Antonio C. Martinez II’s type 2 diabetes reversal

Can fasting improve blood glucose levels and reduce the need for diabetes medications?  Antonio Martinez was eager to find out, so he set out on his own n = 1 experiment.  

Antonio is an Attorney at Law (Martindale Hubbard Distinguished Rating and in The Legal Network Top Lawyers in New York) and businessman who worked for the late Dr Robert C. Atkins MD in government relations and appeared on his radio show in the 90s.  

Antonio was one of the principal lobbyists and strategists involved in the passage of the Dietary Supplement Health and Education Act of 1994 (DSHEA) and has been involved in health care issues in law and policy throughout his career.

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Back in the 90s Antonio adopted a low carb approach to lose weight for a time but says he then resumed a more moderate diet.  It wasn’t until Antonio started to have his own health issues, including type 2 diabetes and a heart attack, that he realised he needed to intensify his efforts.

type 2 diabetes diagnosis

Antonio has a family history of Type 2 Diabetes, with both his mother and father suffering from the condition.  Diagnosed with Type 2 Diabetes in 2002, Antonio was initially put on Metformin and eventually Janumet in 2008.

With the help of anti diabetic medications Antonio maintained a HbA1c in the 6s and was commended for his great blood glucose control.  However even though he kept his blood glucose under the American Diabetes Association recommended maximum HbA1c of 7% Antonio was  still at risk for cardiovascular disease.  

As shown in the chart below, people with a HbA1c of less than 5.0% have the lowest risk of cardiovascular disease and stroke, however it doesn’t seem to count if you are using anti-diabetes medications to reduce blood glucose levels as they simply drive the excess energy back into storage as fat.  

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While anti-diabetic medications help to lower blood glucose levels (the symptom) these medications do not necessarily reduce your disease risk or allow the fat in your organs (the cause) to be released to restore insulin sensitivity (the solution).

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Insulin is an anabolic hormone which means that it enables the body to build energy stores.  If your problem is hyperinsulinemia, Type 2 Diabetes or fatty liver then your goal should be to lower your blood glucose and insulin levels to enable your stored body fat to be used for energy.  Medicating high blood glucose without dietary changes will drive the energy back into storage as fat (including in your heart, liver and pancreas).

The diagram below from Dr Ted Naiman helps to explain how both high insulin levels (hyperinsulinemia) and high blood glucose levels (hyperglycemia) are interrelated and both bad news.

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heart attack!  

Sadly, on March 28, 2014, Antonio suffered a heart attack and had a stent placed in one artery.  

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Upon admission to the hospital he weighed 158 lbs and had a HbA1c of 7%.   After the heart attack Antonio was prescribed aspirin, blood pressure medication, a statin, an anti-coagulant, and a beta blocker.  Within a short time he began to experience side effects from the multiple medications.  

Frustrated, he re-read a number of health and medical materials and told his doctors he would not be taking medications for the rest of his life.  He also watched the documentary “Cereal Killers” which was a light bulb moment for him.  

reduced carbohydrate approach

In July 2014, Antonio told his doctor and cardiologist that he was going on a high fat low carbohydrate diet.  While his doctors did not advise against it, they were skeptical and warned him that he would have to have labs done frequently to monitor the impact of the diet.  

Then in September 2014 Antonio received a call from his doctor who said

Congratulations.  Whatever you are doing, keep doing it. You have a normal HbA1c!  I’m taking you off Janumet. Take Metformin at the lowest dose as a control.

As shown below, Antonio’s HbA1c had come down from 6.6% to 4.9% with the low carbohydrate dietary approach.  He had also dropped thirteen pounds to 145 lbs, his blood pressure had normalized, his HDL increased by 20 points and his triglycerides dropped below 100 mg/dL.  

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tackling dawn phenomenon  

Despite eating only two low carb meals per day Antonio became concerned towards the end of 2015 that his morning blood sugar levels were starting to drift up.  

Dawn Phenomenon is the process where the body secretes a range of hormones and glucose in preparation for the day, however if you are insulin resistant then the insulin response may not be adequate to maintain normal blood glucose levels.  Having already experienced a heart attack he took this seriously and was eager to do whatever he could to reverse the situation.   

So to kick off the new year Antonio adopted a regular fasting regime which involved going to bed without dinner on Sunday night and then not eating until Tuesday evening.  This gives him a 44 to 48 hour fasting window each week.   

The chart below shows Antonio’s blood glucose numbers through December before the fasting protocol and then through January and February with the fasting protocol in place.   

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Real life blood glucose numbers are always going to bounce around, however you can see that Antonio’s average blood glucose values have really improved.   

I am getting the best numbers that I’ve ever had and no Dawn Phenomenon.  

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While the longer fasts are working well for Antonio he could also use shorter more regular fasting periods to keep his blood glucose down.    Check out the Using your glucose meter as a fuel gauge article for some ideas on how you can make sure your average blood glucose is trending in the right direction.

One way of viewing high blood glucose levels and Dawn Phenomenon is the body’s way of releasing excess stored energy into the bloodstream to be used.  If you are insulin resistant the body will use a process called gluconeogenesis to convert excess protein, and even fat to an extent, into glucose.  

Once the excess fat decreases people will often become more insulin sensitive and the body will stop pumping out this extra glucose.  

HbA1c

Starting out with an HbA1c of 5.1% Antonio was already doing pretty well due to his disciplined low carb approach.  However the addition of the fasting protocol helped him break through the plateau and bring his blood glucose levels down even further towards optimal levels.  Based on his blood glucose values he now has an HbA1c of around 4.6% which is pretty much optimal.   

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ketones

Antonio’s ketones are solid but actually trending down after introducing the fasting regime.  The fact that Antonio has lower ketones values is not really a concern given that he’s likely using his ketones more effectively for energy rather than letting them build up in the blood as might be the case with a high fat diet without fasting.   

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I think many people get themselves into trouble chasing high ketone values by adding more dietary fat without improving their metabolism and insulin sensitivity to the point that they can actually use the ketones.   Fasting forces your body to learn to use ketones for fuel.  

glucose : ketone index

The ratio between glucose and ketones (GKI) can be a more useful measure when your blood glucose levels are reducing.  A reducing GKI is an indication that your insulin levels are decreasing and your metabolic health is improving.   

Antonio’s glucose : ketone ratio (GKI) improves each time he fasts and that it is trending down over time.  These low GKI values indicate that he is achieving excellent metabolic health.  

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Thomas Seyfried’s GKI is a useful tool to track your metabolic health once your blood glucose values are approaching optimal levels.  Seyfried aims for his cancer patients to have a GKI of 1.0, though a GKI below 10 is considered to be a fairly low insulin state and less than three is excellent metabolic health for someone not chasing therapeutic ketosis.  

no turning back?

Antonio continues to enjoy the weekly fasts during which he focuses on drinking lots of different teas, coffee, and some bone broth.  His weight has now dropped to 141 pounds and he is wearing the same size clothes as he wore in college.  

When his friends ask him how he reversed his type 2 diabetes and got skinny.  He replies,

By eating a high fat low carbohydrate diet based upon eating real food.

I work to keep my food macros in the range of 70 percent fat, 20 percent protein, 10 percent carbs as my ideal targets.  I do watch my protein intake because excess will convert via gluconeogenesis.

I will likely maintain this approach for the rest of my life.  I am loving my results!

Antonio says:

Another way to look at insulin resistance is your body telling you that you’re eating too much, eating too much of the wrong things or just eating too often.  Our ancestors were hunter foragers whose eating habits were more like feast and famine, not three meals with snacks.  Know and respect your insulin because it will command you to do so or otherwise wreak metabolic havoc on your health.

You can also think of your blood glucose meter as a fuel gauge.  If your blood glucose levels are high then it might be time to stop filling the fuel tank for a while.  

Intermittent fasting is like going to a metabolic gym and working out.  Your body gets the opportunity to repair, recover, regenerate. Used intelligently, it will make the difference for your health and insulin sensitizing.

I am disappointed in the medical establishment because they should know better and they do not.  Why isn’t clinical and therapeutic nutrition education mandatory in medical school and taught with the same emphasis as pharmacology?  

And before go thinking Antonio is a saint that loves deprivation, he likes to feast too!  Here he is with Ivor Cummins at Antonio’s favorite New York restaurant with some red wine..

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… Brussell sprouts salad…

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..some pate…

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…and Le Côte de Beouf.

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Lots of people would call this a ‘heart attack on a plate’, but for Antonio it seems to be working the other way.  Here’s the blood glucose and ketone results the next morning.

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And here’s Antonio recently on the job full of life and vitality.

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Antonio with Former U.S. Senate Majority Leader Tom Daschle in Washington DC, February 2016

cured?

Is Antonio cured of his type 2 diabetes?   The answer depends on your definition of “cured”.   

Will Antonio be able to eat processed junk food five times a day?  Probably not.   

However if Antonio keeps up this fasting protocol along with his low carbohydrate approach then he just might be able to maintain optimal blood glucose levels without fear of another heart attack.  

If that’s your definition of “cured” then the answer might be yes.   

Congratulations Antonio and keep up the great work!

[This article has now been translated to Spanish.  Check it out here.]

references

[1] http://www.thelivinlowcarbshow.com/shownotes/12960/997-attorney-Antonio-martinez-pushing-lchf-through-public-policy-and-the-law/

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

[3] http://www.fitnessunderoath.com/the-44-hour-diet/

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

contact

If you’re going through a similar experience Antonio would love to hear from you via his website at www.acmartinez2.com

optimising blood sugars with RD Dikeman

It has been a transformational journey for RD Dikeman since his son Dave was diagnosed with Type 1 Diabetes, both as a parent and for himself as he has implemented a regimen of what he likes to call “meal skipping” (a.k.a. intermittent fasting) guided by his own blood glucose levels.

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I came across Dave Dikeman, a young man with Type 1 Diabetes, in Episode 831 of Jimmy Moore’s LLVLC Show.  I still remember ten year old Dave saying “finger pricks now or amputations later, the choice is pretty simple”.   Dave’s pragmatic attitude to his condition was another light bulb moment in our family’s journey to learning to manage diabetes.

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It has also been quite a journey for RD Dikeman, Dave’s dad, who recently posted a few comments on the Optimising Nutrition Facebook Group that I thought were worth capturing.

I’ll tell you a quick story about how this whole low carb thing started.

Dave is near death, in the hospital, diagnosed with T1. The doctor rolls in to meet us. A kindly doctor – no Bernstein – but a very kindly man (he took an injection of insulin to show Dave not to be afraid).

So the doctor is talking to Dave and finds out they both went to the same school. So there’s some kinship.  And the doctor recognizes that Dave is a pretty sharp guy and Dave starts asking questions ‘will I die young?’ And Doc is brutally honest ‘you have to control your blood sugars – amputations, blindness and those things are on the table’.  And doc starts to give us a lecture on how to do that.

He has an easel and a sharpie. Anyway, he draws a rollercoaster blood sugar graph and he says ‘carbo makes blood sugar go up and insulin go down and you want to be between 80 and 180 (sigh) mg/dL.’

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And Dave goes ‘I just won’t eat carbo’.  TRUE STORY.!

And ME!! I interrupt and say (throw me down and kerb stomp me everyone) ‘You need carbo for… ENERGY’. LOL!

So I spent the next month force feeding Dave oatmeal. I am heckled daily for this. Every time there is oatmeal. Oatmeal on a TV commercial.  Oatmeal at restaurant.  Heckled!

About a month later guess who discovered ‘The Bernstein Book‘!!! NOT ME!! It was Roxanne (my wife).  So that is two fails for me.

I will say the happiest moment of my life was reading Bernstein’s ‘law of small numbers’. I knew then that we had a way out of this mess.

Being 100% wrong never felt so good.  I have a good leader. The whole thing was his idea.

Since then, RD has become passionate about the low carb way of eating and helping other people learn more about diabetes.  He is an admin on the Type One Grit Facebook Page which is a great source of support and inspiration for people with Type One Diabetes.  He and Dave also produce Dr Bernstein’s Diabetes University which captures nuggets from Dr B on YouTube.

RD lives low carb theory…

I don’t eat any carbohydrate-glucose foods. No sugar, manipulated sugar fruits, grains or starch. Ever. Carbs are only from fibrous veggies and nuts.

and it seems to be working.

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Dr Bernstein’s recommended target blood glucose is 83mg/dL (or 4.6mmol/L) with a recommendation that people with Type 1 Diabetes actively work to keep within a ten point range of this target number (i.e. 73 to 93mg/dL or 4.0 to 5.2mmol/L).

Dr B tells the story of how, back in the day, blood glucose meter sales reps would come to his office.  He would get them to demonstrate how it worked by testing it on themselves so he could see their blood glucose number.  Sure enough, the blood glucose levels of these healthy young non-diabetic sales reps was always around 83mg/dL.

Since then there has been  plenty of research that showing the benefits of having an average blood glucose level of around 83mg/dL including reducing your risk of cancer, obesity, heart disease and a range of other metabolic issues.

Some people operate happily at the lower end of this range, particularly if they are younger and / or insulin sensitive and producing ketones.  Generally though, the body of someone with a healthy metabolism will bring them back to a blood sugar of around 83mg/dL (or 4.6mmol/L).

Not too high.  Not too low.  Just right.

The table below shows a generalised relationship between blood glucose, ketones, HbA1c and the glucose : ketone ratio (GKI).  There’s no perfect number for everyone, however typically the lower your HbA1c, without using blood glucose lowering medications, the lower your risk of metabolic syndrome and related diseases (see the Diabetes 102 article for more details).

ketone BG (mmol/L) BG (mg/dL) GKI HbA1c Comment
0.20 5.9 106 29.5 5.32 good
0.50 5.3 95 10.6 4.93 high normal
0.60 5.2 93 8.6 4.85 high normal
0.70 5.1 91 7.2 4.79 high normal
0.80 5.0 90 6.2 4.74 high normal
0.90 4.9 88 5.5 4.69 high normal
1.00 4.8 87 4.8 4.66 high normal
1.50 4.6 83 3.1 4.51 optimal
2.00 4.5 80 2.2 4.41 low normal
2.50 4.3 78 1.7 4.33 low normal
3.00 4.2 76 1.4 4.27 low normal
3.50 4.2 75 1.2 4.22 low normal
4.00 4.1 74 1.0 4.18 low normal

RD is not technically diabetic himself however he understands the dangers of high blood glucose levels.  RD found that the low carb way of eating helped him lower his own blood glucose, however he still wasn’t consistently achieving Dr Bernstein’s target blood glucose level of 83mg/dL.

What he did find was that when he waited to eat his blood glucose would come down as the body used up the glucose in his blood.  Over time RD developed a practice of meal timing guided by his glucose meter that finally enabled him to optimize his own blood glucose levels.

My blood sugar tells me when it’s time to get some insulin sensitizing exercise at the gym also.

I would say if blood sugar is above normal (83 mg/dL) then beta cells are ‘on’ and insulin is a fat storage hormone (obviously other functions).

It’s your table exactly Marty Kendall!

This is the table that RD is excited about (from the using your glucose meter as a fuel gauge article).

blood glucose action
>  7 day average, well slept and low stress consider delaying eating and / or exercising
< 7 day average if hungry, enjoy nutrient dense foods that align with your insulin sensitivity
< 73mg/dL (4.0 mmol/L) if hungry, eat higher insulin load foods and delay exercise

If your glucose is higher than YOUR average then you may not need to eat right now.

If you are insulin resistant, when you do eat, you should focus on foods that won’t spike your blood glucose levels.

Eating when your blood glucose is less than YOUR current average will allow you to progressively lower your blood glucose.

Decreasing average blood glucose = winning!

For most people it will take some time before they can get their blood glucose down to Dr B’s target of 83mg/dL.  Using this method RD has been able to decrease his HbA1c from 5.3% to 4.8%.

If your blood glucose is below 73mg/dL (4.0mmol/L) then you may benefit from foods with a higher insulin load to replenish glycogen stores.

The continuous glucose meter plot below shows RD’s blood glucose levels after a few years of implementing Dr Bernstein’s advice in his family.  Not bad!

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I am able to lower my HbAc1 about 0.1% every six months. It’s not easy.

If you aren’t at mid 4s, look to belly fat and/or treating your body like an amusement park in younger days (guilty!)

One big takeaway from the journey has been how long it takes to heal the metabolism…. not a surprise if you’ve been sabotaging it for decades, I guess.

RD says it’s more than just the exercise.  It’s the food and the fasting too.

I worked out plenty in 2006.  Same gym.

RD understands that it is important for his long term health to do whatever he can to strip the fat from his body, particularly from his organs.

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As we reverse fatty liver and fatty pancreas  normal insulin sensitivity can be restored which in turn leads to normal blood glucose levels and normal body weight.

RD doesn’t use the scale to track his health, but rather his blood glucose meter.

I know if I eat too much food or if I stop working out, my blood sugar starts rising and I start to put on weight.  This happens even with a low carb diet.

If I fast and work out, my blood sugar returns to normal.  I feel better.

So really, I don’t use the (weight) scale, I can use my blood sugar meter instead.

Fixing your metabolism by learning how to eat and losing weight after years of eating the standard…  well it takes some time…  a few years in my case.

I’m still seeing improvement and motivated.  I’m definitely not going back.

Congrats RD!

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For more details on how to use your blood glucose meter as a fuel gauge check out this article.

how to use your blood sugar meter as a fuel gauge

  • While reducing carbohydrates is the first priority for someone with diabetes, high blood sugar levels and insulin resistance can also be a sign that you are eating too much and / or too often.
  • You can use your blood sugar meter as a fuel gauge to help you understand whether your hunger is real and refine your meal timing to achieve blood sugar levels closer to optimal.
  • Delaying your next meal allows your body to use up the glucose stored in your liver and blood.
  • Intermittent fasting will allow the glucose in your blood stream to be replenished from the glycogen stores in your liver and muscle, rather than more food, and allow energy to flow from your fat stores.

The table outlines a protocol that will help you to use your blood sugar meter as a fuel gauge.

blood sugar action
>  7 day average, well slept and low stress delay eating and / or exercise
< 7 day average if hungry, enjoy nutrient dense foods that align with your insulin sensitivity
< 73mg/dL (4.0 mmol/L) if hungry, eat higher insulin load foods and delay exercise

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This approach is not intended for people who do not produce enough insulin (i.e. type 1 diabetes, type 1.5, LADA and MODY) but rather for people who are insulin resistant and produce large amounts of insulin but still have high blood sugar levels (i.e. pre-diabetes and type 2 diabetes).

reducing insulin

Eating frequently will keep your insulin and blood sugar levels consistently high, particularly if you eat foods with a high insulin load.

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Reducing meal frequency enables blood sugar and  insulin levels to decrease.

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High levels of insulin keeps fat stores locked in storage and glycogen stored in the liver.  Once our fat stores can’t take any more fat they become insulin resistant which makes it harder for insulin to get into the fat cells, but then the pancreas ramps up insulin production trying to clear the high blood glucose levels in the blood and to keep the glucagon stores in the liver.

Reducing insulin levels allows the liver glycogen stores to be emptied, then the body finally turns to body fat for fuel.[1]

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Decreasing body fat, particularly from the liver, pancreas and kidneys leads to improved insulin sensitivity and normalised blood sugar.[2] [3]

Eating larger meals with more carbohydrate causes your blood sugar to stay higher for longer.   Conversely, having smaller meals with a lower insulin load allows your blood sugar to return to baseline faster.

when to eat

You can use your blood sugar meter to help you know whether your hunger is real and whether or not to skip a meal or two or not eat for the day.

If you have some level of insulin resistance then chances are your blood sugar levels will be higher in the morning due to liver glycogen being released as your body prepares for the day (a.k.a. Dawn Phenomenon).

If you are insulin resistant the insulin secreted by your pancreas doesn’t keep up with the release of glucose into the blood stream and hence your blood sugar will be high.  Dr Jason Fung says that the Dawn Phenomenon is your body’s way of purging excess energy.

The Dawn Phenomenon is simply moving sugar from body stores (liver) into the blood. That’s it. If your body stores are filled to bursting, then you will expel as much of that sugar as possible.

By itself it is neither good nor bad. It is simply a marker that your body has too much sugar.

What is the solution? Simple. Either don’t put any sugar in (LCHF) or burn it off (fasting). Even better? LCHF + IF.[4]

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If you test your blood sugar in the morning and it’s higher than your current average then you might want to delay eating until your blood sugar comes back down.  This may mean eating your first meal early afternoon followed by an early dinner (i.e. 16:8 intermittent fasting).   Alternatively, you could skip dinner, which would help to lower morning blood sugar and then eat breakfast and lunch.

Other people find it simplest to not eat for the whole day or even two days at a time and then resume normal eating to satiety the rest of the time.  As you get used to it you may want to try longer fasts which will accelerate the healing process.  Over time you’ll find a routine that suits you and be able to calibrate your feeling of hunger and reduce the frequency of testing.

tailored just for you

Many people agree that intermittent fasting is a good idea, but how do you whether you should be doing Michael Mosely’s 5:2 diet, Hugh Jackman’s 6:8, Kiefer’s Carb Back Loading and Carb Nite, Lyle McDonald’s TKD and CKD, Bert Herring’s Fast Five, Ori Hofmekler’s Warrior Diet, or Martin Berham’s Lean Gains?

There are so many options out there!  How do you know which one is right for you and then how do you know if it’s working?  How can you refine and tweak to reach your goals?  What if you just really feel hungry but it’s not “time to eat” yet!?!?

The advantage of using your blood sugar level as a guide versus a regimented intermittent fasting protocol or a fixed calorie intake is that it accounts for the energy your burn as well as what you’re eating.

Eating is not bad.  In the end it is about balancing your intake with your expenditure which can be a challenge when we are surrounded by cheap hyperpalatable foods.

This approach helps you to fine tune when and how much you eat to your actual requirements.

Your blood sugar meter can help you understand whether your hunger is real and re-calibrate your appetite signals.  If your blood glucose levels are lower than your average then your insulin levels will be decreasing and you’ll be using body fat.  If your blood sugar levels are increasing then you’re likely eating too much and / or too often which will drive high insulin levels which means you’ll be storing energy as fat on your body.

When using this approach, you’re able to eat to eat to satiety while keeping in mind that when you eat next will be influenced by whether or not your binge at this meal.  You could even use this approach to make sure you don’t overdo the refuelling and keep the insulin load of your meals such that your blood sugar doesn’t go over say 120 mg/dL (or 6.7 mmol/L).  A blood sugar level over this is a sure sign that your glycogen stores are full and well and truly spilling over into your blood stream.

Many people find that they are able to eat less overall when intermittent fasting compared to trying to eat numerous ‘small’ meals.

Saint Augustine wisely said:

“Complete abstinence is easier than perfect moderation.”

I think this also applies to our meal timing and portion sizing.

By choosing to eat only when your blood sugar is below YOUR average blood sugar level you can tailor the approach to your current situation and metabolic health.

Waiting until your blood sugar reaches optimal levels is not going to be realistic for most people.  It’s best to start from where you are now and work towards optimal.

In the study Adherence to hunger training using blood sugar monitoring: a feasibility study[5] the researchers found that participants did much better when they set their own personalised blood sugar target rather than waiting until their blood sugar levels reached some optimal target before eating.  The other noteworthy observation from this study was that people who were obese lost a significant amount of weight by using their blood glucose levels to guide when they should eat!

Overweight participants achieved significant weight loss over the two-week period, with an average loss of 1.5 kg (95 % CI 2.2, 0.9) and a corresponding reduction in BMI of 0.6 kg/m2 (95 % CI 0.3, 0.8), p < 0.001).

By contrast, lean participants maintained their weight.

the end game

The long term goal is to achieve an optimal HbA1c of 4.5% which equates to an average blood sugar level of 83 mg/dL (or 4.6 mmol/L).

There are lots of really good reasons to keep your blood glucose and insulin levels in check such as reducing your risk for cancer…[6]

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…heart attack, stroke[7] and a whole range of western diseases.[8]

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People with Type 1 Diabetes following Dr Bernstein’s protocol try to keep their blood glucose within ten points of the optimal target level of 83 mg/dL (4.6 mmol/l).  This means that they will dose with insulin when their blood glucose rises above 93 mg/dL (or 5.2 mmol/l) and then eat to bring their glucose levels back up when they drop below 73mg/dL (or 4.0 mmol/L).

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Someone who has a functioning pancreas but is struggling with insulin resistance, hyperinsulinemia and / or obesity can use a similar process to manage their blood glucose and insulin levels.  But rather than dosing with insulin to bring their blood glucose down (they typically already have more than enough insulin!) they simply delay eating until they burn through the excess blood glucose.

Waiting to eat until your blood glucose levels are below your recent average will ensure that they decrease over time.  Most glucose meters will display the average glucose level for the last seven, fourteen and thirty days so it is easy to tell what your current target is.

If you’re really eager you could go to the trouble of graphing your blood sugar numbers, but in the end, if your seven-day average is less than your fourteen day average then you’re moving in the right direction.

Over time you want to see your average blood glucose levels coming down, so if you see them drifting up then you it’s a sign that you need to intensify your fasting somehow.

Normalising blood sugar and insulin will often lead to optimal weight, particularly if you’re insulin resistant.  However, some people will still need to pay attention to cutting calories once your blood sugar and insulin is normalised.

when not to use this approach

Exercise may raise your blood sugar in the short term due to the body dumping glycogen from your liver into the bloodstream for fuel.  If you don’t eat as much before or after exercise your body will have to replenish the glycogen stores from the energy stores on your body.

There will be times when you’re really hungry or it will be appropriate to eat for social reasons such as a party, family gathering etc.  Periodic feasting is a normal part of our culture.  This system would help you to get back on track and work around these times.

You should also keep in mind that there are other things that affect blood sugar including stress, sleep, sickness, hormones and exercise that you will need to manage and be mindful of when deciding whether to delay a meal due to your blood sugar being high.

Fasting may not be ideal if you’re already stressed, sick, not sleeping well and / or are pushing the exercise envelope.  During these times, it may be better to focus on life maintenance and listen to your appetite.

If you are taking insulin or other blood sugar lowering medications you will need to make sure they are reduced so you do not have to eat to raise your blood sugar because of the medication.

The problem with injected insulin or many other diabetes medications is that, while it may help to reduce blood sugar levels, it also drives the energy back into the cells rather than allowing the stored energy to flow out of storage.

The more you reduce insulin (injected or produced from your own pancreas) the quicker the healing can occur.  However, at the same time it would be prudent to reduce medications progressively to prevent your blood glucose levels from going too low.[10]

High blood sugar levels can be a sign that you’re stressed, exhausted or your hormones are out of whack (including time of the month for females), all of which will lead to insulin resistance.  You can use Heart Rate Variability to track your stress and exhaustion with an app such as Elite HRV which enables you to see when you’re exhausted and need to back off and rest.

If you just don’t feel like fasting and your blood sugar levels are high it’s probably a sign that you need to rest, relax, sleep, meditate, see some real sunlight during the day and stop gazing into the iPad before you go to bed.   Using f.lux on your computer or blue blocking glasses after sunset is worth considering.

While longer therapeutic fasts can be beneficial, a shorter feast / fast cycle that brings your blood sugar levels down to below your average is likely to be more useful to improve your metabolism while reducing the extreme swings in water weight or any concerns that you’re not getting adequate protein to support lean body mass.

ketones and the glucose: ketone index (GKI)

The simplest approach is just to measure your blood sugar levels when you feel hungry and not eat until they drop below your target level.  You could still use this approach even once you have improved your insulin sensitivity to lose weight by targeting even lower blood glucose levels before eating.

Monitoring your blood sugar will work whether you are insulin sensitive or insulin resistant, obese or normal weight.  The body does an amazing job of replenishing your glycogen stores and stabilising your blood glucose whether it be from carbohydrates, gluconeogenesis from amino acids or even gluconeogenesis of fat once you are highly insulin sensitive.

Once you are starting to get your blood sugar levels under control you could start to track your ketones or the glucose: ketone index (GKI).  Decreasing glucose along with rising ketones is a sign that your glycogen stores are being depleted, your insulin levels are reducing and you your hunger is legitimate.[11]

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Tracking the ratio between your glucose and ketones (GKI)[12] and delay eating until your GKI is under a certain level could be a useful strategy if you are aiming for therapeutic ketosis.

Alternatively, you could simply not eat until your ketone levels were greater than a certain level.  You could start with a target ketone level of 0.4 mmol/L and keep winding that up till you achieve your desired results.  However testing blood ketones every time you feel hungry could be expensive.

There is no need to worry about ketones and the GKI though if your average glucose is above 90mg/dL (5.0 mmol/L) because it’s likely that your insulin will be high and your ketones still low.

While all these things are important and useful, make sure to use them as tools to help you live life rather than taking over your life and stressing you out.  Your goals need to be realistic and tailored to your situation.

Hopefully in time this ‘hunger training’ approach will help you build new habits around eating which will mean you won’t need to rely on the testing.

fast well, feast well

Keep in mind if you are eating less food less often you will need to maximise nutrient density when you do eat, including ensuring that you are getting adequate protein to maintain lean muscle mass over the long term.

Best of luck if you chose to try this approach.  I look forward to hearing how you go.  Be sure to share your experience in the comments below.

post last updated May 2017

references

[1] http://bja.oxfordjournals.org/content/85/1/69.long

[2] https://intensivedietarymanagement.com/fatty-pancreas-t2d-9/

[3] http://care.diabetesjournals.org/content/early/2015/11/29/dc15-0750?patientinform-links=yes&legid=diacare;dc15-0750v1

[4] https://intensivedietarymanagement.com/dawn-phenomenon-t2d-8/

[5] http://nutritionandmetabolism.biomedcentral.com/articles/10.1186/s12986-015-0017-2

[6] http://onlinelibrary.wiley.com/doi/10.1002/ijc.29917/epdf

[7] http://cardiab.biomedcentral.com/articles/10.1186/1475-2840-12-164

[8] http://diabesity.ejournals.ca/index.php/diabesity/article/view/19

[9] http://lowcarbbetterhealth.blogspot.com.au/2016/02/day-37-2016-weight-loss-and-blood.html

[10] https://optimisingnutrition.com/2015/08/17/balancing-diet-and-diabetes-medications/

[11] http://www.nature.com/articles/ncomms10580.epdf?shared_access_token=MUKioJXu6KVY753YIDoPVNRgN0jAjWel9jnR3ZoTv0NZFUsLxRRWAKMsrNHEbSj2q0khGxVdwhqgBvlELqp6rtnjRj5ppdqpqF9VFYO_6UzYPSf3Z5ZW4kFdG4GQIZ71IGlh7tQHXrGHJ2Nz7rN5iw-9csWuhb9uHxuz_-28FyOP6Tcmjd1H9Uxq9OwlIQTy

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

fine tuning your diet to suit your goals – Jane

  • Optimising blood glucose, nutrients and gut bacteria can be a delicate balancing act.
  • Some people require a very low carbohydrate approach to achieve normal blood glucose levels, while some may also need to implement a fasting regime as well.
  • Some may also benefit from increased fibre and / or reduced calorie density to improve gut health and achieve further weight loss, however for others this may have unacceptable impacts on their blood glucose.

background

Jane is an experienced ketogenic dieter who has found over years of testing that she is now able to manage her blood sugars to consistently between 70 and 100mg/dL (3.9 to 5.6mmol/L).   Her HbA1c is now 5.1% which is good and her blood lipid numbers are great.

After a long period of fighting and trying to normalise her blood glucose levels using a ketogenic diet, Jane has come to a point where she has stopped monitoring her blood sugars throughout the day and dropped back to occasional checking.

As you can see from the plot below of protein versus net carbs, Jane’s diet is definitely ketogenic (note: the unlabelled points are based on her actual daily food diary, the labelled points are the variations discussed below).

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nutritional analysis of base case diet

The table below shows the comparison of one day from Jane’s food diary with the more than two hundred meals and food diaries that I have analysed to date.  Jane’s base diet ranks at 52 out of 200 when we use the diabetes ranking, so she is doing pretty well overall, with very high scores in the insulin load and protein categories.   As you can see from the scores on the bottom row of the table below, the area where there is still some room for improvement is the fibre as well as vitamins and minerals.

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The nutritional analysis of Jane’s food diary is shown below.  A score of 100 in the nutrient balance and / or the protein quality score would equate to obtaining 100% of the FDA Daily Value (DV) for the various nutrients with 1000 calories.[1]  So  especially given that Jane’s priority is blood glucose control, a score of 40 for the nutrients is good .  A score of 139 for protein quality is excellent , meaning that she is more than meeting her protein requirements.  At 5g per day, her dietary fibre is less than the DV of 25g per day recommended for women.[2]

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with added spinach and mushroom

If Jane wanted to improve her vitamin and mineral score she could add some high fibre nutrient-dense veggies that would not significantly raise blood sugar.  To this end, I have added some extra mushrooms and spinach to the analysis of Jane’s food diary.  The addition of the extra mushroom and spinach produces an improved vitamin and mineral score.  However, this approach would be less ketogenic with 37g of net carbs compared to 15g in the base scenario (see chart and table above).

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with egg

Jane told me that she would be worried these extra carbohydrates from the veggies would raise her blood glucose too much, plus she doesn’t like mushrooms.  She suggested adding egg, which improved the vitamin and mineral score compared to the base but decreased the insulin score as shown below.  The added egg increases the vitamin and mineral score from 40 to 65 (nearly as much as the spinach and mushroom scenario) with only 21g of net carbohydrates per day.

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While the spinach and mushroom option does do better in terms of vitamins and minerals, the egg gives a better total score in the multi criteria analysis.  Hence adding the egg, rather than the spinach and mushrooms would align better with Jane’s goals.

weight loss approach – reduced calorie density and increased fibre

If Jane was looking to reduce body fat and potentially improve her health and vitality through consuming nutrient dense lower calorie density foods she could consider adding more high fibre, low calorie density foods that would make her feel satiated and possibly feed gut bacteria.

Jane says,

I strongly believe in the tie to gut health, enzymes and nutrition as a key.  If LCHF isn’t working then there is some major gut health, hormone or enzyme deficiency going on.

As discussed in the ketogenic fibre article, focusing on a nutrient dense, low calorie density approach that has minimal carbohydrates may help with improvement in both gastrointestinal and overall health.  In the longer term though adding in some more fibrous foods may be beneficial for people to promote good gut bacteria.

The revised food diary shown below has a significant amount of spinach and broccoli and gives a very solid 26g of fibre per day with only 22g of net carbohydrates, which is still “low carb” by most standards.  Some people prefer to use total carbohydrates rather than net carbohydrates.  However, plant based fibre is typically not digestible and thus is unlikely to impact blood sugar significantly.

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While food packaging in the USA shows total carbohydrates with fibre listed separately, in the UK and Australia food labelling already shows net carbohydrates.

This option with egg also has a lower calorie density along with a higher nutrient density compared to the base option meaning that Jane is likely to feel more satiated and find it harder to overeat which may be useful if weight loss is a goal.

Jane may be concerned that this type of approach would adversely affect her blood glucose levels that she’s worked so hard to reduce.  It would be worth going slowly and monitoring post-meal blood sugars while she makes her transition to more nutrient dense high fibre foods.

If she was seeing post meal blood sugars greater than 120 mg/dL (6.7mmol/L), fasting blood sugars drifting above 90 mg/dL (5.0mmol/L) and an average of greater than 100mg/dL (5.4mmol/L) she may want to revert back to her more ketogenic approach.

discussion

Overall, Jane’s ketogenic diet approach is working well for her at the moment, but her situation raises a number of questions.

If Jane was struggling to achieve normal blood sugars with a ketogenic diet, then it is possible that she has a beta cell burnout meaning that her pancreas is no longer able to produce enough insulin (which is not the case given her HbA1c of 5.1%).  If this were the case, then it may be useful to measure her fasting insulin and c-peptide levels to determine whether she is still producing significant amounts of insulin (refer to the article Balancing Diet and Diabetes Medications for more discussion).  However this does not appear to be the case for Jane as she has a good HbA1c although it does require a very highly ketogenic diet approach to achieve this.

Another approach to reducing blood sugars is to focus on stripping the glucagon from the liver through fasting and more intense carbohydrate restriction (as per Westman’s carbohydrate restriction[3] and Fung’s fasting protocols[4]).   However with a very low carbohydrate diet of 1600 calories per day Jane probably does not need to pursue further calorie or glucose restriction, although it would be interesting to see if some periods of fasting help to further improve insulin sensitivity.

Yet another approach would be to focus on healing the gut and other factors that cause someone to become insulin resistant.  Inflammation and infection will often lead to insulin resistance.  If diabetes is an autoimmunity issue that starts in the gut, then the question is what can we do to balance gut bacteria that will enable the body to heal through maximising nutrition together with probiotics and prebiotics (as per Perlmutter[5] and the paleo approach to diabetes[6])?

If Jane desires to go down this road she might need to tolerate slightly higher blood sugars as her body adjusts to plant-based carbohydrates (refer to the Ketogenic Fibre article for a list of foods that will provide fibre without raising blood glucose levels).  Over time, she may find that blood glucose levels settle down as the gastrointestinal microflora balance adapts and she progresses beyond the initial physiological insulin resistance.

As you can see, there is no simple or perfect approach here but rather a number of options that may be useful to consider and test depending on the individual’s circumstances and goals.

 

references

[1] http://nutritiondata.self.com/help/nutrient-balance-indicator

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

[3] https://www.youtube.com/watch?v=dSLf4bzAyOM

[4] https://intensivedietarymanagement.com/tag/intermittent-fasting/

[5] http://www.drperlmutter.com/new-understanding-obesity-epidemic/

[6] http://robbwolf.com/category/real-life-testimonials/diabetes-real-life-testimonials/

slow-cooked “Heart on Fire” with creamed kale

This recipe for slow cooked “heart on fire” with creamed kale is from Mark Sisson’s blog (see recipe here).

It has a nice range of nutrient dense meat (heart), spices and nutrient dense vegetables.

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Although heart is generally considered to be highly nutrient dense, I have been surprised at how hard it has been to find recipes that involve organ meats. The recipes that I have analysed don’t do spectacularly on the nutrient density rankings, mostly because they use not so good ingredients to mask the strong flavors which means the recipe doesn’t do so well overall nutritionally.

Chicken heart is certainly a nutrient dense meat, however it’s not vastly superior to other complete protein options such as sardines or whole eggs.

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Venturing out to try heart or liver is a great option if you’re into that sort of thing, but not imperative to get good quality protein.

comparison of protein sources

net carbs

insulin load carb insulin fat protein fibre
10g 27g 38% 61% 24%

9g