insulin of these higher carbohydrate diets into account (see the Diet Wars… Which One is  Optimal article for more details).

It breaks my heart to see diabetics living with a highly diminished quality when there is the potential to greatly reduce the impact of diabetes by more informed food choices.

For people with diabetes and their carers diet is important and maybe a matter of life and death, or at least a decision that will greatly affect their quality and length of life.

beef heart chili

This Beef Heart Chili recipe is by Kathleen Guertin from Robb Wolf’s website.  It ranks really well in the weight loss and athletic / metabolically healthy meal rankings due to it’s high nutrient density and low calorie density.

Organ meats top the list when it comes to nutrient density, however I haven’t found a lot of recipes using organ meats that rank really well.  Perhaps it’s because people feel they need to put a lot of not so healthy things with their organ meats to drown out the taste?

This recipe uses heart, ground beef along with a range of spices to build a solid nutritional profile.

If you look closely at the chart below you’ll see that I’ve used pork heart as there is no data for beef heart in the NutritionSELF database.

Robb has had a massive influence on my thinking, along with many others. I like the way he brings everything back to evolutionary principles that need to make sense in the broader context rather than just looking at isolated studies.  I also like the way he promotes quantifying nutritional density as a way to beat the nutritionists at their own game.

Robb believes that Mat Lalonde’s nutritional density work will show the nutritionists that Paleo is better than the recommended western diet using their own system!

I’m hoping that nutritional density combined with the insulin index component will take things one step further to provide a quantitative basis to demonstrate that one meal is better than another.

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The details for a 500 calorie serving (the recipe is for two servings) are shown below.  This recipe does really well on the weight loss ranking because it has a low calorie density and a solid, great nutrient levels and a solid amount of fibre.

net carbs

insulin load carb insulin fat protein fibre
20g 40g 50% 49% 28%

9g

If you are insulin resistant or are sensitive to tomatoes you may want to reduce the tomatoes.  I’ve re-run the numbers with 5 ounces of tomatoes rather than the 26 ounces in the original recipe.  Still not perfectly diabetic friendly, but an improvement and slightly closer to the Bernstein target of 12g carbohydrates per meal.

net carbs

insulin load carb insulin fat protein fibre
15g 36g 42% 53% 30%

6g