- 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.
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).
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.
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. 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.
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).
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.
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.
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.
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.
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 and Fung’s fasting protocols). 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 and the paleo approach to diabetes)?
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.