optimising micronutrients and macronutrients for different goals

  • This article looks at the macro and micronutrient split for the most nutrient dense foods using a multi criteria analysis tailored for different goals (i.e. diabetes, therapeutic ketosis, weight loss and athletic performance).
  • High protein foods are typically much more nutrient dense than high carbohydrate foods.
  • The optimal protein intake for athletes, people who are metabolically healthy and people who are trying to lose weight is virtually unrestricted, particularly as the blood glucose impact from gluconeogenesis is not a concern and the amount of protein someone can eat is self-limiting.
  • People with diabetes and metabolic syndrome may benefit from a more moderate protein intake in order to reduce their insulin load to the point that that their pancreas can keep up and maintain normal blood glucose levels.

the setup

In a number of previous articles I have discussed minimum glucose and protein requirements based on starvation experiments.  Thinking that these are recommendations for protein a number of people responded noting that 0.8g/kg lean body mass (LBM) or 8% of calories is too low. [1]

My typical response to these comments has been along the lines of:

  • We need to get adequate amino acids from protein, just like we need adequate vitamins and minerals.
  • It’s all about finding the balance between adequate nutrition while keeping your dietary glucose load low enough so your pancreas can function efficiently.
  • The optimal approach is going to be different for each individual, depending on your needs, activity levels, personal situation and goals.

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But what does this look like in practice?  What is the optimal macronutrient ratio that balances the competing goals of maximising nutrition while not overloading our body’s capacity to process those nutrients?  How do we get adequate protein for growth, repair and mental function while avoiding high blood glucose and excess body fat?

How do you find a way through all the contradictory health advice from different health camps saying ‘you can’t eat too much protein’, ‘maximise your veggies’, ‘eat fat to lose fat’, or others saying ‘intermittent fasting is the rediscovered cure for everything’?

different strokes for different folks

Context matters when it comes to designing the optimal diet.

In the article Your Personal Food Ranking System I outlined a multi criteria system to help prioritise food choices for different situations.  The system uses different weightings for a range of parameters available from the USDA food database.  I then used these parameters and weightings to develop lists of optimal foods for different situations (i.e. weight loss, diabetes / nutritional ketosis, therapeutic ketosis, and athlete / metabolically healthy) highlighting foods from the top 25% of the foods ranked using those weightings.

In developing these lists of optimal foods I also included cost considerations as a factor.  However in the discussion of optimal nutrition I don’t think cost is as important.  I also wanted to use the full USDA database of nearly 8000 foods rather than the smaller database of around 1000 foods that I have cost data for.

So we are left with the following parameters from which to develop a food ranking system:

  • nutrient density / calorie,
  • nutrient density / weight,
  • fibre / calorie,
  • fibre / weight,
  • percentage of insulinogenic calories, and
  • calories / weight.

fibre

Fibre can be useful to help feed and increase the diversity of our gut bacteria which appears to be good for a range of benefits including insulin sensitivity and autoimmunity.

The amount of fibre per calorie also seems to be a good proxy for the degree of processing involved in carbohydrate containing foods.

  • Highly processed foods = bad.
  • Minimally processed foods = good.

calorie density

Regardless of calories, it seems we eat about the same weight of food per day. [2]

Calorie density is related to fibre content.  Decreasing calorie density is a useful way to spontaneously manage energy intake.

A low calorie density typically means that your food contains a lot of water, so by itself it isn’t particularly useful;  a fortified energy drink or a slice of watermelon will end up scoring highly when we only consider nutrient density per calorie.

Considering both calorie density and fibre together ends up being a much more useful approach.

proportion of insulinogenic calories

If you are insulin resistant or obese then managing the insulin load of your diet will be an important consideration.  The percentage of insulinogenic calories concept builds on the food insulin index testing which demonstrates that both carbohydrates and protein require insulin. [3]

Keeping your percentage of insulinogenic calories low (as defined by the formula below) means reducing net carbohydrates, increasing fibre and possibly moderating protein.

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This formula biases against non-fibre carbohydrates.  As noted earlier, one of the major concerns people have with this approach to identifying optimal foods is that we still need our protein.  So the question is, “to what extent would protein be penalised if we also try to maximise our nutrients?”

nutrient density

The nutrient density concept builds on the excellent work of Mat Lalonde which he discusses in this video from AHS 2012.

Lalonde shortlisted the following essential nutrients [4] which have been used in the nutritional analysis as part of the multi criteria analysis:

Essential fatty acids [5]

  1. alphalinolenic acid (omega-3) (18:3)
  2. docosahexaenoic acid (omega-3) (22:6)

Amino acids

  1. cysteine
  2. isoleucine
  3. leucine
  4. lysine
  5. phenylalanine
  6. threonine
  7. tryptophan
  8. tyrosine
  9. valine
  10. methionine
  11. histidine

Vitamins

  1. choline
  2. thiamine
  3. riboflavin
  4. niacin
  5. pantothenic acid
  6. vitamin A
  7. vitamin B12
  8. vitamin B6
  9. vitamin C
  10. vitamin D
  11. vitamin E
  12. vitamin K

Minerals

  1. calcium
  2. copper
  3. iron
  4. magnesium
  5. manganese
  6. phosphorus
  7. potassium
  8. selenium
  9. sodium
  10. zinc

It is worth noting that the list of essential amino acids, vitamins and minerals has about equal number of elements (i.e. eleven amino acids, twelve vitamins and ten minerals).  Hence it is unlikely that we would end up biasing towards high protein foods just because we have more amino acids being counted than say vitamins or minerals.

The nutrient density for a certain food is based on a relative score calculated by comparing the amount of a particular nutrient in each food with the all of the foods in the database.

For example, if a food has an average amount of vitamin C compared to the 8000 other foods in the database it will get a score of zero because it is zero standard deviations from the mean.  If it has a large amount of a certain nutrient then it will receive a high score.  If it is two standard deviations from the mean then it gets a score of two for that nutrient.  If however it is five standard deviations from the mean it gets a maximum score of three in order to avoid prioritising foods that have massive amounts of one nutrient versus foods that have high amounts of a number of nutrients.

Kale

One example of where this limitation comes into play is kale, which has a massive amount of vitamin K, [6] versus spinach which has a high amount of vitamin K but also has a range of other nutrients and ends up with a higher overall nutrient density score.  Because of the upper limit on the score for a single nutrient, this system would give a higher ranking to spinach which has a more well-rounded nutrient profile rather than simply being an over achiever in one or two nutrients.

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No weighting of individual nutrients has been applied.  Weighting one nutrient as more important than another could be useful for a particular person with a particular goal or health condition.  However at the same time it’s nice to keep the analysis ‘clean’ to avoid arguments about bias. [7]  This unweighted approach highlights foods that have a broad spectrum of nutrients at significant levels.

minimum protein

So what is the minimum amount of protein that we require?

  • According to Nuttall and Gannon [8] the body requires between 32 and 46g of high quality dietary protein per day to maintain protein balance in a starvation situation. This equates to around 6 to 7% of calories in a 2000 to 2500 calorie diet but in starvation this is how much your body will cannibalize off your muscle per day if it gets no food, with the rest coming from body fat stores.
  • The recommended daily intake (RDI) of 0.8g/kg LBM is based on an estimated average requirement (EAR) of 0.66g/kg LBM which is the amount estimated to ensure that 50% of the population are not deficient.
  • Ron Rosedale, an advocate of ketogenic diets and minimising insulin as far as possible, recommends 1.0g/kg LBM for most people, 1.25g/kg LBM if you exercise and 0.8g/kg LBM for people with diabetes. [9] [10] [11] [12]

typical protein intake

As a reference point, the American diet typically consists of between 65 and 100g of protein per day.  According to NHANES fat and protein intake has decreased over the last few decades as carbohydrate content has increased. [13]

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maximum protein

Most people will find it difficult to eat more than 30% of their calories from protein from whole foods, though you can push to higher levels by using protein powders.

Protein is very satiating so our intake is typically self-limiting.  The upper limit of protein intake for our liver is said to be 200 to 300g per day, or 35 to 40% of calories from protein. [14]

The term ‘rabbit starvation’ refers to a situation where people who only have lean rabbits to eat starve because they just can’t process any more protein. [15]

This video from Dr Donald Layman gives an overview of the benefits of protein.  He says that the range of safe protein intake varies between 0.8g/kg LBM and 2.5g/kg LBM.

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Steve Phinney’s WFKD triangle suggests that people will find it hard to achieve nutritional ketosis with protein levels greater than 30% of calories or 2.4g/kg LBM, even if they have very low carbohydrate levels.

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In The Myth of 1 g/lb: Optimal Protein Intake for Bodybuilders[16] Menno Henselmans argues that there is a limit to how much protein we can metabolise to grow muscle.  More protein does not necessarily mean more “gainz”.  As shown in the figure below:

  • people who are sedentary will be unlikely to gain more muscle with more than 0.8kg/kg lean body mass;
  • an endurance athlete may not gain more muscle with more than 1.3g/kg lean body mass; and
  • a strength athlete will not activate more protein synthesis by eating more than around 1.8g/kg lean body mass.

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Interestingly Luis Villasenor (aka Darth Luiggi, pictured below), who runs Ketogains and is studying under Henselmans, recently changed the upper limit on his Ketogains macro calculator to include an upper limit of 1.8g/kg total body mass for protein to reflect Menno’s findings.

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Luis said his rationale behind the protein levels in the Ketogains macro calculator:

  • lower limit of 0.8 to 1.0g per pound of lean pound of body weight, and  .
  • upper limit that will not affect ketosis = 1.8g per total kilogram.

Luis says that protein grams over 1.8g/kg total body mass should be counted as 50% toward daily carb intake and that higher levels of protein can hinder ketone production.  Higher levels of protein are not necessarily going to be a problem if your carbs are low and / or you are insulin sensitive and have your blood glucose levels under control.  This approach certainly seems to be working for Luis!

While there is a limit to the amount of amino acids we can use for muscle growth and repair, it’s important to note that amino acids are also important for mental health.  Julia Ross’s Mood Cure details how nutrients can be targeted to address depression and a range of other mental health issues. [17]  So protein in excess of what is required for our muscles is not necessarily wasted.

To summarise, the table below shows a comparison of these minimum and maximum levels in terms of percentage of daily calories, grams per kilogram of lean body mass and grams per day for a 2250 calorie per day diet for a man with 74kg lean body mass (LBM).

scenario PRO (g/day) PRO (%) g/kg LBM
minimum (starvation) 32 6% 0.4
RDI / sedentary 59 11% 0.8
typical 90 16% 1.2
strength athlete 133 24% 1.8
WFKD max 169 30% 2.3
maximum 197 35% 2.7

the Goldilocks glucose zone

I believe that consideration of optimal protein intake needs to have some regard for the carbohydrate level, given that we can get the glucose we need from both protein and carbohydrate.  If we increase the glucose load (from carbohydrates and / or protein) above what our body can tolerate then we drive up blood glucose and insulin levels, thus ending up with obesity and diabetes.

In the Goldilocks Glucose Zone article I looked at how we can obtain glucose from both carbohydrate and protein (through gluconeogenesis).  If we are more towards the bottom left of the plot of protein versus carbohydrate chart, our diet is more likely to be more ketogenic.  However, the more we minimise protein and carbohydrates the more we risk not obtaining the fibre and nutrients that might be harder to find on a higher fat diet diet of butter, coconut oil and avocado.

What this means in practice is that the more ketogenic our diet is, the more intentional we have to be about achieving adequate nutrition and maximising the nutrient density of the foods that we eat.

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therapeutic ketosis

Let’s first look at the most extreme end of the spectrum, therapeutic ketosis.  This approach is based on the theory that a low insulin load diet will help control conditions such as cancer and epilepsy.

The table below shows the weighting criteria for therapeutic ketosis, with a low percentage of insulinogenic calories being the primary goal.  Minimal weighting is given to fibre and calorie density with moderate weighting given to nutrient density.

ND / cal fibre / cal ND / weight calories / 100g insulinogenic (%)
10% 5% 10% 5% 70%

People who are aiming for therapeutic ketosis in an effort to conquer cancer or epilepsy are typically motivated to reduce the insulin load of their diet, sometimes at the expense of nutrition.

Check out Andrew Scarborough’s story for a fascinating example of someone who has worked very hard to maximise nutrition while still having a very low insulin load.   Andrew focuses on maximising omega-3 fats and has to avoid ketogenic favourites such as avocado and coconut oil due to his intolerances.

I’ve sorted the foods in the USDA food database using these weightings and plotted the highest ranking 5% of these foods against the protein versus net carbs chart with the various levels of ketosis.  On average these foods have a very low 1.4% net carbohydrates and a fairly low 11% protein (i.e. approximately the RDI minimum level for sedentary people).

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In the bottom left hand corner of the chart butter, cream and oils make the list due to their very low percentage of insulinogenic calories.  However what I find most interesting is to look at the foods that make the list due to their higher nutritional value such as spices, olives, bacon and cheese.

You can download the list of the top 500 foods ranked using this system here to review the outputs of the system in more detail.  Because nutrient density and fibre don’t play a big part in this ranking there are lot of high fat foods here that don’t have a lot of amazing nutritional properties, so you’ll need to use your discretion to find foods from this list that suit your goals other than just being high fat.

diabetes and nutritional ketosis

The table below shows the weighting to identify optimal foods for diabetes and nutritional ketosis.  This approach is less extreme than the therapeutic ketosis approach with only half the weighting in the multi criteria analysis being given to the insulinogenic properties with some of the weighting spread to nutritional density and calorie density.

ND / cal fibre / cal ND / weight calories / 100g insulinogenic (%)
10% 10% 10% 10% 60%

The plot below shows the top 5% of foods in the USDA database ranked using this weighting in terms of protein versus net carbohydrates.  On average these foods have 2% net carbohydrates and 20% protein which aligns reasonably well with what we see practiced in the low carbohydrate and diabetic community.

Protein levels are moderate in order to ensure adequate levels of amino acids while managing the insulin load of the diet.  With such low levels of carbohydrates this approach is certainly still ketogenic!

To give some context it’s worth noting that the typical western diet is about 15% of calories from protein, [18] so most people would need to eat more protein to achieve these levels.

Again, it’s interesting to look at the outliers that make the cut due to their nutritional density such as black pepper, parsley, rosemary, spinach and liver.  Although these foods have a higher percentage of insulinogenic calories it would be hard to overeat them.

You can download the top 500 foods using this system here.

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weight loss

This approach to the weighting of the multi criteria ranking is designed for someone who already has their blood glucose levels under control, but still wants to lose more weight.

Some people find that they can achieve their target weight on a ketogenic diet.  However others don’t have the same degree of success and perhaps may need more help to reduce their calories lower through food choices to help them lose weight.

While many people find that a higher fat diet will naturally lead to increased satiety with the reduced insulin load enabling stored body fat to be released for fuel, it is still possible to overdo your calories on a high fat diet.  Too many calories, even with ketogenic macronutrient ratios, can still mess with your insulin sensitivity and cause weight gain. [19]

Chris Gardner’s A to Z trial [20] highlighted that people with insulin resistance lost the most weight if they reduced their insulin load, while people who were not insulin resistant could lose weight on any diet as long it was low enough in calories. [21] [22]

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The table below shows the weighting for the suggested optimal foods for weight loss which prioritises high fibre, high nutrient density and low calorie density foods rather than focusing as much on insulin load.

ND / cal fibre / cal ND / weight calories / 100g insulinogenic (%)
15% 10% 15% 20% 40%

This approach might be appropriate for a person that still has weight to lose but has gained control of their blood glucose levels and meets the following criteria:

  • HbA1c < 5.4mmol/L
  • fasting blood sugar < 5.0mmol/L (90mg/dL)
  • average blood sugar < 5.4mmol/L (100mg/dL)
  • post meal blood sugar < 6.7mmol/L (120mg/dL)

Being overweight and / or having a larger than desirable waist line is usually a good sign you are insulin resistant, so most people wanting to lose weight should typically start with the diabetes / nutritional ketosis approach (possibly with some intermittent fasting) until they get their blood glucose levels and insulin resistance under control.

As indicated by the chart above from the analysis of Gardner’s study, the low carb approach worked the best regardless of insulin resistance status.  Designing a diet that is high in fibre, has high nutrient density,  while still being fairly low in carbohydrates and calories, may help automatically limit food intake and manage calorie intake. This way we are focusing on food quality rather than having to count calories!

The plot below shows the top 500 foods using the weight loss ranking.  You will note that there are a lot of foods that sit well outside the ketogenic triangle.  On average we have 4% net carbohydrates and 36% protein.

Once we reduce the emphasis on glucose load the system will strongly prioritise protein rather than carbohydrate-based foods to source nutrition!

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With the priority on high fibre and low calorie density, this approach would simply make it physically difficult for someone to overeat.  The insulin load will naturally be reduced because you just won’t be able to binge on calorie dense foods!

If you can manage to eat 2250 calories per day (i.e. typical intake[23]) of the top 10% of foods prioritised using these weightings you would be eating 150g of net carbs but also 130g of fibre!  Most people would struggle to eat this much fibre and volume of food.  If they were able to consume only 1500 calories per day they would be getting 120g of protein, 100g net carbs and 85g of fibre.

While 100g of net carbohydrates is high by low carb standards it is much less than the 300g per day consumed by most people and is unlikely to drive insulin resistance in most people because the carbohydrates being consumed would have an extremely low glycemic index!

If you find your blood glucose levels are drifting up using this approach (i.e. post meal blood sugars of greater than 6.7mmol/L or 120mg/dL) you could revert back to the diabetic / nutritional ketosis approach to make certain you are keeping your insulin levels low enough to be able to successfully lose weight.

You can download the top 500 highest ranking foods using this approach here.

athletes and metabolically healthy

As shown in the weightings in the table below, this approach maximises nutrient density without trying to minimise calorie density.  If you’re a lean athlete trying to refuel quickly you won’t want to be eating a pile of low calorie density lettuce and spinach to fill your calorie needs.  You will be interested in maximising nutrient density to maximise health and athletic performance.

ND / cal fibre / cal ND / weight calories / 100g insulinogenic (%)
30% 10% 30% 10% 20%

The top 500 foods using this ranking are plotted below.  On average these foods are 4% net carbohydrate and 36% protein.  Most people will find it difficult to eat greater than 30% protein from whole food sources, so as with the weight loss approach, this scenario would enable you to basically eat as much protein as you wanted from real food sources.

If you’re lean and insulin sensitive then it’s hard to eat too much protein.  Again, if you found that your blood glucose levels were driving up with this approach you should revert to foods with a lower insulin load.

You can download the top 500 highest ranking foods using this approach here.

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without consideration of insulin load

To see if the insulin load was adversely biasing the analysis against carbohydrate and towards protein, I thought that it would be worth running the analysis without the percentage of insulinogenic calories as a consideration.

The table below shows the weightings used for this scenario which heavily bias towards nutrient density and with a smaller weighting towards fibre and calorie density.

ND / cal fibre / cal ND / weight calories / 100g insulinogenic (%)
35% 15% 35% 15% 0%

The chart below shows the most nutrient dense 500 foods plotted on the protein versus net carbohydrates chart with an average of 54% protein and 12% carbohydrates.  While the carbohydrates comes up a little compared to the other scenarios the protein is very high.

If the insulin load is not considered the macronutrient split of the highest ranking foods is 54% protein and 12% carbohydrates.  However this isn’t realistic as we can’t physically eat that much protein, so we will end up eating either more fat or carbohydrate rather than all that protein.  If you have some level of insulin resistance, fat is the logical choice rather than carbohydrates in order to maintain normal blood glucose levels.

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You can download the highest ranking 500 foods using this criteria here.

summary

The table below lists the average protein and net carbs for the highest ranking foods for the four dietary approaches.  The figure below shows this graphically.

approach protein (%) net carbs (%) insulinogenic (%) protein (g) net carb (g)
therapeutic ketosis 11% 1% 8% 62 6
diabetes / nutritional ketosis 20% 2% 13% 113 11
weight loss (2250 cal) 36% 4% 24% 203 22
weight loss (1500 cal) 29% 3% 19% 109 11
athlete / metabolically healthy 36% 12% 38% 203 67
typical western diet 16% 50% 59% 90 281

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When it comes to weight loss it’s also useful to consider the fat that is coming from your body.  I have shown the macronutrient split for the weight loss scenario both in terms of a 2250 calorie per day diet and as a 1500 calorie per day diet assuming that the calorie deficit is coming from fat stores.

For athletes and the metabolically healthy, protein is largely unrestricted when it comes to maximising nutrient density.  The maximum amount of protein for people who are insulin sensitive will come down to how much they can physically eat.

Even if blood glucose levels are not a concern the most nutrient dense foods are still quite low in net carbohydrates.

If you have some degree of insulin resistance or elevated blood sugar it may be useful to moderate protein levels to some extent as well as cutting carbs.  If you are watching your blood glucose levels and / or ketones you can wind the amount of protein back until you achieve your target levels.

In all scenarios nutrient density was maximised, with much less carbohydrate relative to the western diet.

references

[1] See comments section in https://optimisingnutrition.wordpress.com/2015/06/15/the-blood-glucose-glucagon-and-insulin-response-to-protein/ and https://optimisingnutrition.wordpress.com/2015/06/22/why-Regardwe-get-fat-and-what-to-do-about-it-v2/

[2] http://www.precisionnutrition.com/what-are-your-4-lbs

[3] It’s worth noting that Metformin works by limiting gluconeogenesis (i.e. the conversion of protein into glucose) in order to help the body better manage blood glucose levels (see http://www.ncbi.nlm.nih.gov/pubmed/24847880).

[4] http://ketopia.com/nutrient-density-sticking-to-the-essentials-mathieu-lalonde-ahs12/

[5] The omega 6 fatty acids are also classed as essentially however it is generally recognised that we have more e

[6] Possibly more than the body could ever use especially in a low fat environment given that it is a fat soluble nutrient.

[7] For example see Chris Masterjohn’s review of Joel Furhman’s ANDI index at http://www.westonaprice.org/book-reviews/eat-to-live-by-joel-fuhrman/

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

[9] http://www.ketogenic-diet-resource.com/daily-protein-requirement.html

[10] http://drrosedale.com/blog/2011/11/21/ron-rosedale-protein-the-good-the-bad-and-the-ugly/#axzz3gVOJ69np

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

[12] While Rosedale has his reasons for reducing protein such as longevity and avoiding the mTOR metabolic pathway, this minimal protein approach may not be ideal if your goal is to maximise nutrition.  Check out this interesting discussion between Robb Wolf and Jamie Scott from the 52 minute mark in this podcast about the balance between health and longevity when it comes to optimal protein intake levels.  – http://robbwolf.com/2015/07/21/episode-279-jamie-scott-the-state-of-paleo-and-ahsnz/.  I tend to agree with the approach to maximise health and vitality now rather than eating for theoretical longevity with reduced health and vitality now.

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

[14] http://www.paleoplan.com/2011/04-22/meat-is-not-the-devil-high-protein/

[15] https://en.wikipedia.org/wiki/Rabbit_starvation

[16] http://bayesianbodybuilding.com/the-myth-of-1glb-optimal-protein-intake-for-bodybuilders/

[17] http://www.moodcure.com

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

[19] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819381/

[20] http://jama.jamanetwork.com/article.aspx?articleid=205916

[21] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3504183/

[22] http://profgrant.com/2015/07/21/5-reasons-sugar-not-fat-is-the-problem/

[23] http://www.nhs.uk/chq/pages/1126.aspx?categoryid=51

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chia seed pudding

Our good friend Tash Kimlin made these chia puddings when she came around for lunch and they have become a regular low carb staple for us.

The good thing about chia seeds for people with diabetes is that the carbs in them are 80% fibre, so the insulin requirement drops right down. Chia seeds are also a great source of omega 3 fatty acids.

Even with a small amount of mango and raspberries for taste and additional vitamins there is less than 10g of net carbs and overall it has only 14% insulinogenic calories.

The basic ingredients are straight forward and include:

  • 300ml coconut cream
  • 100ml water
  • ¼ cup chia seeds
  • 2 tbs stevia (or sweetener of choice)

To prepare you will mix ingredients together, refrigerate until it sets and add fruit or whatever topping you chose.

There are a range of permutations of this recipe online with further preparation details such as this one or this one.

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net carbs

insulin load carb insulin fat protein

fibre

10g 14g 73% 68% 7%

15g

You can reduce the carb load by leaving out the fruit if you wanted to bring down the insulin load further, however the change is only marginal.

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net carbs insulin load carb insulin fat protein fibre
7g 11g 68% 67% 8% 13g

If you are trying to achieve tight blood sugar control I suggest you test before and after having this as some people find that their blood sugars rise with coconut cream.  The fibre in the chia may react in some people in different ways and may become more digestible if they are soaked for longer.

fine tuning your diet to suit your goals – Wendy

  • There is no single dietary template that works for everyone.
  • Different individuals have particular needs and goals, and nutrition should be adjusted accordingly.
  • It can be useful to compare how your diet stacks up against other dietary approaches to identify where you might further refine and improve your diet.
  • The insulin load of your diet should not exceed the capacity of your pancreas to keep up and achieve normal blood glucose levels.
  • Once excellent blood glucose levels are achieved, reviewing your nutrient density, calorie density and fibre intake can be a useful  refinement to optimise your diet to achieve your goals.

keeping it simple…

Eating should not be complex!

I could understand how some people might find all this discussion about nutrition a bit daunting and / or irrelevant.

If all this talk about food is confusing and leaves you a bit perplexed then I apologise.

The reality is that if most people ate a range of whole foods from natural sources they would be pretty much OK.   Most people will not turn into ripped physique competitors with bulging six packs without meticulously tracking food intake, however most would be able to achieve good health and vitality.

A good diet is something that people will stick to and enjoy without tracking and obsessing over too much.  At the point it becomes enjoyable, effortless and normal it stops being a diet and becomes just a way of eating!

To this end I’ve created a list of optimal foods and optimal meals to suit different goals that people can just run with without too much hassle or conscious thought.

finding your path in all the noise

Unfortunately many of us have spent too long either eating poorly and need some more intense intervention, or have more specific dietary needs (e.g. diabetes, cancer, epilepsy etc) that require more targeted approaches.

My key aim in all of this is to demonstrate how a nutrient dense diet with a managed glucose load can be optimal, and modified to suit a person’s goals.  Rather than giving general platitudes I hope I can add something to the discussion and help people tweak their diet to achieve specific goals.

There is a lot of sometimes-conflicting dietary guidance out there that makes it hard to synthesise it all into a coherent plan that’s right for you.  You may be ketogenic, vegetarian, LCHF, LCHP, Paleo, ‘peagan’, or zero carb, or just do ‘everything in moderation’ (whatever that means).

taking it to the next level

No one eats optimally all the time, however it’s useful to know what can be done to improve things if you want to move further in a particular direction.

If you’re not getting the results from your current approach, you might be motivated enough to refine your current regimen to move further forward in the desired direction.   Unfortunately a lot of people fall into this category and are left looking for a bit more specific guidance on what they can do to reach their goals.

Some people are already putting a lot of thought and effort into what they eat, but sometimes not getting everything they hoped for, whether it be athletic performance, blood sugar control or weight loss.

Quantification of insulin load, nutrient density and fibre are powerful tools to further manipulate your diet in the pursuit of specific goals.  In this article we look at how we can review and refine our current diet to suit specific goals.

I hope that reviewing the application of a number of tools to real life examples can demonstrate how we can manage the glucose load of our diet while at the same time optimising the vitamins, minerals and amino acids.

I think it’s useful to review, refine and tweak someone’s existing diet rather than trying to get them to adopt a whole new way of eating that might be hard to stick to in the long term.  So to this end I’ve reviewed a number of people’s actual food diaries to see what the system would tell us about how they can move forward in a particular direction.

The plan is to profile a dietary analysis every couple of weeks to see how we might apply the tools detailed throughout this blog to optimise their nutrition while keeping in mind their insulin load.

so let’s meet Wendy…

Wendy describes herself as being obese for her entire adult life, except for a few short-lived diet-induced periods (using “eat less, move more” diet templates).  Despite obesity, Wendy had good blood lipids and fasting glucose until early 2014, when fasting glucose crept into the pre-diabetic range.  She had been hypertensive since her mid-20’s, diagnosed as essential or idiopathic hypertension (i.e. no known cause), but was advised it was caused by her obesity.

In early 2014, at age 44, Wendy began exercising regularly and then changed her diet first to lower-carb (inspired by Robert Lustig) and then ultimately low-carb.  She lost over 70 pounds over eighteen months, going from a BMI of 39 to 27.  Wendy says she is comfortable with low-carb eating as a life-long proposition, along with regular exercise (mostly yoga and strength training, with some HIIT).

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Wendy had some insulin resistance before making these changes, but now has blood sugars that are “typically in the 70s, 80s or 90s” and a fasting insulin of 5.1mIU/ml (i.e. upper end of the excellent range).

Wendy’s most recent HbA1C was 5.2% which is pretty good (see Diabetes 102 for more details of target blood sugar and HbA1c levels), so it appears that her insulin resistance has improved with her recent weight loss or at least is in remission with her improved diet and exercise regimen.  Wendy has also been able to drop all hypertension medications and now regularly home-tests blood pressure at slightly-below-normal levels.

Wendy has been very active on the Optimising Nutrition, Managing Insulin blog with a heap of insightful questions and comments.  Lately she’s also been helping me with reviewing and editing of some of the posts on the blog.  She’s certainly an educated, motivated and seasoned nutrition nerd.  You can also read more about Wendy’s journey on her own blog https://fitteratfortyish.wordpress.com/.

If you look at her food diaries you’ll see that the reason she’s lost so much weight already is that she’s eating pretty darn well!  But let’s look at what she could do to further move towards her weight loss goals.

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review of glucose load

First up I’ve analysed Wendy’s macronutrients to determine the insulin load, percentage insulinogenic calories and macronutrient split as shown in the table below.

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With less than 20g net carbohydrates per day, an average of 5% calories from carbohydrates and 23% insulinogenic calories, Wendy’s diet definitely qualifies as low carb!

I’ve plotted the macronutrients from her daily diaries in the chart below (labelled 8, 9 and 10 June).  Two of the three days sit just outside the threshold of Steve Phinney’s well formulated ketogenic diet triangle (i.e. the orange line in the figure below).  This analysis would indicate that Wendy is eating a good diet that would be great for normalisation of blood glucose.

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If Wendy was still having blood sugar issues (say average of greater than 97mg/dL or 5.3mmol/L) she might benefit from reducing her protein to bring her macros back towards the bottom left corner of this chart in order to reduce the total glucose load of the diet and make it more ketogenic.

This is not the case for Wendy though as her blood sugars are now reasonably well controlled, with her insulin resistance improved after her already significant weight loss.  So reducing the insulin load of her diet is not the primary issue.

nutritional analysis – diabetes weighting

I’ve written before about the theory of balancing glucose load while maximising nutrition.  I thought it would be interesting to look at how we could apply this in practice with Wendy’s food diary data.

Using the nutritiondata.self.com recipe analyser I have compared a range of meals and daily food diaries as discussed in the article The Most Nutritious Diabetic Friendly Meals [1] and dietary approaches as discussed in the article Diet Wars…  Which One is Optimal? [2]  In line with this I’ve analysed Wendy’s food diary from 9 June 2015.  The results of the analysis are shown below.

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A score of 100 in either the “nutrient balance” or “protein quality” scores means that you’re covering the recommended daily intake of each of the nutrients with 1000 calories.   What this means in Wendy’s case is that she’s doing pretty well with her protein score at 140.  However there are some possible deficiencies with her vitamins and minerals which are only at 52.

The table below shows a comparison of scores for the 9 June 2015 food diary with the suggested refinements discussed below.  Based on the diabetes weighting (which prioritises low insulin load) Wendy’s diet from 9 June ranks at #77 of 175 which is fairly solid, however there is some room for improvement.

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A score of zero would mean that it is average in comparison to the other meals, greater than zero (blue) means that it is better, while less than zero (red) means that it is worse than average.

The areas that the food from the 9 June 2015 food diary doesn’t do so well is calorie density, vitamins and minerals, and fibre.

so why is fibre and calorie density important?

Every individual is different.  What will work for one person may not work so well for another.  For example, simply applying a body builder or a diabetes dietary approach to Wendy’s situation may not be appropriate given that she wants to continue on her weight loss journey.

The comparison of Wendly’s base diet to the other diets analysed indicates that she could benefit from adding fibre and reducing her calorie density. But why would increasing fibre and reducing calorie density be useful for someone trying to lose weight, particularly when the low carbohydrate approaches advocated by Westman and Eades may likely recommend continuing to focus on a low total carbohydrates (i.e. not net carbohydrates) until goal weight is achieved.

I think the “magic” of the low carbohydrate dietary approach is that it normalises blood glucose levels and reduces insulin so that you can release rather than store fat.  For more detail on the importance of insulin in fat loss check out the article why we get fat and what to do about it v2.

Without a reduction in insulin levels it is difficult to unlock the fat stores for energy. It get frustrated when I hear ‘experts’ in the body building scene just saying that fat people need to achieve a calorie deficit and they’ll be all good, apparently not understanding the effect that a highly insulinogenic diet can have on fat loss and appetite for people who are insulin resistant.

Chris Gardner’s A to Z trial [3] identified that people who are insulin resistant typically only lose weight on a low carbohydrate diet.[4]  The reduced insulin load allows energy to be released from fat stores which in turn leads to increased satiety and decreased calories.  However people who don’t have insulin resistance issues can lose weight with reduced calories regardless of the carbohydrate level as long as they create a calorie deficit.

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However, once you’ve normalised your blood glucose levels and insulin I think all bets are off.  There may be a limit to how far a diet with liberal quantities of added fat will take you when it comes to weight loss.  Somehow you do need to work out a sustainable way to burn more calories than you consume.  However I don’t think this is as simple as just counting calories and maintaining deficit.

While a low carbohydrate / ketogenic diet in maintenance mode involves high levels of dietary fat, you don’t necessarily need to be adding extra dietary fat while you’re trying to lose weight.  If you’re trying to lose weight ideally the energy from fat can come from your body fat stores as shown diagrammatically below in Steve Phinney’s four phases of a ketogenic diet diagram.

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I’ve got a lot of time for Jonathan Bailor who isn’t a big fan of calorie counting.  He prefers rather to manipulate diet so that you naturally feel satiated with fewer calories.  As noted in this video he advocates for nutrient dense foods that have plenty of water, fibre and protein to naturally feel full so you don’t need to manually track calories.  This video gives a good overview of Bailor’s philosophy which I think makes sense for most people.

In my food ranking system I have tried to codify Bailor’s approach using the USDA foods database, and have used a similar approach in the meal ranking system.  The highest ranking meal using the weight loss weighting is Terry Wahls’ lamb skillet meal which is shown below.

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While this meal might have 24g of total carbohydrate there is 16g of fibre, meaning that there is only 8g of net carbs.  So if we abandon the concept of total carbohydrate and focus on net carbohydrates when it comes to real unprocessed whole foods, we can keep our insulin load low and achieve satiety naturally by eating a larger volume of nutrient dense high fibre foods.  This will ideally allow us stop worrying about counting calories while still keeping our insulin load fairly low.

One of the criticisms of Terry Wahls’ diet approach is that there is just so much food and it’s hard to eat it all to get your calories.  If you do not want to lose weight Wahls recommends adding MCT or coconut oil to increase the calorie density.  However you can see how not being able to fit in enough calories (as opposed to just counting calories) would help you to sustain a lower calorie approach without as much conscious effort.

Similarly, Dave Asprey criticises Joel Fuhrman’s ANDI score as a recipe for starvation, which is sort of what we’re after if we are trying to lose weight. [5]  So sure, maybe you’re not going to feel full eating parsley and watercress, but that doesn’t mean you shouldn’t try to eat as many non-starchy veggies as you possibly can as your first priority, and then fill up on the other foods.

While counting calories can be useful and effective as an educational tool, I your appetite will probably win out in the long run unless you find a way of eating that will naturally keep you satiated.  I believe a high fibre, nutrient dense, lower calorie density approach can be helpful to achieve this goal.

See the optimal foods for weight loss article for more details on this topic or this list of foods that are ranked based on these criteria.

improved calorie density and nutrient density

So in Wendy’s case, in order to improve the vitamin and mineral score I’ve reduced the chicken from lunch and added in some spinach and mushroom.  This has raised the “Nutrient Balance” score from 52 to 75.  The chicken is quite calorie dense in comparison to the spinach and mushroom, and you can eat a lot of these veggies without increasing calories very much.

This updated food diary then ranks at #50 of 175 meals analysed (previously #77) based on the diabetes weighting as shown above.  The overall fibre increases from a fairly low 13g to a more reasonable 21g.  This is closer to the recommended daily minimum fibre intake of 25g for women and 30g for men [6]).

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This change does increase the net carbohydrates from 11g to 32g and the insulin load from 60g to 77g, so someone who did have serious insulin resistance or diabetes should monitor their blood sugars to make sure they were not adversely affected by shifting to this approach.

For most people this increase in net carbohydrates would not be a major concern, particularly as the increase in carbohydrates is from low glycemic whole foods which tend to raise blood sugars much less than manufactured products.   You might also find that you end up naturally eating fewer calories because of the high volume of food and the high nutrient density which might leave you satisfied with fewer calories.

reducing calorie density for weight loss

For Wendy, though, blood glucose / insulin resistance is not the primary issue.  Her current priority is to move forward with her weight loss which has now stalled, more than a year into continuous weight loss.

Eliminating processed carbohydrates is critical to the success of the low carbohydrate approach but what do you replace them with?  As per Terry Wahls’ approach I would recommend trying to maximise nutrient dense non-starchy veggies in the first instance and then supplementing with added fats (if required) to make sure you’re satiated.  If we focus on eating as much high fibre, nutrient dense, low calorie density foods as we can we no longer have to worry about limiting how much we eat!

So if we want to tweak Wendy’s meal plan more towards the weight loss goal by decreasing calorie density we can:

  • use a whole avocado rather than half an avocado to increase the fibre,
  • drop the added olive oil (to the extent that is practical for cooking),
  • drop the “half and half” cream to one tablespoon rather than four in the coffee, and
  • drop the calorie dense macadamias.

If we sort the meal revisions based on the weight loss weighting (which emphasises high fibre and low calorie density) we can see that the revised diabetes diet has a ranking of 43.

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With these changes we’ve nearly doubled the weight of the food for the day while keeping the total calories the same.  Fibre has gone up from 13 to 26g which meets the minimum recommended minimum fibre intake.  This approach will be a lot more filling, which is useful if weight loss is the goal.

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Net carbs have gone from 10g in the original scenario to 50g per day.  This is still considered low carbohydrate; however Wendy should keep an eye on her blood sugars as her HbA1c is good but not yet in the excellent range.  If they go outside the normal range (see criteria here), she should revert to the nutrient dense diabetes approach (see criteria and foods here).

Different people will have different carbohydrate tolerances, and these can change as your body heals and releases fat from your belly, liver and pancreas.  Most reasonably healthy people would be able to deal with this level of carbohydrate, particularly given that it is from low calorie density, low GI carbohydrates from vegetables.

As shown in the updated nutritional analysis below, the protein quality score is still pretty high at 135 (down from 140) and the quantity of protein is still quite high at 26% of calories (down from 27%).  The only way to increase the protein quality score without increasing calories further would be to incorporate organ meats, which is not everyone’s cup of tea.   The nutritional completeness score has increased to 88 which is a significant change from the base diet that had 52!

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Reducing excess insulin (as indicated by poor blood sugar control and high body fat levels) is the first priority, however once blood glucose and insulin are stabilised, targeting high fibre nutrient dense foods (while still keeping the insulin load as low as possible) is likely to be the next step when it comes to weight loss.

If there were any nutritional issues that were causing the body to hold onto weight, these may be improved with the highly nutrient dense diet and possibly help to break through the weight stall.

references

[1] https://optimisingnutrition.wordpress.com/2015/03/22/the-most-nutritious-diabetic-friendly-meals/

[2] https://optimisingnutrition.wordpress.com/2015/03/22/best_diet/

[3] http://jama.jamanetwork.com/article.aspx?articleid=205916

[4] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3504183/

[5] https://www.bulletproofexec.com/cdc-superfoods-andi-score-debunked/

[6] https://www.nrv.gov.au/nutrients/dietary-fibre

Five Sisters Cafe halloumi, bacon and eggs

This is my favourite breakfast when do breakfast with my sister at the Five Sisters Cafe in West End, Brisbane.

It does very well across the board with only 4g net carbs, a fabulous protein score and a great nutrient score owing to the spinach.

So indulgent and delicious!

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net carbs

insulin load carb insulin fat protein

fibre

3g 20g 15% 71% 25%

2g

If we have the bread the fibre and nutrients comes up only slightly however the net carbs increases to 17g and the overall score decreases due to the higher insulin load.  So the bread is certainly not a great option if you have blood sugar issues.

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net carbs

insulin load carb insulin fat protein

fibre

17g 33g 52% 61% 23%

3g

balancing diet and diabetes medications

  • High blood glucose levels (glucose toxicity) and high insulin levels (hyperinsulinemia) are both bad news for your health.
  • The highest priority in the treatment of diabetes should be to reduce foods that require large amounts of insulin.
  • Over reliance on medications can lead to ‘learned helplessness’, meaning that people do not use a dietary intervention to what is primary a dietary disease.
  • Periods of fasting and intense exercise also improve insulin sensitivity.
  • A lower insulin load diet and improved insulin sensitivity will enable you to reduce and possibly eliminate medications.

when do you need insulin?

Last year I was tracking my blood sugars.  I was concerned with what I saw.

Based on my average sugars of about 6.2mmol/L my HbA1c would have been about 5.5%.  I wasn’t happy because I knew it was still well away from ideal. [1]  I knew that improving my blood sugars was likely the key to losing the weight that I had been struggling with.

In an odd sort of way I was jealous of my wife who has type 1 diabetes.  She could manipulate her blood glucose levels manually with her insulin pump, but I wasn’t sure what to do to bring my blood glucose levels down to more healthy levels.

Given that doctors will typically not give insulin until your HbA1c is greater than 7.0% [2] there was no way a doctor was going to prescribe me with insulin.  My doctor told me to lose some weight to combat the developing signs of fatty liver in my blood tests.

In January 2015 I found Jason’s Fung’s videos [3] and kicked myself in the butt.  Intermittent fasting seemed to do the trick to break the insulin resistance even though I had been following a lower carb paleo approach for a while.  I was able to get my blood sugars back down to an average of 5.4mmol/L to give me an estimated HbA1c of about 4.8% and in the process of actively trying to manage my blood glucose levels I lost ten kilograms.

Fasting and improving insulin sensitivity

Dr Jason Fung [4] has recently increased the focus on fasting and dietary intervention and discourages an over-reliance on insulin to manage diabetes.

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Jason says that focussing on medicating the symptoms of diabetes rather than addressing the root cause of insulin resistance can lead to a ‘learned helplessness’ where people do not pursue a dietary solution to what is largely a dietary problem.

Addressing diabetes by giving insulin to address the symptom of high blood glucose levels is like giving an alcoholic alcohol to relieve the symptoms of their alcohol withdrawal. 

Meanwhile, Dr Richard Bernstein says that most of his type 2 diabetics need to remain on small doses of insulin in addition to minimising carbohydrate in order to achieve ‘normal blood sugars’.[5]

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In this video Dr Bernstein however notes a number of negative consequences of taking exogenous insulin including:

  • inconvenience,
  • it can make you fat if you eat a lot of carbohydrate, and
  • it can cause hypoglycaemia (i.e. low blood glucose levels).

the balance between diet and medication

So how do we find the optimal balance between an over-reliance on exogenous insulin and medication while still achieving normal blood sugars?

Dr Ted Naiman of BurnFatNotSugar.com says that when he sees a new diabetic patient he checks their fasting insulin and C-peptide levels to understand whether they are still producing insulin or if their pancreas is already burned out.

If you don’t have access to these tests another option is to test your ketones and blood glucose levels to establish the ratio of glucose to ketones, which can also help you estimate your insulin levels (see the glucose : ketone index).

High insulin and high blood glucose means that you are insulin resistant (i.e. hyperinsulinemia).

Low insulin and high blood glucose means that you are insulin deficient and your pancreas is not producing enough insulin (i.e. type 1.5 diabetes, LADA).

Dr Naiman (pictured below – he practices what he preaches!) says he “avoids insulin like the plague” if at all possible, preferring to focus on diet, fasting and exercise.

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Ted says that if you are still producing insulin but have high blood glucose levels the urgent need is to reduce the insulin load of the diet, start an exercise routine to improve insulin sensitivity, and ideally commence intermittent fasting ASAP!  If you continue to consume a diet with a high insulin load you risk burning out the beta cells of your pancreas at which point you will require insulin.

Ted has produced an excellent summary of intermittent fasting and the various ways to put it into practice that you can download here.  For more detail you also can check out Brad Pilon’s Eat Stop Eat or Jason Fung’s series on the topic.

the dangers of glucose toxicity

As discussed in the Diabetes 102 article there are a range of well-established risk factors for high blood sugars including accelerated brain shrinkage, cancer, obesity, heart disease and stroke.

This article from Jenny Ruhl’s Blood Sugar 101 lists a number of other complications related to high blood sugars including nerve damage, beta cell destruction, heart disease, diabetic retinopathy, and kidney disease.

Just in case you weren’t already aware… elevated blood glucose levels are very bad news!

If you want to be healthy, feel good, look good and live a long life, then your number one priority should be to do whatever it takes to achieve excellent blood sugars.

the dangers of insulin toxicity

I was interested to hear Professor Tim Noakes tell Robb Wolf in episode 273 of the Paleo Solution Podcast

You really want to keep your control through diet and minimal medication and never use insulin.

What I take this to mean is not that insulin is forbidden for people who need it, but rather that you should do whatever you can to not get to the point that you need to be injecting insulin to control your blood glucose levels.

Dr Fung points to the ACCORD Study[6] along with the ADVANCE, VADT and ORIGIN studies which showed worse outcomes for people with type 1 diabetes who targeted a lower HbA1c of 6.0% rather than a more typical 7.5%.

The figure below from the ACCORD study shows the reduction in HbA1c with intensive therapy (i.e. more insulin) to “successfully” reduce blood sugar levels.  What they found however was that the people in the intensive therapy group were 22% more likely to die (i.e. all-cause mortality) in spite of having ‘better’ blood glucose levels!

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This may sound contradictory, because at the same time we know that reduced HbA1c levels actually lead to better health outcomes in the general population.  So what’s the difference?  Why are these studies suggesting that trying to normalise blood glucose levels are dangerous?  Is there something about people with diabetes that makes it unhealthy for them to have lower blood sugars?

There is plenty of debate on what these studies really mean, [7] [8] [9] however Dr Fung says it is the use of medication in the absence of dietary intervention that is making the difference.  Simply applying more insulin or other medications without addressing the diet is not only illogical it’s very dangerous!

This aligns with the data shown below[10] which shows that reducing HbA1c is highly beneficial when it comes to heart attack and stroke risk, however doing it through the use of antidiabetic medication does not help.

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Ivor Cummings does a great job on his blog of highlighting a wide range of studies that demonstrate that insulin resistance is by far the dominant risk factor for heart disease. [11] [12] [13] [14] [15]  All we do when we medicate a high carbohydrate diet with insulin is to exacerbate the insulin resistance.

So is insulin all bad?  Not necessarily.  Insulin is important for a range of bodily functions including growth.  However, high levels of insulin to cover high levels of dietary carbohydrate is a recipe for metabolic disaster.

Rather than relying on insulin, Dr Fung recommends a low insulin load diet combined with periods of fasting to improve insulin sensitivity and reduce insulin and blood sugar levels.  Dr Fung told me that people need to “reduce both blood glucose and insulin to reduce glucotoxicity and insulin toxicity.”  He says a HbA1c of less than “6.0% is defined as normal, although the lower you get, the better. However, this only applies if you are using diet rather than medications.” [16]

two sides of the same coin?

Both Dr Fung and Dr Bernstein focus primarily on non-medical interventions which include:

  1. A low carbohydrate / low glucose load / low insulinogenic diet. I suggest you focus on foods from this list and meals from here to bring your blood sugars under control.
  2. Exercise will improve your insulin sensitivity and help to remove excess glucose from your system. High intensity short duration exercise is ideal along with regular movement through the day.  Rather than forcing yourself to exercise out of guilt you may find once you balance your blood sugars with diet rather than medication you have more energy and want to move more.
  3. Fasting is a great way to restore insulin sensitivity and reduce blood glucose levels naturally. It might be considered by some to be extreme, however it’s the most aggressive and effective approach to move the metabolic needle in the right direction.  And it’s not that hard, particularly if you’ve got a lot of weight to lose and you’re looking down the barrel of major health complications.

Bob Briggs does a great job of putting this into simple terms that are easy to understand and apply.

refining insulin levels for type 1 diabetics

For someone with type 1 diabetes balancing dietary insulin load with exogenous insulin is an ongoing process of fine tuning.

Getting the basal insulin dose is important, particularly if you’re following a reduced carbohydrate approach, as it can represent up to 80% of the daily insulin dose.  Unless you’re fasting you are unlikely to have a higher basal : bolus ratio than this.  Covering too much of your food with basal insulin can be dangerous if you need to skip or delay a meal for any reason (e.g. sleeping in on the weekend).

The scatter plot of blood glucose readings below shows my wife Monica’s blood glucose readings.  We use this data to review and refine her basal insulin rates (80% of her insulin dose) every couple of weeks.

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While we are still on a journey, her blood glucose levels are the best they’ve been in her adult life and we’ve seen massive improvements since switching to a more nutrient dense low insulin load diet.

If her blood sugars drift up in a particular period of the day she will increase the basal rate on her pump in the two hours leading up to the point where the blood glucose levels are high.  Conversely, if there are a cluster of hypos (lows) at a particular point in time she will drop back the basal insulin leading up to that time.  Ideally we try to keep the high / low bars on the top chart on the red line, but not below it.

Her basal rates (shown below) are lower over night with a higher dose in the morning to cover the ‘dawn phenomenon’ which is the body’s way of supplying glucagon and adrenaline in preparation for the day ahead.

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We’ve experimented with reducing basal insulin rates and running higher blood glucose levels to avoid lows and to reduce the overall insulin load.  However this hasn’t really worked as Moni just doesn’t feel good with higher blood glucose levels.

It’s a delicate balancing act between blood glucose levels and insulin load.  Your mileage may vary.  You’ll need to refine things based on how you feel and with what you are comfortable with.

It’s also a good idea to look at the data over a longer period to make sure you’re not just reacting to recent events.  Diet, hormones, stress, sickness and exhaustion all influence blood sugars and insulin requirements.

Knee jerk reactions to recent events can throw everything out of whack.  We’ve found it better to make small refinements rather than large changes.

Some female diabetics also refine their basal rates around their monthly cycle as insulin resistance typically increases by around 15% in the four days leading up to their period.  It’s worth tracking this and being ready to adjust insulin dosage.

the law of small numbers

The most important thing to know is that managing the insulin load of your diet is the most important thing you can do to improve blood glucose control.  If you have a high degree of variability in your blood glucose from hour to hour due to a highly insulinogenic diet you’ll never be able to bring blood glucose levels down without risking going too low.

Most endocrinologists will recommend against targeting optimal blood glucose levels due to the risk of hypoglycaemia (low glucose levels).  However reducing the insulin load of the diet will mean that the amplitude of the blood glucose swings are smaller, which will enable you to bring the overall average blood glucose level down using the basal insulin and smaller food bolus and correcting insulin doses.

Bernstein talks about the ‘law of small numbers’.  If you are consuming a high carbohydrate diet then you will need ‘industrial doses’ of insulin and there is no way to calculate the insulin dose perfectly, so the errors compound and the resulting blood sugar swings are out of control.  It’s the severe blood glucose swings that make you feel really bad, even more so than high or the low blood sugars alone.

adjusting insulin doses for type 2 diabetics

For the most part the observations from people with type 1 diabetes also apply to those with type 2 diabetes.  A type 2 diabetic can balance their dietary insulin load with the insulin produced by their own pancreas supplemented with insulin sensitising drugs such as Metformin or injected insulin.

The first priority when transitioning to a low carbohydrate diet is to avoid driving your blood sugars low with too much medication.   Rather than going low all the time it’s better to reduce your medications to a point where higher blood glucose levels will remind you that you need to manage blood glucose by controlling your diet.

If your medications are too high you will likely end up having to eat extra food to treat low blood glucose levels all the time.  So not only do you have more insulin than you want (which will stop you using stored body fat for energy) you have to eat more than you need because of excess medication (which will also get stored as fat).

It’s hard to give an exact target blood sugar range, however the following guidelines may be useful:

  1. Blood glucose levels less than 4.0mmol/L (73mg/dL) are typically considered low (unless you are young and / or have high ketone levels). If you are seeing these blood glucose levels you should decrease your diabetes medications.
  2. Post meal blood sugars should be less than 6.7mmol/L (120mg/dL). If you’re seeing higher blood glucose levels than this after meals then you shouldn’t eat what you just ate again.
  3. A fasting blood sugar of less than 5.0mmol/L (90mg/dL) and an average blood sugar of less than 5.4mmol/L (100mg/dL) is ideal.

Once you reduce your dietary insulin load (i.e. by reducing carbohydrates, moderating your protein and maximising high fibre foods) you will not require as much medication and may need to reduce your medications to prevent hypos (low blood sugars).

If your dietary insulin load reduces further you will be able to reduce, and possibly eliminate, your diabetes medications as your own pancreas is able to keep up with your decreased insulin requirements.

If you are able to further reduce your insulin load your blood sugars will come closer to normal levels.  With reduced insulin you will be able to use your body fat stores for fuel and ideally lose weight.

Depending on your goals and level of dedication (or OCD), you might get to a point where injecting small amounts of insulin is no longer worth the hassle.  This is something that you should work through with your doctor who prescribed the insulin and / or medications.

 

references

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

[2] http://www.diabetesselfmanagement.com/managing-diabetes/treatment-approaches/type-2-diabetes-and-insulin/

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

[4] https://intensivedietarymanagement.com/

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

[6] http://www.nejm.org/doi/full/10.1056/NEJMoa0802743#t=articleTop

[7] http://phlauntdiabetesupdates.blogspot.com/2012/10/new-page-why-lowering-a1c-below-60-is.html

[8] http://diatribe.org/issues/10/learning-curve

[9] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518370/

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

[11] http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2004.01371.x/epdf

[12] http://www.thefatemperor.com/blog/2015/5/5/hilarious-apob-now-being-used-as-predictor-of-insulin-resistance-cholesterol-lchf

[13] http://www.thefatemperor.com/blog/2015/4/30/insulin-resistance-the-primary-cause-of-coronary-artery-disease-bar-none-lchf

[14] http://jaha.ahajournals.org/content/4/4/e001524.full.pdf+html

[15] http://www.thefatemperor.com/blog/2015/5/3/cholesterol-lchf-whats-the-only-thing-that-matters-for-repeat-heart-attacks

[16] https://intensivedietarymanagement.com/lchf-for-type-1-diabetes/

coffee with cream and stevia

The reality is, coffee is a ‘food group’ for many people, including me.

I think this is fine in the context of a balanced life that contains adequate rest and sleep and not too much stress.  Chris Kresser recently did a great podcast on the case for and against coffee that you can check out here.

We used to do great lattes with coconut sugar or chocolate powder (mocha).  These taste amazing, but once we started to get serious about blood sugar control we realised that a massive proportion of our carbs were coming from the milk and sugar in our coffees.

This option with cream and Stevia is my current default option when I’m not just having it black (which I’m slowly getting more and more used to).

As you can see below, the cream will give you some nutrition while having minimal carbohydrates.

The cream does contain calories, so if you’re going to have a few you should consider it as a meal alternative as you might bulletproof coffee.

We’ve started getting liquid Stevia these days which comes in all sorts of yummy flavours that the kids love in milk rather than something like Milo.

The nutritional analysis below shows that the coffee with cream will have a negligible insulinogenic effect, while the cream is a good source of fat and protein.  Don’t count on it to give you your vitamins and minerals though.

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We get this amazing unprocessed cream from a Malaney Dairies that is not watered down.  It tastes amazing!  And only 3.6% insulinogenic calories (using this calculator).

And thanks to Kyle Masterman for sending through this photo of his CGM after double cream in his black coffee showing that cream and coffee is very vengle on the blood glucose levels.

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As you can see form the data in the table below there’s probably no need to worry about dosing with insulin for this if you have diabetes.

net carbs

insulin load carb insulin fat protein

fibre

1g 2g 65% 94% 3%

0g

calculating insulin dose for type 1 diabetes

  • This article reviews a range of approaches to calculating insulin requirements for people with type 1 diabetes.
  • The simplest approach is standard carbohydrate counting, which may be ideal for someone whose diet is dominated by carbohydrates.
  • Bernstein recommends standardised meals for which the insulin dose is refined based on ongoing testing and refinement.
  • Stephen Ponder’s ‘sugar surfing’ builds on carbohydrate counting, with correcting insulin given when blood glucose levels rise above a threshold due to gluconeogenesis.
  • The food insulin index approach predicts insulin requirements based testing in healthy people of the insulin response to popular foods.
  • The total available glucose (TAG) advocates a ‘dual wave bolus’ where insulin for the carbohydrates is given with the meal, with a second square wave bolus given for the protein which is typically slower to digest and metabolise.

introduction

In the article Standing on the Shoulders of Giants we met a handful of people who have achieved excellent blood sugar control in spite of having type 1 diabetes.  Common elements of their success include:

  • keeping carbohydrates low to prevent the blood sugar roller coaster,
  • accurately dosing for a controlled amount of dietary carbohydrate,
  • targeting normal blood sugar ranges (i.e. 83mg/dL or 4.6mmol/L) with regular correcting doses,
  • regular exercise and / or intermittent fasting to improve insulin sensitivity, and
  • having a reliable method to account for the insulinogenic effect of protein.

Everyone’s diabetes management regimen is going to be different.  There will be a degree of trial and error to find what will work best for you.  This article reviews a number of approaches that you can learn from to see what suits you.

carbohydrate counting

In the 1970s Dr Richard Bernstein got hold of a blood glucose meter (long before they were easily available) and started experimenting on himself to understand how much a certain amount of carbohydrate raised his blood glucose levels and how much insulin he required to bring his blood glucose back down.

From this style of experimentation we can determine the “carbohydrate to insulin ratio” (i.e. how much insulin is required for a certain amount of carbohydrates).

Carbohydrate counting is now the standard approach that most people with type 1 diabetes are taught.  This approach involves estimating the grams of carbohydrate in your food for each meal.  With this knowledge you can then program the amount of carbohydrates eaten into the insulin pump which calculates the insulin dose based on a pre-set carbohydrate to insulin ratio.

The advantage of this approach is that it is relatively simple.  However it does not consider the insulin required for protein which is typically addressed with correcting doses or sometimes basal insulin.

Carbohydrate counting is a good starting point, but it is by no means perfect. [1] [2]

Bernstein’s own approach

Dr Richard Bernstein advises that his patients, in addition to restricting carbohydrates (i.e. no more than 6g of carbohydrates for breakfast, 12g for lunch and 12g dinner), to have the same meals every day which allows insulin doses to be refined to optimise for blood sugars.  If your blood glucose levels run high one day you can add a little more insulin the next day or a little less if they are running low.

Bernstein also advises targeting an average blood glucose of 83mg/dL (4.6mmol/L), and that you correct if blood glucose levels go outside a ten point range from this target (i.e. 73mg/dL to 93mg/dL or 4.0mmol/L to 5.2mmol/L).  A small bolus of insulin is given to bring blood glucose levels down and a certain portion of a glucose tablet is used to bring blood sugars back up precisely.

Bernstein advises that people with type 1 diabetes modulate the quantity of protein to manage their weight.  If you’re a growing child, protein is essentially unrestricted.  If you’re trying to lose weight protein can be reduced to further reduce insulin.

Bernstein says that protein requires about half as much insulin as carbohydrates and outlines how to dose for it in this video from Dr Bernstein’s Diabetes University.  In practice, though, his approach to dosing for protein requires consistent meals and fine tuning of insulin dose.

sugar surfing

Another popular method is ‘sugar surfing’ which is effectively a ‘bolt-on’ to carbohydrate counting developed by Dr Stephen Ponder to manage the glucose response to things other than carbohydrates.

This approach involves dosing for carbohydrates with the meal, and then watching the continuous glucose monitor (CGM) and giving regular ‘micro doses’ of insulin to keep blood sugar under around 93mmol/L (5.2mmol/L).  Typically two or three separate doses will be required to bring a ‘protein spike’ under control for someone with type 1 diabetes.

Injected insulin works over a period of up to eight hours and it is difficult to match the timing of the insulin action with digestion.  The advantages of this approach are that it allows for the variability in the time of protein digestion which varies from person to person and is different for different foods and hence difficult to predict accurately.

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I think the secret to making ‘sugar surfing’ work is to turn the waves that you’re surfing into more manageable ripples by following a diet with a reduced insulin load.

food Insulin Index

“It is possible that other methods of matching insulin with food are not being studied because of the belief that carbohydrate counting is a well-founded, evidence-based therapy,” the researchers concluded. “Indeed, this meta-analysis shows the scarcity of high-level evidence.” [3]

One of the experiments documented in Clinical Application of the Food Insulin Index to Diabetes Mellitus (Bell, 2014) [4] demonstrated that type 1 diabetics calculating their insulin requirement using the food insulin index approach achieved significantly improved blood glucose control compared with those using standard carbohydrate counting.

Estimating the insulin required for the meal from carbohydrate and protein rather than carbohydrate alone is potentially a massive step forward in improving blood sugar control for people with type 1 diabetes.

The limitation of using the approach practiced in the study is that the food selection tested is limited to the one hundred or so popular processed supermarket foods.

If you’ve read my blog you’ll know that I’ve tried to develop a robust method for calculating the insulin requirement for foods based on their macronutrients without having to test them in vivo (i.e. in real, living people). [5] [6] [7]  The chart below shows how we can use the food insulin index test data to more accurately predict the insulin demand of a particular food using this formula.

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Rather than separating doses for carbohydrates and protein, the food insulin index approach assumes that all of the insulin is given with the meal.  The risk with this is that the insulin will take action before the protein digests which will lead to low blood glucose.

Total Available Glucose (TAG)

The TAG (Total Available Glucose) approach is based on a book by Mary Joan Oexmann published in 1989. [8]  This method calculates the insulin required for carbohydrate, protein (54% of carbohydrate) and fat (10% of carbohydrate).

If we gave all the insulin calculated for both carbohydrates and protein when we sat down to eat a high protein meal it is possible that the insulin would take effect before the protein digested, leading to low blood glucose before the gluconeogenesis from the protein had time to kick in.

To deal with the fact that glucose from protein can take longer to show up in the blood stream people who follow the TAG approach typically use a ‘dual wave bolus’.  The insulin for the carbohydrates is dosed with the meal, while the insulin for the protein is infused slowly as a separate “square wave bolus” over a period of three hours or so.  The need for the carbohydrate and protein boluses to be split will depend on the amount of protein in your meal and how quickly protein raises your blood sugars.

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separate boluses for carbohydrates and protein

A few people who achieve excellent blood sugar control simply use two separate boluses – one for carbohydrates before the meal with another one for protein around an hour after the meal.

This approach requires that the insulin for the protein and carbohydrate are calculated separately with the protein bolus being given a number of hours after the meal.

This approach can be refined using a CGM to confirm when the blood sugar response to the protein kicks in and hence when the bolus for protein is required.

insulin calculator

To assist in calculating the bolus for carbohydrates and protein Ted Naiman of Burn Fat Not Sugar has created this insulin calculator.

You can run it on your computer or phone, enter the properties of the food that you are about to eat and it will calculate the appropriate dose for carbohydrate and protein.  The outputs from this calculator will give you all the required data to follow any of the insulin dosing strategies above.

People who have used it so far have found it beneficial.

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An example screen grab from the calculator is shown below with the explanation of inputs and outputs following.

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inputs

  • If you are using a manufactured food product in a packet you can simply use the nutritional details per serve (protein, fat, carbohydrates) and then factor for the number of serves.
  • If you are in the US you will need to enter the total carbohydrates and fibre values. If you’re in the UK or Australia you don’t need to enter the fibre as it is already subtracted from the carbohydrate count.
  • The protein multiplier is based on the food insulin index testing in non-diabetic people, [9] however you can modify this if you want, based on your own trial and error testing. The analysis of the quantity of amino acids (as detailed in the article the insulin index v2) suggests that this value is unlikely to exceed 80 to 90%.
  • A default carb to insulin ratio of 22 has been used, however you can enter yours from your pump or calculate it based on this article.  [10]
  • You can enter your bolus insulin on board (BoB) which will be subtracted from the carbohydrate insulin dose.

outputs

  • The first line of the outputs is the percentage of insulinogenic calories. As a reference keep in mind that a whole egg is about 25% insulinogenic calories.  A high percentage of insulinogenic calories is not ideal for people with diabetes and insulin resistance.  It may be helpful to select nutritious foods with a low insulin load from this list.
  • The insulin load is calculated using the following formula (i.e. for both carbohydrates and protein).

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  • The percentage of glucose from carbohydrate could be used if you were going to split your dose into an initial bolus for carbohydrates with a separate bolus for protein. This value can be entered into your pump if you’re using a dual wave bolus, with the protein bolus typically given over a longer period.
  • You can use the grams of carbohydrates or the quantity of insulin for the carbohydrates and the protein if you’re using separate boluses.

meals

If you are following the meals from the blog you will notice that the net carbs, total insulin load and percentage of insulin for carbohydrates have been included in a table at the end of each recipe assuming a standardised 500 calorie meal.

our experience

Moni has experimented with dosing separately for the protein component of the meal, however it typically turns out that her blood glucose has risen by the time she doses for the protein.  It seems that for her, the glucose from the protein (via gluconeogenesis) hits her bloodstream quickly and hence delaying the dose for protein is not appropriate for her.

We are also trying to focus on a handful of nutrient dense meals with pre-determined insulin doses.  The table below shows the insulin required for a 500 calorie serving for a range of meals.  All of these have limited carbohydrates and the insulin dose for the protein is greater than the carbohydrate dose.  I have provided hyperlinks to some of the meals that are already published on the blog.

If you can’t handle the thought of weighing and measuring and then calculating the insulin dose for everything you eat, as a ‘rule of thumb’ all of these meals require dosing as if they were about 20 to 25 grams of carbs.  If you are choosing meals with a low insulin load then the insulin dosing for food ends up representing only about 20% of the daily dose.

meal

carbs (g)

protein (g)

 insulin load (g)

bacon, eggs, avocado and spinach

4

15

19

spinach and cheddar scrambled eggs

6

18

24

steak, broccoli, spinach, haloumi

6

20

26

coffee with cream and stevia

1

1

2

chia seed pudding – no fruit

7

4

11

broccoli, bacon, cream and mozzarella

3

17

20

sausages, avocado, sour cream, tomato

7

13

20

bacon, eggs, spinach and pesto

4

16

20

bacon and eggs

3

18

21

bacon, eggs, avocado and sauerkraut

5

21

26

fathead pizza with anchovies and pesto

4

13

17

bacon asparagus and eggs

3

18

21

For us, this approach combines a number of aspects from the various approaches discussed above:

  • all of these meals having less than 12g of carbs as recommended by Bernstein,
  • calculated insulin dose for both protein and carbohydrates,
  • nutrient dense meals, and
  • relatively low percentage of insulinogenic calories (i.e. high fat meals) meaning that the overall insulin dose stays relatively low.

We’re all on a journey.  I hope this helps you move towards finding a strategy that is optimal for you.

References

[1] http://www.thelancet.com/journals/landia/article/PIIS2213-8587(13)70144-X/abstract

[2] http://www.medpagetoday.com/Endocrinology/Diabetes/42610

[3] http://www.thelancet.com/journals/landia/article/PIIS2213-8587(13)70144-X/abstract

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

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

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

[7] https://optimisingnutrition.wordpress.com/?p=2637

[8] http://www.amazon.com/T-A-G-A-Diabetic-Food-System/dp/0688084583

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

[10] http://www.bd.com/us/diabetes/page.aspx?cat=7001&id=7303

bacon, eggs, spinach and mushroom

These shots are from our camping breakfast over Easter.  It rained for most of it so it was good to have something warm and yummy in the mud and cold!

You probably recognise the theme…  spinach, eggs plus some other stuff!  This time with mushrooms and some coconut oil for cooking and to increase the fat.

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Bacon is always great!  It makes everything taste better.

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We threw in a little bit of tomato here for taste.

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The nutritional analysis is shown below.  Pretty solid overall.

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Details for a 500 calorie meal are shown below.  Even with the tomato, spinach and mushrooms we are under the 12g carbs recommended by Bernstein for lunch and dinner.

net carbs

insulin load carb insulin fat protein

fibre

12g 35g 36% 64% 24%

8g

For people that are particularly carbohydrate sensitive I’ve re-run the analysis without the tomato.

A little bit of tomato doesn’t make much difference.  A larger amount of tomato will provide extra vitamin C, E and K but reduce the protein score and increase the carbohydrates content.

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Without the tomato the net carbs comes down from 12 to 10 grams.

net carbs

insulin load carb insulin fat protein

fibre

10g 32g 31% 66% 25%

5g

standing on the shoulders of giants

  • People who have type 1 diabetes and excellent blood glucose control are statistically rare.
  • These ‘overachievers’ typically have been influenced by the work of Dr Richard Bernstein.
  • People successful in their management of type 1 diabetes control the amount of carbohydrate in their diet to prevent “the blood sugar roller coaster”.
  • As well as calculating the insulin required for carbohydrate, those who manage type 1 diabetes well typically also have a way to calculate their insulin dose for protein.
  • Exercise and fasting also help to improve insulin sensitivity.

background

According to the T1D Exchange [1], 1.2% of type 1 diabetics in the US have a ‘normal’ HbA1c of less than 5.7%.  Twenty nine (29) of the twenty five thousand type 1 diabetics in the database (i.e. 0.1%) have an HbA1c of less than 5.0%.

I am privileged to know quite a few people who are conquering type 1 diabetes through the TYPEONEGRIT Facebook group [2] where you will regularly see posts like this one.

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Rather than just talking about the theory I thought it would be useful to profile a handful of the people that have been an inspiration to us and have shown what it takes to not just survive but thrive with type 1 diabetes.

What do each these people have in common that we can learn from?  What do they do differently based on their situation?

Dr Richard Bernstein

Dr Richard K Bernstein [3] has been the ‘voice in the wilderness’ of the low carbohydrate movement for four decades.  I first came across Dr Bernstein in episode 683 of Jimmy Moore’s LLVLC Show.[4]

Despite having type 1 diabetes himself since the age of twelve he is still going strong at eighty one years of age.  Bernstein’s is a fascinating story and an example of what can be achieved.

Richard Bernstein started his working career as an engineer.  His wife is a doctor so he was able to purchase one of the early blood glucose metres in 1969.  In those days blood glucose metres were primarily used to determine if someone who landed in the hospital emergency department at night was unconscious because they were drunk or had high blood glucose levels.

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Bernstein, an avid self-experimenter, measured his blood sugars six times a day, and over time gained an understanding of how much a certain amount of carbohydrate raised his blood glucose levels, and conversely, how much a certain amount of insulin lowered them.

At the time he was told it was a waste of time encouraging people with diabetes to measure their blood glucose levels because there was no value in people with diabetes achieving normal blood glucose levels. [5]  In spite of this, Bernstein’s early learnings are now the basis of the basal / bolus insulin dosing calculations built into every insulin pump which is used today by the majority of type one diabetics.

At 45 years of age Bernstein went to medical school in an effort to get people to listen to his theories.  These theories are still considered fringe today, possibly because they do not align with the dietary recommendations generated by the USDA.

Bernstein documented his system in the comprehensive book Dr Bernstein’s Diabetes Solution[6]  He is also in the process of recording a series of YouTube videos, Dr Bernstein’s Diabetes University. [7]  I find it fascinating to hear him talk about his Body By Science-style heavy lifting workouts at eighty-one! [8]

He recommends that people with type 1 diabetes eat no more than 6g of carbohydrate at breakfast, with no more than 12g of carbohydrates at lunch and dinner.  This enables people with diabetes to stay off the blood sugar roller coaster and manage their blood glucose levels with smaller doses of insulin.

Bernstein also acknowledges that protein requires insulin, [9] however, for the most part he accounts for this by eating consistent meals and refining insulin doses based on blood glucose measurement after each meal.

Troy Stapleton

I had the privilege of meeting Dr Troy Stapleton at a screening of Cereal Killers [10] in Brisbane in August 2014 where he was on a panel fielding questions after the movie.  After the session we cornered him for about an hour.

It was inspiring for us to see someone thriving with type 1 diabetes.  At the time my wife Monica was struggling to even think of working because she didn’t have the energy to make it through the day without an afternoon nap before picking up the kids from school.  But here was Troy successfully running a radiology department!

The photo below shows Troy (right) with Tim Noakes [11] (centre) and Ron Raab [12] (left) when they debated Carbohydrates – Victims or Villains at the  Annual Scientific Meeting of the Australian Diabetes Society and Australian Diabetes Educators Association in Melbourne in August 2014.

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I got to catch up with Troy again at the Low Carb Down Under seminar in Brisbane in November 2014. [13]  His presentation was excellent and I got to spend some time with him during the Steve Phinney masterclass [14] the next day.  He warmly asked how Moni was doing and took a real interest in helping us on our journey.

Troy’s story is worth checking out if you have not seen it yet.

There is nothing confrontational about Troy’s approach.  Troy just eats real whole healthy food.  Troy  just shows what can be done and gets on with doing it.

Rather than saying that everyone should do what he is doing he just says that people should be educated about the options and given the choice.

As well as following Bernstein and Taubes he’s also a fan of Mark Sisson’s primal / Paleo approach and likes to check everything against the evolutionary template rather than relying on associational studies.

When he initially self-diagnosed himself with type 1 diabetes and he went to the endocrinology department of his hospital, they told him to eat 240g of carbs each day and cover it with insulin.

Troy says “Within one week I went back to ask about low carb but was told I needed carbs and that low carb would not work. I continued reading for the next 2 months and became increasingly convinced that low carb was the way to go. I switched to low carb in December 2012 and have never looked back. My blood glucose lowered and stabilised, my insulin dose reduced, my hypos almost vanished and my depression/anxiety resolved.”

He explains how he has been able to extend the ‘honeymoon phase’ [15] of his type 1 diabetes in spite of having the disease for two and a half years.  By keeping his carbohydrates low he is able to maintain the function of the beta cells of his pancreas.    At this point in time he only needs to dose with long acting insulin, and with only an occasional bolus of insulin with a meal.

Unfortunately people newly diagnosed with type 1 diabetes often burn through their remaining pancreatic beta cells by following the standard dietary guidance and hence their ‘honeymoon phase’ is short (and sweet?), with insulin doses increasing as the pancreas gives out and insulin resistance progressively worsens.

Troy told me his HbA1cs are running in the low fives.  His diabetes is controlled with long acting insulin, a low insulin load diet and regular cycling and surfing which he loves!  He said if his HbA1c starts to drift up in the future he will add more regular insulin boluses with meals.

Dave and RD Dikeman

I came across Dave Dikeman and his father RD Dikeman via episode 831 of Jimmy Moore’s LLVLC show. [16]  I still remember nine year old Dave saying “finger pricks now or amputations later, the choice is pretty simple”.

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It seemed so clear and logical for young Dave.  However, what he was saying was radical to us after muddling around with mainstream advice for diabetes and no clear direction on how to achieve excellent blood sugar control.

Dave’s father, RD, is a theoretical physicist and chief scientist for Department of Defence contractor Lockheed Martin.  RD became passionate about diabetes after finding Dr Bernstein’s book, and after floundering with standard diabetes advice in the months following diagnosis.

Dave is now thriving on the Bernstein plan which includes lots of protein foods for growing kids.

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Like many family members of diabetics who find low carb, RD he also has his own story of how a reduced carbohydrate diet has helped him to turn his health around.

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The continuous glucose metre plot below shows RD’s own blood glucose levels after a few years of implementing Dr Bernstein’s advice in his family.

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This article by RD and Dave [17] offers a fascinating window into their thinking and the secrets of their success in managing type 1 diabetes.  Their analysis demonstrates that it is not possible to achieve normal blood sugars with large amounts of carbohydrate in the diet.

“It would be impossible for an artificial pancreas based on a CGM and automated insulin dosing via a pump – both of which have inherent lags – to respond quickly enough to high blood sugars caused by large doses of carbohydrate before unsafe levels of hyperglycemia occur.”

The Dikemans set up the TYPEONEGRIT Facebook group [18] to support others with type 1 diabetes on the journey following Bernstein’s protocols.  As recommended by Troy Stapleton, we joined the group late last year  and I can’t say enough about how helpful it has been to see people actually implementing Bernstein’s recommendations in day to day real life.

It is one thing to read the theory, but it’s a whole different thing to see all these people with flat line blood sugars, be able to ask lots of ‘dumb questions’ and share day to day struggles of what is a fairly radical departure from what most people consider ‘normal’.

Once you see the theory in practice you realise that you might be able to do it too.  When you see these healthy, vibrant passionate people you stop worrying about whether you’ll have a heart attack tomorrow due to the high fat diet.

The Dikemans also produce Dr Bernstein’s Diabetes University [19] which is getting the word out to a whole new audience through YouTube videos of Dr B.

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Lisa & Daniel Scherger

Lisa Scherger is a lady with a fire in her belly when it comes to managing her son Daniel’s type 1 diabetes!  If you haven’t seen her short presentation from the Low Carb Down Under seminar in Brisbane in November 2014 [20] make sure you take the time to do it now!

Lisa recently obtained a Dexcom continuous glucose metre [21] which has enabled them to take blood glucose management to a new level and further refine their dosing for protein.

On Lisa’s blog [22] she recently shared her ‘secret’ to flat line blood sugars and how to deal with the blood glucose ‘spike’ caused by protein.

So, for the carbs and fibre I bolused 40 minutes before dinner. Then I bolused for the protein conversion to glucose (gluconeogenesis) 1 hour after the end of the meal so that the insulin would start circulating around the time the spike was due to occur.

Lisa is adamant that accounting for protein in addition to carbohydrates is critical to optimising blood glucose control.

Last night I forgot to set my alarm to do the protein bolus, and I was up until 4am trying to get blood glucose levels down. Daniel’s protein spike starts exactly 2 hours after the meal, and once it starts I can’t stop it. He needs to inject for the protein 1.25 hours after the meal so that the insulin is circulating at the right time.

Learning to dose for protein as well as carbohydrate is a learning curve.  Getting flat line blood sugars typically takes some trial and error to refine and perfect.

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However the results of Lisa’s attention to detail speak for themselves, with an HbA1c consistently less than 5.0%…

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…and a son who is thriving in both his academic and athletic pursuits.

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Angela Erickson

Angela is another member of the TYPEONEGRIT Facebook group who recently completed an eighty hour fast in an effort to reset her insulin sensitivity.  During the fast she was measuring ketone levels of up to 3.4mmol/L and soon after recorded an HbA1c of 4.7%.

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When I asked her what she would say were the secrets of her success were she said:

  1. learning my proper formula for protein that works for me,
  2. exercise, and
  3. fasting.

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Angela boluses for carbohydrates 15 minutes before the meal and then doses for the protein 1.5 hours after the meal using the pump, or two hours after with a faster acting intra muscular (IM) shot.

As well as ‘barely eating carbs’ she also manages her protein to make sure it’s not excessive, averaging about one gram per kilogram of body weight per day.

Angela also said she boluses to correct back to 83mg/dl (4.6mmol/L) whenever she hits 90mg/dL (5.0mmol/L) unless she has eaten within the past two hours.

Fasting is not a critical piece of Dr Bernstein’s regime, however, Angela found that she was able to improve her insulin sensitivity with periods of fasting.  After one day of fasting she found she had to decrease her basal rates to 70% and to 50% after three days of fasting.  And this improved insulin sensitivity continued after the fasting was over.

Periods of fasting can be useful for people with type 1 diabetes to refine their basal rates.   Similarly, fasting can also reset insulin resistance for people who do not have type 1 diabetes.  The fact that you can see it numerically on an insulin pump is a clear demonstration of what is occurring in the rest of the population after they fast.

When I asked whether she thought the fasting or the low insulin load diet was most important she said, “I’m not sure which is more important. I think ketones are powerful healers.  I feel somewhat euphoric after longer fasts and it gives my body a break.  I’m trying to heal and drop my few extra pounds.”

Lucy Smith

We met this gorgeous family at the Type 1 GRIT picnic in Brisbane recently.  Lucy is the one in the middle in the photo below with her new diabetes alert dog in training.

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The photo below shows Lucy with her hospital food when she was diagnosed with type 1 diabetes a bit over a year ago.  Let’s just say she doesn’t eat like that any more.

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This video of Lucy’s first year with type 1 diabetes is a touching insight into what it’s like for a young person to live with type 1 diabetes.

The Smiths are part of the CGM in the cloud crew [23] who have managed to hack their daughter’s CGM via an Android phone in her backpack that broadcasts her blood glucose level every five minutes to the cloud.  The most amazing thing about all this is that it has been created as an aftermarket hack by parents. DEXCOM have rushed the DEXCOM Share to market to keep up with this technology (US only).

Both her parents and Lucy’s teacher wear a pebble watch [24] with the Nightscout app [25] on it that that enables them to see Lucy’s current blood sugar level.  If they see it’s going out of range the parents will SMS her teacher who usually advises that she has just done a finger prick  and is treating the low.

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And it’s working!  Though at 4.8%, Lucy’s last HbA1c was outside the target range of 7.8-8.5 for someone her age!

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Allison Bleckley Herschede

Alison is one of the admins of the TYPEONEGRIT Facebook group [26] and coaches the nearly one thousand members who have type 1 diabetes and their carers towards achieving better blood sugar control.

When it comes to dealing with protein, Allison practices what some refer to as ‘sugar surfing’ [27] with a bolus given for carbohydrates with the meal.  She then watches her CGM and doses with small ‘micro doses’ to bring blood sugar back down if it goes above 93mg/dL (or 5.2mmol/L).

The difference for Allison though between normal ‘sugar surfing’ and her Bernstein-influenced approach is that she keeps her carbohydrates low so the ‘waves’ are more like ripples that are easier to manage.

Allison has developed some guidelines for achieving an excellent HbA1c, including:

  1. Target 4.6mmol/L (i.e. 83mg/dL).
  2. Veggies and protein before carbs.
  3. Multiple injections may be necessary for a high protein meal. Watch the CGM two to three hours post meal.
  4. If female, modify basal rates around monthly cycle.
  5. Take insulin sensitising supplements R-Alpha Lipoic Acid, Biotin, Chromium.
  6. Take one unit bolus upon waking to account for the Dawn Phenomenon. [28]

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You can read more about Allison’s journey with type 1 on her My Primal Nest blog including her experience with type 1 diabetes and pregnancy.

Recently she recorded these videos demonstrating how to use a home HbA1c metre…

… and her own surprise at the result is priceless.

In the comments to these videos where she showed that she’d clocked HbA1c of 4.4% she said “…I’m doing this fasting diet thing. Less than 800 cal, 5 days on 2 off. Supposed to mimic the fasting state. Well my insulin needs have greatly dropped.  It’s nuts.”

our journey

We are still on the journey but we learned so much from these awesome people!

My wife Monica has done an awesome job implementing the recipes posted on the TYPEONEGRIT Facebook group in our kitchen and has made low carbohydrate cooking a delicious art form.  After three decades of HbA1cs of around 8% she is now under 6% and the improvement in quality of life is enormous!

The greatest improvement to date for our family has been following a reduced insulin load diet which means that the insulin dose for food and correcting insulin dose is lower overall and the fluctuation in blood glucose levels are greatly reduced.

After seeing the success of all these people with CGMs, we’re now looking at getting a DEXCOM CGM for Moni, although unfortunately there are no subsidies in Australia so it’s not cheap!

It’s never going to be perfect, but when the correcting doses are smaller you’ve got a better chance of having more stable blood sugars.

The improvements to date have enabled Monica to have the energy to work as a supply teacher pretty much full time while still doing a great job of looking after the family!

When her blood sugars are under control she needs much less sleep, and her mood and energy levels are much better.

It’s always a journey.  You don’t arrive.  It’s a constant challenge.

Is it worth it?  Yes it is!  The quality of life for our whole family has seen a massive change and we’re eager to keep it moving forward.

 

references

[1] https://t1dexchange.org/pages/

[2] https://www.facebook.com/groups/660633730675058/

[3] http://www.diabetes-book.com/

[4] http://www.thelivinlowcarbshow.com/shownotes/7930/683-llvlc-classic-low-carb-diabetes-doctor-richard-bernstein/

[5] https://www.youtube.com/watch?v=WFNGdKSXx64

[6] http://www.diabetes-book.com/

[7] https://www.youtube.com/channel/UCuJ11OJynsvHMsN48LG18Ag

[8] https://www.youtube.com/watch?v=Z80-c0CXYqc

[9] https://www.youtube.com/watch?v=ctaaN9U3sGQ

[10] http://www.cerealkillersmovie.com/

[11] http://www.thenoakesfoundation.org/prof-noakes

[12] http://www.diabetes-low-carb.org/about-ron.html

[13] http://www.lowcarbdownunder.com.au/events/low-carb-brisbane-november-22nd-2014/

[14] https://www.youtube.com/watch?v=8NvFyGGXYiI

[15] http://www.diabetes.co.uk/blood-glucose/honeymoon-phase.html

[16] http://livinlavidalowcarb.com/blog/the-llvlc-show-episode-831-dave-dikeman-is-a-10-year-old-type-1-diabetic-on-fire-for-low-carb-living/22923

[17] https://myglu.org/articles/our-journey-with-the-low-carb-diet-and-the-manual-artificial-pancreas

[18] https://www.facebook.com/groups/660633730675058/

[19] https://www.youtube.com/channel/UCuJ11OJynsvHMsN48LG18Ag

[20] http://www.lowcarbdownunder.com.au/events/low-carb-brisbane-november-22nd-2014/

[21] http://www.dexcom.com/au

[22] http://diabeticalien.blogspot.com.au/2015/04/preventing-protein-spike.html

[23] https://www.facebook.com/groups/cgminthecloud/

[24] https://getpebble.com/#/.0kvx26:Fuqt

[25] http://www.nightscout.info/

[26] https://www.facebook.com/groups/660633730675058/

[27] http://stephenpondermd.com/

[28] https://en.wikipedia.org/wiki/Dawn_phenomenon