keto… do you want some more?

key points

  • “Keto” is booming!   But there is still a lot of confusion about what exactly constitutes “optimal ketosis”.
  • Most of the magic of ketosis occurs when you burn your own body fat rather than eat more dietary fat or consume exogenous ketones.
  • If your goal is weight loss or diabetes management, chase lower blood glucose levels, not higher ketone levels.
  • Our bodies switch to burning more fat via ketogenesis when we eat less digestible carbohydrates and protein available.
  • While many people get caught up chasing ‘optimal ketosis’, anything above 0.2 mmol/L with lower blood sugar levels is a sign that your insulin sensitivity and metabolic health is improving.
  • Eating ‘fat to satiety’ on a low carb or ketogenic diet can help you achieve ‘non-diabetic’ blood sugar levels.   However, some degree of self-discipline may still be required to achieve optimal health and desirable body fat levels.

Keto is so hot right now!

Every woman and her cat seem to be getting on the keto bandwagon.

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Whether it be cookbooks, Facebook groups or forums, keto is booming!

If everyone else is getting on the keto train then surely you need some?

And more must be better?

Right?

If you’re not doing it yet then maybe you’re missing out?

Or like every exponential trend, is there a crash just over the horizon?

Like tulip bulbs in the 1630s?

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Or perhaps Bitcoin right now?

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My keto journey

Personally, I’ve had a keen interest in ketosis for a while.

I was into keto before it was cool.

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I followed Dave Asprey’s Bulletproof coffcoffeeze.  I even bought a bunch of his expensive mycotoxin free beans.

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I eagerly followed Jimmy Moore’s updates during his n=1 ketosis experiment during 2012.

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I was so eager to follow in his footsteps as soon as I could!

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I got hold of Keto Clarity as soon as it was released.  I started adding butter and MCT oil to my coffee and eating liberal amounts of cheese, cream and coconut products in an effort to get my ketone values into what I understood to be the “optimal ketone zone”.[1]

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I spent a good chunk of money on strips to test my blood ketones regularly to see if I was achieving ‘optimal ketosis’.

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Calories and energy balance didn’t matter.

I had faith.

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But unfortunately, I wasn’t one of the blessed that could ‘eat fat to satiety’ and be as lean and healthy as I’d hoped.

The picture below is my work profile shot a year or so after chasing higher ketones with more refined dietary fat.

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I was as heavy as I’d ever been, had early signs of fatty liver and prediabetes.

I realise now that I had been trying to drive exogenous ketosis with lots of extra dietary fat.

What I really needed was to learn how to achieve endogenous ketosis to burn off my unwanted body fat.

My quest to understand what went wrong has taken me on a fascinating journey in an effort to manage my own health as well as to understand how to assist my wife Monica better manage her type 1 diabetes.

In this post, I hope to share some of my learnings and insights to help people get what they really need from their keto journey and avoid the common pitfalls.

Virta Facebook Live Q&A

I recently had the opportunity to pose some of my most pressing questions about optimal ketone levels and protein intake to the Godfather of Keto, Dr Stephen Phinney in a recent Facebook live Q&A.

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Dr Phinney addressed one of my questions in the live broadcast as well as responding in writing in writing on the Virta blog.

I have included my question on optimal ketone levels and Dr Phinney’s response below along with my own additional thoughts.

But first, I think it’s important to understand what ketosis actually is.

What is ketosis?

Ketosis occurs when there is a lack of Oxaloacetate from non-fibre digestible carbohydrates and protein to enable fat to be oxidised in the Krebs cycle.    When Oxaloacetate availability reduces, the body produces Acetoacetyl CoA and Acetoacetate (AcAc) via ketosis.

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You can also think of this in terms of insulin load.  That is, when the net carbs and protein in the diet are reduced we switch to burn more of our fat via ketogenesis rather than in the Krebs cycle.

I used to think that we were only burning fat when via ketosis, but I now understand that’s not correct.  Ketosis is just how we burn fat when the Kreb cycle can’t operate normally.  Ketosis is an important biochemical process that allowed us to survive through times when food was scarce.

As described by Dr David Sinclair in this video, lots of good things happen during periods of low energy availability (e.g. increased autophagy, AND+ and SIRT1).  Our bodies go into emergency repair mode to increase our chances of being around to procreate in future times of plenty.

Energy restriction is the only thing that has conclusively been proved to promote longevity in humans.  But it’s hard, so it’s not very popular.  When food is available, left to our own devices, our bodies tend to store up a little extra fat for the winter.  Unfortunately, in our modern environment, winter never comes.

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If your NAD+ levels are lower, more Acetoacetate (AcAc) will be converted to Beta-hydroxybutyrate (BHB) in the blood.  If your NADH+:NADH ratio is high there will be more Acetoacetate in circulation.  Acetone can be thought of as the vapour that is released from Acetoacetate.   So, if less Acetoacetate is being converted to BHB, you will register higher breath ketones.  Chris Masterjohn explains this in more detail in this video.

Reduced NAD+ levels are associated with ageing, and increased NADH levels are associated with over fueling and diabetes.  Thus, high levels of BHB and low levels of breath acetone are not a good sign.

You may be interested to know that fat loss from the body is better correlated with higher breath acetone levels rather than ketones in the blood.[2]

Personally, I find when I take Niacin supplements (vitamin B3 increases NAD+) my BHB plummets and my breath acetone skyrockets.

In summary, the amount of beta-hydroxybutyrate in your bloodstream at any point in time is influenced by the amount of fat ingested, your NAD+:NADH ratio as well as the rate at which they are using BHB.

What are normal ketone levels?

We all like to compare others to others to understand if we are normal.

I thought it would be interesting to crowdsource some data to understand what normal ketone levels are in people following a low carb or ketogenic diet.  I wanted to understand if everyone was struggling to reach the ‘optimal ketone zone’ like I was.

The chart below shows the compilation of more than three thousand blood ketone and glucose data points crowdsourced from people following a low carb or ketogenic diet (with particular thanks to Michel from Ketonix for the anonymous data).  Ketone values are shown in blue on the bottom and glucose is in orange on top.

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Diabetic ketoacidosis

Someone with uncontrolled type 1 diabetes will have a very low NAD+:NADH ratio and hence very high levels of BHB (i.e. greater than 8 mmol/L).  This is termed “ketoacidosis” and is accompanied by very high blood glucose levels.  Someone with uncontrolled type 1 diabetes would be off the chart to the right.

High levels of BHB are dangerous because they are acidic.  However, people who do not have Type 1 diabetes typically have blood ketone values less than 4.0mmol/L.  People with a functioning pancreas do not need to fear acidic ketones, particularly if they are sitting to the left of this chart with lower levels of energy floating around in their blood.

The bloodstream, our metabolic highway

You can think of our bloodstream as our metabolic highway that helps get the energy to the cells that need it.  We want enough energy in the blood to fuel the body, but not so much that a traffic jam occurs.

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Really high levels of glucose in the bloodstream lead to glycation.  Similarly, high levels of free fatty acids lead to oxidised LDL which increases your risk of heart disease.

If your bloodstream is full like syrup with excess glucose, ketones and fatty acids then the energy and nutrients can’t get where they need to go.  Your kidneys will be working overtime clearing out the nutrients from the blood that your body does not require.

Your body raises insulin in an effort to stop energy flowing out of storage while you are still using up the energy in your blood.

When your bloodstream is clogged with energy there will be no opportunity for the body to cleanse and undertake autophagy.  Detoxification won’t be able to occur as effectively, and your fat stores will continue to build up toxins.

Exogenous vs endogenous ketosis

I now realise where I went wrong in my early keto journey was that I didn’t understand the difference between exogenous and endogenous ketosis.

I now realise that I was trying to address my pre-diabetes and obesity with a classical or therapeutic ketogenic diet which is intended to be used for epilepsy, cancer, Alzheimer’s, Parkinson’s and dementia.

All this excess energy was just exacerbating the situation I was trying to solve.

Exogenous ketosis

The chart below shows the blood glucose and ketone levels during exogenous ketosis.  While glucose may not be high, but we have high levels of ketones and likely higher levels of triglycerides in the bloodstream largely from external sources.

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This may be helpful in a situation such as epilepsy, Alzheimer’s, Parkinson’s or dementia where glucose is not being processed efficiently by the brain.  Excess glucose is thought to fuel the growth of some cancers, so reducing glucose and increasing ketones enables us to fuel the brain while not feeding the cancer cells.

Endogenous ketosis

The chart below shows what happens in endogenous ketosis.  In fasting or energy restriction your blood sugar will decrease.

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As you can see from this chart, your blood ketones may not be as high due to your high NAD+:NADH ratio and the fact that you are not pushing in large amounts of external fat.  Ketones will also be used for energy rather than building up in the bloodstream.

In this lower energy state, your body will be pulling fat from your belly and bum to offset the deficit of energy from glucose and ketones in the bloodstream.

Your blood will no longer be a congested and the toxins will be able to flow out of your fat stores.  Your kidneys will cleanse your bloodstream, and you will excrete the waste that was stored in your fat.

You will increase autophagy as you old proteins, and pre-cancerous cells are cleansed and eaten up by your body.  Your insulin levels will also decrease, and your fat stores will become insulin sensitive again.

Without constant incoming energy, the fat in your pancreas, liver, heart, brain, eyes etc will then be used for energy.  You will feel younger and lighter and start to think more clearly!   You will effectively be slowing the aging process!

Ketosis vs diabetes and obesity

Someone managing diabetes and/or seeking weight loss should ideally target a lower overall level of energy in their bloodstream.  Having less energy in the blood, whether in the form of glucose, ketones or free fatty acids, forces the body to supply more energy from body fat.

The chart below shows the levels of blood ketones that relate to higher and lower levels of glucose and ‘total energy’ from glucose and ketones.

The three thousand blood ketone and glucose levels have been divided into five ‘bins’ based on their total energy content.  The smallest is shown on the left with the largest total energy shown on the right.

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This data suggests that good metabolic health is characterised by not having excessive levels of energy floating around in the bloodstream.  Lower glucose levels tend to correlate with lower blood ketones.  The lowest blood glucose levels are associated with a blood ketone level of about 0.3 to 0.7mmol/L.

Virta ketone data

When I recently re-read the paper detailing the results of the first ten weeks of the Virta trial I was intrigued to see that, even though they were targeting ‘nutritional ketosis’  the average BHB level achieved was only just above the cut off for nutritional ketosis.  The average BHB was 0.6mmol/L with a standard deviation of 0.6 mmol/L.

To better understand what this means, the chart below, many people had ketone levels below the cut off for nutritional ketosis of 0.5 mmol/L.  The largest ‘bin’ of ketone values as 0.1 to 0.3 mmol/L.[3]  The second largest grouping was 0.3 to 0.5 mmol/L.

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It struck me that these blood ketone levels aligned reasonably closely with the values shown in my crowdsourced data.  My question to Virta and Dr Phinney’s response is shown below:

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Dr Phinney’s comment that it was the people with the higher ketone levels that experienced better results in the long term made me think of the relationship between ketones and blood glucose which is also based on the crowdsourced data.

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In fasting, people who are more insulin sensitive can more easily produce ketones when there is no food, while people with high levels of insulin have high blood sugar levels and tend to have lower levels of ketones as shown in the chart below.

So perhaps the people who did the best were the ones that were already more insulin sensitive and thus were able to go longer periods between food, especially once the insulin load of their diet was reduced and their blood sugar and insulin levels came down closer normal levels?

What does all this mean in practice?

At this point, you’re probably confused.  Is it even worth testing ketones?  And if I do, what values should I be targeting?

My conclusion, after doing a lot of self-testing as well as analysis of a lot of other people’s data is that, unless you require ketosis for therapeutic purposes your blood ketone levels probably don’t matter that much.

Some level of blood ketones is good to have (say 0.2 mmol/L or more), but more is not necessarily better.

And for goodness sake, don’t go chasing higher blood ketones with more dietary fat if your goal is fat loss from your body!

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For people trying to manage obesity and/or diabetes, ketosis is a fascinating side effect of a lower energy state when you have less carbohydrate and protein to burn.  But it is not the end goal.  Ketosis is part of the process that occurs as we burn out own body fat.

So how do I optimise my blood sugars?

A diet with a lower insulin load (i.e. less non-fibre carbohydrates and less insulinogenic protein) will enable someone with diabetes to stabilise their blood glucose levels.  They will require less insulin so their pancreas can more easily keep up to maintain healthy blood glucose levels.

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Stable blood sugars and removal of processed carbohydrates often helps to normalise appetite and spontaneous weight loss.

As body fat stores become less full your adipose tissue will become more insulin sensitive and can then absorb the day to day energy flux without needing to spill excess energy into the bloodstream.  Because your body fat is doing the job properly, you won’t see high levels of blood sugar in your blood.

Your body is always rebalancing your fuel system (i.e. glucose, ketones and free fatty acids) depending on your needs and dietary energy sources.

We can store a little bit of glucose in our bloodstream and liver, but the major fuel tank is our fat stores.  When our adipose tissue is full and can’t take anymore everything else backs up and overflows.

How to stay below your “Personal Fat Threshold”

Fascinating recent work by Professor Roy Taylor at Newcastle University in the UK has shown that reducing fat from the vital organs like the pancreas can actually reverse diabetes.[4]

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Professor Taylor coined the term ‘Personal Fat Threshold’ which is the point at which your adipose tissue can no longer easily absorb the extra energy from the food we eat and starts to send more of it to other places in our body.  It’s like our fat storage balloon is full.[5]

Once we exceed our personal fat threshold any extra is energy shuttled off to the bloodstream in the form of high glucose, high free fatty acids and higher ketones) as well as the other parts of the body that are more insulin sensitive than our adipose tissue such as our liver, pancreas, heart, eyes, kidney, brain and heart).

The problem however with Professor Taylor’s approach was that it was an 800 calorie per day short-term intervention based on Optifast meal replacement shakes. The ideal approach would be to design a nutritious set of foods that would provide the nutrients you need without excessive energy. 

Many people find that a low carb diet will help stabilise blood sugar levels.  However, many, if not most, people find that they need to restrict energy intake and/or increase the nutrient:energy ratio of their diet in order to achieve the blood glucose control and body fat levels that are associated with optimal longevity.  This can be achieved through intermittent fasting, time restricted feeding, meal skipping,  ‘clean eating’, calorie counting or whatever works for you.

Regardless of how you feel about any of these concepts, you need to do whatever it takes to reduce the inputs to the point that you see the energy in your bloodstream decrease.  How much discipline and deprivation you want to enforce on yourself depends on how close you want to get to optimal.

While it’s good to see your body fat levels reducing, measuring your blood sugar is probably the most effective way to get a cost-effective and immediate understanding of whether you actually need to eat (see How to use your glucose meter as a fuel gauge for more details on this concept).

The figures below show the relationship between HbA1c to various symptoms of metabolic disease such as diabetes, heart disease and stroke.[6]

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All-cause mortality is lowest with an HbA1c of somewhere between 4.5 and 5.0%.[7]image13.jpg

Can we achieve optimal in our modern environment?

This Australian Aboriginal hunter from more than 100 years ago is my favourite example of optimal metabolic health.

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Everything he could find to eat would have been filled with nutrients.  He wouldn’t have overeaten because he had to hunt or gather everything, and that took a lot of effort.

Every year or so he would have had a period of externally enforced fasting when food wasn’t so plentiful.  And if he was the fattest and slowest in his tribe he might have been prey to wild animals.

Today we like to reminisce about paleo and ancestral times.  However, I don’t think we can ever go back to mimic how this guy lived, even if we wanted to.

While we can get unprocessed organic fairly nutrient dense foods, we will probably never achieve the food scarcity context that he had.

Today food is fairly cheap and easy to get hold of.  And whenever when we eat ‘to satiety’ we are programmed by evolution to prepare for a famine on a long boat ride where only the people who could store energy survived.

Food is pleasure.

Food is entertainment.

Food is social connection.

Food is emotional.

People like to rail against the idea that we might need to limit our energy intake.  However, in today’s context, I think we need to work out how to recreate the useful elements of ‘the good old days’ in a modern context.

Unless we’re prepared to live in the desert and leave our credit cards behind, perhaps things like periods of fasting to reduce our blood glucose levels, gyms to build strength, energy tracking apps like Cronometer to ensure we are eating nutritious food (and not too much of it) all play a role in our modern context?

It’s not going to be a popular concept, but some level of deprivation or self-control may be necessary if you want to achieve optimal health and delay the diseases of aging.

It’s OK if you don’t want to go all in and invest everything it takes to achieve optimal health, but it’s still useful to understand how to get even part of the way there.

Introducing, our new toy!   The Nutrient Optimiser

It can be confusing to know how much of each macronutrient you should be eating.  Everyone has different goals and circumstances.

Over the last few months, I’ve been working with a very talented programmer, Alex Zotov, to develop some handy software called the Nutrient Optimiser to help people navigate all this information and help people put it into practice.

The table below shows how we how we segregate people based on their different goals based on your blood sugar levels, HbA1c, waist:height ratio and trigliceride:HDL ratio.  From there we can target the most nutrient dense foods and meals while also keeping your blood sugars stable, fueling your activity or help you to lose body fat.

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If you do have diabetes, then a low carb/keto diet will help stabilise your blood sugars and will often help to stabilise your appetite.  But then, as you improve your health you can continue to refine your food choices to and increase the nutrient density of your diet even more.

Meanwhile, if you’ve got great blood sugars but want to lose body fat there’s no reason to be eating a super high fat therapeutic ketogenic diet designed to control epileptic seizures.

The first instalment of the Nutrient Optmiser is a free calculator that will help you identify the ideal macronutrient ranges, energy intake and as well as a shortlist of optimal foods and meals to suit your goals.  We’d love you to check it and let us know what you think.   We hope it will help a lot of people avoid the confusion of keto and move forward towards optimal.

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references

[1]https://www.amazon.com.au/Keto-Clarity-Definitive-Benefits-Low-Carb/dp/1628600071

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

[3]http://assets.virtahealth.com/docs/Virta_Clinic_10-week_outcomes.pdf

[4]http://www.ncl.ac.uk/press/articles/archive/2017/09/type2diabetesisreversible/

[5] https://www.ncbi.nlm.nih.gov/pubmed/25515001

[6]https://cardiab.biomedcentral.com/articles/10.1186/1475-2840-12-164

[7]http://circoutcomes.ahajournals.org/content/3/6/661

[8]https://www.perfectketo.com/how-too-much-protein-is-bad-for-ketosis/

[9]https://nutritionfacts.org/video/the-great-protein-fiasco/

[10]https://digitalcommons.wku.edu/ijes/vol10/iss8/16/

[11]https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

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

micros > macros?

Most of the time, when it comes to nutrition, we like to think in terms of macronutrients.

  • Carbs.
  • Fat.
  • Protein.
  • Fibre.

Simple!

But maybe too simple?

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In the good old days, before your food was grown in nutrient depleted soil and the creation of nutrient-poor processed frankenfood, we just ate food.  We didn’t have to worry about micronutrients.  Pretty much everything we ate was full of them!

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These days micronutrients are harder to come by.  In a number of previous articles, I have suggested that maximising micronutrients as your first priority (before calories or macronutrients) will likely to be a more useful guide to help us genuinely optimise our nutrition.

Unfortunately, it’s hard to think in terms of micronutrients.  With thirty-four essential nutrients and many more conditionally-essential and beneficial nutrients and compounds in the food we eat, there are just too many moving parts to keep in our working memory.

Before the creation of hyper-palatable flavoured and coloured foods, our appetite was a useful to help us seek out the nutrients we need.  Over the years it had come to be the perfect nutrient optimiser, prioritising the foods we needed at any point in time.  Unfortunately, in our modern food environment, our paleolithic instincts are no match for modern food chemistry.

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Today, we need a little extra help to discern fake foods from the real foods that actually contain the nutrients we need to thrive.

This article outlines how we can utilise macronutrients to assist us, like training wheels, to help us get pretty close ot ideal nutrition.  We can then focus on eating nutrient-dense foods that will help us thrive and to enable us to look, feel and perform at our best.

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Macronutrient wars

Many diet communities built around a specific macronutrient profile that they believe is optimal.

Different people believe in a wide range of macronutrient philosophies as the cornerstone of their nutritional approach.  One of the many variations is IIFYM.

If It Fits Your Macros (IIFYM) or Flexible Dieting was a trend in the bodybuilding community based on the idea that you could eat pretty much anything you wanted as long as you hit your macro targets.[1] [2] [3]

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IIFYM blossomed as a response to the ‘clean eating’ trend that grew around the Paleo diet[4] trend which emphasised food quality and was largely ‘macro agnostic’.

With IIFYM:

  • protein is set based on your lean body mass (LBM) and activity levels (typically 1.8g/kg LBM),
  • energy intake is calculated and then tweaked based on your desired rate of loss/gain,
  • fat is generally set at 25%, and
  • the remainder of your energy requirement is filled with carbs.[5]

IIFYM… the good

There are some good things about IIFYM / flexible including:

  1. It’s simple.
  2. It avoids macronutrient extremes which often drive micronutrient deficiencies.[6]
  3. A consistent energy deficit will work for most people, particularly the young fitness enthusiast who does not have diabetes.

IIFYM… the bad

However, there are a number of downsides to the IIFYM / Flexible Dieting approach, such as:

  1. No consideration of micronutrients.  Food quality becomes critical when restricting quantity over the long term to avoid deficiencies and cravings.[7]
  2. Little emphasis is placed on food quality.  While they might fit your macros, low nutrient density foods can be hyper-palatable and lead to overeating.  Foods with a higher nutrient density are more likely to be satiating, have a lower energy density and be harder to overeat.   Someone can get all their food from processed packaged foods and still comply with the IIFYM approach.
  3. Doesn’t cater well to people who are insulin resistant/diabetic.
  4. Recent research does not support the minimisation of dietary fat.  While too much refined fat is not optimal, the fat that comes with nutritious whole food should not be a concern for most people.
  5. Tracking specific macros and calories replaces a neurosis about micromanaging food quality with an obsession with hitting particular macro targets.
  6. It may be hard to hit exact macronutrient targets with whole foods.

The minimum effective dose of macros

In reality, there is a range of macronutrient that will give you a substantial level of essential micronutrients.

The article Nutrition… How to Get the Minimum Effective Dose outlined the macronutrient ranges that give us the best chance of getting a reasonable micronutrient profile.

The vertical axis in the charts below shows the Nutrient Density Score which is a measure of the amount of micronutrients in a range of foods.

As shown in the example below, if we could get three times the recommended daily intake of all the thirty-four essential nutrients, we would get a perfect nutrient score of 100%.   There is probably limited benefit in getting more than three times the recommended daily intake of a particular nutrient.  At that point, you’ll likely benefit by focusing on foods that contain the nutrients you are not getting as much of.

I have calculated the nutrient density score for a range of dietary approaches to understand the relationship between micronutrient adequacy and macronutrients.  Check out the detail in this post if you’re interested.

Protein

Of all the nutrients, protein has the highest correlation with nutrient density.

If we assume a nutrient density score of 70% as our minimum effective dose of nutrition (as denoted by the red line on the chart below), we can get a reasonable nutritional outcome when our protein intake is at least 19% of our energy intake.

Nutrient density seems to peak when we get around 45% of our energy from protein.  .

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If you have ever tried to more protein and track your intake, you will appreciate how hard it actually is to hit 45% of your energy intake from protein!   As you increase protein intake to more than 45% of calories, you would need to depend more and more on processed foods, so the overall nutrient density decreases.

The minimum effective dose level of 19% of energy happens to align reasonably well with 1.8g/kg LBM protein which aligns IIFYM recommendation for protein.  This is also aligns with the point at which strength gains start to plateau for strength athletes as shown in the chart from Lemon below.

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Protein even more important when we are trying to lose weight.  Recent research suggests that our need for protein increases if we want to prevent loss of lean muscle mass in a significant energy deficit.

If we are active and/or doing resistance training, then our requirement for protein is even higher.  As shown in the chart below from a recent review paper by Stuart Phillips,[8] lean muscle mass is best preserved when we have at least 2.6g/kg total body weight (BW) protein if we are targeting an aggressive deficit (e.g. 35%).  If we are chasing a less aggressive energy deficit, then 1.5 g/kg BW protein seems to be adequate.image38.png

So, unless you require a therapeutic ketogenic diet (i.e. as an adjunct treatment for cancer, epilepsy, Alzheimer’s, Parkinson’s, etc.), it appears prudent to think of 1.8g/kg LBM as a minimum protein intake.  Higher intakes will likely be beneficial if your goal is to maximise nutrient density or lose fat without losing muscle.

As an aside, you needn’t worry about ‘too much protein kicking you out of ketosis’   The images below are from my recent Ketogains Bootcamp where I was eating plenty of protein, had low blood glucose levels and plenty of endogenous blood and breath ketones from my own body fat. 

As detailed in the Optimal ketone and blood sugar levels for ketosis article, if you are trying to lose weight or manage diabetes you really want to drive a low energy state in your bloodstream  If you are burning body fat and/or are decreasing your blood sugar levels then ketones will come along for the ride.  You don’t need to active chase them or track them.

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The chart below shows the nutrient profile we get when we minimise protein.

There is a concerning trend of people trying to minimise protein to minimise insulin and mTOR.  While these things are not good in excess, neither is missing out on essential nutrients of having consumed excessive amounts of energy to get the nutrients you need.

Given that not consuming an excessive amount of energy is the only thing that has been proved to extend lifespan in human it makes a lot more sense to me to increase your nutrient : energy ratio so you don’t have to eat as much to get the nutrients you need.

Carbohydrates

While the optimum intake of non-fibre carbohydrate is about 30%, it seems that the minimum effective dose of non-fibre carbohydrates is effectively zero.

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Although we can get lots of vitamins and minerals from non-starchy veggies, people who do not feel the need to consume plants in their diet can get a substantial amount of nutrition from organ meats, shellfish and the like with minimal carbs.

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The chart below shows the nutrient profile you could acheive if you focused on the most nutrient dense animal based foods.

If you are metabolically healthy, there’s nothing wrong with consuming up to 65% carbohydrates, particularly if they are from unprocessed sources.  However, nutrient density starts to fall off beyond 65% as processed grains and sugars begin to dominate your diet.

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The chart below shows the nutrient profile that you could achieve if you focused on the most nutrient dense plant-based foods.

Regardless of your dietary preferences, ethical position or religious beliefs, quantifying nutrient density is an exciting tool to help you optimise your food choices and find optimal nutrition within the wide range of reasonable carbohydrate intake levels.

Fat

Although fat doesn’t correlate well with nutrient density,[9] it seems we struggle to get a good nutritional profile with less than about 10% dietary fat (or about 0.4g/kg LBM dietary fat).

At the other extreme, we could consume up to around 65% of our energy from fat without having a detrimental impact on our nutritional profile.    Similar to carbohydrates, it starts to get harder to get a broad range of essential micronutrients if we are getting more than 65% of our energy intake from fat.

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The proportion of insulinogenic calories

The percentage of insulinogenic calories is a measure of the insulin we require to metabolise our food due to non-fibre carbohydrates and protein it contains.[10] [11] For someone who is metabolically healthy, insulin load does not need to be a major concern.

Optimal nutrient density seems to occur around 40% insulinogenic calories.   Diets with more than 65% insulinogenic calories tend to be very low fat, very low in protein or very high in processed carbohydrates.   Similarly, our nutritional profile with a very high fat very low insulin load diet is not so flash either.

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I have drawn three windows on the chart of % insulinogenic vs nutrient density score to show suggested target ranges for:

  1. someone who is insulin resistant has prediabetes or knows they have a family history of diabetes,
  2. someone with diabetes who needs to follow a low carb or nutritional ketogenic approach to manage their blood sugar, and
  3. therapeutic ketosis.

If you are insulin resistant or have a family history of diabetes, then keeping your insulin load below 50% is likely a good idea.

If you already have diabetes, then lowering your insulin load to less than 25% of your energy requirement will help stabilise blood sugar and insulin levels.  You also need to keep an eye on nutrient density so you can build health with the food you are eating.  The chart below shows the nutrient profile you can acheive with a nutrient dense low carb approach.  

Meanwhile, someone who requires therapeutic ketosis (for the treatment of cancer, epilepsy, Alzheimer’s, Parkinson’s etc.) typically requires an insulin load less than 15% of their energy requirement to see therapeutic benefits.  The chart below shows the nutrient profile that you can achieve with a high-fat ketogenic diet if you focus on maximising nutrient density.

However, keep in mind that driving your insulin load unnecessarily low can lead to a poor nutritional outcome.   The chart below shows the nutrinet profile of the most ketogenic foods without consdieration of nutrient density.

Personally, I think you need to find the balance between insulin load and nutrient density that works for you.  Ideally, a therapeutic ketogenic approach would only a short-term undertaking until the condition stabilises and you can transition to a nutrient dense low carb approach for maintenance.

Minimum effective dose + nutrient density for the win!

The table below shows the guidelines for the minimum effective dose of protein, fat and insulin load for different goals in terms of your lean body mass (LBM).

  • In all but the therapeutic ketosis scenario, we should aim to hit our 1.8g/kg LBM of protein.
  • We may need a lower protein intake to achieve therapeutic levels of ketosis.
  • In the therapeutic ketosis, diabetes and insulin resistant scenarios we limit insulin load to 1.1, 1.8 and 2.9g/kg LBM respectively to enable the pancreas to keep up and maintain healthy blood sugar levels. This will mean you need to reduce carbohydrates, and to a lesser extent protein.
approach min protein

(g/kg LBM)

min fat

(g/kg LBM)

max insulin load

(g/kg LBM)

therapeutic ketosis 0.8 0.4 1.1
diabetes / nutritional ketosis 1.8 0.4 1.8
weight loss (insulin resistant) 1.8 0.4 2.9
weight loss (insulin sensitive) 1.8 0.4
most nutrient dense 1.8 0.4
nutrient dense maintenance 1.8 0.4
bodybuilder (bulking) 1.8 0.4
endurance athlete 1.8 0.4

Once we have the protein, fat and insulin load ranges set, we are free, unencumbered by concerns about meeting theoretical macronutrient targets, to fill the rest of our diet with foods and meals that are most suited to our goals.

These macronutrient windows function a bit like bumper rails for a child at a bowling alley.  As long as you stick within those ranges, you have a good chance of getting a reasonable nutritional outcome.

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Once you learn to focus on nutrient dense foods, you will no longer need the bumper rails.

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The table below shows how the parameters of insulin load, energy density and nutrient density are used to optimise our food choices to suit our goals.  In some cases (i.e. weight gain or loss) we may intentionally focus on managing energy intake.  For most people, focusing on more nutrient-dense foods will get you most of the way.

approach insulin load energy density nutrient density target calories
therapeutic ketogenic very low lower
diabetes / nutritional ketosis low lower adequate
weight loss (insulin resistant) low low good lower
weight loss (insulin sensitive) lowest maximum very low
most nutrient dense maximum
nutrient dense maintenance high high
bodybuilder (bulking) high good higher
endurance athlete very high high

How to set your target energy intake

If you are trying to lose weight and going to the effort of tracking, it is useful to have an upper limit energy intake that you make sure you don’t exceed.

While there are many inaccuracies involved in our energy in and energy out calculations, tracking your food in an app like Cronometer can be a useful self-education tool to understand the quantity and quality of your diet.

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Most macro calculators calculate your Basal Metabolic Rate (BMR) based on your lean body mass (LBM) and activity levels.  From this, you can estimate the amount of energy you might need to gain weight or the amount you will need to limit to lose weight.

These formulas, while a useful starting point, are only indicative, and should be used as a starting point.  I’ve run the Nutrient Optimiser analysis for plenty of people who are lean but eating a lot more calories than you might expect.  Conversely, many people who are obese seem to be eating much less than you might think they would be.  This may be in part due to measurement error or optimism bias, but everybody’s metabolism seems to be unique due to a wide range of factors.

The best way to determine your actual energy requirement is to track your intake and reduce or increase from there to ensure you are gaining or losing as required.  This is an iterative process based on your long-term trend.

Maximum rate of fat loss

The maximum rate of fat loss you can sustain without significant muscle loss is influenced by your current body fat levels.  Someone with a lot more body fat might be able to maintain a larger energy deficit than someone who is already lean.

The paper A limit on the energy transfer rate from the human fat store in hypophagia (Alpert, 2005) proposed that this maximum rate of fat loss is 31 calories per pound of body fat.[12]  According to Alex Ritson, in a recent Sigma Nutrition podcasts, this was later revised down to a maximum rate of fat loss of 21 calories per pound of body fat without losing significant muscle mass.[13]

While you may not want to target this maximum rate deficit every day, it is useful to be aware of this number.  If you don’t feel hungry, there is no need to keep eating to hit some arbitrary energy intake above this.

The table below shows an example of what this might look like in practice.

  obese lean
weight (kg) 110 70
weight (lb) 242 154
LBM (lbs) 157 135
% BF 35% 12%
BF (lbs) 85 18
BMR 2106 1871
max deficit (cals) 1,785 378
max deficit (%) 85% 20%

The obese person can nearly meet their entire maintenance energy intake from body fat while the lean person could only mobilise enough body fat to provide about a fifth their energy requirements.

Image result for fat and skinny

While out might have enough body fat to survive an extended famine, I wouldn’t recommend fasting for extended periods without paying attention to periods of nutrient-dense refeeding.

Research into the Protein Sparing Modified Fast suggests that nitrogen balance is maintained with a minimum of 1.4g/kg of ideal body weight for men and 1.2g/kg of ideal body weight for women.[14] [15]

Once we account for body fat, 1.4 g/kg IBW ends up pretty close to the 1.8g/kg LBM minimum effective dose level discussed above).

So it seems reasonable to use 1.8g/kg LBM protein plus 0.4g/kg LBM fat as an absolute minimum energy intake to make sure you can get the nutrients you need.

Should I keep eating until I hit my calorie target if I’m not hungry?

Many people find their appetite stabilises once they take out refined carbohydrates from their diet and stabilise their blood sugar levels.  Others find that focusing on nutrient-dense foods decrease their appetite and lead to spontaneous satiety.[16]  Meanwhile, others just find it tough to keep within their calorie limits.[17]  The bottom line here is, if you have obtained your minimum protein intake to preserve your lean muscle mass, there is no real need to keep eating if you don’t feel hungry.

Rather than some specific target, I think it is much more useful to think in terms of a range of energy intake that will enable you to reach your goals.  If you’re hungry there is no harm eating up to your upper limit calorie intake.  However, if you are trying to lose weight, then there is no point eating more than you need to to get the nutrients you need.

The daily thought process for someone following this process would be…

  1. Have I met my minimum calorie target?  If not, keep eating nutrient-dense foods.
  2. Have I met my minimum protein intake?  If not, keep eating nutrient-dense foods.
  3. Do I feel hungry?  If no, don’t eat.  If yes, eat nutrient dense foods that align with your goals until you hit your absolute minimum energy target.
  4. Do you still feel hungry?  If yes, then eat nutrient dense foods until you hit your maximum calorie intake.
  5. Have I exceeded my maximum energy intake?  If yes, then stop eating.

Summary

So in summary:

  • Focusing on specific macronutrient targets takes the focus off food quality and micronutrients and can be counterproductive.
  • There is a range of macronutrients within which you can get a reasonable nutritional outcome that aligns with your goals. Within these limits, your focus should be on getting all the micronutrients you need.
  • If you are are insulin resistant or have diabetes then it’s prudent to focus on less insulinogenic foods.  However, there is no point driving your insulin load to the point that you compromise nutrient density unnecessarily.

How to calculate your target macronutrient range

I know all these numbers can be confusing!

To help make this process easier we have developed a free report at NutrientOptimiser.com.

Simply enter your goals, preferences, weight and estimated body fat % and the Nutrient Optimiser will spit out a free report with your recommended macronutrient ranges as well as a shortlist of suggested foods and meals that will help you optimise your nutrition that will align with your goals.

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To get your free report you go to NutrientOptimiser.com, tell us what you’re interested in and enter your email address.

As your situation changes (e.g. you lose weight or your blood sugars stabilise) you will be able to come back and update your details and get new macro targets as well as optimal meals and foods.

We think this is unique and exciting.  We hope it will help a lot of people cut through the dietary confusion.  We would love you to test it and give us some feedback.

 

I have included some worked examples of that the macronutrient ranges would look like in practice in the appendix below.  But the best way to understand how it works is just to go have a play and see what the Nutrient Optimiser would recommend for you!

 

Example macronutrient ranges

So let’s look at how this will look in practice with some worked examples.

Let’s take the example of Paul, who currently weighs 90 kg and has 19% body fat.  He’s done the Nutrient Optimiser analysis but wants to know what targets to put in Cronometer.

We will look at how he could use this approach to setting macronutrient ranges in the following scenarios:

  1. therapeutic ketosis,
  2. low carb / nutritional ketosis,
  3. insulin resistant weight loss, and
  4. weight gain / athletic performance.

Therapeutic ketosis

Paul is interested in the ketogenic diet and recommends it to many of his clients.

The table below shows the range of protein, fat, carbohydrates (in grams) if Paul was aiming for therapeutic ketosis along with the basis for the upper and lower limits.

  lower upper comment
protein (g) 58 80 Minimum protein based on 0.8g/kg LBM.

The upper limit is based on 15% insulinogenic calories assuming no carbs.

fat (g) 180 212 Minimum based on weight maintenance with minimum protein and carbs.

Maximum based on weight maintenance with minimum protein and carbs.

carbs (g) 0 48 The upper limit corresponds to minimum protein and 15% insulinogenic calories.
energy (calories) Calories are not limited on a therapeutic ketogenic diet.  Many people using chasing therapeutic ketosis are looking to keep weight on, so very high levels of dietary fat intake is not a concern.

The chart below shows the resultant macronutrient ranges for the therapeutic ketogenic dietary approach in terms of percentage of energy intake.    As you can see, regardless of the scenario, Paul’s energy would largely come from fat.

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The foods listed below would give Paul the best chance of achieving therapeutic levels of ketosis while maximising high micronutrients as much as possible.

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The chart below shows the nutrient profile of the foods listed above.  The nutrients coloured yellow typically harder to obtain on a therapeutic ketogenic diet and have been emphasised in the foods listed above.

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If you’re following a therapeutic ketogenic diet as an adjunct therapy for cancer, epilepsy, Alzheimer’s or dementia, then you’ll likely also be tracking glucose and ketone levels.

If you are following a disciplined high fat ketogenic diet, you should expect to see lower blood sugars and higher ketone levels.

If you want to get serious, you can track your Glucose Ketone Index (GKI) which was developed by ketogenic cancer researcher Dr Thomas Seyfried.[18]  Through fasting, higher fat and a lower insulin load many people who require therapeutic ketosis aim for a GKI value of less than 1.0 which means your ketone values are higher than your glucose levels.  If you are just looking to manage diabetes then having a GKI less than 10 is a healthy place to be on a day to day basis when not fasting.

Therapeutic ketosis takes a lot of dedication and discipline.  Many people find that their condition resolves after a period and they can transition to a low carb / nutritional ketosis approach without triggering adverse symptoms.

Diabetes / low carb / nutritional ketosis

A diet for management of diabetes is not as restrictive as a therapeutic ketogenic diet and provides a higher level of nutrition.  The table below shows the low carb style macronutrient range that would keep Paul in nutritional ketosis.

  lower upper comment
protein (g) 131 239 Minimum protein is based 1.8g/kg LBM.

Upper limit based on maximum insulin load of 1.8g/kg LBM with zero carbs.

fat (g) 131 178 Lower limit is based on weight maintenance with maximum protein and carbs.

The upper limit is based on weight maintenance with minimum protein and minimum carbs.

carbs (g) 0 60 The upper limit corresponds to minimum protein (1.8g/kg LBM) and a maximum 1.8g/kg LBM insulin load.
energy (cals) Calories are not necessarily controlled on a low carbohydrate diet.  The initial focus should be on stabilising blood sugars and appetite.  From there we can force an energy deficit if necessary.

The figure below shows the range of macronutrients that will fit within the guidelines of a low carbohydrate diet to stabilise blood sugar or achieve nutritional ketosis.

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This food list will enable you to maximise your micronutrients on a low carbohydrate diet.

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Compared to a therapeutic ketogenic diet, the low carbohydrate diet provides a significantly high level of nutrient density.  The nutrients shown in yellow that are harder to find on a low carbohydrate dietary approach that have been emphasised.

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If you are following a low carbohydrate dietary approach, you will likely be tracking your blood sugars on a regular basis.  Once you are able to stabilise your blood sugars to non-diabetic levels using a low carb diet, we can then start to focus on reducing energy to lose weight (i.e. if your waist : height ratio is greater than 0.5 or you have a higher than desirable level of body fat).  From there you can start to focus on an energy deficit if you do not find you are achieving your desired level of weight loss with a low carb diet alone.

average blood sugar  

hbA1c (%)

 

trig:HDL ratio

mg/dL mmol/L
diabetes > 140 > 7.8 > 6.5% > 3.0
pre-diabetes 108 – 140 6.0 – 7.8 5.4 – 6.5% 2.0 – 3.0
insulin resistant 100 – 108 5.4 – 6.0 5.0 – 5.4% 1.0 – 2.0
insulin sensitive < 97 < 5.4 < 5.0% < 1.0

Many people find that they actually need to drop their body fat levels further before they are able to achieve truly optimal blood glucose levels.

Aggressive weight loss

Paul actually wants to lose weight fairly aggressively, but without compromising his hard-earned lean muscle mass.

If we take 21 calories per pound of fat as the maximum rate of fat loss without significant loss of muscle, then Paul could theoretically cut up to 790 calories from his typical energy intake without significantly compromising his lean muscle mass.  This deficit would leave him with 1349 calories.  He will still be able to get his minimum protein and fat intake levels at this energy level.

Paul is eager to lose fat fast, so he wants to target an aggressive deficit of at least 20%.  However, if he’s not hungry, there’s no real point in consuming beyond 1349 calories per day (i.e. a 37% deficit).  Paul is also still mindful of his blood sugars and insulin resistance, so we will also ensure his insulin load remains under 2.9 g/kg LBM.

  lower upper comment
protein (g) 131 214 Minimum protein is based on 1.8g/kg LBM which is fine if he is only targeting a 20% deficit.

The upper limit is based on 2.9g/kg LBM insulin load.

fat (g) 29 132 Maximum fat is based on 20% energy deficit with min protein and carbs.
carbs (g) 0 231 Maximum carbs is based on target energy deficit with minimum protein and fat.
energy (cals) 1349 1711 Lower energy intake is based on BMR -21 cal/lb fat mass.  The maximum is based on 20% deficit against BMR.

The screenshot below from Paul’s Cronometer showing how he can enter his target protein range.  Simply click on the bar for energy, protein, carbs and fat to enter the target range.

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The figure below shows the macro split including the energy from body fat (shown in yellow).

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This figure shows the food proportion of protein, fat and carbs when we only look at the food intake.  When we consider the food intake alone, between 30 and 55% of energy is intake will be from.

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The foods below will maximise nutrition to align with this aggressive fat loss approach.

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The chart below shows the high level of nutrients provided by the foods listed above.  These foods also have a very low energy density meaning that they will be hard to overeat.

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If your goal is aggressive fat loss, then you will likely be tracking your energy intake and body weight and fat on a regular basis to make sure you are achieving your desired results.

There is little value in regularly tracking blood sugars or ketones with this style of approach as they will likely be excellent if you are maintaining a significant energy deficit.

Paul’s focus with should be on making sure he gets adequate protein and nutrient dense foods while keeping under his energy target.

As an aside, Paul is doing well and sitting at #2 on the Nutrient Optimiser Leaderboard.  You can see Paul’s detailed Nutrient Optimiser report here.

Maximum fat loss

The table below shows the macronutrient ranges if Paul was to target maximum energy restriction while minimising the risk of muscle loss.  This is based on the maximum energy deficit of 21 calories per pound of body fat.

  lower upper comment
protein (g) 234 241 Minimum protein is based on 2.6g/kg BW in view of the aggressive deficit.

The upper limit is based on maximum 2.9g/kg LBM insulin load.

fat (g) 29 150 Max fat is based on 37% energy deficit with min protein and carbs.
carbs (g) 0 108 Max carbs is based on target energy deficit with minimum protein and fat.

We also want to limit Paul’s insulin load to less than 40% of his maintenance energy intake

energy (als) 1348

 

A maximum deficit of 21 calories per pound of body fat (i.e. 37% deficit)

Even though the protein levels are very high and he has some history of insulin resistance, I do not think Paul is likely to see elevated blood sugar levels with such a massive deficit.

Some protein may be converted to glucose via GNG, however, there will already be such a dramatic energy deficit that he would likely be seeing very low blood sugar levels.

The chart below shows the macronutrient split, including body fat.

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This chart shows the macronutrient split of this approach when we consider the food only.  These foods contain between 56 and 72% protein which starts to make this style of approach difficult without significant reliance on protein powders.  Achieving a strict Protein Sparing Modified Fast is actually quite difficult in practice because attaining such a high level of protein intake with such an aggressive deficit is quite hard.

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The foods below will give you the best chance of minimising energy intake while getting adequate protein and nutrients.

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The chart below shows the nutrient profile of these foods with the harder to find nutrients emphasised.

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Weight gain

If Paul was wanting to gain weight, he could target a 20% energy surplus and choose nutrient dense and energy dense foods so he could achieve this.

  lower upper comment
protein (g) 131 289 Minimum protein is based on 1.8g/kg LBM.

The upper limit is based on 50% of energy from protein.

fat (g) 29 185 Maximum fat is based on 20% energy surplus with minimum protein and carbs.
carbs (g) 0 348 Maximum carbohydrates is based on target energy surplus with min protein and fat.
energy (als) 2567 The maximum is based on a 20% energy surplus against BMR.

The list of nutrient dense and energy dense foods below would help Paul to maximise nutrient density in an energy surplus.

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The chart below shows the nutrients provided by these energy-dense foods.

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You should make a calculator for that!

To get your optimal macronutrient ranges please check out the new calculator at NutrientOptimiser.com.

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We hope you love it!  Let us know how we can make it more useful to help you achieve your goals.

 

 

references

[1] https://www.iifym.com/

[2] https://www.bodybuilding.com/fun/your-complete-guide-to-iifym

[3] https://www.avatarnutrition.com/

[4] Incidentally, paleo has been in decline since January 2014 while IIFYM peaked in mid 2016.  Currently keto and vegan are the hot new diet trends.

[5] https://healthyeater.com/flexible-dieting-calculator

[6] https://optimisingnutrition.com/2017/03/19/micronutrients-at-macronutrient-extremes/

[7] https://optimisingnutrition.com/2017/06/17/psmf/

[8] https://www.ncbi.nlm.nih.gov/pubmed/29182451/

[9] https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

[10] https://optimisingnutrition.com/2015/03/30/food_insulin_index/

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

[12] https://www.ncbi.nlm.nih.gov/pubmed/15615615

[13] https://sigmanutrition.com/episode207/

[14] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1646394/

[15] http://www.ketotic.org/2014/01/how-much-protein-is-enough.html

[16] https://nutritionj.biomedcentral.com/articles/10.1186/1475-2891-9-51

[17] https://ketogains.com/tag/tyler-cartwright/

[18] https://www.researchgate.net/publication/274011072_The_glucose_ketone_index_calculator_A_simple_tool_to_monitor_therapeutic_efficacy_for_metabolic_management_of_brain_cancer