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does insulin resistance REALLY cause obesity?

April 12, 2018 Marty Kendall 8 Comments

Many people believe that insulin resistance causes obesity. But as you’ll see in this article, it may very well be the other way around.

Excess body fat appears to drive insulin resistance. But first, your fat cells need to be insulin sensitive to fill and expand beyond your Personal Fat Threshold.

Once your adipose tissue becomes resistant any excess energy is then shunted into your bloodstream and vital organs, leading to the most prevalent modern diseases such as diabetes, heart disease, Alzheimer’s and Parkinson’s.

What does insulin do?

There is a lot of focus at the moment in some circles on insulin and how to minimise if not eliminate it. But we need to keep in mind that insulin actually performs a range of critical functions in your body, such as:

Facilitating the use of protein to build and repair our muscles and organs,
Acting like a brake on our liver to regulate the release of glucose into the bloodstream,
Storing excess energy (ideally in our adipose tissue) for later use, and
Suppressing the use of our body fat (lipolysis) while the energy from your food is used up.

What happens if we have no insulin?

You may not always like the fat storing function of insulin, but we have to take the good with the bad. We simply cannot live without it.

Not producing enough endogenous insulin is called type 1 diabetes. If you develop type 1 diabetes you will:

Not be able to use protein to build your muscles and vital organs,
Experience elevated blood sugar levels as your liver produces excess glucose,
Experience uncontrolled lipolysis, meaning that your fat stores will be quickly mobilised, and
Experience elevated blood glucose and BHB ketones (a.k.a. diabetic ketoacidosis).

You may be a little bit jealous of people with type 1 diabetes, thinking that if you could only decrease your insulin a little bit, you’d lose weight.

But having zero insulin is a life-threatening situation. It’s been less than a century since we’ve been able to treat people with type 1 diabetes (like my wife Monica) with exogenous insulin to keep them alive.

As shown in the photos below, people with uncontrolled type 1 are essentially falling apart. They are quickly leaching their stored energy into their bloodstream via uncontrolled gluconeogenesis and lipolysis.

However, as demonstrated in the ‘after’ photos on the right-hand side, once they receive insulin treatment, people with type 1 are able to use the energy from the food they eat, and no longer consume their muscles for fuel.

The most successful approach for people with type 1 diabetes tends to involve fewer carbohydrates without limitations on protein, particularly for growing children.

Adequate insulin dosing is critical to maintaining healthy blood sugar levels as well as enabling the use of protein for growth, repair and maintenance of muscle.

A more modern example is Dave Dikeman, son of RD Dikeman who is one of the admins of Type 1 Grit who follow Dr Bernstein’s recommendations for the treatment of diabetes.

Dave is shown here in hospital after diagnosis and below recently with his dad. While some people warn nitrogen poisoning, Dave seems to be thriving on about 250g of protein per day (i.e. about 4.7 g/kg LBM).

Getting adequate insulin to metabolise the protein required for growth and repair while limiting carbohydrates to maintain normal blood sugar levels appears to be crucial to success for people with diabetes.

What happens if I am insulin sensitive?

Being “insulin sensitive” means that don’t need much insulin to get the job done.

Glucose can enter your cells to be used for energy.
Your liver responds to insulin and controls the release of glucose and ketones into the bloodstream.
You will build muscle relatively easily.
Your body can efficiently store excess energy as fat, and your adipose tissue can grow quickly.

Having great insulin sensitivity is a double-edged sword. While you can control the release of glucose and ketones from your liver into your bloodstream and build muscle, you can also build fat stores quickly. You need to be insulin sensitive to become morbidly obese.

I used to believe that if I could become insulin sensitive by reducing carbohydrates and protein. I thought the key to success was to increase my ketones by eating more fat so I could melt away my body fat, a bit like someone with untreated type 1 diabetes. (There is a practice called diabulimia where some type 1s intentionally restrict their insulin dosing to lose weight, however, this is a very dangerous practice which drives ketoacidosis, fatigue, muscle wasting, high cholesterol and death).

But ironically it turns out that having insulin-sensitive adipose tissue actually enables your body fat stores to expand to accept more and more energy from the food you eat before they start being channelled into other areas of your body.

People who are obese are often insulin resistant. However, this is not always the case. You can be insulin resistant and still be lean. You can be obese and still be relatively insulin sensitive. If you are both insulin resistant and obese, the obesity probably came first.

How do I become insulin resistant?

Professor Roy Taylor has done some fascinating work showing that different people develop diabetes at different body fat levels.^[1] He coined the term ‘Personal Fat Threshold’ to describe this observation.

For whatever reason, some people develop diabetes at a low level of body fat while other people need to become obese before they experience elevated blood sugars.^[2] Some people are ‘blessed’ with the ability to expand their fat stores a lot more than others before their fat stores become full.

While most people want to be lean with low levels of body fat, the ability to continue to expand your fat stores can be an advantage. People who could successfully store lots of energy in their adipose tissue were more likely to survive a famine or a long journey in a canoe to settle a new island or continent. This phenotype is sometimes called metabolically healthy obese.

Unfortunately, these populations appear to suffer the most when exposed to hyper-palatable nutrient poor insulinogenic western food. Highly insulin sensitive and primed for storage of available foods, they very quickly become obese and eventually, after gaining a lot of body fat, diabetic.

They also seem to be genetically programmed to ensure that they survive the next famine more than others, so when given the opportunity they become more ‘addicted’ to these energy-dense obesogenic foods. For example, sales of Coca-Cola are the highest on a per person basis in Australia’s Northern Territory in where there is a high proportion of indigenous Aborigines.

Even today, when famines are less common, being able to build large energy stores in your adipose tissue is still an advantage. These people can store more energy on their body before it gets funnelled into places that fat does not belong (e.g. your liver^[3], pancreas, heart^[4], eyes and brain^[5]).

It’s when your fat stores become insulin resistant and cannot store any more energy things get ugly.^[6]^[7] When your fat stores get full and can not accept any more energy we say they become resistant to the effects of insulin.^[8] Your pancreas ramps up its efforts to store energy.

But in spite of the increasing levels of insulin, less and less energy can be forced into fat stores. It’s at this point that the excess energy starts to get funnelled into areas of your body that are now more insulin sensitive than your body fat like your liver, pancreas, heart, eyes and brain.

In this video, Ivor Cummins discusses the concept of adipose tissue hypertrophy and how diabetes begins in the fat cells.

I also highly recommend this widely shared podcast with Mike Julian and Alex Leaf, where they share their insights.

Like many of my posts, most of the insights in this article are gleaned from them based on the latest research that they share in the Optimising Nutrition Facebook Group.

If you haven’t seen it yet, this video from Ted Naimin is a must watch on the topic of insulin resistance.

People who have lower personal fat threshold are sometimes called TOFI (i.e. thin on the outside, fat on the inside). These people may look skinny because they have less body fat stored underneath the skin (subcutaneous fat) but they often have lower levels of muscle and much higher amounts of fat stored around their vital organs (visceral fat) and will see elevated blood sugars much earlier.^[9] Being TOFI is arguably more dangerous than to be metabolically healthy obese.

An extreme example of TOFI is lipodystrophy were people cannot gain body fat and quickly develop diabetes, hyperinsulinemia, fatty liver, hypertriglyceridemia and heart disease because they aren’t able to buffer their energy in their fat stores before it goes to their vital organs.

So as you can see, if we want to be accurate, it’s not obesity per se that is causing metabolic dysfunction, it is being overfat relative to your Personal Fat Threshold.

Optimal vs insulin resistant blood sugar and ketone levels

As your body fat stores start to fill, you will also see elevated levels of energy in your bloodstream in the form of elevated glucose, ketones and free fatty acids.

The table below shows the official diagnosis criteria for Type 2 diabetes in terms of fasting glucose, blood glucose after eating and HbA1c.

	fasting		after meal		HbA1c	% pop
	mg/dL	mmol/L	mg/dL	mmol/L	%	% pop
“normal”	< 100	< 5.6	< 140	< 7.8	< 6.0%	50%
pre-diabetic	100 – 126	5.6 to 7.0	140 to 200	7.8 to 11.1	6.0-6.4%	40%
type 2 diabetic	> 126	> 7.0	> 200	> 11.1	> 6.4%	10%

However, while the diagnostic criteria define half the population currently as ‘normal’, normal is far from optimal. If you’re chasing optimal health, the table below shows target blood sugar and HbA1c values that correspond to optimal blood sugar control.

risk level	HbA1c	average blood sugar
risk level	(%)	(mmol/L)	(mg/dL)
optimal	4.5	4.6	83
excellent	< 5.0	< 5.4	< 97
good	< 5.4	< 6.0	< 108
danger	> 6.5	> 7.8	> 140

The body tends to find a balance between glucose and ketones depending on available fuel sources. However, the presence of higher BHB ketones is not necessarily a sign of optimal health. Higher BHB ketone levels can be a bad sign, especially when they are accompanied by higher blood glucose and free fatty acids.

The chart below shows the sum of about three thousand data points from glucose and BHB ketones measurements for people following a low carbohydrate or ketogenic diet.

It appears from this data that people who are metabolically healthy tend to have lower blood glucose and lower ketone values, even if they are following a ketogenic diet. If your goal is to use body fat for fuel, then you will want to be further to the left of this chart with a lower total energy in your bloodstream from glucose and ketones.

Initially, in an energy deficit, you will lose water weight quickly as you empty your glycogen stores, then your blood sugars will reduce. Then eventually once the faster burning fuel sources are consumed your body will turn to stored body fat.

The table below shows the blood glucose and ketone values if we divide the three thousand data points in the chart above into five quintiles. It appears that lower blood glucose levels are typically associated with lower ketone levels even on a ketogenic diet.

You may see higher ketone values during a long-term fast or calorie restriction, but generally, ketone levels in the fed state in healthy person on a low carb or ketogenic diet might range between 0.3 and say 1.1 mmol/L with blood glucose less than 5.0mmol/L or 90 mg/dL.

quintile	average BG (mmol/L)	BG (mg/dL)	ketones (mmol/L)			total energy (mmol/L)
quintile	average BG (mmol/L)	BG (mg/dL)	25th	average	75th	total energy (mmol/L)
1	4.5	80	0.3	0.6	0.7	5.0
2	4.9	88	0.4	0.8	1.1	5.7
3	5.1	92	0.6	1.1	1.5	6.2
4	5.1	92	1.2	1.8	2.3	6.9
5	5.1	92	2.2	3.2	4.0	8.3

To use an engineering analogy, you can think of your liver as dam wall holding back the floodgates of energy in your body while insulin is the signal to raise the floodgates. If you have a flood of energy coming in your liver will have to release some of the excess energy into the bloodstream.

If you have lower levels of energy coming in from your diet you will need less insulin to force the liver to hold back the flood of energy stored in your body.

Once you decrease the energy coming in from your diet, your pancreas will be able to slow the production of insulin, which will allow your body fat stores to fill the energy gap.

The ketone data from the recent Virta study^[10] below also supports the case for ketones being correlated with body fat levels for people on a ketogenic diet.

The participants’ ketone levels initially jumped to around 0.6 mmol/L as they switched from a more insulinogenic standard western diet to a ketogenic diet. But as you can see ketone levels continued to decrease over time to about 0.3 mmol/L as:

They lost body fat and then their weight loss stabilised,
The amount of energy in their system decreased,
Their blood sugars decreased, and
Their overall metabolic health improved.

The chart below shows the weight loss over the same period of decreasing ketone values.

As detailed in this article, BHB ketones can be seen as a storage or transport form of ketones that can be used by the brain and heart but need to be converted back to Acetoacetate to be used by the rest of the body. While they appear to be useful in some therapeutic situations, higher BHB, for the most part, should be seen as an indication of excess energy status rather than excellent metabolic health.

How do I become insulin sensitive?

Professor Taylor’s research also demonstrated that people become insulin sensitive again once they come back under their own ‘Personal Fat Threshold’ by reducing the pressure in their adipose tissue cells (i.e. lose weight).

With only a small amount of weight loss, their blood sugars come back into line and they start to lose fat from in and around their vital organs.^[11]^[12]^[13]^[14] Or to think of it another way, once you use up the surplus energy in your bloodstream, your body will start feeding on the fat stored in your vital organs as the first priority.

Once our body fat levels decrease to below our Personal Fat Threshold, it seems that they quickly become insulin sensitive and can take in any excess energy. There is less overflow of energy from the fat cells to spill out into the bloodstream.

The bad news here is that once your adipose tissue becomes insulin sensitive again it can grow quite easily given an environment with surplus energy. Being more insulin sensitive is part of the reason why it’s so easy to regain weight.

While a low carb diet masks the symptoms of diabetes by stabilising blood glucose levels without a significant reduction in body fat levels, people who lose a significant amount of body fat below their Personal Fat Threshold are no longer diabetic and can pass an oral glucose tolerance test. Their fat stores can quickly expand to absorb the incoming energy. Unfortunately, as soon as they put the weight back on (i.e. refill their fat stores), they become diabetic again.

One criticism of Professor Taylor’s work is that it was done with Optifast shakes to ensure rapid weight loss while still getting adequate nutrition (even though it was from meal replacement shakes full of supplements). The ideal would be that people could learn to create nutrient-dense whole food meals. Many people find this hard to do in real life, hence the use of meal replacement shakes in order to remove this variable. The Nutrient Optimiser has been designed to help people form new habits of eating nutrient dense meals that are aligned with their goals.

How do I know if I’m insulin resistant or insulin sensitive?

There are a range of ways to test to if you are insulin resistant.

Blood sugar

The simplest way is just to test your blood sugar fasting and before a meal. The tables above show some suggested levels at which you should start to be concerned. If your blood sugars are elevated then it’s an indication that you are exceeding your Personal Fat Threshold.

Fasting insulin

Fasting insulin levels are also a good guide to determine if you are starting to develop insulin resistance.

Healthy hunter-gatherer populations have a fasting insulin of 3 – 6 mIU/mL.^[15]The average insulin levels in western populations are 8.6 mIU/L.
Meanwhile, the western reference range for fasting insulin is anything less than 25 mIU/L.^[16] (This is not optimal.)

Oral glucose tolerance test

One of the most common tests used in diabetes is the OGTT which is where you drink a sugary drink and see how much your glucose rises over time.^[17]

Insulin response patterns (Kraft test)

A more accurate way to understand you are insulin resistant is to test your insulin response to food.

In the chart below the negligible insulin response (blue) is Type 1 diabetes (i.e. insufficient insulin), the green is a healthy insulin response, while the yellow (pattern II), orange (pattern III) and red (pattern IV) are indicative of diabetes and insulin resistance.

While you may have great blood sugar levels, your pancreas may still be working overtime to store the energy from your food in your fat stores, so it doesn’t spill over into your bloodstream.

A Kraft insulin dynamics test, while expensive, is the gold standard in insulin testing. Dr Kraft’s analysis suggested that 80% of people are using excess insulin to suppress glucose, while a normal glucose screen would suggest that only two-thirds of people are fine.^[18]^[19]

HOMA-IR

If you have your fasting insulin and glucose data, you can calculate your HOMA-IR which is a measure of the amount of insulin that you need to maintain your blood sugars. This can be useful for low carbers who sometimes have higher fasting glucose but lower insulin.

The formula is shown below or you can use an online calculator like this one.

Less than 1.0 means you are insulin-sensitive which is optimal.
Above 1.9 indicates early insulin resistance.
Above 2.9 indicates significant insulin resistance.^[20]Triglyceride:HDL ratio

You can also use your blood cholesterol test data to understand if you are really insulin resistant. A triglyceride:HDL ratio greater than 3 (in US units) suggests that you may be insulin resistant. A trig:HDL ratio less than 1.1 is optimal.^[21]^[22] You can use a calculator like this one to make sure you get the units right.

Abdominal obesity

Waist to height ratio is a simple and effective way to understand if you need to take evasive action to lose weight.

A waist to height ratio of greater than 0.5 for men and 0.46 for women is associated with increased risk mortality.^[23]

Regardless of whether you are insulin sensitive or insulin resistant, it is highly advisable to do what it takes to reduce your body fat to get your waist to height ratio in check.

Some people will find that they still need to lose further weight to get within their personal fat threshold to get optimal blood glucose and insulin levels.

If you are insulin resistant, your fat tends to get stored in your organs so you may have a big hard ‘beer’ belly. Someone with abdominal obesity may find their belly is hard because more fat is stored inside around their organs.

If you are insulin sensitive, you may have a big belly but it might hang down more like a floppy garbage bag. Someone like this is ‘blessed’ to have insulin sensitive adipose tissue that continues to expand more before they develop diabetes and the complications of metabolic syndrome.^[24]

Summary

The table below shows values for various parameters that are indicative of insulin resistance.^[25] If you are looking for optimal health, you should target values similar to those in the Quartile 1 column.

Do medications help?

While replacement of normal healthy levels of insulin is critical for people with type 1 diabetes, supraphysiological doses of insulin only mask symptoms of a poor diet for people whose pancreas is still functioning well.

The chart below shows that complications of diabetes (i.e. cardiovascular disease, stroke, coronary heart disease) increase with higher HbA1c. Lowering HbA1c however by just using anti-diabetic medications to suppress blood sugar does not help the outcome.

Excess exogenous insulin forces the excess energy into our fat stores, and then subsequently into other more sensitive areas of the body such as our vital organs, brain and eyes.

You can’t just keep eating loads of processed insulinogenic crap and trust that all will be well because your blood sugars are lower. Exogenous insulin combined with a poor diet actually exacerbates the complications of diabetes.

You need to fix your diet and then add enough insulin to maintain healthy blood glucose levels and effectively use the protein in your diet to build and repair your muscles.

Basal vs bolus insulin

Insulin-dependent diabetics dose with both bolus (or burst) insulin and basal (or background) insulin. Bolus insulin is mealtime insulin and basal is needed whether you eat or not to enable you to keep your stored energy behind the floodgates of your liver.

You can reduce the amount of bolus insulin required for food in the short term by reducing the insulin load of your diet.

For someone on a standard mixed diet, about half of their insulin dosing will be bolus with half as basal. For someone on a low carb diet with a lower insulin load, the majority of their insulin demand will be for basal insulin, with only a small amount required to cover food.

Most low carbers or ketogenic dieters focus on reducing the insulin load of their diet by removing carbohydrates, and sometimes protein, without paying much attention to incoming energy from fat.

This is fine on a whole food Atkins type diet because reducing carbs will typically force a reduction in overall energy intake. Ignoring energy balance becomes a problem though when you start to ‘hack’ your low carb/keto diet with refined fats, fat bombs and fatty coffee that enable you to get heaps of energy with few carbs and negligible micronutrients.

The irony here is that, in the bigger picture, insulin demand is actually related to your overall stored energy status, as described in this video from Chris Masterjohn.

As shown in the chart below, people with a larger BMI typically have higher levels of insulin because, as the stored energy in your system continues to increase (regardless of the macronutrient source), our insulin levels have to increase to hold back the flood of stored energy while the excess energy in our system is used up.

The chart below shows that someone who is obese and insulin resistant will have higher insulin levels when they are fasting. They will also have much higher excursions of insulin after eating due to their insulin resistant adipose tissue not accepting the excess energy.

As our body fat stores continue to build and we keep on taking in energy, our pancreas continues to ramp up insulin production to keep energy in storage until you need it. In the “good old days” this wasn’t a problem because there were always times when we didn’t have food available. These days food is relatively cheap, easy to obtain and always associated with celebrations, family, social occasions and self-soothing. So you are always in storage mode.

As you remain obese, you become resistant to your own insulin and need more and more insulin to do the job.^[26]^[27] Eventually, your pancreas can burn out through overuse, and you become an insulin-dependent Type 2 diabetic.

Overall, the macro-nutrient composition of our diet only has a relatively small influence on our insulin levels. Our basal insulin has a much more significant effect on our fasting insulin levels.

We can manipulate our diet by reducing carbohydrates to reduce the bolus insulin demand of our food. However, we can have a much more dramatic impact on our insulin levels by reducing the total energy levels in our body by finding a way to maintain a long-term energy deficit.

How to reverse insulin resistance?

TL;DR… Reduce body fat while preserving lean muscle mass.

How to preserve lean muscle mass

Lean muscle mass is important because it burns both fat and glucose. Without muscle, you won’t be able to quickly use the energy from fat and carbs that you eat.

Lean muscle mass is also critical to insulin sensitivity and longevity. As you get older, it becomes harder to maintain lean muscle mass.^[28] You will need more protein as you get older to slow the inevitable loss of muscle mass. Once you become weak and frail, your chances of falling and breaking your hip and never getting up again increase!

There is ongoing discussion/argument/controversy about how much protein is ‘too much’. My analysis of nutrient density suggests that getting a minimum of 1.8 g/kg LBM or about 20% of energy is a good starting point. More can be better if you are active, lifting heavy or trying to lose fat.

If you focus on getting the nutrients that are harder to find, adequate protein is really a non-issue. The nutrient profile of the most nutrient-dense foods shown below is generated by prioritising foods that contain the harder to find micro-nutrients (i.e. choline, calcium, magnesium, vitamin E, potassium, pantothenic acid & zinc).

By contrast, if we focus on avoiding protein, we get an abysmal nutrient profile as shown below. This is why I get so frustrated when people get worked up about ‘too much protein’ or minimising protein in order to achieve elevated ketones as if that was the ultimate goal of health.

We also risk malnutrition if we focus on the most ketogenic foods (i.e. high fat, low carb, low protein). For most people, their primary goal is health and weight loss and to look great naked, not having high ketones.

So, unless you need a therapeutic ketogenic diet to manage epilepsy, Parkinson’s, Alzheimer’s, dementia or something similar, then there is no need to compromise your nutrition profile by trying to avoid protein or maximise ketones.

Ironically, it’s the people who are insulin resistant that probably needs more protein because they are not able to use the protein available as effectively and they are also losing more amino acids into the blood stream via poorly controlled gluconeogenesis in the liver.

For comparison, the three nutrient profiles are shown below (most nutrient dense, low protein and most ketogenic). Incorporating more of these nutrient dense foods is a great ‘hack’ to ensure you are getting enough nutrients without excessive energy intake.

How to lose body fat

The short, boring, answer that won’t sell a million gimmicky diet books is to maintain an energy deficit for a long enough period. This can take the form of:

Intermittent fasting (ideally with nutrient dense feeding to prevent malnutrition and binge eating),
Calorie counting (perhaps with occasional diet breaks),
Maximising nutrient density with whole foods which tends to lead to fewer cravings and less energy dense foods which are harder to overeat, or
Some other approach that works for you that enables you to maintain an energy deficit in the long term.

We have designed the Nutrient Optimiser to help you get started on your journey to optimise your nutrition. Free Report will give you:

Recommended macronutrient ranges,
Recommended calorie intake to suit your goals,
Suggested foods to maximise nutrient density, and
Suggested meals to start you off on your journey into nutritious eating.

Some people may find some of the concepts in this post hard complex and difficult to implement. The Nutrient Optimiser which will continue to adapt as you improve your metabolic health. We are also working on a dashboard that will track your the biometric data that you have (e.g. weight, blood sugars, waist:height ratio, food logs, ketones etc.) to guide you on the path to help you reach your goal.

Who needs a low carb diet?

So, if insulin resistance is primarily about managing our energy levels, does anyone need a low carb diet?

Insulin-dependent diabetics

Being married to someone with type 1 diabetes and involved in the online diabetes community I have seen firsthand the importance of managing carbohydrate intake.

For someone injecting insulin to cover carbohydrates and protein, a low carb diet enables them to match the smaller dietary insulin load with smaller doses of exogenous insulin.

There will always be errors in calculations in matching insulin to food, so a smaller insulin load enables you to reduce the errors in insulin dosing. Dr Richard Bernstein calls this The Law of Small Numbers.

Similarly, if you have type 2 diabetes and are injecting insulin, reducing the insulin load of your diet can help you reduce the amount of exogenous insulin you require. This can in turn help reduce the swings in blood sugar which can help to stabilise appetite and reduce overall food intake which will lead to weight loss.

Conversely, dosing with lots of insulin to cover a poor diet will lead to worsening insulin resistance with larger and larger doses of insulin to cover their poor diet. This vicious cycle of progressively larger doses ends in tragedy as it becomes more difficult to maintain safe levels of glucose control and typical diabetic symptoms such as peripheral neuropathy, kidney and eyesight disease become unavoidable.

Lots of exogenous insulin will also suppress lipolysis and make you hungrier which will drive appetite further.

So, if you are taking antidiabetic medications, then a lower carb diet is a no-brainer.

What about everyone else?

For people who are insulin resistant but not full-blown diabetic, I’m still a big believer in reducing the insulin load of your diet to the point that you can achieve stable blood glucose levels, but not so much that you compromise nutrient density. There is a trade-off between insulin load and nutrient density.

Unfortunately, some people get so caught up in being ketogenic that they end up decreasing nutrient density and increasing the energy density of their diet so much that they end up putting on weight due to an excess energy intake.

There is now a growing movement of online groups of people who have been burned by this ‘keto or bust’ mentality, chasing ketone readings by ingesting copious amounts of refined dietary fats or exogenous ketones.

I think a more prudent approach is to titrate carbs down to the point that you achieve great blood sugars and then focus on improving food quality and nutrient density.

For most people, reducing carbohydrates is helpful, not because it may increase ketones, but because it is a means to manage and minimize chronically elevated blood glucose and insulin levels which are the primary drivers of metabolic complications. Ultimately, we still need to address the cause of the problem (insulin resistance) via creating an energy deficit and losing body fat to below your Personal Fat Threshold.

There are a range of studies that suggest that a lower carbohydrate diet is better for weight loss for people who are insulin resistant.^[29]^[30]^[31]^[32] However, the recent DIETFITS Randomised Clinical Trial of 609 obese participants at Standford led by Christopher Gardner indicates that there wasn’t a statistically significant difference between the effects of a healthy lower fat versus a healthy lower carb diet for people who do not have diabetes.

The chart below shows that people who were more insulin resistant lost slightly more weight on a low carb diet (but not enough to be deemed statistically significant)/

On average, both diet groups reduced their energy intake by about 500 calories, not by tracking, but by focusing on improving their diet quality (though again, the healthy low carb diet group reduced their energy intake by about 50 calories more than the healthy low-fat group).

Perhaps one of the main reasons that a low carb diet works so well for so many people is that so many of them are insulin resistant. A low carb diet quickly helps to stabilise blood glucose and insulin levels which in turn helps to normalise appetite as well as eliminating many processed nutrient poor hyper-palatable foods.

In this video, Chris Gardner explains that study and points out that it was the people who changed their relationship with food and learned to make more nutrient-dense whole food from fresh ingredients at home that did the best overall.

In line with these insights, the Nutrient Optimiser algorithm firth helps you to stabilise your blood glucose levels with a lower carbohydrate diet and then guides you to focus on more nutrient-dense whole foods which tend to be more satiating and enable you to spontaneously reduce your energy intake.

Summary

If you are insulin sensitive, you will be able to grow both muscle and fat more effectively.
While many people think that insulin resistance causes obesity, you actually need to be relatively insulin sensitive to get morbidly obese.
You become insulin resistant when your fat cells become too full to hold the excess energy that you are taking in.
When you reach your Personal Fat Threshold, your body can no longer force excess energy into storage in your fat cells and it gets stuffed into other places that are more sensitive like your liver, your brain, your heart, your pancreas.
When your fat can no longer take up excess energy, it overflows into your bloodstream in the form of elevated glucose, ketones and free fatty acids.
Reducing carbohydrates can help manage the symptoms of diabetes and stabilise blood sugars. It can also avoid the excess fat storage that can often come with the use of excess exogenous insulin. However, for people who do not have diabetes, focusing on nutrient-dense whole foods and maintaining an energy deficit will likely be more important to reverse diabetes and improve insulin resistance.
You can reverse insulin resistance by maintaining an energy deficit until you are below your Personal Fat Threshold. Your adipose stores will then have room to take up the extra energy without spilling it into the bloodstream and your vital organs.

Thanks

Special thanks for Mike Julian for sharing many of the insights and synthesis of ideas contained in this article as well as RD Dikeman (Type One GRIT), Alex Leaf (Examine.com), Raphi Sirt (BreakNutrition.com). Ben McDonald (Impulsive Keto), Carrie Burns Diulus, Mattias Lindberg (Diet Doctor), Phil Thompson, Robin Reyes and Gillian Ferwerda for their review comments!

References

^[1]https://www.ncbi.nlm.nih.gov/pubmed/25515001

^[2]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4405637/

^[3]https://en.wikipedia.org/wiki/Fatty_liver

^[4]https://www.nhs.uk/conditions/coronary-heart-disease/causes/

^[5]https://www.medicalnewstoday.com/articles/298729.php

^[6]https://www.medicalnewstoday.com/articles/265405.php

^[7]https://en.wikipedia.org/wiki/Metabolically_healthy_obesity

^[8]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4405637/

^[9]https://en.wikipedia.org/wiki/File:Coronal_Image_of_a_TOFI_and_a_Normal_Control.jpg

^[10]https://link.springer.com/article/10.1007%2Fs13300-018-0373-9

^[11]https://www.ncbi.nlm.nih.gov/pubmed/26628414

^[12]https://www.express.co.uk/life-style/health/623499/losing-one-gram-fat-cure-diabetes

^[13]https://idmprogram.com/fatty-pancreas-t2d-9/

^[14]https://www.dietdoctor.com/how-losing-one-single-gram-of-fat-might-cure-diabetes

^[15]http://wholehealthsource.blogspot.com.au/2009/12/whats-ideal-fasting-insulin-level.html

^[16]https://emedicine.medscape.com/article/2089224-overview

^[17]https://cf.research.chop.edu/ogtt.php

^[18]https://www.facebook.com/BurnFatNotSugar/photos/a.364522923705531.1073741827.364516160372874/532154686942353/?type=3&theater

^[19]https://www.amazon.com/Diabetes-Epidemic-You-Joseph-Kraft/dp/142517812X

^[20]https://www.thebloodcode.com/homa-ir-calculator/

^[21]https://www.thebloodcode.com/know-your-tghdl-ratio-triglyceride-hdl-cholesterol/

^[22] The disposal of triglycerides provides insight into what your body is able to do with excess energy. Normal areas of short-term energy storage, like the liver, are at capacity. This proxy informs the actual behaviour of free nutrient. If the trigs are high, especially if the HDL is also diminished, it is implied that nutrient is unable to find easy storage locations with the current level of basal insulin.

^[23]http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0103483

^[24]http://www.mdpi.com/2072-6643/7/11/5475

^[25]https://www.ncbi.nlm.nih.gov/pubmed/19789156

^[26]https://www.ncbi.nlm.nih.gov/pubmed/8168647

^[27]http://sci-hub.tw/10.2337/diab.43.5.696#

^[28]https://www.nrv.gov.au/nutrients/protein

^[29]https://onlinelibrary.wiley.com/doi/full/10.1002/oby.21331

^[30]https://www.ncbi.nlm.nih.gov/pubmed/17063925

^[31]https://www.ncbi.nlm.nih.gov/pubmed/15897479

^[32]https://www.ncbi.nlm.nih.gov/pubmed/16306558

articles, carnivore diet

optimising Dr Shawn Baker’s carnivore diet from first principles

April 2, 2018 Marty Kendall 9 Comments

A recent article looking at Dr Baker’s carnivore diet identified some micronutrient gaps. This article looks at how we could make some small tweaks to fill these gaps and help him stabilise his blood sugars and naturally boost his testosterone levels.

Rather than making radical wholesale changes that you probably won’t stick to, the Nutrient Optimiser helps you to make small improvements to your diet.

This article is a ‘worked example’ of how the Nutrient Optimiser could help refine your diet to achieve your goals while working within whatever constraints you may have.

What are the fundamental principles of nutrition?

I don’t consider myself an advocate of zero carb/carnivore as the ultimate diet for everyone, but I’m intrigued. I want to understand the fundamental principles of human nutrition.

There are plenty of anecdotes, zealots and firmly held beliefs when it comes to nutrition.

Everyone has an opinion, everyone has experience, everyone feels strongly about nutrition because everyone eats.

However, while many people feel a lot of conviction about their way of eating, there seem to be people both thriving and doing poorly on a range of diets that appear to be polar opposites, whether it be carnivore, keto, paleo or whatever.

While some people believe that diets work because you eliminate all plants (carnivore/zero carb) or animals (i.e. vegan), I’m sceptical about the “magic” of any specific dietary approach. I want to understand the fundamental principles of nutrition.

We have tried to make carnivore work in our family to try to help with my wife’s Type 1 and all the autoimmune issues that seem to surround it. Eating a lot of beef tends to require a lot of insulin for my wife and it can be hard to dose the right amount of insulin to match it. We also found it to be pretty expensive, especially with two growing teenagers. While I can eat just about anything I choose to, the rest of the family tend to like more variety, so we’ve never been successful going full carnivore.

I’m currently reading Ray Dalio’s Principles where he describes the process of “backtesting” his theories over centuries of historical financial data to design the trading systems that enabled him to develop Bridgewater Capital into the world’s most successful hedge fund.

Not only has Dalio used backtesting to eliminate bias from his trading he has developed a company culture of radical honesty around an “idea meritocracy” where anyone in the company is invited to give brutally honest feedback on every member of the company to ensure that they continue to eliminate any biases from their culture.

As someone who spent a while developing my own trading systems and an engineer who relies on data analysis in my day job, this sort of approach resonates with me. It is this systems thinking that I have tried to use in the field of nutrition in the development of the Nutrient Optimiser algorithm.

Nutrition science is quite a young area of research. We only started to think in terms of nutrients around a century ago. Humans are complex organisms. Just like the financial markets, we find ourselves in a range of different environments with different goals and hence require different approaches depending on our situation and goal (e.g. athletes, bodybuilders, diabetes, weight loss, pregnancy, longevity etc.).

Engineering has a range of safety factors while trading the financial markets requires an understanding of risk and dealing with probability and uncertainty. Similarly, nutrition is about making the best decisions that we can base on the knowledge that we have. I’m not claiming that the RDI are perfectly accurate, but as you will see we’re really talking about orders of magnitude differences in nutrients as a proportion of the recommended daily intake.

I’ve been fortunate to be part of groups like the Optimising Nutrition Facebook Group which tends to be a brutal idea meritocracy when it comes to nutrition where you can learn a lot from smart people based on the latest research.

Over the years I have identified the following principles of nutrition that can be quantified and used to create a systematised approach in the Nutrient Optimser algorithm. I’m not saying these are the be all and end all and there will never be anything better, but these are the most useful parameters that I have found that can be quantified. Before getting into how we can upgrade Shawn’s current diet, let me quickly touch on these.

Principle 1. Insulin load

While the importance of insulin has been overstated by many people, the reality is that if you have diabetes, lowering the insulin load of your diet will help stabilise your blood sugar levels. And even if you are not diagnosed with diabetes, keeping stable blood sugars is an important health marker.^{^[1]}

If you are injecting insulin or taking other medications to control your blood sugar levels, then decreasing your dietary insulin load (which is a function of the non-fibre carbohydrates, and to a lesser extent protein) is an important first step.

However, as shown in the chart below, we can lower insulin load too much to the point that we compromise the nutrient content of our diet. We need to find the balance point between nutrient density and insulin load.

Unless you have type 1 diabetes, you can never take your insulin levels to zero. Insulin is like a brake in your system that stops your stored energy from being used while external energy is coming in.

While living on butter, bacon and oil might help you stabilise your blood sugars, your blood sugar and insulin levels will not decrease to optimal levels until you stop jamming excess energy into your mouth.

Principle 2. Nutrient density

Maximising nutrient density means getting the nutrients you need to thrive without consuming too much energy.

While the daily recommended nutrient targets have their limitations (e.g. bioavailability; anti-nutrients; and context such as activity levels, gender and food combinations), we can identify food and meals that have more of the cluster of micronutrients that you are currently not getting as much of.

Eating foods that are quantitatively nutrient dense tends to force out the processed junk food. Foods that are nutrient dense are typically whole foods that don’t need to be coloured, flavoured and engineered to look and taste like they contain the nutrients we need. They have them naturally in the form and quantities that we have come to thrive on.

Principle 3. Energy density

We can also quantitatively manipulate energy density to help us refine our food choices to help us get more or less energy in. Athletes will want to be able to consume more energy while choosing more low energy dense foods will help you lose body fat.^{^[2]}

Principle 3. Energy intake (aka calories)

Just like insulin, there is plenty of controversy around calories.

Some think calories don’t matter.

Some don’t think they exist.

But most people acknowledge that energy balance matters.

However, it’s reasonable to say that just focusing on calories is not the best way to control them or improve your diet. Without trying to improve the quality of our food, we can end up missing out on the nutrition we need. But if we dial in insulin load, energy density and nutrient density then satiety and energy intake naturally look after themselves and help you achieve a more normal body fat level.

However, sometimes it’s still useful to actively manage our calorie intake. Sometimes this is only required to help retrain our eating habits, or if you want to achieve really low levels of body fat. Anyone stepping on stage in a bodybuilding competition with single digit body fat percentages is probably tracking their food to ensure they get the results they are after, dialling in calories while making sure they’re getting adequate protein to support their muscle mass.

Principle 5. Food sensitivities

Whether it be due to toxins in our environment, excess refined foods, or whatever, food sensitivities are becoming more common. Many people seem to benefit from eliminating certain foods from their diet, whether it be autoimmune triggering foods, wheat/gluten or whatever.

This is where the zero carb/carnivore dietary approach seems to shine by removing plant-based foods that could cause an autoimmune or digestive response reaction. However, I’m not sure everyone needs to eliminate all plant foods.

Just to keep things interesting, Tommy Wood noted that:

“Neu5gc antibodies seem to be increased in Hashimoto’s (see Jaminet and Gundry), probably propagated by the gut microbiota. So eliminating red meat may help others with certain autoimmune conditions.

“When it comes to “real” food, I think we should be able to tolerate being the omnivores that we are. A true need for any hard eliminations (be that carbs, meat, or anything else) suggests that the underlying problem hasn’t been fixed. Almost all of it is symptom control.

“Though that doesn’t include allergies, obviously. And doesn’t mean you can always figure out how to fix the underlying problem. Good symptom control might be the best we can do in some situations.”

A carnivorous approach may work well for some people to eliminate most inflammatory foods. You could then start to add back the most nutrient dense foods to see what you can tolerate while still getting all the nutrients you need. This is basically what we’re going to do with Dr Baker’s diet in the rest of this post.

Dr Baker’s baseline diet

To recap, the article Dr Shawn Baker’s Carnivore Diet: A Review looked at his typical diet of ribeye steak, mince (ground meat), cheese, eggs, shrimp and salmon.

Here’s what it looks like in terms of nutrients vs the daily recommended intake levels. We can see from this that he is getting a lot of amino acids, zinc, iron, B2, B3 and B6 while a number of the other vitamins, minerals and omega 3s are relatively low.

Note: Shawn didn’t mention sodium in the Tweet above, so I haven’t included it in this analysis. However, I understand that he does salt his food and is now finding benefit from supplementing with sodium to support this massive activity levels. Most of the time I see people not getting enough potassium and magnesium from their diet rather than sodium, and very few people achieve desirable potassium:sodium ratio.

With about 4100 calories per day Shawn ends up getting about 6.1g/kg LBM of protein, and he meets the DRI for all but ten essential nutrients.

However, keep in mind that the DRIs are based on an average male eating 2000 calories per day. Someone trying to lose weight might only be eating 1200 to 1500 calories per day so they would be getting even fewer nutrients.

For comparison purposes, the chart below shows Dr Baker’s diet in terms of nutrients per 2000 calories. With a more normal energy intake, he would be not meeting the DRI for fifteen essential nutrients.

A lot of the time discussion about these issues degenerates into whether or not the DRIs are accurate. Hopefully, this chart illustrates that there are multiple orders of magnitude differences in % DRI for some of these nutrients. The goal of the Nutrient Optimiser is to rebalance this to some extent while still working within your preferences (e.g. zero carb etc).

It’s interesting to hear Shawn talking about supplementing with electrolytes which are often more important for very active people.^{^[3]} Interestingly, it’s the electrolytes like potassium, magnesium and calcium that can be harder to get on a low carb/keto /carnivore diet with a lower intake of green leafy veggies. I recently heard a 2 Keto Dudes podcast where cohost Carl Franklin was saying that he had developed a tremor in his right hand after a period of eating mainly porchetta that was instantly solved with magnesium supplementation. Traditional cultures like the Masai would likely have obtained a lot more of these nutrients from eating nose to tail and even drinking fresh blood, rather than eating drained and aged muscle meat.

I’m happy to accept that you probably don’t need to supplement with vitamin C, manganese, vitamin E, calcium, vitamin K1 if you are thriving on a carnivorous diet. However, it seems that magnesium, potassium and sodium are still very important and the RDIs are still quite relevant.

Scenarios to test

I realise that the DRIs have their shortcomings (e.g. bioavailability, context, antinutrients etc.). I delved into these issues in the previous post if you want to check that out.

In this article, I want to focus on the scenarios below where we could fine tune Dr Baker’s diet to get more nutrients as well as helping him lower his blood sugar levels. (Note: Robb Wolf has now published Shawn Baker’s full blood test results on his blog here if you’re interested in checking them out).

There is plenty of discussions out there on the interwebs as to whether a HbA1c is really a concern for Shawn in his context. Some people say that the excess protein is being converted to glucose. Some think it’s just the higher energy levels. Some think that it’s higher lived red blood cells which are causing the higher HbA1c. Some think he might have an underlying autoimmune condition that is causing his pancreas to not produce enough insulin. I’m not saying I know.

Symptomatically he appears to be doing fine with his higher glucose and lower testosterone levels. I just want to demonstrate how the Nutrient Optimiser would help someone wanting to lower the dietary insulin load to enable their pancreas to keep up.

So, putting the minutia aside, let’s assume we want to find foods that contain more of the nutrients that Shawn’s diet is not providing in large quantities. I also want to test a couple of scenarios:

with and without plant-based foods, and
maximum nutrient density per calorie vs a more energy dense, higher fat, diabetes-friendly approach.

Shawn is currently eating 6.1 g/kg LBM of protein and has nearly diabetic blood sugar levels and HbA1c.^{^[4]} Most of the time I’m the one banging on that you shouldn’t be afraid of protein. However, I wonder whether Shawn might do better with a higher fat, lower protein, zero carb approach. You can convert protein to energy, but it is hard for the body to do, compared to using fat or carbs for energy.

Very low protein diets tend to be low in other nutrients, however more than 1.8g/kg LBM doesn’t seem to make a difference for most people in terms of building additional muscle mass. Less protein and more fat might be gentler on his metabolism and help him fuel his activity levels. Reducing the insulin load of his diet to the point that his pancreas can keep up and maintain normal blood sugar might be beneficial.

Ted Naiman’s depiction of the protein : energy ratio below illustrates this concept. A high protein : energy ratio may be useful for people who want to get nutrients and protein without too much energy and drive high levels of satiety that will help them eat less. However, for someone like Shawn, trying to get more energy into fuel activity, a lower protein energy ratio might be more useful. A diet with a lower protein : energy level is less nutrient dense but also less insulinogenic which may be helpful for someone like Shawn who has blood sugars and near diabetics HbA1c.

Ted suggests a protein : energy (i.e. protein / (fat + carbs) all in grams) of around 3:1 for someone trying to lose weight while with something closer to 1:1 for someone trying to maintain their current body fat levels or fuel a lot of activity. Interestingly, Shawn’s current protein : energy ratio is 2.75 which is closer to the weight loss approach.

Scenario 1 – Carnivore with max nutrient density

In this scenario, we will look to improve the nutrient content of Shawn’s diet while remaining carnivore, given that it’s working pretty well for him and helping his digestive issues.

The table below shows the nutrients for which Shawn would fail to meet the DRI if he was eating a standard 2000 calories per day.

nutrient	% DRI / 2000 calories
Vitamin C	0%
Manganese	2%
Vitamin E	13%
Vitamin A	17%
Vitamin D	19%
Vitamin K1	21%
Folate	27%
Calcium	35%
Pantothenic Acid (B5)	35%
Omega 3	37%
Thiamine (B1)	65%
Sodium	68%
Magnesium	71%
Copper	77%
Potassium	89%

The chart below shows the nutrients that are associated with testosterone levels according to extensive research by Spectracell. Shawn is currently getting plenty of zinc, carnitine and vitamin B6, however boosting the vitamin C, vitamin E, vitamin D, vitamin K and folate in his diet may help him naturally boost his testosterone levels which are on the lower end.

We can use the Nutrient Optimser algorithm to identify the zero carb foods that contain more of the nutrients for which Shawn is not meeting the DRI.

Listed below are the top 20 foods that would provide nutrients to complement Shawn’s current diet. (I have crossed out shrimp and salmon because Shawn is already eating these.)

● liver

● caviar

● cod

● crab

● fish roe

● mussel

● lobster

● anchovy

● trout

● crayfish

● ~~shrimp~~

● ~~salmon~~

● lamb kidney

● Halibut

● egg yolk

● Haddock

● Pollock

● Perch

● sardine

● oysters

So let’s say Shawn added 30g of liver (I’ve only added 30g of liver, so we don’t exceed the upper limit for Vitamin A) a tablespoon of caviar, and swapped out some of his steak for cod (Dwayne ‘The Rock’ Johnson also eats a lot of cod) which is high protein and nutrient dense^{^[5]}. The table below shows Shawn’s updated daily diet.

The updated nutrient profile with Shawn’s refined diet shown below. These additional foods give us a large boost in vitamin A, copper, omega 3 and magnesium, so we are now only missing the DRI for 11 nutrients rather than fifteen.

This scenario has a protein : energy ratio of 3.7 which is great if Shawn was trying to lose weight, but perhaps not ideal to support a lot of activity.

Scenario 2 – Nutrient dense carnivore – diabetes friendly

As I mentioned earlier, Shawn may benefit from a higher fat, lower insulin load, carnivorous approach given his elevated blood sugar and HbA1c. While most people probably need to be eating more protein, Shawn’s pancreas seems to be struggling to keep up with the insulin required to metabolise 560 g of protein per day or an insulin load of 300 g/day.

Listed below are the higher fat foods that could provide the nutrients that Shawn is missing from his diet with a lower insulin load.

● egg yolk

● mackerel

● caviar

● liver sausage

● cream

● liverwurst

● whole egg

● sweetbread

● lamb brains

● sour cream

● beef brains

● cream cheese

● bacon

● bratwurst

● butter

● salami

● limburger cheese

● camembert

● fish roe

● liver pate

The table below shows the updated Cronometer food diary with the lean ribeye steak switched for a fattier T-bone and fattier hamburger mince. I have also added mackerel, bacon and liverwurst.

The chart below shows the nutrient profile of these foods. Even though we have more fat, we are able to meet the DRI for all but eleven of the essential nutrients. These foods contain 61% fat and 39% protein which is a more reasonable level for someone wanting to maintain weight and fuel a lot of activity. With these foods, Shawn would not be missing the DRI for twelve essential nutrients. These foods have a lower protein : energy ratio of 1.4 which is more appropriate for weight maintenance or to support a lot of activity.

Scenario 3 – Omnivorous with max nutrient density

So let’s say Shawn wanted to maximise nutrient density from all foods, including some plants, given his main goal is performance rather than just being zero carb. However, given that Shawn seems to have some digestive issues from his previous high carb processed foods diet we will eliminate any inflammatory foods using the autoimmune protocol filter. The top twenty foods are shown below:

● spinach

● watercress

● beet greens

● basil

● chard

● parsley

● turnip greens

● endive

● amaranth leaves

● lettuce

● chives

● broccoli

● arugula

● collards

● escarole

● kale

● radicchio

● celery

● cauliflower

● zucchini

● onions

● winter squash

● sauerkraut

● liver

● caviar

● cod

The Cronometer output below shows the updated intake with a little less ribeye and ground beef with some spinach, broccoli, sauerkraut and liver added in.

Shawn would need to test and see how he does with the addition of spinach and broccoli. While some people don’t tolerate any fibrous foods,^[6] I don’t think most people are suffering from excessive amounts of cruciferous vegetables.

From a macronutrient point of view, this ends up being only 2% net carbs which is low by most standards. From a protein : energy ratio perspective these foods come in at 2.7 which is probably higher than we want for someone trying to fuel a lot of activity.

The updated nutrient profile is shown below. We are now meeting the DRI for all but six essential nutrients. Overall the nutrient profile is more balanced. We are still getting plenty of amino acids and other nutrients that were high before while we are getting more of the nutrients at the top of the chart.

Scenario 4 – Omnivorous diabetes friendly

In this scenario, we will look to fill the nutrient gaps with a lower insulin load and a lower protein : energy ratio. The highest ranking foods listed below contain the nutrients Shawn is not getting while having a lower insulin load and more fat.

● beet greens

● spinach

● turnip greens

● chard

● olives

● lettuce

● arugula

● mackerel

● broccoli

● avocado

● zucchini

● sauerkraut

● caviar

● liver sausage

● blackberries

● cucumber

● celery

● cloves

● liverwurst

● sweetbread

● radishes

● summer squash

● cauliflower

● raspberries

The chart below shows the updated Cronometer food diary with the following changes:

● fattier T-bone steak rather than ribeye,

● fattier hamburger mince

● 2 oz liverwurst

● spinach

● olives

● avocado

● mackerel rather than salmon

The chart below shows the updated nutrient profile for this approach. Even though we have 60% fat, we are only missing out on six essential nutrients. We are still getting heaps of protein, but the lower insulin load (i.e. 22% of calories rather than 34% of calories) could help his pancreas keep up and maintain more stable blood sugars. This list of food would also give Shawn a protein:energy ratio of 1.3 which might be better to help him fuel his activity.

Comparison

The table below compared the scenarios in terms of:

● calories,

● target DRI levels not achieved,

● nutrient score,

● % protein

● % fat, and

● % insulinogenic.

scenario	calories	nutrient score	protein (%)	fat (%)	insulinogenic (%)	Protein: energy
baseline	4122	60%	55%	45%	31%	2.75
baseline / 2000 calories	2000	60%	55%	45%	31%	2.75
nutrient dense carnivore	2000	66%	62%	38%	34%	3.7
nutritious diabetes-friendly carnivore	2000	62%	39%	61%	22%	1.44
nutrient dense omnivore	2000	75%	56%	42%	32%	2.71
nutritious diabetes-friendly omnivore	2000	70%	38%	60%	22%	1.33

The chart below shows the % of the Daily Recommended intake for the various nutrients that were not meeting the DRI in the baseline scenario per 2000 calories achieved.

Hopefully, this helps to illustrate how the nutrient optimiser can be used to refine your food choices while still working within the constraints (e.g. digestion, preferences) and goals (e.g. diabetes management or energy density).

If you’re interested in fine-tuning your diet, the Nutrient Optimiser Free Report will suggest target macro ranges and foods suit your goals and dietary preferances.

references

^{^[1]} https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4543190/

^{^[2]} https://www.nature.com/articles/ijo2017303?error=cookies_not_supported&code=3eb7a8f0-ccb7-4e11-97ea-a70e4355d7fd

^{^[3]} https://robbwolf.com/2018/03/13/episode-385-dr-shawn-baker-carnivore-diet-and-dr-bakers-blood-work/

^{^[4]} https://robbwolf.com/2018/03/13/episode-385-dr-shawn-baker-carnivore-diet-and-dr-bakers-blood-work/

^{^[5]} https://fivethirtyeight.com/features/dwayne-the-rock-johnson-eats-about-821-pounds-of-cod-per-year/

^{^[6]} https://www.gutsense.org/fiber-menace/about-fiber-menace-book.html

articles, athletes, nutritious high energy density foods, psmf diet

how to use energy density to fine-tune your nutrition

March 17, 2018 Marty Kendall 5 Comments

This article looks at energy density and how you can use it to fine-tune your diet to reach your goals.

What is energy density?

Energy density, a measure of the calories in a given weight of food, is the is the third component of Nutrient Optimiser algorithm that you can use once you have nutrient density and insulin load dialled in,

It makes sense intuitively that bulky food full of water and fibre will help you to feel full, even though they don’t provide a lot of energy.

Imagine if all you had to eat were non-starchy, fibrous vegetables like lettuce, broccoli, and celery. You would struggle to get enough energy.

Your stomach can only hold so much.

However, we gravitate to higher energy density foods to ensure we get the energy we need.

We get a dopamine hit from energy-dense foods helps to ensure our survival a species. This drove us to hunt down, dig up or fight with bees to get energy-dense foods.

However today, in a world of engineered foods, full of refined carbs and added fats, lower energy density foods may be helpful to reverse engineer your food environment if you are trying to lose weight.

Who should consider lower energy density foods?

Focusing on lower energy density foods only needs to be a priority once you are eating nutrient dense foods and have stabilised your blood sugars. People who are obese and insulin resistant often don’t do well with only celery, broccoli, mushrooms, grapefruit and lettuce to eat. Hunger and appetite often win in the long run.

While insulin resistant people often have plenty of stored body fat, their insulin levels are still very high. They may struggle to access their stored body fat and avoid the cravings driven by the blood sugar rollercoaster. A nutrient dense low carb diet with ‘fat to satiety’ can help these people stabilise their blood sugars without hunger.

Focusing on more nutritious foods that stabilise blood sugars is enough to help many people lose some weight. However, many find that their weight loss stalls after a while when using a ‘fat to satiety’ approach. Not fearing fat may have helped them start their journey, but ramping up their fat intake to higher and higher levels often doesn’t achieve the desired results.

At this point, lower energy density foods and meals can be useful to help take the next step to lose more body fat once your blood sugars are stable and you are in the habit of eating nutritious food. An extreme version of this approach is the Protein Sparing Modified Fast (PSMF) as detailed in Lyle McDonald’s Rapid Fat Loss Handbook and this article.

In short, the PSMF is often used by bodybuilders or weight loss clinics to provide the vitamins, minerals, essential fatty acids and protein necessary with the minimum amount of calories to prevent loss of muscle mass and prevent cravings in dieting.

Low energy density foods

If you’re interested in trying out a lower energy density approach, the nutrient dense low energy density foods listed below will provide plenty of nutrients without too much energy.

Focusing on these foods will allow you to get all the nutrients you need without too much energy and be able to sustain a long-term energy deficit without excessive cravings. This chart shows how these foods stack up in terms of nutrients compared to the average of all foods in the USDA database.

Higher energy density foods

Alternatively, we can use energy density parameter to identify foods with a higher energy density to fuel your athletic endeavours or endurance event without having to resort to energy gels which will provide fast digesting energy but not a lot of nutrition.

The list of food will provide you with more energy while still being nutrient dense. This list contains more nuts, seeds, dairy and fattier cuts of meat.

As shown in this chart, these high energy density foods are not as nutrient dense as the lower energy density foods, however, they are still an improvement compared to the average of all of the food in the USDA database.

Energy density and satiety

Satiety is complex and involves more than just eating foods that are bulkier. Ensuring your diet contains enough protein (the most satiating macronutrient) and micronutrients (to avoid cravings), along with stabilising swings in your blood sugar (with a lower insulin load diet) are all pieces of the satiety puzzle.

One of the most interesting pieces of research into satiety is a 1995 paper by Susanne Holt and colleagues, “A satiety index of common foods”.^[3] This study fed participants 1000 kJ (239 calories) of various foods and looked at how much people ate at a subsequent meal. The study found that how much our stomach stretches is a significant factor in determining how satiating a particular food is.

The chart below shows SELFNutritionData.com‘s analysis of the data from the 1995 paper which they used to develop their Fullness Factor^[4]. This regression analysis shows that satiety per calorie tends to be positively correlated with:

lower energy density (i.e. calories per 100g of food),
higher protein content,
higher fibre, and
lower fat.

The most energy dense foods

The table below shows the energy density (i.e. calories per 100 g) of a range of foods and their weight per 500 calories.

food	calories / 100g	weight / 500 calories (g)
mushrooms	15	3333
celery	16	3125
broccoli	31	1613
oranges	47	1064
apples	65	769
fish	168	298
steak	250	200
Mars Bar	451	111
cookies	476	105
chips	1242	40
oil	1879	27

You might be able to eat more at dinner if you had a 40 g of chips for lunch compared to three kilograms of mushrooms or celery even though they both contain the same amount of energy.

Show me the data!

For those who like to see the numbers, the table below shows the energy density, nutrient density, macros and % insulinogenic of a range of food lists that we can quantify. The list is sorted from the lowest energy density to the highest energy density.

The energy density of real food can range from 30 to 450 calories per 100 grams.
The lowest and highest energy density foods are not necessarily the most nutrient dense, however, nutrient dense food tends to have a lower energy density.
The foods that contain very high levels of fat will be energy dense and not necessarily as nutritious on a calorie for calorie basis.
The weight loss approaches have a lower energy density. However, if you are trying to maintain weight or are very active you can still get a fairly nutritious outcome with higher energy approach.

approach	nutrient density score	density (cals/100g)	protein (%)	fat (%)	net carbs(%)	insulinogenic (%)
lowest energy density	61	30	20	10	52	63
weight loss (insulin sensitive)	93	83	42	17	26	50
weight loss (insulin resistant)	92	104	41	25	19	42
highest fibre foods	64	105	20	9	42	53
the most nutritious foods	93	107	43	18	24	49
highest protein foods	57	131	77	21	2	45
maintenance	90	240	40	25	26	48
energy dense foods for athletes	87	351	34	36	21	40
lowest fibre foods	41	404	20	76	3	14
well formulated ketogenic	47	426	16	73	4	13
most ketogenic foods	30	467	15	80	3	11

When do we use energy density?

The table below shows when Nutrient Optimiser uses energy density diet based on your blood glucose levels and waist to height ratio.

approach	average blood sugar		HbA1c (%)	waist : height ratio	energy density
approach	(mg/dL)	(mmol/L)	HbA1c (%)	waist : height ratio	energy density
weight loss (insulin resistant)	100 – 108	5.4 – 6.0	5.0 – 5.4%	> 0.5	lower
weight loss (insulin sensitive)	< 97	< 5.4	< 5.0%	> 0.5	lower
Bodybuilder (bulking)	< 97	< 5.4	< 5.0%	< 0.5	higher
endurance athlete	< 97	< 5.4	< 5.0%	< 0.5	higher

If you haven’t yet, make sure you head over to the Nutrient Optimiser get your free report complete which includes a list of foods and meals tailored to your goals.

Refereences

^[1] https://betterdoctor.com/health/the-ironman-who-runs-on-fat-not-sugar/

^[2] https://www.fxmedicine.com.au/content/counteracting-insulin-resistance-low-carb-high-fat-diet-prof-tim-noakes

^[3] https://www.ncbi.nlm.nih.gov/pubmed/7498104

^[4] http://nutritiondata.self.com/topics/fullness-factor

articles, carnivore diet

Dr Shawn Baker’s Carnivore Diet: a review

March 14, 2018 Marty Kendall 26 Comments

Interest in the controversial carnivore diet (a.k.a. zero carb) diet is booming!

After trying low carb, paleo, and keto, for some people cutting out all carbs and plant foods is the next logical progression in their journey towards optimal health and diabetes control.

But, to some people, this sounds counterintuitive!

Could eating only meat be healthy?

What about all those nutrients you get from plants?

Won’t you get too much protein?

What about fibre?

This article looks at the pros and cons of the carnivore diet through the lens of the Nutrient Optimiser.

I’m not sure that the carnivore diet is optimal for everyone. But in light of all the n = 1s, it’s hard to say it doesn’t work really well for some people.

Does the carnivore diet break all the rules of nutrition?

I’m inquisitive. Thinking out loud.

My aim is to understand the common factors of nutrition that help people thrive so we can apply them in a systematised manner.

Why is the carnivore diet becoming popular?

Other than Shawn Baker, there are a few interesting examples of people who have successfully followed a carnivorous diet for a long time and seem to be thriving.

Joe and Charlene Anderson

Charlene (45) and Joe (60) Anderson have been eating nothing but fatty steak for nineteen years, including through two healthy pregnancies.^[1] ^[2] ^[3]

Transitioning to a meat-only diet wasn’t all smooth sailing. Joe says:

Once I tried a specific, fatty, meat-only diet I felt miserable at first. Massive headaches, depression, fatigue and nausea were common. By the end of two weeks, however, the veil lifted and I felt great! I discovered that eating this clean meat-only diet was very healing, and I had my own demons and ill health that had to be expelled.

Charlene’s path to healing has taken considerably longer. Although she felt great immediately removing all the fibers, vegetables, and grains that she had been eating for years, she also felt the effects of starving out her Lyme bacteria. Her body would cycle back and forth from feeling great as the Lyme died off, to feeling horrible because the Lyme was dying off. She gritted her teeth, dug in, and stayed on plan.^[4]

Charlene looks to be doing just fine these days.^[5] ^[6]

You can read more about Charlene’s journey at Meat Heals or follow Joe on Twitter.

Amber O’Hearn

Amber is another prominent zero carber who progressed to a carnivorous diet after her success with low carb stalled. She cut out all plant foods (other than coffee) and found her bipolar benefited significantly and her weight loss improved!

Amber has done a ton of thoughtful research and documented her journey at ketotic.org, empiri.ca. She doesn’t claim that the carnivorous way of life is right for everyone, but she makes a good case for why we may not necessarily need fruit and “heart healthy grains” to be healthy.

Dr Georgia Ede

Psychiatrist Dr Georgia Ede on her Diagnosis Diet blog highlights anti-nutrients in plant-based foods (e.g. phytic acid, goitrogens, oxalates, and tannins) in not just grains and soy, but also cruciferous veggies such as spinach and broccoli, that also contain lots of vitamins and minerals. Georgia says:

Nutrient bioavailability from plants is in many cases significantly compromised. Just because a plant contains a nutrient does not mean we can access it. One example: due to the oxalate within spinach, virtually none of the iron within spinach is available to the human body. As a second example, the zinc in oysters is virtually impossible to absorb if the oysters are consumed with corn tortillas.

There are too many variables to consider in a mixed diet to be certain how foods will interact in various individuals. Recommended daily intakes for nutrients are based on faulty assumptions and the data used to generate them comes from people eating standard diets. Diets high in refined carbs deplete many nutrients, increasing our apparent requirements.

While some people may benefit from restricting these compounds in their diet, I’m not sure that it’s necessary or optimal for everyone. Many stressors in life are hormetic and can make you stronger in the long term.

And while the likes of oxalates can affect availability you can’t absorb nutrients if they’re not actually available in the foods you are eating. There is a trade-off between quantity and absorption. It’s hard to quantify these things but the calculations that I’ve done based on the limited data available indications that you should eat your spinach if you enjoy it.

Dr Gundry

While not strictly a carnivore, Dr Stephen Gundry has recently released The Plant Paradox where he speaks of the dangers of lectins and antinutrients in grains and legumes that many people struggle with, especially if they are prone to an autoimmune response. To be clear, while his book title may be misleading, he still supports eating green leafy vegetables.

Paleo Medicina

While many people are talking about meat causing cancer Paleo Medicina are using a carnivore diet to treat cancer, autoimmune and other chronic conditions. This Ketogeek podcast interview with biologist and clinical researcher Dr Zsofia Clemens is an intriguing listen!

Online groups

There are also a number of large online groups of people who swear by just eating meat, including Principia Carnivora and Zeroing in On Health.

What I find fascinating is that these groups are every bit as passionate about their dietary approach as the plant-based vegans who also claim that their diet was responsible for healing them of all their ailments. While online groups are amazing for bringing together like-minded people to support each other on their journey, they are not exactly randomised trials and can suffer from confirmation bias, groupthink and survivorship bias (i.e. only the people that benefit continue to contribute to the group). (note: I’m not accusing anyone particular of these traits, just nothing that online groups can be subject to these symptoms. It’s hard to seperate the anedoate from the science).

Dr Baker has also established the World Carnivore Tribe group which has a ton of positive anecdotes as well as Meat Heals which has been set up to gather n=1 experiences on a carnivorous way of life. There’s no deny a LOT of people have found improved their quality of life when they simplified their diet to meat only.

It makes me wonder what the common factors of the optimal human diet are when people are zealous advocates of what appear to be polar opposite approaches. How do we identify what works and systematise it to help everyone to move towards optimal?

Rather than forcing vegans to be carnivores and carnivores to be vegan, how can we optimise your food choices while still respecting your preferences?

Dr Shawn Baker

Dr Shawn Baker (@SBakerMB, shawnbaker1967) is the latest high profile proponent of the carnivore approach to nutrition to burst onto the scene. To say Shawn has a fascinating backstory would be an understatement (as described in his interview with Joe Rogan).

Shawn is a strength athlete who needs a lot of food. In the past, this included plenty of cereals, low-fat yogurt, skim milk, pasta and grains to maintain weight with his high level of activity.^[7]

After experiencing digestive issues (note the similar story with others who have benefitted from zero carb), he progressively experimented with his diet, moving from the typical high carb to paleo, then low carb, then a targeted ketogenic diet. However, he found that he would suffer gut distress when he added carbs back in on the cyclic keto approach, and eventually settled on a meat-only carnivorous dietary approach.

He has since gone to set world records in indoor rowing and continues to workout like a beast at 51.

Video of 350m row- 49.6 sec (1:10.8 pace) at 44spm- this is world class for any age group! (I turn 51 in 4 weeks) Fueled strictly by the powers of meat and desire!! #carnivore #meatheal

A post shared by Shawn Baker (@shawnbaker1967) on Dec 11, 2017 at 2:57pm PST

He has been interviewed on a number of podcasts promoting nequalsmany, where he is trying to pool the experiences and test data from a range of people following a carnivorous diet.

Shawn saw a need to gather health and performance data from people following a carnivorous diet to try to understand why they seemed to be thriving in spite of cutting across a lot of mainstream health recommendations.

While I haven’t seen any analysis of the crowdsourced data yet, he recently carried out some testing on himself after a year as a carnivore, which we will look at later in this post.

Nutritional analysis

Personally, I’m intrigued at how someone like Shawn could be thriving, so I pinged Dr Baker on Twitter to get his standard diet to analyse in the Nutrient Optimiser.

The Nutrient Optimiser is a tool designed to help people balance their diet primarily at a micronutrient level. It then identifies food that provides the nutrients that they need that they are currently not getting in adequate quantities.

As well as maximising micronutrients, the Nutrient Optimiser can manipulate macronutrients and energy density to help you achieve your goals, for example:

if you are managing diabetes, we can reduce the insulin load of your diet to help stabilise your blood sugar levels or even further to achieve therapeutic ketosis,
if you are fuelling for an endurance event, we can wind up the energy density to enable you to get more energy in, and
if you are looking to lose weight, we can reduce energy density to ensure you get the nutrient you need with foods that are more filling.

What I like most about the Nutrient Optimiser is that it removes the conflicts of interest to demonstrate that the foods that we know intuitively are bad for us (e.g. hyper-palatable processed junk foods) provide minimal levels of nutrition and should be avoided.

Balancing your nutrition at a micronutrient level helps to cut through the confusion and commercial bias using widely recognised nutrient targets. Whether you want to eat only plants for ethical reasons or only animal-based foods because that’s all your sensitive digestion can tolerate, the Nutrient Optimiser can help you find the food that will work for you.

My hope is that the Nutrient Optimiser be adopted widely as to help improve your diet regardless of your preferences or goals.

Limitations of a plant-based diet

In systems design, things get interesting when you take them to their limits.

You need to test how something performs at the extremes to iron out the bugs. In the case of the Nutrient Optimiser, the limits to be tested are macronutrient extremes (carbs, fat, protein) or extremes of plant- vs animal-based food sources.

One of the problems with the Daily Reference Intake (DRI ) for essential nutrients is that they were developed in the context of a angriculture-based western diet. At the extremes, we need to understand which parameters are still relevant and which ones need to be modified.

In a previous post, we looked at the nutritional sufficiency of the recipes in Dr Greger’s How Not to Die Cookbook. As shown in the micronutrient nutritional profile below, a plant-based diet contains adequate quantities of most of the essential nutrients other than omega 3, vitamin B12, and choline.

However, as carnivore diet proponents will be quick to point out, not all nutrients provided by animal- and plant-based foods are the same. Although certain vitamins and mineral exist under the same name, their form and bioavailability differ between plants and animals.

For example, iron in animal foods exists in the form of heme and is more bioavailable than the elemental iron supplied by plants. Animal foods also provide forms of nutrients that the body requires, such as retinol (vitamin A) and EPA / DHA (omega-3s), whereas plant foods supply precursors to these nutrients (beta-carotene and alpha-linolenic acid, respectively).

Unfortunately, we don’t yet have enough data to quantify these variables accurately. I hope that in the next few years there will be more research that will help us quantify the effect of bioavailability and antinutrients on the quantity of nutrients absorbed compared to just waht goes into our mouth. We do need to keep these limitations in mind when analysing a purely plant-based diet, especially if someone is displaying symptoms of deficiency in the nutrients that are borderline.

Carnivore diet

In a similar way, we need to understand the limitations that may apply to a carnivorous diet. The chart below shows the nutrient profile of a carnivore diet versus all foods in the food system USDA database. It seems to be harder to meet the Daily Recommended Intake levels for vitamin K1, calcium, vitamin E, vitamin C, and folate. Magnesium and potassium just barely make it.

If you don’t mind some organ meats, you can get a very respectable micronutrient profile in real life. A great example is Amy, who comes in at #13 on the Nutrient Optimiser Leaderboard with her carnivorous diet with plenty of organ meats, and is meeting the daily intake levels for everything except vitamin C, manganese, vitamin K1, calcium, magnesium, vitamin E, and vitamin D (check out her full report here).

Of course, not everyone likes offal. The chart below shows the nutrient profile if we remove it. We would struggle to get adequate vitamin K1, manganese, folate, calcium, vitamin C, vitamin A, vitamin E, and magnesium. The nutrient score drops from 75% to 67% (although, even without accounting for bioavailability, it is still better than the plant-based diet at 63%).

Shawn Baker’s diet analysis

Let’s look at what we learn from analysing Dr Baker’s diet. Shown below is Dr Baker’s average daily intake with lots of steak and hamburger mince with some cheese, eggs, shrimp, and salmon entered into Cronometer.

The micronutrient fingerprint of Dr Baker’s diet is shown below. You can check out his full Nutrient Optimiser analysis here.

At the bottom of the chart (see zoomed in segment below), we see that Dr Baker’s diet has a ton of vitamin B12, zinc, iron, and amino acids. However, at the top of the chart, we see that Dr Baker’s diet is lacking in vitamin C, manganese, vitamin A, vitamin D, vitamin K1, folate, calcium, omega 3, and pantothenic acid (at least when you use the RDI as your benchmark).

However, what do we make of the fact that Dr Baker and a number of his friends appear to be thriving? Are the recommended nutrient levels just plain wrong? Which ones are relevant in this context?

In response to my preliminary analysis, Shawn commented:

As you point out, some of the micronutrients may become less of a requirement based upon overall dietary scheme.

Personally, I don’t necessarily believe the DRIs are relevant to a carnivorous diet in general and would look at clinical endpoints. For example, calcium deficiency has a clinical manifestation and developing signs of it should lead to deterioration of health rather than its enhancement as I’ve experienced and the same with countless other pure meat eaters.

It is relevant to note that there are many zero-carb people that have been going many years, to some several decades, on just muscle meats and no offal at all and who also maintain excellent health.

There is no point in telling someone to stop doing something if they are thriving. However, at the same time I can’t stop thinking of Dr Bruce Ames’ Triage Theory which suggests that, in the absence of adequate nutrients, the body will prioritise nutrients geared towards short-term survival rather than optimal health and longevity.

Dr Baker’s n=1 data

Dr Baker has been spearheading a nequalsmany crowdsourcing of a range of data from people following a carnivorous diet. While I’m eager to see the full analysis of the data when it’s available when it is analysed, Shawn recently discussed his own test results after fourteen months on a carnivorous diet with Robb Wolf. I highly recommend you have a listen to the interview on the Paleo Solution Podcast.

Cholesterol

To my eyes, Dr Baker’s cholesterol values are fairly unremarkable other than to note that his TG:HDL ratio is 1.3 (which is good) and his total cholesterol : HDL is 4.6 which is OK.^[8] ^[9] However, I’m no expert in this contentious area.

Alex Leaf of Examine.com noted that “High LDL-p, low HDL to LDL ratio, low HDL to non-HDL ratio are All strong CVD risk factors”.

Meanwhile, while Dave Feldman of Cholesterol Code offered the following comments:

LDL-C and LDL-P are both on the lower end for a low carber who is as lean and fit as Dr Baker is. I suspect this is due to his emphasis on resistance training, which can reduce LDL scores due to a higher rate of use for muscle repair.
Small LDL-P is low at 283, and clearly very Pattern A.
HDL-C — 40 mg/dL is low for a zero carber.
HDL-P was highlighted as being low (out of range) at 28. However, I see this frequently with low carbers across the board.
Triglycerides — 54 is certainly very correlative with a very athletic, insulin sensitive metabolism.
Lipoprotein (a) — 2 nmol/L is one of the lowest scores I’ve ever seen (maybe THE lowest).
The score I most care about is Remnant Cholesterol which is calculated by subtracting both HDL-C and LDL-C from Total Cholesterol. His score of just 11 mg/dL is extremely low risk and suggests he has a very efficient fat metabolism.

HbA1c

What is more interesting and puzzling is Baker’s HbA1c of 6.3% with a fasting blood sugar of 121 mg/dL.

This HbA1c level puts him on the borderline of prediabetes and full-blown type 2 diabetes,^[10] which I wouldn’t have expected. A HbA1c of 6.4% and a fasting glucose of 126 is the cut off for type 2 diabetes. HbA1c of less than 5.0% and fasting glucose of less than 95 mg/dL are typically associated with lower all-cause mortality.^[11] ^[12]

What is puzzling here is that, while Shawn’s HbA1c is high, he has a fasting insulin level of 2.6 mIU/L which is very low which either suggests he is very insulin sensitive or his pancreas is not producing enough insulin. (Since the release of he Robb Wolf podcast there has been a ton of speculation about his results. It will be interesting to see if he follows up on any of the gratuitous suggests for futher testing.

Some people point to HbA1c being an unreliable measure due to the fact that red blood cells live longer in healthier people, however Dr Baker’s blood sugar measurements correlate with the HbA1c values.

Some will say that the 6.1 g/kg/LBM or 560 g of protein per day is driving gluconeogenesis. (This is a contentious and complicated topic that I have covered at length in the article Why do my blood sugars rise after a high protein meal?)

If you look at things from a total energy perspective you could say that Shawn is just eating a lot to fuel his activity (more than 4000 calories per day) and hence his blood sugars are staying high.

Perhaps it’s a case of extreme physiological insulin resistance where the body chooses to keep glucose levels higher where there is less glucose available and lower insulin levels?

However, I think it’s worth noting that essential minerals such as potassium, calcium, and sodium are essential for maintaining insulin sensitivity.^[13] ^[14] ^[15] While the body does a pretty good job of maintaining acid/base balance, the kidneys still need enough substrate (e.g. alkaline minerals such as potassium, magnesium, and sodium) to be able to do this. Once the kidneys stop being able to tightly regulate pH we can get metabolic acidosis which goes hand in hand with type 2 diabetes.^[16] ^[17] ^[18] ^[19] (This is another complex and contentious topic that I covered in Alkaline Diet vs Acidic Ketones.)

It’s interesting to hear in his discussion with Robb that Dr Baker is finding benefit from adding sodium and electrolytes. Many people on a low carb dietary approach find that supplementing minerals is important. The Nutrient Optimiser analysis typically finds that people need more potassium or magnesium rather than sodium. Sodium is fairly easy to get while potassium and magnesium is much harder for most people. There are a range of studies suggesting that a higher potassium : sodium ratio is desirable.^[20] ^[21] ^[22]

At the same time, Dr Baker’s HbA1c could have been a lot higher before he started his carnivore diet due to the high dietary load to fuel so much exercise and bulking and the meat only diet could be improving his HbA1c. We just don’t know from the data currently available. I look forward to the full analysis of the data from the nequalsmany participants. However, based on the results of Shawn’s n=1 it may be too early to say that zero carb is the cure for type 2 diabetes.

Testosterone

While there are anecdotes of an animal-based carnivorous diet raising testosterone levels, Dr Baker’s endogenous testosterone levels are lower than you might expect given his level of muscularity, leanness, and endurance.

As discussed in the interview with Robb he is experiencing no symptoms of low testosterone and suggests that, similar to TSH and insulin, he may be more sensitive to testosterone and hence the body doesn’t need as much of it. Others have been more sceptical of Baker’s testosterone results.

Are the nutrient recommendations relevant to someone following a carnivorous approach?

Given that the RDIs are designed to prevent nutrient deficiencies in most of the population, they will be conservative for most people when it comes to deficiencies. However, what constitutes optimal is a different matter.

The challenge in using the RDIs at extremes is that they have not been adjusted to cater for varying requirements of people following a vegan, keto, or carnivorous approach.

Many people are quick to dismiss the RDIs entirely in view of the numerous anecdotes of people thriving with no plant-based foods. But I’m eager to understand, as much as we can with the available data, how the parameters might change and what is still relevant and important.

While the DRIs are based on people eating a standard western diet, anecdotally many people seem to find they need to supplement electrolytes when they reduce or remove carbohydrates sources from their diet, so I don’t think we can say that someone on a carnivorous diet would have a lower requirement for electrolytes such as sodium, magnesium or potassium.

Does the carnivore diet break the Nutrient Optimiser?

Dr Baker isn’t going out of his way to chase micronutrients. I think the fact that he’s eating more than 4000 calories per day will help to make up for the lower availability of some nutrients in animal vs plant based foods.

A fairer illustration of the potential of the potential of a carnivorous is the nutrient profile for Amy which is shown below, who is following a carnivore diet with heaps of organ meat.

Although Amy has gone out of her way to maximise her micronutrients as much as anyone practically could with a carnivorous diet she is still not meeting the RDI for vitamin K1, vitamin C, calcium, vitamin E, sodium, and magnesium. But is this an issue?

The Nutrient Optimiser has a zero carb/carnivore diet option for people who chose to eat that way for preference or due to other issues. This allows people who chose to follow this approach to help manage autoimmune or digestive issues to fine tune their micronutrients as much as possible within those constraints.

The question for me, then, is whether we need to worry about these perceived deficiencies?

Vitamin K2 can be converted to K1

Vitamin K1 is primarily found in plants while K2 is synthesised by bacteria in the large intestine of animals and humans.

The issue here is that Vitamin K2 (menaquinones MK1 through MK4) is only a fairly recent discovery. Hence the USDA food database only contains data on the quantity of K1 (phylloquinone) in foods.

The good news is that most people can convert K2 to K1 and vice versa depending on demand.^[23] Hence, low dietary vitamin K1 intake may not be an issue if you are getting plenty of K2 from sources such as eggs, butter, and liver.

Some nutrients are more bioavailable

As we mentioned before, vitamin A and omega 3 are more bioavailable from animal-based sources. However, I don’t think this is a real issue either way as it is quite easy to get plenty of these nutrients on a carnivorous diet.

The effect of anti-nutrients on absorption

Iron, calcium, and magnesium may be more bioavailable when there are no oxalates in the diet.^[24] Adequate iron is rarely a problem for someone eating adequate amounts of animal-based protein. Excess iron is often a problem in males. Shawn’s ferratin is within range but perhaps above optimal for males.

Calcium and magnesium do tend to be harder to find, but without plant matter in the diet, it may be more bioavailable.

Grains and legumes can contain lectins, glutens, and phytates that can affect the absorption of minerals like potassium and magnesium.^[25] Unfortunately, we don’t yet have enough data to calculate how much of the various nutrients are getting into your system from the food once you account for bioavailability. Plus, cooking vegetables greatly reduces anti-nutrient levels, which adds another layer of complexity to figuring out how much we absorb in a diet of both cooked and raw foods.

For many people, grains just aren’t worth it, especially if they have pre-existing digestive issues. I’m not sure, however, that the same principle applies to all vegetables.

Personally, my digestion is pretty robust, so I’m not too worried about oxalates in spinach. I figure the benefit of getting all the vitamins more than offsets the negative impacts, at least for me. Some plant-based compounds (e.g. sulforaphane) may have a beneficial hormetic effect.^[26]^[27] ^[28] ^[29] However, for some people, their gut is so messed up by modern processed foods that they find they need to cut out all fibre containing foods.

Essential nutrients we require less of when we eat less glucose

There is some evidence to suggest that Vitamin C is not as much of a priority for someone with less glucose to process. There are examples of plenty of people surviving with minimal vitamin C on a zero carb diet.^[30]

Vitamin C is also probably underreported from animal food and often assumed to be zero. If you want to dig into this more, you can check out Amber O’Hearn’s comprehensive article on vitamin C on a ketogenic diet.

Nutrients that there are is no deficiency testing for

Manganese

There are also a number of nutrients that are based on population average intakes rather than deficiency testing, such as manganese.^[31]

Given that manganese is associated with carbohydrate metabolism, there may be a lesser requirement for people following a carnivorous diet. There may be limited use in chasing targets that are simply based on average intakes of people eating a typical western diet.

Manganese is high in organ meats, which are prized by cultures that do not have access to a lot of plant-based foods, so it is possible to get adequate quantities. While someone on a zero-carb diet may not need as much, manganese still seems to be a useful nutrient.

Vitamin E

Similarly, the RDI for Vitamin E is based on median population intake levels^[32] rathher than any deficiency testing and it is possible that the requirements may be lower for someone not eating as much glucose.

Pantothenic acid (Vitamin B5)

Shawn is not quite meeting the RDI for Vitamin B5 but may not need more unless he has high intakes of alcohol or coffee or has high levels of stress. The target levels are based on the average intake from population studies, so there’s probably no need to chase the target here for someone on a carnivore diet.

Nutrients that are still important

Vitamin D

Without a lot of seafood, Shawn is not getting a lot of Vitamin D from his food. However, a lack of dietary vitamin D is not unique to carnivores. The RDI levels for vitamin D levels are based on the amount required to maintain serum 25(OH)D levels with minimal sunlight. Interestingly, as shown in the test results, Shawn’s serum vitamin D levels are on the lower end of normal.

Folate

Shawn is getting lower levels of folate compared to the estimated average requirement. Again, folate can easily be obtained from organ meats which are prized in cultures that do not have access to plant-based foods.

Calcium

Shawn is also not meeting the RDI for calcium. Calcium can be obtained on a carnivore diet from eggs and sardines or other bony fish. Target calcium levels are based on balance studies,^[33] and your calcium requirements will increase with age.

Omega 3

Shawn is getting a solid amount of omega 3, though not enough to meet the RDI levels or achieve ideal omega 3 : omega 6 balance. Again, omega 3 is not hard to get from animal-based products if they include some seafood.

Magnesium and potassium

Magnesium and potassium are two minerals that many people do not get enough of when they reduce their carbohydrate intake, particularly green veggies.

The keto flu is a common symptom that people experience early in their ketogenic journey that they can fix with supplementation of alkalising minerals.

I struggle to see that there is a lesser requirement for these minerals on a keto or carnivore diet. Though itis conceivable that bioavailability is improved when plants are removed from the diet, there is not really enough data to quantify this.

Don’t focus on just one nutrient

All in all, I think nutrients are important. However, getting wrapped up in chasing the absolute DRI for individual nutrients can be problematic due to the numerous factors outlined above. Our nutrient requirements will also change based on a range of things such as activity, life stage, the other things you are eating, your gut health and nutrient absorption.

Life is all about making the best choices we can with imperfect data. We can’t let the lack of perfect stop us from using the data that we have available. To smooth out the limitations of individual nutrients, the Nutrient Optimiser prioritises foods that contain a cluster of the ten or so nutrients you are getting less of and identifies the foods and meals that contain these nutrients in larger quantities.

So sure, maybe you don’t need as much K1, manganese, vitamin C on a carnivorous diet, the Nutrient Optimiser will help you find the foods that contain the other nutrients that can be harder with your preferred approach to find the nutrients that are still important.

Historically, humans seem to adapt pretty well to a wide range of food environments over time. What we don’t seem to do well with is modern hyperpalatable nutrient poor energy-dense foods that are flavoured and coloured to make us think that they are good for us, but actually contain very little actual nutrition.

What about the Maasai?

Many people refer to the Maasai tribe in Africa, who survive on nothing but milk, meat, and blood from their animals, as a precedent for the carnivorous approach.

While they are a thriving, beautiful people, keep in mind that they are drinking blood from their animals and eating fresh meat, nose to tail.

This is not the same as eating only drained muscle meat that has been hung for a long time. It’s pretty hard to get fresh, undrained meat let alone fresh blood in the west.

Who should try a carnivorous diet?

One common theme I see for people who seem to thrive on a carnivorous approach is some sort of gut issues (e.g. permeability or bacterial overgrowth) or some sort of autoimmune condition, perhaps due to long-term exposure to processed low nutrient-poor foods.

If your gut is already compromised, then cutting down on fibre and other plant matter, particularly grains, nuts and seeds seems to work wonders for many people. If you have issues that you find are only healed by staying strictly carnivore then, by all means, stick with it.

You could also use carnivore as an elimination phase and then slowly reintroduce other foods back in to see if you can tolerate them. You may enjoy a diet that is less restrictive and makes it easier to get the nutrients you need from your diet. I recommend checking out Chris Kresser’s The Paleo Cure or Natasha Campbell McBride’s GAPS Diet if you want to follow this elimination and reintroduction type approach.

Some people find great success with a carnivore dietary approach. There are a ton of great testimonials at meatheals.com. At the same time, I have seen many others that carnivore didn’t work out for. One friend Samantha found that she became hypersensitive to the smallest whiff of flour and found improvement through a course of probiotics.

The general motto of the carnivore crowd is to just eat meat when hungry. This works well for many, but not all.

Ironically, during the finalisation of this article, I contacted Amy (who has the amazing carnivore nutrient profile shown above) and she advised she was no longer following a zero carb dietary approach and was now pursuing a nutrient dense omnivorous approach. She had found that she started to gain weight after 2.5 years on a carnivorous diet and her thyroid function diminished. Amy, who was previously an admin for a major carnivore Facebook group, says:

“All of these, coupled with my EXTREMELY high LDL cholesterol of 500 and my 7-year lack of menstrual cycle, points directly to a failing thyroid. ZC made it WORSE… MUCH worse. I went back to a mixed diet in January of this year. Within 2 weeks of this diet change, I regained all of my natural bowel motility. And, surprisingly, within 2 months my menstrual cycle returned after 7 years of absence!! I regained my energy, and I’m now walking daily again, doing daily hour-long sessions of yoga (which I used to love doing years ago), lifting weights 3 days a week, and doing 20 minute HIIT workouts 3 days a week. I’ve put on some weight, but I look and feel very healthy. I notice that I’m frequently hot now instead of cold, which I presume is a symptom of my thyroid upregulating to where it should be. I am scheduled to have a complete thyroid panel, lipid panel, and other hormone tests run at the end of March to see where I am. But I can clearly tell you that ZC did NOT do MY body any favors.”

Overall, it’s probably fair to say that a carnivore diet can benefit many, however, I think it’s probably too soon to say it’s optimal for everyone. If you do want to pursue a carnivorous diet, then the Nutrient Optimiser can help you identify foods to get as much nutrition as you can within that framework. If you find that you want something with a little bit more variety and want to include some plants, then autoimmune, lactose-free, nut free, or shellfish free options are available to suit your allergies, preferences and intolerances

Summary

Some people seem to benefit from a zero carb/carnivore diet, particularly if they have pre-existing gut permeability or bacterial overgrowth.
Cutting out nutrient-poor processed inflammatory foods is a common denominator in many successful diets.
It is harder to get some nutrients without plants, however, some of these nutrients may not be such a big deal if you are not eating a lot of carbohydrates.
While there are plenty of anecdotes, there is not yet a lot of large-scale quantitative research into the long-term impacts of a carnivore diet.
It’s still a good idea to maximise the micronutrients in your diet irrespective of your overarching dietary template.

Food lists

I have included some food lists that may be of interest if you want to pursue a carnivorous approach or have major digestive issues.

Carnivore / zero carb

The foods listed below will provide you with the most nutrients per calorie without plants. The food at the top of each section contains more of the nutrients that are harder to find per calorie.

The nutrient profile of these foods is shown in the chart below.

Carnivore / zero carb (diabetes friendly)

The problem with the nutrient dense carnivore approach is that it contains a lot of protein (63%). This may drive satiety (meaning it will be hard to get enough calories in) or potentially be problematic for someone dosing with insulin due to the insulinogenic nature of the protein. The foods below contain more fat which will make it easier to get adequate energy as well as reduce insulin requirements.

The nutrient profile of these foods is shown below (i.e. more fat, less protein and lower micronutrients per calorie).

Autoimmune & SIBO

Many people who benefit from a carnivorous have messed up digestion and/or autoimmune issues. If you don’t want to go full carnivore, the food list below removes the most inflammatory foods and foods that commonly cause digestive issues while still contain a lot of nutrients.

The nutrient profile of these foods is shown below.

Autoimmune (low carb)

The food list below will provide nutrients with more fat which will enable you to get enough energy.

The nutrient profile of these foods is shownn below.

nutrient dense

For comparison, the most nutrient-dense foods are shown below.

The nutrient profile of these foods is shown below. Keep in mind that these are the nutrients contained in the food and some of these nutrients will be less bioavailable.

Thanks

Special thanks to Shawn Baker, Robb Wolf, Alex Leaf, Amber O’Hearn, Dave Feldman, Robin Reyes, Helen Kendall and Raphi Sirt for their input and review into this article.

References

^[1] http://www.getbig.com/boards/index.php?topic=574036.0

^[2] https://www.inquisitr.com/2083582/carnivore-family-has-eaten-a-zero-carb-all-beef-diet-for-the-past-17-years/

^[3] https://gistonice.wordpress.com/2015/05/11/when-eating-only-meat-becomes-a-way-of-life-family-lives-on-only-meat-for-the-past-17-years/

^[4] http://www.getbig.com/boards/index.php?topic=574036.0

^[5] https://zerocarbzen.com/tag/lyme-disease/

^[6] https://thenortheasttoday.com/anderson-family-on-meat-diet-for-17-years/

^[7] https://www.breaknutrition.com/episode-17-dr-shawn-baker-lifts-like-crane-eats-like-lion/

^[8] https://www.ncbi.nlm.nih.gov/pubmed/11176761

^[9] https://www.thebloodcode.com/know-your-tghdl-ratio-triglyceride-hdl-cholesterol/

^[10] https://optimisingnutrition.com/2015/03/22/diabetes-102/

^[11] https://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

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

^[13] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC301822/

^[14] https://www.ncbi.nlm.nih.gov/pubmed/21036373

^[15] https://optimisingnutrition.com/2017/10/21/redesigning-nutrition-from-first-principles/

^[16] https://optimisingnutrition.com/2016/11/19/the-alkaline-diet-vs-acidic-ketones/

^[17] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4424466/

^[18] http://downloads.hindawi.com/journals/jeph/2012/727630.pdf

^[19] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195546/

^[20] https://www.ncbi.nlm.nih.gov/pubmed/2224920/

^[21] https://www.facebook.com/groups/OKL4Vitality/permalink/677232549136149/?hc_location=ufi

^[22] https://www.facebook.com/groups/OKL4Vitality/permalink/652513618274709/?hc_location=ufi

^[23] https://chrismasterjohnphd.com/2016/12/09/the-ultimate-vitamin-k2-resource/

^[24] https://www.ncbi.nlm.nih.gov/pubmed/17440529

^[25] jn.nutrition.org/cgi/content/full/129/7/1434S

^[26] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2635914/

^[27] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4273949/

^[28] http://roguehealthandfitness.com/hormesis-health/

^[29] http://www.organiclifestylemagazine.com/sulforaphane-why-your-cells-need-cruciferous-vegetables

^[30] http://breaknutrition.com/ketogenic-diet-vitamin-c-101/

^[31] https://www.nrv.gov.au/nutrients/manganese

^[32] https://www.nrv.gov.au/nutrients/vitamin-e

^[33] https://www.nrv.gov.au/nutrients/calcium

articles, blood sugar, diabetes, insulin index, insulin load, insulin resistance

how to optimise the insulin load of your diet

March 9, 2018 Marty Kendall 5 Comments

Insulin is the primary hormone that controls your metabolism.

You need some to survive.

But too much can be bad news.

Insulin helps drive amino acids into your muscles to help them grow.

Insulin helps glucose enter the cells to fuel your mitochondria to produce energy.

Meanwhile, insulin also works as a brake to keep energy in storage.

When you eat, your pancreas secretes insulin to slow the release of energy from body fat stores through your liver until the energy coming in from your mouth and in your bloodstream are used up.

How do we become insulin resistant?

I don’t know about you, but I find it hard to resist the yummy food that always seems to be available.

We no longer have to hunt or gather our food. It is always available, relatively cheap and flavoured to ensure we can easily eat lots of it.

In our modern food environment, it’s hard to ‘eat to satiety’ without usually eating a little bit too much. It’s like we’re saving for a winter that never comes.

Then, to make it even harder, the food industry optimises their products for ‘bliss point’ (with just the right amount of sugar, salt, fat and artificial colours and sweeteners) and creates hyper-palatable foods to drive profit.

Unfortunately, this all has an impact on more than just our taste buds.

Eventually, as you continue to consume more energy than you can use, your fat stores become inflamed and can’t take in any more energy.^[1] ^[2]

Your pancreas ramps up its efforts to hold back the pressure of excess energy in our liver and body fat stores.^[3] ^[4]

If excess energy keeps coming in, the pancreas re-doubles its efforts to clear the glucose from the blood with more and more insulin.

First, the fat stores become full, then the bloodstream and eventually insulin drives the excess energy into other areas in the body that are still insulin sensitive such as your liver, heart, pancreas, eyes and brain.

Over the long term, this combination of high insulin levels and high energy leads to heart disease, fatty liver, Alzheimer’s, Parkinson’s and a whole host of modern diseases.^[5] ^[6] ^[7]

Type 1 diabetes

People with type 1 diabetes, like my wife Monica, give us an opportunity to understand how insulin works.

The picture below shows “JL” one of the first type 1 diabetics to receive insulin treatment in 1922. The picture on the left is after diagnosis with diabetes but before treatment with insulin. The photo on the right is the same child two months.

With insulin injections, he can stop the uncontrolled release of his fat and muscle stores and quickly put weight back on.

For reasons we don’t fully understand, the pancreas can stop producing insulin. People with type 1 diabetes need to inject insulin to “cover” the food they eat as well as “basal insulin” to mimic what a healthy pancreas does automatically between meals.

Wise food choices are critical to stabilising blood sugar levels. Foods that require a significant amount of insulin tend to cause large swings in blood sugar levels.

If your blood levels are high, you will feel tired and will need to take a large dose of insulin to slow the release of glucose from your liver.

If your blood sugars are low, you will feel the need to eat food, preferably something sweet to raise your blood sugars quickly!

It’s hard to control your appetite with these rollercoaster-like swings in blood glucose like the one shown in the chart below. Our appetite and survival instincts are strong, and we will eat to raise our blood glucose levels to feel good again.

daily blood sugar data of type 1 diabetic on typical western diet

Foods with a lower insulin load allow people with type 1 diabetes to smooth out their blood sugar swings and stabilise their food cravings.

daily blood sugar data for the same person with type 1 diabetes on a low carb diet

Type 2 diabetes

While the cause of the disease is different, people with type 1 and type 2 diabetes are in a similar situation. They both have an overall insulin insufficiency. People with type 1 don’t produce enough insulin and need to inject insulin.

The insulin resistance in people with type 2 diabetes means that their pancreas cannot produce enough insulin to keep their blood sugar levels stable. Their fat stores cannot hold all the energy in the system, so it spills out into the bloodstream, and we see elevated blood glucose levels.

For people with type 2 diabetes, reducing the insulin load of the food they eat will enable their pancreas to keep up to maintain more stable blood sugars. Once the wild swings of glucose and insulin stabilise, it is often easier to go longer between meals or make better food choices.

Insulin sensitivity

While insulin resistance and diabetes are often associated with obesity, you can be fat and still have normal blood sugars and be insulin sensitive.

People who are insulin sensitive can easily store energy in their adipose tissue and release energy easily later when they are not eating.

Their fat stores of insulin sensitive people are still functioning well. They take in energy from the food they eat and relatively quickly release it when they are not eating.^[8]

If you are insulin sensitive with stable blood sugar levels and want to lose body fat you will probably do well if you focus on eating foods with a higher nutrient density and a lower energy density. However, if you are insulin resistant, you will likely also benefit from eating foods with a smaller insulin load, at least until your blood sugars stabilise.

Which approach is best for you?

Nutrition is complex, and there is still a lot of disagreement about the role that insulin resistance plays in health and weight loss. However ultimately, most of us are trying to hack our system to get the nutrients we need without excessive energy.

The Nutrient Optimiser algorithm considers your blood sugars, HbA1c, triglyceride:HDL ratio and waist:height ratio to optimise your blood sugars are while also maximising nutrient density as much as possible.

The food insulin index data

Now we’re going to take a quick look under the hood of the Nutrient Optimiser algorithm to see how the insulin load parameter works.

The chart below shows the relationship between the carbohydrate content of our food and our insulin response.^[9] ^[10] ^[11] ^[12]

carbohydrates vs insulin response (click to enlarge)

The quantity of carbohydrate in your diet explains the majority of your insulin response. However, if you look carefully in the bottom left corner of the chart above, you will see that there are high protein foods that cause a large insulin response and high fibre foods that cause a smaller insulin response.

Once we account for the effect of fibre and protein, we get a much better prediction of our insulin response to food. This understanding of the various factors that influence insulin response enables you to prioritise foods that cause a smaller insulin response, as well as more accurately calculate insulin dosing for people with diabetes.

If you are injecting insulin to manage your diabetes then understanding how to quantify the insulin load of your diet can help you more accurately calculate your insulin dose (as detailed in this post). If you require therapeutic ketosis, you can also identify foods that will minimise your insulin response.

Protein

While protein does require some insulin to build and repair our muscles, the chart below shows us that increasing the proportion of energy from protein will typically force out processed carbohydrates and trigger a lower insulin response.

Higher levels of protein also tend to generate a smaller glucose response compared to carbohydrates.

It’s also important to note that protein is the most satiating macronutrient. If you want to reduce your energy intake without having to meticulously track calories and without excessive hunger it’s important not to avoid protein. Reducing the amount of energy in your diet will allow the energy in your bloodstream (i.e. glucose, ketones and free fatty acids) to be used up and your insulin levels will come down even further.

Fat

Obtaining more of your energy from fat will decrease your insulin response…

…as well as your glucose response.

However, keep in mind that, as well as the food you eat, your insulin levels are influenced by the food you eat as well as the amount of energy already in your system.

High-fat foods are often energy dense and easy to overeat. Your pancreas will still need to elevate insulin levels while your body uses up the energy from your diet, so they can still drive insulin resistance if eaten to excess.

The insulin load is a great tool to manage the short-term volatility of your blood sugar levels. However, if you look at the big picture, lower insulin levels correspond to lower energy in your system (i.e. from your diet and body fat).

Once your blood sugars are stable, it may be prudent to focus on reducing the fat in your diet if you want to use your excess body fat. This will help to further reduce your blood sugars and insulin levels floating around in your blood towards optimal levels.

Insulin load vs nutrient density

Like many things in life, there is a trade-off as we push things to extremes. The chart below shows that we tend to optimise nutrient density with about 40% insulinogenic calories.^[13]

If you are insulin resistant, you will probably do better if you maintained less than 40% insulinogenic calories. If you have diabetes, then you’ll probably need to stay below 25% insulinogenic calories. If you require a therapeutic ketogenic diet (i.e. for the treatment of cancer, epilepsy, Alzheimer’s, dementia or Parkinson), then you will need to maintain a very low insulin load, which typically means consuming more fat and even reducing your protein intake.

It may not be ideal to maintain such a low insulin load for a long time. The more you push the insulin load of your diet to either extreme the more you will compromise your micronutrient profile.

What do I do with all this information?

While you may find all this detail a little confusing, you don’t have to worry too much about all the numbers.

We have designed the Nutrient Optimiser algorithm to calculate your target macronutrient ranges to suit your goals and suggest foods and meals that will help you keep your blood sugars stable and normalise your insulin levels while also maximising the nutrient content of your diet.

Once you attain normal blood sugars, you will ‘level up’ to the next stage of your nutritional journey.

Stay tuned…

In our next instalment, where we will discuss how we can manage the energy density of your food to enable you to get more calories in if you are running a marathon, or help you to feel more satiated with less energy if you are trying to lose weight.

References

^[1] https://www.ncbi.nlm.nih.gov/pubmed/25733684

^[2] https://www.ncbi.nlm.nih.gov/pubmed/25515001

^[3] https://www.youtube.com/watch?v=i2WRi7mP1ck

^[4] https://www.youtube.com/watch?v=Cdork0TA90U

^[5] https://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

^[6] https://optimisingnutrition.com/2015/03/22/diabetes-102/

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

^[8] https://en.wikipedia.org/wiki/Metabolically_healthy_obesity

^[9] https://optimisingnutrition.com/2015/03/30/food_insulin_index/

^[10] https://optimisingnutrition.com/2015/03/23/most-ketogenic-diet-foods/

^[11] https://www.researchgate.net/profile/Peter_Petocz/publication/13872119_Holt_SHA_Brand_Miller_JC_Petocz_P_An_insulin_index_of_foods_the_insulin_demand_generated_by_1000-kJ_portions_of_common_foods_Am_J_Clin_Nutr_66_1264-1276/links/00b495189da41714fa000000.pdf/download?version=vs

^[12] https://ses.library.usyd.edu.au/handle/2123/11945

^[13] https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

^[14] https://examine.com/nutrition/low-fat-vs-low-carb-for-weight-loss/

^[15] https://www.sciencedirect.com/science/article/pii/S1551714416302166

^[16] http://onlinelibrary.wiley.com/doi/10.1002/oby.21331/full

^[17] https://drruscio.com/high-carb-low-carb-science-actually-says-episode-43/

articles, nutrient density

How to maximise nutrient density

March 3, 2018 Marty Kendall 10 Comments

We surveyed the Nutrient Optimiser Facebook Group to see what they wanted to learn more about.

Overwhelmingly, the most requested topic was nutrient density.

Given that nutrient density is the central component of the Nutrient Optimiser algorithm, it’s the perfect place to start this educational series.

Managing nutrient density ensures you get all the micronutrients you need without too much energy.

This short article will give you an understanding of what “nutrient density” means, why it is important and how you can use the Nutrient Optimiser to improve your diet.

Macronutrients

Most of the time people think in terms of the macronutrients:

protein,
carbohydrates,
fat, and
fibre).

While consideration of macronutrients can be useful, it doesn’t do much to ensure we are obtaining the micronutrients that we need.

Many get enthusiastic about specific macronutrient ratios (e.g. high fat, low carb, low protein, low fat etc.). Unfortunately, poorly defined macronutrient extremes can be detrimental to your micronutrient profile. But when you focus on micronutrients,, macronutrients largely look after themselves.

Essential Micronutrients

There is a wide range of compounds in our food that we are adapted to thrive on. But it’s the essential nutrients that we can’t make from other sources that we need to get from our food.

These essential micronutrients are listed below, divided into their categories of vitamins, minerals, amino acids and essential fatty acids.

vitamins

choline
thiamine
riboflavin
niacin
pantothenic acid
vitamin A
vitamin B12
vitamin B6
vitamin C
vitamin D
vitamin E
vitamin K

minerals

calcium
copper
iron
magnesium
manganese
phosphorus
potassium
selenium
sodium
zinc

amino acids

cysteine
isoleucine
leucine
lysine
phenylalanine
threonine
tryptophan
tyrosine
valine
methionine
histidine

essential fatty acids

eicosapentaenoic acid (EPA)
docosahexaenoic acid (DHA)

There are conditionally essential nutrients, beneficial nutrients and other compounds that we are aware of but don’t measure. There’s no need to worry too much about these other substances.

If you are eating minimally processed whole foods with plenty of the essential micronutrients, you’ll likely be getting more than enough of all the other beneficial nutrients.

Recommended daily intake levels

Recommended daily intake levels of the essential nutrients have been established for both sexes at various life stages (i.e. pregnant, young or old).

These recommended intake levels are typically based on the amount that is required to prevent nutrient deficiencies. It’s usually better to get more than the minimum amount of the essential nutrients where possible.

While supplements can be a useful stop-gap measure, we strongly recommend obtaining more of your nutrients from whole foods which contain all the other beneficial nutrients.

The Nutrient Optimiser will help you determine which nutrients you are currently not getting enough of and which foods and meals will help you fill your micronutrient gaps.

Emphasising the harder-to-find nutrients

Building on the previous work of the likes of Bruce Ames, Joel Fuhrman and Mat Lalonde, the Nutrient Optimiser algorithm focuses on boosting only the nutrients that you are not getting as much of.

If a particular group of nutrients is easy to find or you are already getting heaps of them, there’s no need to focus on trying to get more of them.

The Nutrient Optimiser helps you to rebalance your diet by focusing on the foods that contain the nutrients you are not getting enough of.

The purple bars in the chart below show the nutrients in all the foods in the USDA food database.

As you can see, some micronutrients are easier to find than others. Nutrients such as vitamin C, vitamin K and vitamin B12 are generally easy to get enough of while nutrients such as choline, calcium, magnesium and potassium are harder to find.

The light blue bars show the nutrients in the highest ranking 10% of foods in the USDA database when we focus on boosting the nutrients that are harder to find.

We get a massive boost in the nutrients that are harder to find while still getting plenty of the other nutrients.

Nutrient ratios

The Nutrient Optimiser algorithm also looks at the balance between nutrients that operate synergistically.

While the quantity of nutrients is important, the ratio between key nutrients also needs to be considered. If the nutrient ratios fall outside the target range, they don’t get prioritised.

ratios	target
Zinc : Copper	8 – 12
Potassium : Sodium	> 2
Calcium : Magnesium	< 2
Iron : Copper	10 – 15
Calcium : Phosphorus	> 1.3

By doing this, the Nutrient Optimiser guides you to eat more of the foods that will help to improve your nutrient balance as well as getting more nutrients per calorie.

Your appetite is the original and ultimate Nutrient Optimiser

The human taste buds have evolved to be the ultimate Nutrient Optimiser, telling you which foods and nutrients you need at a particular point in time.

Wild animals seek out the foods they need at a particular point in time. Similarly, in the absence of processed hyper-palatable flavoured foods, our cravings guide us to the foods we need.

However, these days, in our modern food environment we have lost the ability to determine what we need. Our appetite has been tricked into eating foods that look and taste amazing. However, these manufactured foods often contain negligible nutrients.

The Nutrient Optimiser will help you to shortlist foods and meals that contain the nutrients. Once you’re eating real food that contains nutrients, you can learn to trust your appetite again.

Personalised for you

We have put a lot of effort into developing optimal food lists for different contexts.

We can prioritise the nutrients that are harder to find in the USDA foods database.
We can prioritise the nutrients that are associated with various health conditions.
We can prioritise nutrients that are harder to find in conventional dietary patterns (e.g. ketogenic, low carb, paleo, plant-based, standard western diet, vegan etc.).
We can even prioritise the nutrients that most people are missing out on.

But none of these approaches considers what YOU are eating now and what nutrients you personally need more of.

That’s why we created the Nutrient Optimiser.

The Nutrient Optimiser can use your food log (exported from Cronometer) to identify the nutrients that you are not getting enough of.

The Nutrient Optimiser algorithm then creates your personalised nutritional solution to identify the foods and meals that will fill your current nutritional gaps.

This is truly personalised nutrition, optimised for YOU.

What YOU should eat

Rather than stressing about what NOT to eat, the Nutrient Optimiser helps you focus on what you SHOULD be eating to optimise your diet from first principles.

Once you are getting your fill of the foods that you should be eating, our cravings for the other foods tend to dissipate. Worrying about what not to eat becomes a non-issue.

One common observation from people who have used the Nutrient Optimiser to refine their food choices is how little food they need to be satisfied.

Once you solve satiety, optimal weight and body fat levels often look after themselves.

Nutrient density is central

Nutrient density is central to the Nutrient Optimiser algorithm. However, it is not the only parameter.

The Nutrient Optimiser algorithm also considers:

insulin load (to help tweak your diet if you are insulin resistant or have diabetes), and
energy density (which can be useful to make your diet even more satiating, so more fat can come from your body).

We’ll cover these other parameters in the following articles.

articles, exogenous ketones, ketones, ketosis

Is the acetone:glucose ratio the Holy Grail of tracking optimal ketosis?

February 24, 2018 Marty Kendall 11 Comments

Key points

The real magic of ketosis seems to occur in a lower energy state.
High levels of beta-hydroxybutyrate ketones (BHB) can be a good sign, particularly with lower blood glucose levels.
Unfortunately, forcing in extra energy in the pursuit of higher BHB levels (e.g. exogenous ketones or refined fat) has the potential to drive higher insulin and insulin resistance.
As we lose weight, improve our metabolic health and stop over fueling, many people start to see lower levels of BHB.
While it can be used as an alternative to glucose in the brain, BHB needs to be converted to acetoacetate to be used by the body.
If you are making and using ketones without consuming excessive energy you will likely see lower blood glucose, higher breath acetone and lower BHB levels.
The ratio between breath acetone and glucose can be a useful indicator of genuine nutritional ketosis and a healthy metabolism.

Introduction

In previous articles we’ve looked at why chasing higher blood ketones with more dietary fat or exogenous ketones might not be smart.^[1] ^[2]

We also looked briefly at the glucose:ketone ratio as a useful parameter to track therapeutic ketosis.^[3] ^[4]

This article looks at the ratio between acetone (a form of ketones that can be measured on your breath) and your blood glucose.

It appears that this ratio may be helpful if you require therapeutic ketosis (e.g. to manage cancer, epilepsy, Parkinson, Alzheimers, dementia etc) or to optimise your metabolic health for weight loss, general health or longevity.

We crunch the numbers to see how you can use breath acetone to help you optimise your metabolic health.

[TL;DR… Higher breath acetone with lower blood glucose seems to be a good place to be. Breath acetone is potentially more useful than monitoring BHB in the blood.]

What is ketosis?

Ketosis is trending hard at the moment.

But what is it?

And do you really need more of it?

Some people think that we need to be “in ketosis” to burn fat. Hence, many people think that more ketosis is better, especially if you have body fat you want to burn.

While this message helps sell keto-related products, it’s technically not correct.

Ketosis is an alternative metabolic pathway that our body uses when there is not enough oxaloacetate in our diet (from carbs or protein) to burn fat via the Krebs cycle. When this occurs, fat that can’t be oxidised in the Krebs cycle is oxidised via ketosis.

This is a “sliding scale” sort of thing. People following a typical western diet will have lower levels of blood ketones (e.g. 0.1 or 0.2 mmol/L),^[5] while people eating more fat and less carbs may have higher levels.

The fact that we can use this backup metabolic pathway has helped us survive many a famine to procreate another day.

Ketosis is a critical component of our metabolism and our survival as a species.

Are ketones magical?

Our understanding ketones and ketosis is evolving fast.

Some people believe that ketones have unique and special signalling properties.^[6] ^[7] While others feel that these beneficial properties of ketosis are limited to endogenous ketosis (i.e. when we predominantly burn stored body fat).^[8]

When our energy levels are low, we also see an upregulation of mitochondrial biogenesis, sirtuins, autophagy and NAD+ which are also highly beneficial.

But perhaps it’s actually all of these things working together that causes the benefits that many people associate with “being in ketosis”, not just the ketones themselves.

When energy levels are low, our body goes into repair mode to ensure survival and we switch over to burn body fat. Our blood ketones rise significantly after a few days without food.

The chart below shows about three thousand data points from people following a low carbohydrate or ketogenic diet measuring blood ketones and blood glucose at the same time. Blood ketones (shown in blue) are not necessarily high for most people while they are eating normally, even if blood sugar levels are low (shown as orange).

We can drive high blood ketones by taking exogenous ketones and/or lots of refined fat (the right-hand end of this chart). But, unless you’re about to do some explosive exercise to burn off all this energy, this over fueling may not be optimal.

Oxidative priority

Our appetite does an excellent job of making sure we get the fuel if it’s available. Our metabolism is pretty good at balancing the different fuel sources based on inputs and demand.

While our bodies are adapted to deal with a range of fuel sources, it struggles to deal with too much energy for a long time.

The chart below (from a paper by Ray Cronise, David Sinclair and Andrew Bremer, with the addition of exogenous ketones courtesy of Craig Emmerich) shows the order that we generally prioritise the use of different fuel sources.

Alcohol will be burned off first because it’s effectively a poison that the body can’t store. (Alcoholics can have really low HbA1c levels because insulin rises to shut off the release of glucose into the bloodstream while the alcohol is burned off.^[9])
Similar to alcohol, ketones are used up as a priority because we can’t channel them back into storage in the body. Ketones are acidic and high levels of ketones in the blood lead to diabetic ketoacidosis. (note: As discussed below, Beta-hydroxybutyrate (BHB) can be thought of as the storage form of ketones. While BHB can be used directly by the brain, it needs to be converted back to acetoacetate to be used by the rest of the body.)
Protein is not a great fuel, so we can’t store much of it in the blood. It’s hard for the body to convert protein to energy so it’s hard to overeat.^[10]
Carbohydrates can be a useful source of fuel for explosive efforts. But glucose can be toxic in large quantities (it leads to glycation) so the body tries to limit the amount in the bloodstream.
If glucose levels are high, the body won’t burn off the fat from our diet. Fat is last in line to be burned because it’s such an effective way of storing energy.
Similarly, if the level of fat in our diet is high we won’t burn off the fat on our body effectively. (High levels of fat in the bloodstream can lead to oxidised LDL, so the body wants to keep it moving rather than building up high levels.)

Your body increases insulin to hold back the release of stored energy until the energy in the blood decreases. As you burn through all these fuel sources the body decreases your insulin levels to eventually allow the release of your stored fuel for use to make up the difference.

You can think of a lower energy state as one where you don’t have a lot of fuel lined up in front of our body fat, while a high energy state occurs where your body has to ramp up insulin levels to hold your stored energy back from being used while the energy from your mouth is being used.

When you look at it from this perspective you see that nutrition is essentially a process of optimising our food choices to ensure we get the nutrients and fuel we need without stacking up too much energy in front of our body fat stores.^[11] ^[12]

Low carb and weight loss

More stable blood glucose levels help people normalise appetite. People often eat less when they are no longer on the blood glucose roller coaster. For people with diabetes, weight loss is often a spontaneous response to reducing carbohydrates as demonstrated by the recently released Virta one year trial results.^[13]

However, while high blood ketones (BHB) is often targeted as evidence of being “in ketosis”, BHB levels often typically taper off over time, especially if you are lean, active, metabolically healthy and weight stable.

It seems that as our fat stores become ‘less full’ we don’t store as much energy in the bloodstream. And, as we will see later, once our NAD+: NADH ratio increases, less acetoacetate is pushed off to into storage as BHB.

One of the most fascinating outcomes of the one-year Virta study was that over the period of a year, participants’ BHB levels went from 0.17 mmol/L to an average of 0.54 mmol/L after 10 weeks and then settled back to 0.3 mmol/L after a year.^[14]

I found it ironic that in this study of treating diabetes with a ‘ketogenic diet’ that, on average, these people only temporarily dipped into “nutritional ketosis” (defined as having BHB > 0.5 mmol/L). Then in the long term, they settled back to much lower levels of BHB.

Even under the supervision of the doctors and dietitians who are the world experts in ketosis and literally wrote the book on the topic, at no time did they go near “optimal ketosis” (as defined as having BHB between 1.0 mmol/L and 3.0 mmol/L^[15]).

Blood sugar and HbA1c

While the science around ketosis is still controversial, we do know that a lower HbA1c and lower blood sugar levels can be beneficial in terms of long-term health and avoiding many common killers (e.g. diabetes, heart disease, cancer, stroke etc).

The chart below shows that a HbA1c of 4.5% (i.e. a proxy for your average blood sugar level) gives the lowest hazard ratio (i.e. lowest risk of mortality from all causes).^[16] ^[17]

As shown below, a lower HbA1c is beneficial in terms of reducing your risk of stroke, heart disease, cardiovascular disease and many of the modern diseases.

The risk of focusing on beta-hydroxybutyrate as your measure of ketosis

However, if at first, you don’t succeed in achieving “optimal ketone levels” many people resort to the following to raise their blood ketone levels:

load up on high levels of refined fat such as Bulletproof Coffee with butter and MCT oil,

[warning: These foods are typically more energy dense and less satiating, so many people find them easy to overeat. While most people don’t need to avoid dietary fat, simply eating ‘fat to satiety’ doesn’t lead to long-term weight loss for many people.]

eat less protein to reduce oxaloacetate and force more fat to be burned via ketosis rather than the Krebs Cycle,

[warning: Replacing energy from protein and carbohydrates with fat can lead to a less nutrient dense selection of foods as evidenced by many of the lower ranking people in the Nutrient Optimiser Leaderboard. In this recent article Volek and Phinney suggested that protein intake is between 1.5 and 2.0 g/kg reference weight and that while reducing protein will help to increase ketosis you should not drop below 1.2 g/kg BW.^[18]],

eat a more acidic diet with less electrolytes to ensure that the keto acids are not able to be balanced with alkaline minerals such as magnesium, potassium and calcium), or

[warning: This approach may lead to the keto flu in the short term and insulin resistance^[19] and metabolic acidosis in the longer term.^[20]]

eat a diet that contains less B vitamins to decrease your NAD+:NADH ratio to force more acetoacetate to be stored and converted to BHB.

[warning: B vitamins are important for efficient and effective energy production].

The glucose:BHB index

So we do know that lower glucose levels are a good thing and high blood ketones are not necessarily bad. They can actually nourish the brain if we are insulin resistant and aren’t using glucose well and this is helpful where therapeutic ketosis is required (i.e. Alzheimer’s, epilepsy, Parkinson’s, cancer etc).

But high ketones are not great if they are also accompanied by high blood glucose levels and/or free fatty acids.

So, the way to make sure we are not overloading our system in our pursuit of ketosis is to ensure that our higher ketone levels are also accompanied by lower glucose levels.

Enter the glucose: ketone index which was developed by Professor Thomas Seyfried of Boston College^[21] ^[22] to help optimise the metabolism of cancer patients.

Seyfried subscribes to the Warburg hypothesis of cancer which says that cancer cells ferment glucose and, hence, reducing the glucose supply to cancer cells can help them slow proliferation.

To help understand what this looks like in practice I have plotted more than 1200 blood glucose versus ketone values in the chart below and divided them up into five groups based on their GKI value. The average GKI values of these groups of data points are shown on the charts (i.e. GKI = 1.5, 2.8, 4.5, 7.5 and 20).

The worst metabolic health is the GKI = 20 population (green dots at the bottom of the chart) with high blood glucose levels and low ketones. This means that glucose values are twenty times that of the ketone values.

Meanwhile, the people with the lower glucose and the higher ketone are likely to be in a better place metabolically. They will be more likely to experience the positive therapeutic benefits associated with “being in ketosis”.

Before you go chasing a super low GKI value, be aware that most people are not going to get GKI values under than 2.0 until they fast for a few days, even if they are following a ketogenic diet. The chart below shows what you could expect if you fasted for seven days.

The glucose : acetone index

Both Michel Lundell from Ketonix and Dave Korsunsky from Heads of Health recently told me that, building on the GKI concept, a number of people are tracking the ratio between their breath acetone readings and their glucose levels.

In order to better understand the relationship between breath acetone and ketones, I have plotted about two and a half thousand glucose and breath ketone readings taken at the same time in the chart below.

You can see from this chart that there is a similar relationship between glucose and breath ketones as with blood ketones. However, there is less scatter compared to the previous chart. It seems that blood glucose and breath acetone are more closely correlated than blood ketones.

It’s hard to have high breath acetone with high blood glucose levels. You can’t ‘game the system’ in the same way you can with BHB by forcing in exogenous fat or ketones.

As your energy and insulin levels start to rise, more of your acetoacetate will be shunted off to storage as BHB. So, while some refer to BHB as ‘the gold standard”, it’s hard to know whether high blood ketone values are due to a low energy state or if your bloodstream is full of energy so you need to store more as BHB.

I think the optimal situation to be in is to have lower blood glucose levels with a solid amount of breath acetone in your system which suggests you are producing ketones without driving excess energy.

If you have good metabolic health, you’ll probably be in the purple or green area on this chart. If you are achieving a therapeutic level of ketosis or fasting for longer periods, you will ideally be in the upper left corner of this chart (green or light blue) with low glucose and high breath ketones.

The chart above shows breath acetone (BrAce on the Ketonix scale of 0 to 100) and the blood glucose in mmol/L. To calculate your BrAce:BG ratio you can divide your Ketonix reading by your blood glucose level. If you’re going to measure it’s probably better to measure your glucose and ketones in the morning when you first wake up. They key is to measure these values all at the same time. While it’s interesting to see how you compare with others it’s most important to make sure your values moving in the right direction over time.

The chart below shows glucose vs breath acetone with glucose in mg/dL (American units). If you have Ketonix and blood glucose meter you can test and see how you compare.

Are breath ketones a better measure of health than BHB?

If you’re really interested in this topic, I recommend you watch this video from Chris Masterjohn that explains in detail how ketones are made and used.

In summary:

Acetoacetate is the first ketone body made in the liver (unfortunately, it’s hard to measure).
If your NAD+:NADH ratio is low, more acetoacetate will be converted to BHB, which can be measured in the blood.
While the brain can use BHB directly, BHB needs to be converted back to acetoacetate to be used in the rest of the body.
When the level of energy in your bloodstream decreases, your NAD+:NADH ratio increases and insulin levels decrease. You will then be able to shuttle the ketones stored as BHB back to acetoacetate to be used for energy in the rest of the body.

Acetone is like a vapour that is released from acetoacetate, similar to nail polish fumes. If you are releasing a high level of breath acetone, then people might say you have a ‘fruity’ smell on your breath or you will experience a different, metallic taste in your mouth.

It’s not easy to measure acetate in the blood, but devices like the Ketonix are becoming more popular to measure acetone in your breath. Acetone on your breath is not a direct measure of the quantity of acetoacetate in your system but it’s a useful proxy. Imagine the difference in smell if you have a small thimble versus a massive drum of nail polish. You’re going to get more fumes coming off a large amount of acetone.

The take-home point here is that if our NAD+:NADH ratio is high, and our overall energy levels are low then not as much acetoacetate will be converted to BHB, and hence more acetoacetate will be available in the blood and more acetone will be measured on the breath.

Meanwhile, if you have excess energy in your system, you will have high levels of ketones in their “storage form” available for use only by the brain. Conversely, if you have a lower energy state that is more conducive to burning body fat, you may have less BHB and more acetoacetate.

So, breath acetone is more of a measure of ketones ready to be used by your body while BHB is more of a measure of ketones being stored for later use.

Why does the balance of acetone vs BHB vs BrAce matter?

NAD+ is a metabolite that declines with age.^[23] A lot of the anti-aging research at the moment is focusing on how we can boost NAD+ levels.^[24] ^[25] ^[26] ^[27] ^[28] IV NAD+ treatments are being used for drug addiction, anti-ageing and quick recovery from a really big night.^[29] ^[30] ^[31]

The secret here is that, while you can take supplements and injections to boost NAD+, most people can get plenty from B vitamins (particularly vitamin B3 (niacin) which is dirt cheap).^[32]

NAD is also made from tryptophan in the diet.

NADH builds up when we become over-fueled and is typically higher in conditions such as diabetes.^[33] When we eat and get energy from food, a hydrogen ion (H+) and two electrons (2e-) attaches to NAD+ and we get NADH. When we use the energy and go without foods the reverse reaction occurs. NADH decreases and NAD+ builds up.

Too much energy in our system drives high NADH levels. Just like in a car engine, we can drown our mitochondria in fuel and they choke.

When we have lots of fuel in our system NADH rises but then if we don’t have enough NAD+ we can’t use it. So we’re drowning in fuel but we can’t use it!

Bringing this back to measuring ketones… if we have a higher NAD+:NADH ratio we will see higher breath acetone, lower blood glucose and lower levels of BHB (which is a good thing).

Tell me what to do!!!

So ideally we want to see:

higher breath acetone,
lower blood glucose levels, and
blood ketone values of maybe greater than 0.2 mmol/L (they’re not really a big deal unless you specifically require high levels of blood ketones to feed your brain in conditions such as epilepsy, Alzheimer’s or Parkinson’s).

How to get higher NAD+ levels and higher acetoacetate

Boosting your NAD+ levels can be achieved by:

Eating nutrient dense foods with plenty of B vitamins (which are a precursor to NAD+),
Not avoiding protein (particularly tryptophan), and
Supplementing with niacin.

If you find your breath acetone is on the lower end you can try supplementing with Niacin. When I supplement with Niacel or Niacin my BHB levels drop and my breath acetone rises substantially.

Be warned, you can get a flushing reaction so make sure you start slowly. There is no need to take super high levels, particularly if you’re already keto-adapted.

You can supplement to the point that you start to see higher Ketonix readings. Or, if you don’t have a Ketonix, to the point that you get a funky metallic taste in your mouth.

You might want to start with 25 mg or 50 mg of Nicotinic Acid and build up to 100 mg or even 200 mg if you don’t see any flushing or a rise in your breath acetone.

If you’re wanting to start gently, the Carson Lab niacin is the only one I’ve been able to find in 50 mg in Australia via iHerb.
The 100 mg Nicotinic Acid is actually a lot cheaper (only 5 c per tab).
Nicotinamide Riboside can be useful for people who can’t as easily convert niacin to NAD+, but it’s more expensive.

However, rather than supplementing, nutrient dense minimally processed whole foods are ideal, at least as a starting point before you start adding supplements. The Nutrient Optimiser has been designed to help you find the most nutritious whole foods to balance your macro and micronutrients.

If you require therapeutic ketosis the Nutrient Optimiser free report will give you a suggested macro range that will also help you avoid excessive energy. It will also give you a short list of nutrient dense meals and foods that will help boost your mitochondrial function.

If you’re interested, the Nutrient Optimiser full report will give you a longer list of foods and meals. You also have the option to upload your Cronometer data to progressively fine-tune your diet to achieve your goals.

How to get lower blood glucose levels

The key to achieving lower blood glucose levels is:

Avoid processed, and nutrient-poor high carbohydrate foods (e.g. processed grains, cereals and sugars),
Eat less often / fast / avoid snacking,
Eat less overall.

If you do these things, you will see your blood glucose levels decrease, your NAD+ levels increase, and your breath acetone levels increase.

You can stabilise your blood glucose levels by eating a diet with more fat and less carbohydrates, but to really shift your NAD+:NADH ratio in a favourable direction, you may need to reduce your body fat to more optimal levels.

The article How to use your blood glucose meter as a fuel gauge can guide you through how to use a glucose meter to re-calibrate your eating routine based on when you really need to eat.

The Nutrient Optimiser will suggest macronutrient ranges and nutritious foods that will help you stabilise your blood sugars.

Thanks

Special thanks to:

Robert Miller for sharing his unique insights into biochemistry.
Michel Lundell from Ketonix for supplying all the data!
Weikko Jaross and Alessandro Ferretti for help with the initial database analysis.
Craig Emmerich. Mike Julian, Ben McDonald, Robin Reyes, Alex Leaf and Helen Kendall for their review and editing.

References

^[1] https://optimisingnutrition.com/2016/08/08/how-to-make-endogenous-ketones-at-home/

^[2] https://optimisingnutrition.com/2017/04/30/are-ketones-insulinogenic-and-does-it-matter/

^[3] https://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

^[4] https://optimisingnutrition.com/2018/02/03/is-too-much-protein-on-keto-a-thing/

^[5] https://link.springer.com/article/10.1007%2Fs13300-018-0373-9

^[6] https://www.ncbi.nlm.nih.gov/pubmed/25686106?dopt=Abstract

^[7] https://www.ncbi.nlm.nih.gov/pubmed/23223453?dopt=Abstract

^[8] https://optimisingnutrition.com/2016/08/08/how-to-make-endogenous-ketones-at-home/

^[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5125693/

^[10] https://www.dropbox.com/s/zej4razn4dn993y/protein%20leverage%20hypothesis%20-%20simpson2005.pdf?dl=0

^[11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5326984/

^[12] https://www.amazon.com/Keto-Complete-Ketogenic-including-Simplified/dp/1628602821

^[13] http://doi.org/10.1007/s13300-018-0373-9

^[14] http://doi.org/10.1007/s13300-018-0373-9

^[15] https://www.amazon.com.au/Art-Science-Low-Carbohydrate-Living/dp/0983490708

^[16] http://circoutcomes.ahajournals.org/content/3/6/661

^[17] This chart is interesting because it shows that very low blood glucose levels can be association with issues such as autoimmune issues or alcoholism which can cause blood sugars to go very low while the body burns through the alcohol.

^[18] https://blog.virtahealth.com/how-much-protein-on-keto/

^[19] https://optimisingnutrition.com/2017/10/21/redesigning-nutrition-from-first-principles/

^[20] https://optimisingnutrition.com/2016/11/19/the-alkaline-diet-vs-acidic-ketones/

^[21] https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/s12986-015-0009-2

^[22] https://www.bc.edu/bc-web/schools/mcas/departments/biology/people/faculty-directory/thomas-seyfried.html

^[23] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852209/

^[24] http://www.lifeextension.com/Magazine/2018/2/Anti-Aging-Effects-Of-NAD/Page-01

^[25] https://www.sciencedaily.com/releases/2017/03/170323141340.htm

^[26] http://www.iflscience.com/health-and-medicine/preliminary-results-early-human-trials-anti-aging-formulas-reveal-no-adverse/

^[27] https://bengreenfieldfitness.com/podcast/anti-aging-podcasts/what-is-nad/

^[28] http://longevityfacts.com/nmn-nad-nicotinamide-mononucleotide-david-sinclair-interview-anti-aging-drug-trials-nicotinamide-adenine-dinucleotide-sirtuins/

^[29] https://www.nadtreatmentcenter.com/6-major-benefits-of-nad-iv-therapy

^[30] https://www.vice.com/en_us/article/bn3vmq/nad-plus-brain-reboot-infusion-injection

^[31] https://bengreenfieldfitness.com/podcast/anti-aging-podcasts/what-is-nad/

^[32] https://openi.nlm.nih.gov/detailedresult.php?img=PMC4588049_cells-04-00520-g001&query=&req=4&npos=-1

^[33] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869616/

articles, how to lower insulin, insulin index, insulin load, insulin resisatnce, protein

is ‘too much protein’ on keto really a thing?

February 3, 2018 Marty Kendall 4 Comments

There is a lot of confusion in keto land about ‘excess protein’.
Insulin and protein are used to build and repair your muscles, organs and the other important parts of your body. This is an important and beneficial use of protein and insulin.
Foods that contain the harder to find nutrients (e.g. potassium, magnesium, choline, vitamin D) typically contain plenty of protein.
Actively avoiding protein and can lead to a less nutritious diet.
Unless you require therapeutic ketosis for the treatment of cancer, epilepsy, Alzheimers, Parkinson or dementia, you should be chasing vitality, health and nutrition along with stable blood sugar levels rather than some arbitrary ketone level.
There are a range of different ways to quantify protein intake. Thinking in terms of percentages can be more confusing than helpful.
It’s hard to over-consume protein because it is highly satiating. However, if you avoid protein your body may drive you to consume more calories until you get the protein it needs.
If you follow your appetite and focus on foods that contain the vitamins and minerals you need you will probably get enough protein.

Virta Facebook Live Q&A

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

Dr Phinney’s response to my question is shown below, including his recommended protein intake levels of 1.2 to 1.75 g per kg reference body weight of protein.

While I largely agree with Dr Phinney’s response, I think it’s worth elaborating on some of the issues that are causing so much confusion at the moment.

Will too much protein kick me out of ketosis?

If you’ve read previous posts on Optimising Nutrition you’ve probably seen my analysis of the food insulin index data that shows that our carbohydrate intake alone doesn’t explain our insulin response to food.

The food insulin index data shows that our insulin response to food is more accurately predicted when we consider the fibre and protein content of our food, not just the carbohydrate.

However, I fear that many people have used the insulin load concept as a reason to avoid protein. I now understand that this is far from optimal within the broader context of good nutrition for health, weight loss and vitality.

If you are interested in learning more the implications of the insulin index data I recommend you check out the following articles:

Effect on blood sugar and insulin

While trading your calories from butter for steak will increase your requirement for insulin, the food insulin index data suggests that as a general rule, getting more of your energy from protein will reduce your insulin requirements as it forces out processed carbohydrates as shown in the chart below.

Getting more energy from protein tends to decrease our glucose response as it forces out nutrient-poor refined high carb foods. Your body can convert protein to glucose (i.e. gluconeogenesis) if it really needs to but it’s a lot of work, so it would much rather get energy from carbs or fat.

Protein is also very satiating. Once we have enough protein, our body tends to crave more fatty and carby foods for energy.^[10]

While it is both financially and metabolically expensive, protein is the most important component of your diet. Different people will need different amounts of protein depending on their life stage and activity levels.

While you probably don’t need to be going out of your way to binge on more protein than you can comfortably consume, actively avoiding protein containing foods is a recipe for nutritional disaster. If you are exercising or lifting heavy then you will naturally crave more protein.

If you actually need higher levels of blood ketones for therapeutic ketosis, it may be a good strategy to consciously restrict protein. However, I don’t’ think the vast majority of people chasing ketones are looking for therapeutic keto for the management of cancer, Alzheimer’s, epilepsy, dementia or Parkinson’s but rather fat loss or diabetes control.

Protein number crunching

The numbers around protein can be confusing due to the units used.

Dr Phinney uses ‘reference body weight’ (RW) (which he says is ‘the weight you were when you were in college’).
The mainstream nutrition world talks in terms of total body weight (BW).
Meanwhile, the sports nutrition community talk in terms of lean body mass (LBM).

In order to understand what this means in practice, let’s look at an example of a woman who is currently 40% body fat but was 25% in college (i.e. her reference weight). For argument’s sake let’s say she was 70 kg in college but she is currently 87 kg or 193 lb. The images below will give you an idea of what these level of body fat levels look like.

In the table below I have calculated what Dr Phinney’s recommended protein intake looks like for this person in terms of:

reference body weight (RW),
lean body mass (LBM), and
body weight (BW).

Based on Dr Phinney’s guidance, this person should be eating between 84 and 123 g of protein per day.

	body fat	weight (kg)	weight (lbs)	lower limit	upper limit
reference weight	25%	70	154	1.2 g/kg RW	1.75 g/kg RW
lean body mass	0%	52.5	116	1.6 g/kg LBM	2.3 g/kg LBM
body weight	40%	87.5	193	1.0 g/kg BW	1.4 g/kg BW
protein (g/day)				84	123

On a practical note, there is nothing low about 2.3 g/kg LBM protein. While I do track my intake I find it hard to get above 2.2 g/kg LBM even when trying to maximise protein. At the same time, the lower limit is well above the official Recommended Daily Intake of 0.84 g/kg for men and 0.75 g/kg for women which are set to maintain nitrogen balance and prevent disease (i.e. not achieve optimal health and vitality).

What about percentages?

Talking about protein in terms of percentages of energy intake can be confusing as it depends on your activity levels or whether you are dieting. Theoretical energy intake requirements are based on your lean body mass and activity levels.

The table below shows what Dr Phinney’s protein recommendation of 1.2 to 1.75 g/kg RW (or 1.6 to 2.3 g/kg LBM) look like for our hypothetical woman above in terms of percentage of energy intake for different energy intakes depending if she was trying to lose weight, maintain weight or was more active.

scenario	calories	lower	upper
30% deficit	1158	29%	42%
sedentary	1654	20%	30%
lightly active	1852	18%	27%
moderately active	2084	16%	24%
vigorously active	2431	14%	20%
protein (g)		84	123

Protein intake in terms of percentage energy intake can vary widely to the point that it’s practically useless. It’s generally much more useful to talk in terms of protein intake in grams per weight lean body mass rather than percentages.

Protein and nutrient density

Since stumbling across the insulin index, one thing I have found consistently is that nutrient-dense foods are not low in protein.

If you are focusing on the foods that contain the harder to find nutrients (e.g. magnesium, magnesium, choline, vitamin D etc) you will be getting plenty of protein.

Conversely, the only way to really get the ultra-low protein intakes being recommended by many people without an energy deficit is to avoid most solid foods and prioritise macadamia nuts, butter and oils. It should not be a surprise that it will be hard to get a broad spectrum of essential nutrients with this sort of dietary approach.

As shown in the chart below, nutrient density tends to increase up to about 50% of energy intake. If you’re eating more than 50% protein you’re likely relying on processed foods and supplements.^[11]

The chart below shows the nutrient profile of the most nutritious foods in the USDA database. If you could stick to these foods you would easily be getting a lot of the essential nutrients without having to consume too much energy.

The problem with these foods is that they can be very satiating which makes it hard to get enough energy in if you are active. However, if you are trying to lose weight these foods may help to ensure that you are getting the nutrients you need with less energy without being hungry.

It’s interesting to see many people who have been experimenting with the Nutrient Optimiser have commented on how little food they can get away with while experiencing minimal levels of hunger. Nutrient dense foods tend to be hard to overeat and also provide you with the nutrients to prevent cravings and hence reduce appetite.

For comparison, the chart below shows the nutrient profile of the ketogenic diet foods. That is, the foods that have the lowest percentage insulinogenic calories. These foods are 80% fat, 15% protein and 3% net carbs). Ironically, an individual consuming these foods will be meeting the minimum levels of protein but they will be missing out on a large number of other vitamins and minerals.

I find that it’s often the people who are trying to actively avoid protein that find themselves at the bottom of the Nutrient Optimiser Leaderboard with a very poor nutrient profile.

The chart below shows the nutrient profile that we get when we actively avoid protein. The only nturients that we get enough of in this scenarios is sodium and vitamin C!

Unless you are chasing therapeutic ketosis for the treatment of cancer, epilepsy, Alzheimers or dementia I think your focus should be on building health and maximising nutrition rather than higher ketone values.

If you are getting the micronutrients you need to thrive you will be getting plenty of protein and won’t need to worry too much about getting adequate protein intake. Conversely, if you are actively avoiding protein you will be unnecessarily sacrificing your other micronutrients (especially if you are replacing your calories from protein and carbs with refined fat).

But will too much protein kick me out of ketosis?

As I write this I have been experimenting with adequate protein with less fat and carbs and maximal nutrients on the Ketogains Bootcamp. A typical daily Cronometer summary is shown below.

My protein is sitting at about 2.2g/kg LBM for me given that I’ve been spending a lot of time in the gym lifting heavy during this time. I’ve also been able to hit many of the nutrients targets while maintaining a significant calorie deficit.

Leading up to this period my blood glucose levels were sitting in the mid 5s (approx 100 mg/dL). However, once I introduced the energy deficit my glucose levels plummet to the mid 4s (approx 80 mg/dL).

And although I don’t worry much about ketones, they seem to be sitting at around 0.7 mmol/L, which I’m pretty happy with.

I know if I keep my blood glucose around this level I will continue to lose weight and continue to improve my glucose control and HbA1c.

I also get plenty of breath acetone from endogenous ketones as shown on my Ketonix below.

Don’t forget the basal insulin!

While there has been a lot of focus on what we can do to not have too much insulin, we need to remember that insulin has a number of important roles including:

to help us get glucose into cells to be used by our mitochondria,
to help build and repair our muscles, and
to control the release of glucose from our liver while the energy in our bloodstream is used up.

People with type 1 diabetes demonstrate happens if we don’t have enough insulin. Not only would we not be able to store the energy we eat as fat and muscle, the brake comes off the liver and all the stored energy in our body comes flowing out in the form of excess glucose and ketones (i.e. diabetic ketoacidosis).

The image below is the same child, “J.L.”, in the 1920s before and after receiving insulin therapy. In a healthy person, insulin suppresses the fuel flow from the liver to healthy levels.

In someone on a standard western diet, basal insulin represents about 30% of the today daily dose. Basal insulin drops to about 50% for someone on a low carb or keto diet. But you can never drop your insulin requirements to zero. You always need this basal to stop the uncontrolled flow of fuel from your liver into your bloodstream.

We focus so much on the effect of the food we eat but we forget that it’s also the excess fuel on your body and floating around in our bloodstream that also plays a massive role in the insulin demand on our pancreas.

Whenever there are high levels of energy sitting in our bloodstream (from glucose, ketones or fat) the pancreas has to ramp up basal insulin production until the fuel in our bloodstream is used up. The more fat there is on our body the harder our pancreas has to work to hold back the pressure of excess fat on our body from being released into our bloodstream.

So, you may believe that your mug of Bulletproof coffee or the fat bomb may not be raising your insulin levels because it does not contain glucose or protein. However, your pancreas is still working overtime to produce more insulin to hold the fat on your bum and until the energy coming in via your mouth is used up.

You may be able to ramp up your energy expenditure for a while by shivering and fidgeting, more but after a time of overdriving energy you’ll likely end up fat and insulin resistant.

If you really want to reduce your insulin levels you need to work on reducing the excess level of energy floating around in your bloodstream (from any source, including fat, carbs, protein or exogenous ketones) so your pancreas will decrease its production of insulin to allow body fat to be used.

Focusing on obtaining the nutrients you need without too much energy seems like common sense to me.

Therapeutic ketosis

Someone targeting therapeutic ketosis to assist with the management of chronic conditions such as cancer, epilepsy, dementia or Alzheimer’s may benefit from higher levels of ketosis and less reliance on glucose. But I don’t think the vast majority of people who are Googling “keto” at the moment are looking for a therapeutic treatment.

Understanding how to quantify the insulin load of our food enables us to accurately tailor or food choices to suit our goals. When it comes to insulin load we need to keep it low enough to get the results we need without compromising the nutritional value of the food we eat too much.

The chart below shows that nutrient density peaks at around 40% insulinogenic calories.

If you are insulin resistant it would be prudent to have less than 40% insulinogenic calories.
Someone on a low carb diet might have less than 25% insulinogenic calories.
Someone targeting therapeutic keto will likely need to have less than 15% insulinogenic calories to see therapeutic levels of ketones.

Unless you really require therapeutic keto then I don’t think there is a need to worry too much about the impact of protein on your blood ketone levels. Actively avoiding protein tends to lead to compromising nutrient density unnecessarily which may lead to nutrient cravings or deficiencies in the long term.

The glucose : ketone index

People who require therapeutic ketosis should also ensure that they are not driving the total energy in their system too high. To do this they can track their glucose as well as ketones. The glucose:ketone ratio (GKI) which was developed by Dr Thomas Seyfried to measure the degree of therapeutic ketosis.^[12]

If you’re interested, your GKI can be calculated by dividing your glucose (in mmol/L) by your ketone values. For example, if your blood glucose is 108 mg/dL and your blood ketones are 0.5mmol/L, GKI = blood glucose / ketone = (108 mg/dL / 18) / 0.5 mmol/L = 6 mmol/L / 0.5mmol/L = 12.

People who are chasing therapeutic ketosis typically do not need to worry about ingesting too much energy. Driving a hypercaloric state with refined fats is not a major concern for someone trying to keep weight on (e.g. cancer cachexia). However, ensuring that they are achieving lower glucose levels will ensure that they are not driving insulin resistance.

For reference, the table below shows the relationship between HbA1c, average glucose, ketones and GKI for different scenarios showing how your GKI and ketones correlate with HbA1c and blood glucose.

metabolic health	HbA1c	average blood glucose		blood ketones	GKI
metabolic health	(%)	(mmol/L)	(mg/dL)	(mmol/L)
low	4.1	3.9	70	> 0.3	< 4
optimal	4.5	4.6	83	> 0.3	< 15
excellent	< 5.0	< 5.4	< 97	> 0.3	< 20
good	< 5.4	< 6	< 108	< 0.3	< 40
danger	> 6.5	7.8	> 140	< 0.3	> 40

Really low GKI values (i.e. very high ketones and very low glucose) are typically seen in extended fasting when glucose levels to drop and ketones from body fat increase in a low insulin state.

The chart below shows my blood ketone and glucose levels during a seven day fast. Amazingly, as my blood glucose levels dropped below 4.0 mmol/L my ketones drifted up to 8 mmol/L. During more recent, however, I haven’t been able to achieve such high ketone levels.

While we can get these high ketone levels during fasting, we typically don’t see them in the fed state. To give you an idea of what to expect, the chart below shows GKI values over time during fasting for RD Dikeman (from Type 1 Grit), Jimmy Moore, Simon Saunders (Keto Island) and myself. As a rule of thumb, you might expect to see a GKI value less than 2 after two or three days of water fasting.

Nutrient density analysis

Being a big fan of Dr Phinney and the Art and Science books, I couldn’t help running his recommended diet through the Nutrient Optimiser. I entered all the meals in the Art and Science of Low Carb Living into Cronometer and ran it through the Nutrient Optimiser.

If you’re interested, you can see the full report here and where these meals rank on the leaderboard here.

So what should you do with all this information?

So, to summarise:

If you have great blood sugars and just want to lose weight then you should focus on maximising nutrient density while reducing the energy levels in your bloodstream. There is no need to worry about “being in ketosis”. You will produce ketones if you are successfully achieving an energy deficit and burning your own body fat stores.
If you are insulin resistant then you will want to limit your insulin load to a maximum of 2.9 g/kg LBM. This will restrict carbohydrates in your diet so your blood sugars stabilise.
If you are trying to manage diabetes then you want to keep your insulin load under 1.8 g/kg LBM. This will restrict carbohydrates and may reduce your protein intake a little.
If you require therapeutic keto then you will want to keep your insulin load less than 1.1 g/kg LBM and may need to consider limiting protein.

The recommended values for protein and insulin load are shown in the table below.

approach	min protein (g/kg LBM)	max insulin load (g/kg LBM)
therapeutic ketosis	0.8	1.1
diabetes / nutritional ketosis	1.8	1.8
weight loss (insulin resistant)	1.8	2.9
weight loss (insulin sensitive)	1.8	–

Can run the numbers for me?

I realise all this data can be confusing if nutrition is not your hobby.

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

The first instalment of the Nutrient Optmiser is a free calculator that will help you identify the ideal macronutrient ranges to suit your goals as well as a shortlist of optimal foods and meals. The table below shows how we can determine the optimal approach for you based on your metabolic health, waist to height ratio and goals.

We’d love you to check it out the Nutrient Optimiser. We’d love to hear what you think and how we can refine it to suit your goals.

We hope it will be really helpful for a LOT of people on their journey towards health through optimal nutrition

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

articles, blood sugar, ketosis, therapeutic ketosis

keto… do you want some more?

January 27, 2018 Marty Kendall 4 Comments

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.

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?

Or perhaps Bitcoin right now?

My keto journey

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

I was into keto before it was cool.

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

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

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

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]

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

Calories and energy balance didn’t matter.

I had faith.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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:

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.

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!

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.

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]

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]

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

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.

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.

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.

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

articles

micros > macros?

January 17, 2018 Marty Kendall 1 Comment

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?

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!

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.

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.

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]

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:

It’s simple.
It avoids macronutrient extremes which often drive micronutrient deficiencies.^[6]
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:

No consideration of micronutrients. Food quality becomes critical when restricting quantity over the long term to avoid deficiencies and cravings.^[7]
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.
Doesn’t cater well to people who are insulin resistant/diabetic.
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.
Tracking specific macros and calories replaces a neurosis about micromanaging food quality with an obsession with hitting particular macro targets.
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. .

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.

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.

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.

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.

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.

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.

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.

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.

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

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

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

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.

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.

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…

Have I met my minimum calorie target? If not, keep eating nutrient-dense foods.
Have I met my minimum protein intake? If not, keep eating nutrient-dense foods.
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.
Do you still feel hungry? If yes, then eat nutrient dense foods until you hit your maximum calorie intake.
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.

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:

therapeutic ketosis,
low carb / nutritional ketosis,
insulin resistant weight loss, and
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.

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

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.

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.

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

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.

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	hbA1c (%)	trig:HDL ratio
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.

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

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.

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

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.

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.

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.

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

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

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.