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.
Your pancreas ramps up its efforts to hold back the pressure of excess energy in our liver and body fat stores.
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.
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.
Foods with a lower insulin load allow people with type 1 diabetes to smooth out their blood sugar swings and stabilise their food cravings.
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.
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.
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.
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.
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.
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.
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.
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.
“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.
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”.
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 ketosiswith lots of extra dietary fat.
What I really needed was to learn how to achieve endogenousketosis 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.
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.
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.
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.
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. 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.
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.
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.
All-cause mortality is lowest with an HbA1c of somewhere between 4.5 and 5.0%.
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.
Check out the original article if you want to see the daily food log chronicled in photos by the popular and published “Registered Dietician”, who claims to specialise in diabetes and is “passionate about being a good role model.”
The quantities and foods that I analysed in the recipe builder at SELFNutritionData are shown below. Besides the fact that the only green things she ate during the day were M&M’s, the food log is not particularly divergent from mainstream dietary advice (i.e. no full-strength Coke or McDonald’s). The nutritional analysis would be much worse if it was a diet full of junk food, which is pretty common for a lot of people these days in this fast-paced convenience-loving world.
This dietician is a national media spokesperson for the Academy of Nutrition and Dietetics. She has published books and written for several magazines. Like most nutritionists, she argues for less fat and more whole grains.
So, let’s see how her daily diet stacks up. The analysis below shows that, when we compare this daily diet against mainstream dietary advice that nutritionists prescribe, it ticks the following boxes:
avoids trans fats,
is low in fat, and
is low in cholesterol.
However, even though the diet is fairly low in fat, it has 29g of saturated fat which is greater than the Heart Association’s recommendation for a maximum of 16g of saturated fat per day. Unfortunately, the recommended limit of saturated fat is actually quite hard to achieve without relying on low fat highly processed foods.
Ironically, due to the focus on avoiding fat and trying to incorporate more “heart healthy whole grains”, the food recommended by nutritionists ironically tends to be lacking in nutrients. It makes no sense!
The registered nutritionist’s daily food log also contains more than 400 grams of carbohydrates which will be a massive challenge to someone who is insulin resistant, would likely generate insulin resistance and eventually diabetes in someone who isn’t there yet.
For comparison, check out the analysis shown below of one of my regular meals (stir-fry veggies with some butter and sardines) which has a muchhigher vitamin and mineral score (94 compared to 55) and better protein score (139 compared to 66).
When it comes to nutrient density and being diabetic friendly, this nutritionist’s daily food log ends up at the bottom of the pile of the four hundred meals that I’ve analysed!
It’s sad that this myopic one-size-fits-all dietary advice is forced on anyone who asks what they should be eating, or anyone whose food is influenced by government nutritional guidelines (e.g. hospitals, schools, jails, nursing homes etc).
Then we are told that dieticians are the only ones that are qualified to give dietary advice, even though the dietary advice that they give revolves around avoidance of saturated fat and more “heart healthy whole grains” and does not actually lead to high levels of micronutrition.
Where it gets even sadder is that this sort of short sighted advice is also given to the people who are the most vulnerable. The photo below is of Lucy Smith in hospital after being diagnosed with Type 1 Diabetes. The diet given to her, as a newly diagnosed Type 1 Diabetic, is Weet-Bix, low fat milk, bananas, low fat toast, orange juice, and peaches.
The analysis for Lucy’s hospital-provided breakfast is shown below.
This single meal contains more than 200 grams of carbohydrates (82% of calories). This breakfast would require a ton of insulin to be injected into her little body, and she would be on a blood glucose / insulin rollercoaster for days to come.
Unfortunately, things don’t seem to have changed much from thirty years ago when my wife Monica was diagnosed with Type 1 Diabetes. In hospital, after diagnosis, she was given so many carbs that she hid the food in pot plants in her hospital ward room because she just couldn’t eat anymore! Twenty-five years later, she learned about the low carb dietary approach and she was finally able to reduce the high levels of insulin required to cover her food.
I’ve witnessed firsthand the massive improvements in quality of life (body composition, inflammation, energy levels, dental health etc) when someone comes off the blood glucose/insulin roller coaster!
Monica has been able to halve her daily insulin dose since no longer ascribing to the dietary advice she has been given by the dieticians and diabetes educators. Her blood glucose levels are now better than ever and when she goes to the dentist, podiatrist and optometrist they tell her she’s doing great and they wouldn’t even know she’s diabetic. And I get to have my wife around for an extra decade or two!
By the way, Lucy is doing well now too. Her parents are some of the most knowledgeable people I know when it comes to optimal foods for diabetics and monitoring blood glucose (as shown in this video from her father Paul).
My friend, Troy Stapleton, is another example of someone living with Type 1 Diabetes who has benefited immensely from a low carbohydrate dietary approach that aligns with his metabolic health. His story and approach have been an inspiration to me. You can also check out the Standing on the Shoulders of Giants article for a few more encouraging stories of people with Type 1 who got their life back after going against nutritionists orders.
As detailed in the article How to optimise your diet for your insulin resistance, if you have the luxury of being more metabolically healthy (i.e. not diabetic) you can focus on more nutrient dense foods or lower energy density if you’re looking to lose some weight.
It amazes me that dieticians can be so militant and belligerent when they are largely passing on the recommendations of the US Department of AGRICULTURE (i.e. the USDA, also known as “Big Ag”), whose mission it is to promote the economic opportunity and production of AGRICULTURE (i.e. grains and seed oils). Talk about putting the fox in charge of the hen house!
Speaking of conflicts of interest, it’s worth noting that major nutritionist organisations funding ‘partners’ are big food manufacturers. Does this influence the recommendations they give? They claim not.
It’s hard to believe their published research or dietary recommendations could be impartial when so heavily sponsored by the food industry.
Despite these conflicts of interest and a poor track record of success over the past four decades, I don’t think we should be gagging the Accredited Dietitians from publishing poor nutritional advice. Everyone should be entitled to their freedom of speech and freedom to choose what they eat.
What I do find ironic is that dieticians can bring spurious cases of malpractice against doctors to their governing bodies when they are acting in line with the latest research and their personal, professional and clinical observations (e.g. Tim Noakes in South Africa and Gary Fettke in Australia). At the same time, the Registered Dieticians have no governing body to report to, only their board of directors and their ‘partners’.
While they purport to be protecting the public interest, one could be excused for thinking that the dieticians’ associations are another marketing arm for big food companies and are protecting commercial interest rather than acting on behalf of public health.
Is it just a coincidence that Nestle’s Milo, which is half sugar, is prescribed by hospital dieticians for pregnant and breastfeeding mothers with diabetes?
Unfortunately, the situation isn’t that much different with the diabetes associations. Why would these institutions ever make recommendations to their members that reduced the amount of medications they needed or reduce the amount of processed food when their financial partners are pharmaceutical companies who manufacture insulin and drugs for diabetes?
What would happen to this financial structure if a significant amount of people started eating whole unprocessed food without a bar code? The share price of these massive medical and pharmaceutical companies would tank!
After battling cancer himself and studying the role of nutrition in metabolic and mitochondrial disease in depth, Gary Fettke now spends his days as an orthopaedic surgeon amputating limbs mainly due to the complications of diabetes.
No, it’s not pretty, but unfortunately it’s very very real.
Each year Gary volunteers as an orthopaedic surgeon in Vanuatu. The contrast between the native people living in their natural environment, eating their native foods, and their relatives in town, eating processed foods, is stark.
I took this photo in a traditional village during our holiday in Vanuatu a couple of years ago. These people eat lots of coconuts (which contains plenty of saturated fat, one of the remaining nutrients that Registered Dieticians still say we should avoid) and fish. These Vanuatu natives are some of the most beautiful, healthiest and happiest people I have ever seen!
Unfortunately, in the capital Port Vila, it’s not so pretty. The diabetes rates are the third highest in the world. One in fifty Vanuatu natives have had an amputation!
It is such a big problem. Their diet has changed quite rapidly over the years, so instead of eating their island’s food, they now eat very large quantities of white rice and of course all the liquid sugar, like Coca-Cola and Fanta, and it’s literally killing them.
After seeing the impact of diet, Gary has been outspoken in Australia, bringing attention to the quality of food that people are eating, especially in hospitals.
Gary and his Nutrition for Life Centre also worked with Chef Pete Evans on the “Saving Australia Diet” on national TV with great results achieved.
Then, in return for his efforts, Gary has been reported by the certified dieticians to the Australian Health Practitioner Regulation Agency; and he has been told he can no longer tell his patients to limit sugar even if they have just had their leg amputated due to the complications of diabetes.
Similarly, Tim Noakes has developed a massive following after realising that he needed to go against his own previous publications and advice when he found he was developing diabetes. The recipe book that he helped write, The Real Meal Revolution, is filled with nutrient dense low carb meals that help people with diabetes achieve normal blood glucose levels, has been massively popular.
Despite his impressive track record of real results, which goes against the general trend of the explosion of diabetes and obesity in western society, Professor Noakes has been reported to the Health Professionals Council of South Africa (HPCSA) and charged with unprofessional conduct, after suggesting that a mother wean her baby on to whole foods rather than processed “baby food”.
This has led to a long and expensive court case which really appears to be more about maintaining the status quo on the supermarket shelves rather than public health.
I think most nutritionists believe that they are doing the right thing by advising their clients to prioritise the avoidance of fat, cholesterol and saturated fat, and eat “heart healthy whole grains”. However, the foundation of this advice seems to be crumbling from underneath them with the most recent updates to the US Dietary Guidelines that now remove the upper limit on fat and removing cholesterol a nutrient of concern.
However, if we have to rely on Big Food to provide processed food products to achieve the reduced saturated fat aspirations of the dietary guidelines (and in so doing produce very otherwise nutrient poor foods), then perhaps we need to declare them broken and look for new ones?
Makes you wonder how we survived (let alone thrived) with the food that was available to us before the highly-processed foods and the low fat dietary guidelines that came to dominate our food choices in the 1970s.
Unfortunately though, fear of saturated fat still dominates the majority of mainstream dietary recommendations out there and leads to nonsensical food rankings that only suit the grain based food industry.
For example, the simplistic Australian Health Star Rating is based on the energy, saturated fat, sodium, sugar content along with the amount of fruits and vegetables in a product. This avoidance-based process gives little consideration for the amount of essential nutrients in a product, regardless of where they came from, and hence often returns nonsensical results.
It’s hard to tell whether the attacks on people like Fettke and Noakes are motivated by:
Well-meaning nutritionists who earnestly believe that higher levels of fat and a lack of “heart healthy whole grains” is going to harm people,
Nutritional institutions sensing that they are becoming irrelevant and making a last-ditch attack at their adversaries in an effort to hold onto their jobs,
Processed food manufacturers (i.e. big food) using their “partner organisations” to attack these outspoken thought leaders so they can maintain their strangle hold on nutritional advice that suits them and sells more of their product (i.e. it’s not a conspiracy, it’s just business), or
Some combination of each of these options.
To cut through the confusion and conflicts of interest, wouldn’t it be great if there was an unbiased quantitative way to judge whether a particular food or meal was optimal based its nutrient density? Perhaps we could even tailor food choices based on blood glucose and metabolic health (i.e. using insulin load), or by manipulating energy density of someone who is insulin sensitive but just needs to lose weight.
If you’ve been following this blog, you may have seen the optimal food lists tailored to specific goals. To this end, I have devised a system to identify foods for different goals and situations. The table below will help you choose your ideal dietary approach and optimal foods based on your blood glucose levels and waist to height ratio.
The first step in improving your nutrition is to minimise processed food that is laced with sugar. These food lists can help you further optimise your food choices to suit your goals whether they be blood glucose management, weight loss or just maintaining optimal health.
Once you normalise your blood glucose levels, you can then start to focus more on nutrient density. If you still have weight to lose, then you can focus on foods with a lower energy density to force more energy to come from your body while still maximising nutrition. You can also find the highest ranking of the four hundred meals that I have analysed listed here.
Several people recently have suggested that I turn the nutrient density ranking system into a mobile app for easy implementation of the ideas and theories outlined on the blog in the real world.
So, my current project is to develop a Nutrient Optimiser that would rank the foods you have eaten based on your current goals (e.g. therapeutic ketosis, diabetes management, weight loss or maximising nutrient density) and recommend new foods to try. The Nutrient Optimiser would progressively retrain your eating patterns towards ideal by helping you to maximise the more optimal foods, and progressively eliminate the foods that don’t align with your goals. Whether you are trying to eat less Maccas, or you are practising Calorie Restriction with Optimal Nutrition (CRON) and trying to live to 120, the Nutrient Optimiser would push you forward to truly optimise your nutrition.
The idea is not to simply create another calorie counting app. There are plenty of those out there already. Rather, the Nutrient Optimiser will help you to maximise nutrient density as much as you can while catering to your other goals.
Rather than being centred on outdated “science” and avoiding boogeymen such as cholesterol, fat and saturated fat, or serving the interest of “financial partners” (e.g. BigFood and BigPharma), the Nutrient Optimiser uses a quantitative algorithm that will help you maximise the nutritional value of the food you eat.
The Nutrient Optimiser, based on the foods logged in the past few weeks, helps you to identify foods that would provide the nutrients that you haven’t been getting as much of. Rather than just tracking calories, the app will continually adapt to what you eat, ensure that you are getting a broad range of foods that contain the nutrients you need, and ensure you don’t get stuck in a nutritional rut.
For people just starting out, it will help them gently move forward, without the judgement of someone looking over their shoulder. It will suggest foods they should buy more of, new foods to try, and maybe which foods they should bin and never buy again.
For people who are truly wanting optimal nutrition, it will hopefully be the ultimate tool to continue to refine their food choices to maximise nutrient density while optimising blood glucose, insulin and body fat levels.
As you continue to log your weight, blood glucose levels and whatever other metrics you want to track, the app will progressively prompt you to “level up” to a more optimal nutritional approach. Then, with your nutritional deficiencies filled, the cravings will dissipate and you will naturally be satisfied with less food.
If something like this is of interest to you and you want to be an early adopter or just check it out the nutritional analysis of other people food logs that have been done so far then then take a look at the Nutrient Optimiser Facebook page and to stay posted as things develop.
Then in 2013, Jason Fung emerged onto the low carb scene with his epic six part Aetiology of Obesity YouTube Series in which he detailed a wide range of theories relating to obesity and diabetes.
Essentially, Jason’s key points are that:
simply treating Type 2 diabetes with more insulin to suppress blood glucose levels while continuing to eat the diet that caused the diabetes is futile,
people with Type 2 diabetes are already secreting plenty of insulin, and
insulin resistance is the real problem that needs to be addressed.
Jason’s Intensive Dietary Management blog has explored a lot of concepts that made their way into his March 2016 book, The Obesity Code. However surprisingly, given that Jason is the fasting guy, the book didn’t talk much about fasting.
my experience with fasting
I have benefited personally from implementing an intermittent fasting routine after getting my head around Jason’s work. I like the way I look and perform, both mentally and physically, after a few days of not eating. I also like the way my belt feels looser and my clothes fit better.
Complete abstinence is easier than perfect moderation.
I recently did a seven day fast and since then I’ve done a series of four day fasts, testing my glucose and blood and breath ketones with a range of different supplements (e.g. alkaline mineral mix, exogenous ketones, bulletproof coffee/fat fast and Nicotinamide Riboside) to see if they made any difference to how I feel and perform, both mentally and physically.
Fasting does become easier with practice as your body gets used to accessing fat for fuel.
I love the mental clarity! My workout performance and capacity even seem to be better when I’ve fasted for a few days.
My key fasting takeaways are:
Fasting is not that hard. Give it a try.
You can build up slowly.
If you don’t feel good. Eat!
The more I learn about health and nutrition, the more I realise how critical it is to be able to burn fat and conserve glucose for occasional use. We get into all sorts of trouble when we get stuck burning glucose.
Our body is like a hybrid car with a slow burning fat motor (with a big fuel tank) and high octane glucose motor (with a small fuel tank). If you’re always filling the small high octane fuel tank to overflowing, you’ll always be stuck burning glucose and your fat burning engine will start to seize up (i.e. insulin resistance and diabetes).
Reducing the processed carbs in our diet enables us to lower our insulin levels and retrain our body to burn fat again. But nothing lowers insulin as aggressively and effectively as not eating.
Even though lots of Jason’s thoughts on fasting seem self-evident, his blog elucidating them has been very popular, perhaps because the concept of fasting is novel in the context of our current nutritional education.
We’ve been trained, or at least given permission, to eat as often as we want by the people that are selling food or sponsored by them.
Jason’s angle on obesity and diabetes comes from his background as a nephrologist (kidney specialist) who deals with chronically ill people who are a long way down the wrong track before they come to his office. Jason also talks about how he had tried to educate his patients about reducing their carbs, however, after eating the same thing for 70 years, this is just too hard for many people to change.
Desperate times call for desperate measures!
Many of these patients come to him jamming in hundreds of units a day of insulin to suppress blood glucose levels, even though their own pancreas is still likely secreting more than enough insulin.
Rather than continuing to hammer more insulin to suppress the symptom (high blood glucose), the solution, according to Jason, is to attack the ultimate cause (insulin resistance) directly.
Jimmy Moore is well known to most people that have an interest in low carb or ketogenic diets. Whether you agree with his approach, it’s safe to say that low carb and keto would not be as popular today without his role.
Meanwhile, Jason talks about trying to educate people about reducing the processed carbs from their diet not working, not because of the science but more due to people not being able to change their eating habits after 70 years.
the Complete Guide to Fasting
You’ve probably heard by now that Jason has teamed up with Jimmy to write The CompleteGuide to Fasting which captures Jason’s extensive thoughts on fasting from the blog along with Jimmy’s n=1 experiences and wraps them up in a cohesive comprehensive manual with a colourful bow.
Similar to The Obesity Code, TCGTF is a compilation of ideas that Jason has developed on his Intensive Dietary Management blog. Blogging is a great way to get the ideas together and thrash them out in a public forum. Some people love to read the latest blog posts and debate the minutiae, however, most people would rather spend the $9 and sit down with a comprehensive book and get the full story.
Unlike The Obesity Code, TCGTF is a bright, ffull-colourproduction with great graphics that will make it worth buying the hard copy to have and to hold.
TCGTF did originally have the working title Fasting Clarity as a follow on from Jimmy’s previous Cholesterol Clarity and Keto Clarity. However, other than Jimmy’s discussion of his n=1 fasting experiences, TCGTF is predominantly written in Jason’s voice building from his blog, so it wouldn’t be appropriate for it to have become the third in Jimmy’s Clarity series.
What is similar to Jimmy’s clarity series is that it’s easy to read and accessible for people who are looking for an entry level resource. This book will be great for people who are interested in the idea of fasting. It is indeed the complete guide to fasting and is full of references to studies, however, it doesn’t go into so much depth as to lose the average reader with scientific detail and jargon.
The book covers:
Jimmy’s n=1 experience with fasting,
Dr George Cahill’s seminal work on the effects of fasting on metabolism, glucose, ghrelin, insulin, and electrolytes,
the history of fasting over the centuries,
myth busting about fasting,
fasting in weight loss,
fasting and diabetes, physical health, and mental clarity,
managing hunger during a fast,
when not to fast, and
when fasting can go wrong.
The book is complete with a section on fasting fluids (water, coffee, tea, broth) and a range of different protocols that you can use depending on what suits you. What did seem out of place are the recipes for proper meals. Apparently, the publisher insisted they include these to widen the appeal (If you don’t like the fasting bit you’ve still got some new recipes?)
Overall, the book will be an obvious addition to the library (or Kindle) of people who are already fans of Jason and / or Jimmy and want a polished, consolidated presentation of all their previous work with a bunch of new material added.
TCGTF will also be a great read for someone who is interested learning more about fasting and wants to start at the beginning. TCGTF is the most comprehensive book on the topic of fasting that I’m aware of.
my additional 2c…
Jason doesn’t mind weighing into a controversial argument, using some hyperbole or dropping the occasional F-bomb for effect and Jimmy’s no stranger to controversy either, so I thought I’d take this opportunity to give you my 2c on some of the topical issues at the fringe that aren’t specifically unpacked in the book. We learn more as we thrash out the controversial issues at the fringes. Many arguments come down to context.
target glucose levels
Jason has come under attack for using the word ‘cured’ in relation to HbAc1 values that most diabetes associations would consider non-diabetic, though are not yet optimal.
In the book Jason does discuss relaxing target blood glucose levels during fasting. This makes sense for someone taking a slew of diabetic medications. They’re probably not going to continue the journey if they end up in a hypoglycaemic coma on day one.
The chart below shows the real life blood glucose variability for someone with Type 1 Diabetes on a standard diet. With such massive fluctuations in glucose levels, it’s impossible to target ideal blood glucose levels (e.g. Dr Bernstein’s magic target blood glucose number of 4.6 mmol/L or 83 mg/dL).
If your glucose levels are swinging wildly due to a poor diet coupled with lots of medication, your glucose levels are simply going to tank when you stop eating. Hence, a safe approach is to back off the medication, at least initially, until your glucose levels have normalized.
Being married to someone with Type 1 Diabetes, I have learned the practical realities of getting blood glucose levels as low as possible while still avoiding dangerous lows. My wife Monica doesn’t feel well when her blood glucose levels are too low, but neither does she feel good with high blood glucose levels. Balancing insulin and food to get blood glucose levels as low as possible without experiencing lows requires constant monitoring.
The chart below shows how scattered blood glucose levels can be even if you’re fairly well controlled. Ideally you want the average blood glucose level to be as low as possible while minimising the number of hypoglycaemic episodes (i.e. below the red line). If you can’t reduce the variability you just can’t bring the average blood glucose level down. The last thing you want is to be eating to raise your blood glucose levels because you had too much blood glucose lowering medication.
Pretty much everyone agrees that it’s dumb to be eating crap food and dosing with industrial levels of insulin to manage blood glucose levels. High levels of exogenous insulin just drive the sugar that is not being used to be stored as fat in your belly, then your organs, and then in the more fragile places like your eyes and the brain.
Jason’s perspective is that people who are chronically insulin resistant and morbidly obese are likely producing more than enough insulin. The last thing they need is exogenous insulin which will keep the fat locked up in their belly and vital organs. Dropping insulin levels as low as possible using a low insulin load diet and fasting coupled with reducing medications will let the fat flow out.
fasting to optimise blood glucose levels
In the long run, neither high insulin nor high glucose levels are optimal.
Once you’ve broken the back of your insulin resistance with fasting, you can continue to drive your blood glucose levels down towards optimal levels.
One of the most popular articles on the Optimising Nutrition blog is how to use your glucose meter as a fuel gauge which details how you can time your fasting based on your blood glucose levels to ensure they continue to reduce.
Your blood glucose levels can help calibrate your hunger and help you to understand if you really need to eat. I think this is a great approach for people whose main issue is high blood glucose levels and who aren’t ready to launch into longer multi day fasts.
In a similar way, a disciplined fasting routine can help optimise blood glucose levels in the long term. The chart below shows a plot of Rebecca Latham’s blood glucose levels over three months where she used her fasting blood glucose numbers AND body weight to decide if she would eat on any given day.
While there is some scatter in the blood glucose levels, you can see that regular fasting does help to reduce blood glucose levels over the long term.
Once you’ve lost your weight , broken the back of your insulin resistance and stopped eating crap food, you may find that you still need some exogenous insulin or other diabetic medication to optimise blood glucose levels if you have burned out your pancreas.
The TGTF book covers off on several fasting regimens such as intermittent fasting, 24 hours, 36 hours, 42 hours and 7 to 14 days. One concept that I’m intrigued by, similar to the idea of using your glucose meter as a fuel gauge, is using your bathroom scale as a fuel gauge.
The reality, at least in my experience, is that we can overcompensate for our fasting during our feasting and end up not moving forward toward our goal.
If your goal is to lose weight I like the idea of tracking your weight and not eating on days that your weight is above your goal weight for that day.
Again, Rebecca Latham has done a great job building an online community around the concept of using weight as a signal to fast through her Facebook group My Low Carb Road – Fasting Support.
The chart below shows Rebecca’s weight loss journey through 2016 where she initially targeted a weight loss of 0.2 pounds AND a reduction of 0.25 mg/dL in blood glucose per day. After three months, she stabilized for a period (during a period when she had a number of major family issues to look after). She is now using a less aggressive weight loss goal as she heads for her long-term target weight at the end of the year.
The chart below shows the fasting frequency required to achieve her goals during 2016. Tracking her weight against her target rate of weight loss has required her to fast a little more than one day in three to stay on track.
Eating quality food is part of the battle, but managing how often you eat is also an important consideration. After you’ve fasted for a few days, you can easily excuse yourself for eating more when you feast again. And maybe it’s OK to enjoy your food when you do eat rather than tracking every calorie and trying to consciously limit them.
The obvious caveat is that there are a lot of other things that influence your scale weight such as muscle gain, water, GI tract contents etc, but this is another way to keep yourself accountable over the long term.
FAST WELL, FEED WELL
Fasting is a key component of the metabolic healing process, but it’s only one part of the story.
Fasting is like ripping out your kitchen to put in a new one. You have to demolish and remove the old stovetop to put the new shiny one back in. You don’t sticky tape the new marble bench top over the crappy old Laminex. You have to clean out the old junk before you implement the new, latest, and greatest model.
In fasting, the demolition process is called autophagy, where the body ‘self eats’ the old proteins and aging body parts. The great thing about minimising all food intake is that you get a deeper cleanse than other options such as fat fast, 500 calories per day or a protein sparing modified fast (PSMF).
But keep in mind that it’s the feast after the fast that builds up the shiny, new body parts that will help you live a longer, healthier, and happier life.
“Fasting without proper refeeding is called anorexia.”
Even fasting guru Valter Longo is now talking about the importance of feast / fast cycles rather than chronic restriction. In the end you need to find the right balance of feasting / fasting, insulin / glucagon, mTOR / AMPK that is right for you.
In TCGTF, Jason and Jimmy talk about prioritising nutrient dense, natural, unprocessed, low carb, moderate protein foods after the fast. I’d like to reiterate that principle and emphasise that nutrient density becomes even more important if you are fasting regularly or for longer periods.
In the long term, I think your body will drive you to seek out more food if you’re not giving it the nutrients it needs to thrive. Conversely, I think if you are providing your body with the nutrients it needs with the minimum of calories I think you will have a better chance of accessing your own body fat and reaching your fat loss goals.
optimising insulin levels AND nutrient density
It’s been great to see the concept of the food insulin index and insulin load being used by so many people! In theory, when people reduce the insulin load of their diet they more easily access their own body fat and thus normalizes appetite.
Some people who are very insulin resistant do well, at least initially, on a very high fat diet. However, as glycogen levels are depleted and blood glucose levels start to normalise, I think it is prudent to transition to the most nutrient dense foods possible while still maintaining good (though maybe not yet optimal) blood glucose levels.
The problem with doubling down on reducing insulin by fasting combined with eating only ultra-low insulinogenic foods is that you end up “refeeding” with refined fat after your fast.
While lowering carbs and improving food quality is the first step, I think that, as soon as possible you should start focusing on building up your metabolic machinery (i.e. muscles and mitochondria). A low carb nutrient dense diet is part of the story, but I don’t see many people with amazing insulin sensitivity that don’t also have a good amount of lean muscle mass which is critical to ‘glucose disposal’, good blood sugar levels and metabolic health.
This recent IHMC video from Doug McGuff provides a stark reminder of why we should all be focusing on maximising strength and lean muscle mass to slow aging.
The chart below shows a comparison of the nutrient density of the various dietary approaches. Unfortunately, a super high fat diet is not necessarily going to be as nutrient dense and thus support muscle growth, weight loss, or optimal mitochondrial function as well as other options.
The chart below (click to enlarge) shows a comparison of the various essential nutrients provided by a high fat therapeutic ketogenic dietary approach versus a nutrient dense approach that would suit someone who is insulin sensitive.
I developed a range of lists of optimal foods that will help people in different situations with different goals to maximise the nutrient density that should be delivered in the feast after the fast. The table below contains links to separate blog posts and printable .pdfs. The table is sorted from highest to lowest nutrient density. In time, you may be able to progress to a more nutrient dense set of foods as your insulin resistance improves.
Jason had a “robust discussion” with Steve Phinney over the topic of ideal protein levels recently during the Q&A session at the recent Low Carb Vail Conference.
To give some context again, Phinney is used to dealing with athletes who require optimal performance and are looking to optimise strength. Meanwhile Jason’s patient population is typically morbidly obese people who are on kidney dialysis and probably have some excess protein, as well as a lot of fat that they could donate to the cause of losing weight.
I also know that Jimmy is a fan of Ron Rosedale’s approach of minimising protein to minimise stimulation of mTOR. Jimmy and Ron are currently working on another book (mTOR Clarity?). Protein also stimulates mTOR which regulates growth which is great when you’re young but perhaps is not so great when you’ve grown more than enough.
The typical concern that people have with protein in a ketogenic context is that it raises blood insulin in people who are insulin resistant. ‘Excess protein’ can be converted to blood glucose via gluconeogenesis in people who are insulin resistant and can’t metabolise fat very well.
Managing insulin dosing for someone with Type 1 Diabetes like my wife Monica is a real issue, though she doesn’t actively avoid protein. She just needs to dose with adequate insulin for the protein being eaten to manage the glucose rise.
The chart below shows the difference in glucose and insulin response to protein in people who have Type 2 Diabetes (yellow lines) versus insulin sensitive (white lines) showing that someone who is insulin resistant will need more insulin to deal with the protein.
As well as insulin resistance, these people are also “anabolic resistant” meaning that some of the protein that they eat is turned into glucose rather than muscle leaving them with muscles that are wasting away.
People who are insulin resistant are leaching protein into their bloodstream as glucose because they can’t mobilise their fat stores for fuel. They are dependent on glucose and they’ll even catabolise their own muscle to get the glucose they need if they stop eating glucose.
While it’s nice to minimise insulin levels, I wonder whether people who are in this situation may actually need more protein to make up for the protein that is being lost by the conversion to glucose to enable them to maintain lean muscle mass. Perhaps it’s actually the people who are insulin sensitive that can get away with lower levels of protein?
As well as improving diet quality which will reduce insulin and thus improve insulin resistance, in the long term it’s also very important to maintain and build muscle to be able to dispose of glucose efficiently and also improve insulin resistance.
In TCGTF Jason talks about the fact that the rate of the use of protein for fuel is reduced during a fast and someone becomes more insulin sensitive. He goes to great lengths to point out that concern over muscle loss shouldn’t stop you trying out fasting (which is a valid point).
A big part of the magic of fasting is that you clean out some of your oldest and dodgiest proteins in your body and set the stage for rebuilding back new high quality parts. But the reality is that you will lose some protein from your body during a fast (though this is not altogether a bad thing).
Bodybuilders often talk about the “anabolic window” after a workout where they can maximise muscle growth after a workout. Similarly, one of the awesome things about fasting is that you reduce your insulin resistance and anabolic resistance meaning that when at the end of your fast your body is primed to allocate the high quality nutrients you eat in the right place (i.e. your muscles not your belly or blood stream).
In the end, I think optimal protein intake has to be guided to some extent by appetite. You’ll want more if you need it, and less if you don’t.
I think if we focus on eating from a shortlist of nutrient dense unprocessed foods we won’t have to worry too much about whether we should be eating 0.8 or 2.2 g/kg of lean body mass.
However, avoiding nutrient dense, protein-containing foods and instead “feasting” on processed fat when you break your fast will be counter-productive if your goal is weight loss and waste a golden opportunity to build new muscle.
are you really insulin resistant?
Insulin resistance and obesity is a continuum.
Not everyone who is obese is necessarily insulin resistant.
If you are really insulin resistant, then fasting, reducing carbs, and maybe increasing the fat content of your diet will enable you to improve your insulin resistance. This will then help with appetite regulation because your ketones will kick in when your blood glucose levels drop.
However, if you continue to overdo your energy intake (e.g. by chasing high ketones with a super high fat, low protein diet), then chances are, just like your body is primed to store protein as muscle, you will be very effective at storing that dietary fat as body fat.
I fear there are a lot of people who are obese but actually insulin sensitive who are pursuing a therapeutic ketogenic dietary approach in the belief that it will lead to weight loss. If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help you identify your optimal dietary approach.
optimal ketone levels
Measuring ketones is really fascinating but confusing as well.
Urine ketones strips have limited use and will disappear as you start to actually use the ketones for energy.
In a similar way blood ketones can be fleeting. Some is better than none, but more is not necessarily better. As shown in the chart of my seven day fast below I have had amazing ketones and felt really buzzed at that point but since then I haven’t been able to repeat this. I think sometimes as your body adapts to burning fat for fuel the ketones may be really high but then as it becomes efficient it will stabilise and run at lower ketone levels even when fasting.
If your ketone levels are high when fasting then that’s great. Keep it up. They might stay high. They might decrease. But don’t chase super high ketones in the fed state unless you are about to race the Tour de France or if you want your body to pump out some extra insulin to bring them back down and store them as fat.
The chart below shows the sum of 1200 data points of ketones and blood glucose levels from about 30 people living a ketogenic lifestyle. Some of the time they have really high blood ketone levels but I think the real magic of fasting happens when the energy in our bloodstream decreases and we force our body to rely on our own body fat stores.
the root cause of insulin resistance is…
So we’ve worked out that large amounts of processed carbs drive high blood glucose and insulin levels which is bad.
We’ve also worked out that insulin resistance drives insulin levels higher, which is bad.
But what is the root cause of insulin resistance?
I think Jason has touched on a key component in that, as with many things, resistance is caused by excess. If we can normalise insulin levels, then our sensitivity to insulin will return, similar to our exposure to caffeine or alcohol.
However, at the same time, I think insulin resistance is potentially more fundamentally caused by our sluggish mitochondria that don’t have enough capacity (number or strength) to process the energy we are throwing at them, regardless of whether they come from protein, carbs, or fat.
A low carb diet lowers the bar to enable us to normalise our blood glucose levels. However, the other end of the spectrum is focusing on training our body and our mitochondria to be able to jump higher. In the long term this is achieved through, among other things, maximising nutrient dense foods and building lean body mass through resistance exercise.
The Complete Guide to Fasting is, as per the title, the complete guide to fasting. It’s the most comprehensive guide to the nuances of fasting out there and there’s a good balance between the technical detail, while still being accessible for the general public.
Fasting can help optimise blood glucose and weight in the long term, with a disciplined regimen.
Fasting makes the body more insulin sensitive and primes it for growth. When you feast after you fast, it is ideal to make sure you maximise nutrient density of the food you eat as much as possible while maintaining reasonable blood glucose levels.
Understanding your current degree of insulin resistance can help you decide which nutritional approach is right for you. As you implement a fasting routine and transition from insulin resistance to insulin sensitivity you will likely benefit from transitioning from a low insulin load approach to a more nutrient dense approach.
Some people produce more ketones than others. Some people have higher blood glucose levels.
What our ketone and glucose values tell us about our metabolic health
Hyperinsulinemia has been called as the “unifying theory of chronic disease”     . It’s beneficial to understand where you stand on the spectrum of metabolic health and insulin sensitivity.
The chart below shows the typical relationship between blood glucose and blood ketone for a range of different degrees of insulin resistance/sensitivity.
If your blood glucose levels are consistently high it’s likely you are not metabolising carbohydrate well. When you go without food, endogenous ketones are slow to kick in because your insulin levels are also high. You feel tired and hungry, and you are likely to eat again sooner and not stop until you feel good.
By contrast, if you are insulin sensitive you may be able to go longer between meals naturally and you will not feel as compelled to eat as much or as often. If someone is insulin resistant, a lower insulin load dietary approach will help with satiety and carb cravings while keeping blood glucose levels and insulin under control.
hyperinsulinemia and metabolic disorders
Exciting research is coming out underway looking at the use of EXOGENOUS ketones as an adjunct treatment for cancer or to provide energy directly to the mitochondria for people with epilepsy, dementia, Alzheimer’s and the like.
EXOGENOUS ketones may help to relieve the debilitating symptoms and side effects of acute hyperinsulinemia, Alzheimer’s, dementia, epilepsy or other conditions where glucose is not used well.
exogenous ketones and the low carb flu
Patrick Arnold, who worked with Dr Dominic D’Agostino to develop the first ketone esters and ketone salts, has noted that exogenous ketones may help alleviate the symptoms of the ‘keto flu’ during the transition from a high carb to a low carb dietary approach.
However, once you have successfully transitioned to a lower carb eating style it may be wise to reduce or eliminate the exogenous ketones to enable your body to fully up-regulate lipolysis (fat burning), maximise ENDOGENOUS ketone production and access your body fat stores.
As discussed in the article Are ketones insulinogenic and does it matter? it exogenous ketones require about half as much insulin as carbohydrate to metabolise (or about the same amount as protein). Hence the continual use of exogenous ketones will limit how much our insulin levels are able to decrease.
Someone with diabetes who follows with a nutrient dense low insulin load dietary approach may be able to successfully normalise their blood glucose and insulin levels. When this happens, your liver will be able to more easily produce ENDOGENOUS ketones which will help improve satiety between meals and decrease appetite which will, in turn, lead to weight loss.
Exercising to train your body to do more with less is also helpful.
my experience with exogenous ketones
The light blue “mild insulin resistance” line is based on my ketone and glucose tests when I started trying to wrap my head around low carb/keto.
I enthusiastically started adding generous amounts of fat from all the yummy stuff (cheese, butter, cream, peanut butter, BPC etc) in the hope of achieving higher ketone levels and therefore weight loss, but I just got fatter and more inflamed as you can see in the photo on the left.
My blood tests suggested I was developing fatty liver in my mid-30s! And I thought I was doing it right with lots of bacon and BPC?!?!?
Part of the reasons shelling out the money for the exogenous ketones was to see if it would provide a fuel source that didn’t need insulin for my wife Monica who has Type 1 Diabetes.
This metabolic jet fuel is definitely fascinating stuff! My experience is that it gave me a buzz like a BPC but also has an acute diuretic effect.
I had hoped it would have a weight loss effect like some people seemed to be saying it would.
I did find it had an amazing impact on my appetite. While it was in my system I didn’t care as much about food. However, once the ketones were used up my appetite came flooding back.
Unfortunately, my hunger and subsequent binge eating seemed to more than offset the short term appetite suppression that had occurred while the exogenous ketones were in my system. And it was not going to be financially viable for me to maintain a constant level of artificially elevated ketone levels which return to normal levels after a couple of hours.
do exogenous ketones help with weight loss?
I asked around to see if anyone had come across studies demonstrating long term weight loss effects of exogenous ketones.It was a VERY enlightening discussion if you want to check it out here.
The Pruvit FAQ says that one of the benefits of Keto//OS is weight loss. However, no reference to the research studies was provided to prove his claim.
Also, the studies that were referenced in the Pruvit FAQ all appeared to relate to the benefits of ENDOGENOUS or nutritional ketosis rather than EXOGENOUS ketone supplementation.
According to Dominic D’Agostino in a Pruvit teleseminar, the EXOGENOUS ketone salts were not designed to be a weight loss product and hence have not been studied for weight loss after all!
The only studies that we could find that mentioned EXOGENOUS ketone supplementation and weight loss were on rats and they found that there was no long term effect on weight loss.
So in spite of my hopeful $250 outlay, it seems that exogenous ketones ARE just a fuel source after all.
Even the experts don’t seem to think exogenous ketones help with fat loss.
The “metabolically healthy” line in the chart above is based on RD Dikeman’s ketone and glucose data when he fasted for 21 days.
Due to his hard-earned metabolic health and improved insulin resistance RD has developed the ability to fairly easily release ketones when he doesn’t eat for a while. RD still doesn’t find going without food effortless, but it is easier than when his insulin levels were much higher which prevented his body from accessing his body fat stores.
Through a disciplined diet and exercise habits RD has achieved a spectacular HbA1c of 4.4%.
Perhaps a two or three day water only fast testing blood glucose and ketones with no exercise would be a useful test of your insulin status? You could use RD’s glucose : ketone gradient as the gold standard.
RD also told me that when he is not fasting and is eating his regular nutrient dense higher protein meals his ketone levels are not particularly high. While RD fairly easily produces ketones when fasting, it seems they are also quickly metabolised so they do not build up in his bloodstream.
Where this gets even more interesting is when we look at the glucose and ketone data in terms of TOTAL ENERGY. That is, the energy coming from both glucose and ketones.
The average TOTAL ENERGY of the three thousand data points from these healthy people working hard to achieve nutritional ketosis is around 6.0mmol/L. It seems the body works to maintain homoeostasis around this level.
When the TOTAL ENERGY in our bloodstream increases outside of the normal range it the body raises insulin to store the excess energy. That is, unless you have untreated type 1 diabetes, in which case you end up in diabetic ketoacidosis with high blood glucose and high ketones due to the lack of insulin available to keep your energy in storage.
Regardless of whether your energy takes the form of glucose, ketones or free fatty acids, they all contribute to acetyl-coA which is oxidised to produce energy. Forcing excess unused energy to build up in the bloodstream is typically desirable and can lead to long term issues (e.g. glycation, oxidised LDL etc).
I’m not sure if ketones can be converted to glucose or body fat, but it makes sense that excess glucose would be converted to body fat via de novo lipogenesis to decrease the TOTAL ENERGY in the blood stream to normal levels.
Ketone bodies have effects on insulin and glucagon secretions that potentially contribute to the control of the rate of their own formation because of antilipolytic and lipolytic hormones, respectively. Ketones also have a direct inhibitory effect on lipolysis in adipose tissue.
Looking at the glucose and ketones together in terms of TOTAL ENERGY was a bit of an ‘ah ha’ moment for me. It helped me to understand why people like Thomas Seyfried and Dominic D’Agostino always talk about the therapeutic benefits and the insulin lowering effects of a calorie restricted ketogenic diet. 
Dealing with high ketones and high glucose is typically not a concern because it doesn’t happen in nature or when eating whole foods. But now we have refined grains, HFCS, processed fats and exogenous ketones to ‘bio hack’ our metabolism and send it into overdrive.
While fat doesn’t normally trigger an insulin response, it seems that excess unused energy, regardless of the source, will trigger an increase in insulin to reduce the TOTAL ENERGY in the blood stream.
I am concerned that if people continue to enthusiastically zealously focus on pursuing higher blood ketones “through whatever means you can” in an effort to amplify fat loss they will promote excess energy in the bloodstream which will lead to insulin resistance and hyperinsulinemia.
Using multi-level marketing tactics to distribute therapeutic supplements to the uneducated masses who are desperate to lose weight with a ‘more is better’ approach also troubles me deeply.
My heart sank when I saw this video.
MORE investigation required?
There are anecdotal reports that exogenous ketones provide mental clarity, enhanced focus and athletic performance benefits. At the same time, there are also people who have been taking these products for a while that don’t appear to be doing so well.
Recently, ketone body supplements (ketone salts and esters) have emerged and may be used to rapidly increase ketone body availability, without the need to first adapt to a ketogenic diet. However, the extent to which ketone bodies regulate skeletal muscle bioenergetics and substrate metabolism during prolonged endurance-type exercise of varying intensity and duration remains unknown. Therefore, at present there are no data available to suggest that ingestion of ketone bodies during exercise improves athletes’ performance under conditions where evidence-based nutritional strategies are applied appropriately.
Ketosis decreased muscle glycolysis and plasma lactate concentrations, while providing an alternative substrate for oxidative phosphorylation. Ketosis increased intramuscular triacylglycerol oxidation during exercise, even in the presence of normal muscle glycogen, co-ingested carbohydrate and elevated insulin. These findings may hold clues to greater human potential and a better understanding of fuel metabolism in health and disease.
I can understand how exogenous ketones could be beneficial for someone who is metabolically healthy and consuming a disciplined hypo-caloric nutrient dense diet. They would likely be able to auto regulate their appetite to easily offset the energy from the EXOGENOUS ketones with less food intake.
While it seems that EXOGENOUS ketones assist in relieving the symptoms of metabolic disorders I’m yet to be convinced that a someone who is obese and / or has Type 2 Diabetes would do as well in the long term, especially if they were hammering both more fat and exogenous ketones (along with maybe some sneaky processed carbs on the side) in an effort to get their blood ketones as higher in the hope of losing body fat.
Some questions that I couldn’t find addressed in the Pruvit FAQ that I think would be interesting to answer through a controlled study in the future are:
What is the safe dose limit of EXOGENOUS ketones for a young child? How would you adjust their maximum intake based on age and weight?
IF EXOGENOUS ketones do have a long term weight loss effect what is the upper limit of intake of EXOGENOUS ketones to avoid stunting a child’s growth?
Is there a difference in the way EXOGENOUS ketones are processed in someone is metabolically healthy versus someone who is very insulin resistant?
Does the effect on appetite continue beyond the point that the ketones are out of your system?
Do you need to take EXOGENOUS ketones continuously to maintain appetite suppression? Does the effect of ENDOGENOUS wear off as your own ENDOGENOUS ketone production down regulates? Do you need to keep taking more and more EXOGENOUS ketones to maintain healthy appetite control?
How should someone with Type 2 Diabetes adjust their medication and insulin dose based on their dose of EXOGENOUS ketones? Should they be under medical supervision during this period?
Is there a difference in health outcome if you are taking EXOGENOUS ketones in the context of a hypocaloric ketogenic diet versus a hypercaloric ketogenic diet? What about a diet high in processed carbs?
Is there a minimum effective dose to achieve optimal long term benefits to your metabolic health or is MORE better?
Are the long term health benefits of EXOGENOUS ketones equivalent to a calorie restricted ketogenic diet?
Unfortunately, I think we will find the answers to these questions sooner rather than later with the large scale experiment that now seems to be well underway.
Alessandro Ferretti recently made the observation that metabolically healthy people tend to have lower TOTAL ENERGY levels at rest (and hence have a lower HbA1c), but are able to quickly mobilize glycogen and fat easily when required (e.g. when fasting or a sprint).
Metabolically healthy people are both metabolically flexible and metabolically efficient.These people would have been able to both conserve energy during a famine and run away from a tiger and live to become our ancestors, while the ones who couldn’t didn’t.
Similar to RD Dikeman, John Halloran is an interesting case. He has been putting a lot of effort into eating nutrient dense foods, intermittent fasting and high-intensity exercise.
He is also committed to improving his metabolic fitness to be more competitive in ice hockey. His resting heart rate is now a spectacular 45 bpm!
And he’s been able to lose 10kg (22lb) in one month!
At 5.2mmol/L (i.e. glucose of 4.0mmol/L plus ketones of 1.2mmol/L) John’s TOTAL ENERGY is well below the average of the 26 people shown in the glucose + ketone chart above. It seems excellent metabolic health is actually characterised by lower TOTAL ENERGY.
MORE is not necessarily BETTER when it comes to health.
Fast well, feed well
To clean up the data a little I removed the ketones vs glucose data points for a couple of people who I thought might be suffering from pancreatic beta cell burnout and one person that was taking exogenous ketones during their fast that had a higher TOTAL ENERGY. I also removed the top 30% of points that I thought were likely high due to measuring after high-fat meals or coffee.
So now the chart below represents the glucose and ketone values for a group of reasonably metabolically healthy people following a strict ketogenic dietary approach, excluding for the effect of high-fat meals, BPC, fat bombs and the like.
The average ketone value for this group of healthy people trying to live a ketogenic lifestyle is 0.7mmol/L. Their average glucose is 4.8mmol/L (or 87mg/dL). The average TOTAL ENERGY is 5.5mmol/L or 99mg/dL.
blood glucose (mmol/L)
total energy (mmol/L)
The table below shows this in US units (mg/dL).
It seems we may not necessarily see really high ketone levels in our blood even if we follow a strict ketogenic diet, particularly if we are metabolically healthy and our body is using to ketones efficiently.
the real magic of ketones
When we deplete glucose we train our body to produce ketones.
This is where autophagy, increased NAD+ and SIRT1 kicks in to trigger mitochondrial biogenesis and ENDOGENOUS ketone production (i.e. the free ones).The REAL magic of ketosis happens when all these things happen and ketones are released as a byproduct.
I do not believe that simply adding EXOGENOUS ketones will have nearly as much benefit to your mitochondria, metabolism and insulin resistance as training your body to produce ENDOGENOUS ketones in a low energy state.
Everything improves when we train our bodies to do more with less (e.g. fasting, high-intensity exercise, or even better fasted HIIT). Resistance to insulin will improve as your insulin receptors are no longer flooded with insulin caused by high TOTAL ENERGY building up in your bloodstream (i.e. from glucose, ketones and even free fatty acids).
Driving up ketones artificially through EXOGENOUS inputs (treating the symptom) does NOT lead to increased metabolic health or mitochondrial biogenesis (cure) particularly if you are driving them higher than normal levels and not using them up with activity.
You may be able to artificially mimic the buzz that you would get when the body produces ketones ENDOGENOUSLY, however, it seems you may just be driving insulin resistance and hyperinsulinemia if you follow a “MORE is better” approach.
Simply managing symptoms with patented products for profit without addressing the underlying cause often doesn’t end well.
Perhaps as more exogenous products come to market without the marketing hype that that comes with multi level marketing (e.g. Julian Baker’s Insta Ketone which are a sixth of the price of the Pruvit products) people will get to see if they really do anything useful.
Just like having low blood glucose is not necessarily good if it is primarily caused by high levels of EXOGENOUS insulin coupled with a poor diet or having lower cholesterol due to statins, having high blood ketone values is not necessarily a good thing if it is achieved it by driving up the TOTAL ENERGY in your blood stream with high levels of purified fat and/or EXOGENOUS ketones.
When we feed our body with quality nutrients we maximise ATP production which will make us feel energised and satisfied. Nutrient dense foods will nourish our mitochondria and reduce our drive to keep on seeking out nutrients from more food.
Greater metabolic efficiency will lead to higher satiety, which leads to less food intake, which leads to a lower TOTAL ENERGY, increased mitochondrial biogenesis, improved insulin sensitivity and lower blood glucose levels.
Prioritising nutrient dense real food is even more important in a ketogenic context.While we can always take supplements, separating nutrients from our energy source is never a great idea, whether it be soda, processed grains, sugar, glucose gels, HFCS, protein powders, processed oils or exogenous ketones.
the best exogenous ketone supplement
If your goal is metabolic health, weight loss and improving your ability to produce ENDOGENOUS ketones, then developing a practice of FEASTING and FASTING is important.
To start out, experiment by extending your fasting periods until your TOTAL ENERGY is decreasing over time. This will cause your circulating insulin levels to decrease which will force your body to produce ENDOGENOUS ketones from your ENDOGENOUS fat stores.
If you want to measure something, see how low you can get your glucose levels before your next meal. Then when you do eat, make sure you choose the most nutrient dense foods you possibly can to build your metabolic machinery and give your mitochondria the best chance of supporting a vibrant, active and happy life.
As my wise friend Raymund Edwards keeps reminding me, FAST WELL, FEED WELL.
What are the most insulinogenic, low nutrient density and energy dense processed foods that everyone should avoid for heath and weight loss?
Generally I think it can be more useful to tell people what they should focus on rather than what they shouldn’t do. It’s like the proverbial hot plate or ‘wet paint’ sign. You can’t unsee it and you just want to touch it!
If you are busy focusing on the good stuff then you just won’t have any space left for the low nutrient density foods, especially once you start feeling the benefits.
Many people are coming to see sugar as universally bad news. But why sugar? Are there other foods that we should avoid for the same reasons?
what’s so bad about sugar anyway?
For the past four decades mainstream food recommendations have been dominated by a fear of fat, particularly saturated fat and cholesterol, which if, taken to the extreme can lead us towards more processed, insulinogenic, nutrient poor, low fat foods.
If you want to maximise the nutritional value of your food, give your pancreas a break so it can keep up, you should AVOID THESE FOODS. Most diet recommendations succeed largely because they eliminate these foods which are typically processed foods.
The chart below (click to enlarge) shows the weightings used in the multi criteria analysis for the various dietary approaches. The avoid list turns the system on its head to identify foods that have poor nutrient density as well as also being energy dense and insulinogenic.
The charts below shows that, compared to the other approaches, the foods on the avoid list are energy dense…
…as well as being nutrient poor, all at the same time!
Considering any of these factors by themselves can be problematic. But when we combine all these parameters them they can be much more useful to identify the foods we should avoid, as well as the ones we should prioritise.
As you can see from this chart, the difference between the nutrients provided by the most nutrient dense foods and the avoid list is vast! You can see how you would be much more satiated with the more nutrient dense food and your cravings turned off.
Soft drinks provide very little nutritional value, are very insulinogenic and have no fibre so will raise your blood sugar and insulin levels quickly.
insulin load (g/100g)
orange and apricot juice
Sweets provide minimal nutrition while being very energy dense and highly insulinogenic. Sugar tops the list of badness, however there are a bunch of other sweets not far behind.
insulin load (g/100g)
high fructose corn syrup
jams and preserves
tapioca pudding (fat free)
fruits and fruit juices
Fruit in its natural state provides fibre, nutrients with a lower energy density. However fruit juice and dried fruit has a much lower nutritional value and are much more insulinogenic.
insulin load (g/100g)
cereals and baked products
Processed grains are cheap and have a long shelf life, however the processing removes most of the fibre and most of the nutrients which means they are highly insulinogenic and energy dense.
insulin load (g/100g)
fudge filled cookies
girl scout cookies
choc chip cookies
ice cream cones
pound cake (fat free)
The table below contains links to separate blog posts and printable .pdfs detailing optimal foods for a range of dietary approaches (sorted from most to least nutrient dense) that may be of interest depending on your situation and goals. You can print them out to stick to your fridge or take on your next shopping expedition for some inspiration.
Living a long, vibrant, healthy life is a common goal. But what can we do to extend our health span?
Should we eat more fruit and veggies? Less processed foods? More protein? Less protein? Exercise more? Lose weight? Sleep more? Get more sun? Less blue light?
The numerous facets of health and longevity are complex and above my pay grade. However, I am willing to add my two cents to the discussion in the areas of insulin, blood glucose, fasting and nutrition along with some input from people I respect.
Dr Ted’s top tips
My wise friend Dr Ted Naiman recently commented on the topic of longevity.
I see centenarians at work, and as far as I can tell it is important to be:
– insulin sensitive,
– active, and
– relatively strong
Extreme careful protein restriction? Not so much. I for one will focus on the first three.
Not only is Ted enviably buff, he also has a neat way of condensing wisdom into short bites that are worth unpacking a little further.
The leading causes of death in adults in the western world (i.e. heart disease, stroke, cancer, Alzheimer’s and Parkinson’s) all have something in common. They are diseases of modern society, related to metabolic health and exacerbated by excessive insulin and / or high blood glucose levels.
People who live longer still die from these same diseases, they just succumb to them later.
This chart (from Barbieri, 2001) shows that insulin resistance generally deteriorates with age. However if you’re one of the few to make it past 90 then chances are your insulin resistance is pretty spectacular!
Ted’s infographic below explains how insulin resistance and metabolic syndrome leads to hyperinsulinemia (elevated insulin) and hyperglycaemia (elevated blood glucose) and then to heart disease and many of the other diseases of modern society.
The chart below indicates that you have a much better chance of delaying the top two causes of death in western society (i.e. heart attack and stroke) if you have a lower HbA1c.
And your chance of maintaining a big brain that is free of Alzheimer’s and Parkinson’s (causes of number four and five) seems to be greatly improved if you keep your blood glucose levels low.
We’ll come back to cancer, cause of death number three, a little later.
While you might be able to make an argument for longevity around restricting protein or even calories based on laboratory experiments, people live in the real world and need adequate strength to move around, stay active and be relatively strong. People who are lean and strong intuitively look healthy and attractive to us.
Longevity research is typically done in yeast, worms, mice or other animals who live protected in captivity. Unfortunately, real people don’t live in protected laboratory environments in a petri dish. We live in the real world where real people break.
Loss of muscle as we age (i.e. sarcopenia) is a major issue. Many older people become brittle and weak. They take a fall, break their hip and never get up. Maintaining strength and lean muscle mass is important.
You don’t see many fat animals in the wild, but at the same time you don’t see skinny animals, unless they are sick. Animals that survive in their natural environment are lean, strong and fast. They have to be to survive, to catch food and avoid being eaten.
Humans in the wild also tend to be strong and lean.
Similar to Ted Naiman, Ian Rambo (pictured below), 62, is a fan of intermittent fasting and a moderate protein diet. Rambo doesn’t look like he’s about to trip and break his hip any time soon.
A lot can be said about exercise, longevity and metabolic health.
Peter Attia, who recently left NUSi to go back to practice medicine with a focus on longevity, says:
Glucose disposal is everything. The best way to get there is by increasing the muscle’s capacity to take up glucose and make glycogen, and that’s best accomplished through lifting heavy weights. Doing so also increases health span (i.e. reducing injuries, lowering pain, and increasing mobility through life).
Exercise depletes the glucose in our blood, liver and muscles and causes us to tap into our fat stores. But it’s more than just about using up energy.
As metabolic health and mitochondrial density improves through exercise, our fat oxidation rate increases. We become metabolically flexible which means that we can easily use glucose or fat for fuel. Once we improve our fitness and insulin sensitivity we get to the point that we can even obtain some of the glucose we need from fat.
My friend Mike Julian commented:
Every triglyceride that is broken down gives up one glycerol molecule. Two glycerol molecules will make one glucose. So the more fat we are capable of burning, the more glucose we can make from fat oxidation, thus the better we get at restoring muscle glycogen without eating carbohydrates.
Also the glycogen that we do burn produces lactate, which is then recycled to make more glucose in the cori cycle, which also contributes to muscle glycogen stores during recovery.
The goal is to increase mitochondrial density so that we are very good at oxidizing fats. When we have poor mitochondrial density we are far more prone to switching over to anaerobic metabolism at low activity levels and anaerobic activities require glucose.
So if we can’t burn fat at high rates due to low numbers of mitochondria, we can’t make much glucose from glycerol via fat oxidation, so in turn our bodies go to plan B which is to make it out of amino acids in order to make up for the rest of what it needs.
So if you increase your mitochondrial density through exercise, you’ll oxidize a higher volume of fat, which will give a higher yield of glucose from glycerol and thus reduce your body’s need to break down aminos from dietary protein and lean mass.
Post exercise increased fat oxidation due to mitochondrial density produces more ketones during the recovery period which get used preferentially so the increased glucose production during that time can go towards refilling of glycogen stores rather than be oxidized for energy. This is why many top keto athletes will fast for a few hours post training. If they eat straight away they miss out on this phenomenon and actually will recover slower.
Building on the prior trials in yeast and worms, the current dietary restriction longevity experiments in rhesus monkeys are looking positive. You can see the monkey on the right who has been living on 30% less calories looks younger and healthier than the monkey on the left who is the same age.
The monkeys who eat less have less age related disease and live longer.
While avoiding excess energy intake is beneficial, there are differing opinions on how this translates to humans in the real world in terms of increased life span.
Peter Attia says:
Most people in this space, the super-in-the-weeds people on this topic that I’ve spoken with at length, do not believe caloric restriction actually enhances survival in the wild.
Nobody disputes that for most species it enhances survival in the laboratory, but once you get into the wild, you’re basically trading one type of mortality for another.
So many things in life are a balance and involve compromise. While you need adequate nutrition to be strong and active, our bodies also age more slowly if we don’t subject ourselves to excess energy.
Another problem with calorie restriction is that unfortunately most of us don’t have the self-discipline to limit our food intake all the time. When we do eat we find it hard to stop until we are satisfied. Our survival instincts don’t know about the studies in the monkeys, the worms and the yeast.
Most people find it hard to maintain constant caloric restriction when they have free will and unlimited access to food. And then the cruel trick for people who do have the discipline to consistently reduce their energy intake is that the body will scale back its energy expenditure to stay within the reduced energy intake.
“Complete abstinence is easier than perfect moderation.”
So if caloric restriction doesn’t necessarily work, then what’s the solution? Jason Fung makes a compelling case for the benefits of intermittent fasting rather than chronic calorie restriction.
When there is a lack of food a process called autophagy (from the Greek auto, “self” and phagein, “to eat”) kicks in and we turn to our own old cells for nutrients. Autophagy is nature’s way of getting the energy we need when we don’t eat in addition to cleaning out the old junk in our bodies and brains. When we get to eat again we build up new, fresh healthier cells.
But this process of cell clean up and regeneration cannot occur without giving the body the chance to clean out the old cells first. We regenerate and slow aging when we don’t always have a constant supply of energy. One of the advantages of intermittent fasting over simply reducing calories is that you get a deeper cleanse of the old cells with total restriction of energy inputs.
In the video below David Sinclair explains how our body makes a special effort to repair itself when there is a lack of food. In a famine your body senses an emergency and sends out Sirtuin proteins to maximise the health of our mitochondria to increase the chance that you will survive the famine and have the best chance of living until a time when food is more plentiful and you can reproduce and pass on your genes. Unfortunately, this emergency repair function just doesn’t happen when food is plentiful. They’re working on drugs that will mimic this effect, but in the meantime, intermittent fasting is free.
Many people hypothesise that restricting protein is an important component to slow aging.
Dr Ron Rosedale talks a lot about the dangers of glycation and the kinase mTOR. His hypothesis, as articulated in the Safe Starches Debate and AHS 2012, is that we should avoid carbohydrates to avoid the dis-benefits of glycation, particularly as we can get the glucose we need from protein and to a lesser extent from fat. When you see that all the major diseases of aging are correlated with high blood sugars and high insulin levels you might think that he is onto something.
In his AHS 2012 talk Rosedale discusses the dangers of mTOR (mammalian target of rapamycin). mTOR is activated when we eat protein and raise insulin and leads to suppression of autophagy. In view of this Rosedale recommends relatively low levels of protein for people with diabetes (e.g. 0.6g/kg) and even lower for people who are battling cancer (e.g. 0.45g/kg).
Vegan luminary Dr Michael Gregor points to the various drawbacks of excess dietary protein and makes a compelling case for restricting animal protein by focusing on plant foods rather than caloric restriction or intermittent fasting.
There’s a fascinating August 2015 paper by Valter Longo et al that gives an overview of the current thinking in longevity. While it mentions protein restriction as a possible area for future investigation, discussion of protein restriction generally seems to be in the context of intermittent restriction with subsequent re-feeding.
To date, very few studies have been performed in humans on the potential beneficial effects of protein and/or amino acid restriction on aging processes or age-associated chronic diseases.
There are obvious benefits in having periods where the body can clean out old proteins, however you also need high quality nutrition to build back the new shiny parts.
While I have gone to great lengths to bring attention to the fact that protein contributes to the insulin load of the diet, I struggle with the concept of chronic protein avoidance when so many of the things I read talk about the mental health benefits of protein, the benefits of lean muscle mass for metabolic health, the satiety benefits of protein and the importance of lean muscle as we get older to ensure we can be active and strong rather than brittle.
Like everything though it’s a balancing act. Binging on protein supplements and egg whites to get big and jacked is not going to lead to optimal health and longevity. Some of these guys are even injecting extra insulin for its anabolic hypertrophy effects on top of the anabolic hormones. This is not healthy and not natural.
So how much protein do you need when you do eat? I think you need enough to be strong and active but at the same time without raising insulin and blood sugars and decreasing ketones.
Lean muscle = good
Insulin sensitivity = good
Excess body fat = bad
High insulin = bad
There’s also a growing momentum around the metabolic theory of cancer (the number three leading cause of death) which hypotheses that excess glucose feeds cancer growth and restricting glucose through a therapeutic ketogenic diet with intermittent fasting will reduce your risk of cancer.
When you hear Seyfriend talk he seems very proud of and excited about the glucose : ketone index (GKI) which he developed as a proxy for a person’s insulin levels. As you can see in the chart below, as our blood glucose levels decrease ketone levels rise.
More than blood glucose or ketones alone, the relationship between your blood glucose and ketones seems to be a good proxy for your insulin sensitivity.
It seems that someone with a GKI of less than 10 has fairly low insulin levels, someone with a GKI of less than 3 has excellent metabolic health, while someone battling cancer might want to target a GKI of 1.0.
Reducing the insulin load of your diet can reduce your glucose levels, increase your ketones and reduce your risk of metabolic syndrome and the most prominent causes of death (i.e. heart disease, stroke, cancer, Alzheimer’s and Parkinson’s).
Just to be clear, you people who achieve these excellent insulin resistance levels don’t get get there by simple adding more fat to their morning coffee but through disciplined intermittent fasting which tends to lead to reduction in body fat which improves insulin resistance.
finding the optimal balance
On one extreme too much food will make us fat and insulin resistant and stop the body from repairing itself.
On the other extreme calorie restriction will make us frail and vulnerable to disease and accidents.
So how do we find the middle ground?
On the topic of carbohydrates Peter Attia says:
You want to consume basically as much glucose as you can tolerate before you start to get out of glucose homeostasis. For me there’s a different number than for the next person, and you have to find what the level is.
I’ve been wearing a continuous glucose monitor for several months now. Every day I just have it spit out my 24-hour average of glucose plus a standard deviation, and I now know my sweet spot. I like to have a 24-hour average of between 91 and 93 mg/dL with a standard deviation less than 10.
We can’t measure insulin in real time. To me, the Holy Grail would be to have an area under the curve of insulin, but this becomes a pretty good proxy.
It’s fascinating to see that Attia, who is a super fit semi pro athlete is going to the effort of wearing a continuous glucose meter full time. CGMs are generally worn by people with type 1 diabetes like my wife.
The process he is describes of reducing dietary glucose intake to a point where blood glucose levels are normalised is essentially the process used by the people we see who are managing type 1 diabetes as well as possible.
The food insulin index testing measured the area under the curve response to various foods (i.e. what Attia describes as the Holy Grail) and has been really useful for us to understand which dietary inputs cause the greatest blood glucose swings and require largest amounts of insulin.
I think the reason that Attia is recommending ‘as much glucose as you can tolerate’ is to fuel your energy needs for activity, maximise nutrition and dietary flexibility. This level of blood glucose control will give him an HbA1c of 4.8% which will put him in the lowest risk category for the most common diseases of aging. But to maintain such a tight standard deviation he’s going to be managing the net carbs and protein in his diet so his blood sugar doesn’t go over 100mg/dL or 5.6mmol/L too often.
Dr Roy Taylor recently released an interesting paper where he proposes that each person has a personal fat threshold. Rather than the BMI chart or body fat, there is a certain level at which the body fat becomes inflamed and insulin resistant which leads to diabetes and all the issues related to metabolic syndrome. What this means in practice is if your blood glucose levels are rising above optimal you need to eat less to lose body fat.
When it comes to protein Attia says:
What I’m telling my patients is really you only need as much protein as is necessary to preserve muscle mass.
You have a sliding scale, which is carbohydrate goes up until you hit your glucose and insulin ceiling, protein comes down until you’re about to erode into muscle mass and slip into positive nitrogen balance, and then fat becomes the delta.
So in somebody like me, that’s probably about 20% carb, 20% protein 60% fat.
I’ve done everything from vegan to full ketogenic. I’ve experimented with the entire spectrum of religions, but nevertheless, that’s the framework.
It’s worth noting here that this quote from Peter is in the context him talking at length about mTOR, ROS, glucose control and protein restriction. Attia is one of the smartest guys in nutrition, medicine and anti-aging science, but he’s not avoiding protein. He’s making sure he gets enough to maintain lean muscle mass but not so much that it messes with his glucose levels or requires a significant glucose response.
Attia also talks about maximising glucose and minimising protein to normalise blood glucose and insulin. Given that the focus is on managing insulin levels, I think you could also take the opposite approach to minimise carbs and maximise protein as much as you can without disrupting glucose or losing ketones. People with type 1 diabetes will tend to consume medium to higher protein levels (which provide glucose but without the same degree of glucose swing) with lower levels of carbohydrates.
Or alternatively find your own balance of net carbs and protein that gives excellent blood glucose levels and some ketones.
When it comes to finding the optimal level of protein and energy Dr Tommy Wood said:
The anti-IGF-1 (insulin like growth factor) crowd confuse me. Lots = bad (cancer). Very little = also bad (sarcopenia and broken hips).
One of the pioneers in the field of longevity is Roy Walford, who developed the concept of Calorie Restriction with Optimal Nutrition (CRON). Many of the ideas in this article and the blog overall are built around Walford’s ideas regarding optimising nutrition for health and longevity.
While Walford lived his theories in practice, he unfortunately died at 79 of ALS so we didn’t really get to find out whether calorie restriction delayed the major diseases of aging for him. The pictures below are taken of Dr Walford before and after two years living in Biosphere 2.
Walford was the crew’s physician and meticulously recorded the health markers of the Biosphere 2 ‘crew members’. It’s interesting to see how markers like the BMI chart, glucose, insulin and HbA1c all improved markedly with the semi-starvation conditions during the experiment, however they reverted to more normal levels after resuming normal eating.
If we are going to fast and / or restrict calories to optimise our metabolic health it’s even more important that we make sure that the food we do eat, when we eat it, provides all the nutrients that we need to thrive and build back new shiny parts of our body. Unfortunately it seems that the optimal nutrition component of Walford’s CRON concept is not discussed much these days.
So what does all this mean? What do we know about maximising our metabolic health and avoiding the primary diseases of aging?
Is too much energy bad… yes.
Is eating all the time bad…. yes.
Is excess protein bad… maybe, maybe not, however the vegans would say that we should avoid animal protein and stick to only plant based foods.
Are excess carbohydrates bad… maybe, maybe not, however the low carb / keto crowd would say that you need to avoid carbohydrates because they raise your insulin.
Is excess protein and excess non-fibre carbohydrates bad… most likely, yes.
Both carbohydrates and protein will raise insulin, blood glucose, IGF-1 and upregulate mTOR which all accelerate aging.
In the end though we have to eat. We are programmed for survival. While not eating too much and intermittent fasting are important considerations, when we do eat though we should maximise the nutrient density and prioritise foods that do not not raise our insulin and blood glucose levels. I think if you get that right a lot of the other things will follow.
There is no perfect dietary solution for all. What is best for you will come down to your situation, goals and preferences.
Some people will prefer zero carb with lots of meat.
Some people feel strongly about avoiding animal products and do well on a plant based diet with minimal processed foods.
Some will aim for a therapeutic ketosis approach to tackle major metabolic issues.
All of these extremes are viable but a balance somewhere in the middle might be easier to maintain in the long term while also maximising the nutrient density of the calories we consume.
What is almost certainly dangerous for most people is the low fat, high insulin load approach that has been recommended for the past few decades and seems to have led to increased consumption of low nutrient density highly processed food products by many.
¿Puede el ayuno intermitente optimizar los niveles de glucosa en la sangre y reducir la necesidad de medicamentos para la diabetes? Antonio Martínez estaba ansioso por descubrirlo, por lo que se propuso realizar un experimento con él mismo.
El Dr. Antonio C. Martinez II., es un Abogado reconocido de nivel distinguido por Martindale Hubbard, y de la Red Legal de los Mejores Abogados (Top Lawyers) en Nueva York y un hombre de negocios que trabajó para el ya fenecido Dr. Robert C. Atkins MD en relaciones gubernamentales y apareció en su programa de radio en los años 90. Fue uno de los principales cabilderos que logró la aprobación de la Ley de Educación y Salud de los Suplementos Dietéticos de 1994 (DSHEA). Ha participado activamente en cuestiones de salud en las leyes y políticas a lo largo de su carrera. En los años 90 Antonio adoptó un enfoque bajo en carbohidratos para bajar de peso durante un tiempo, pero luego retomó una dieta moderada en carbohidratos. No fue hasta que Antonio comenzó a tener sus propios problemas de salud, como la diabetes tipo 2 y un ataque cardíaco, que se dio cuenta que necesitaba intensificar sus esfuerzos para elevar la calidad de su nivel de vida con respecto a su salud.
DIAGNOSTICO: DIABETES TIPO 2
Antonio tiene antecedentes familiares de diabetes tipo 2, ya que ambos padres sufren de la enfermedad, así que es diagnosticado con diabetes tipo 2 en 2002, por lo que los médicos le indicaron inicialmente empezar a tomar Metformina y a partir del 2008 utilizar Janumet. Con la ayuda de éstos Antonio mantenía un HbA1c (HbA1c se refiere a la hemoglobina glucosilada ( A1c ), que identifica la concentración promedio de glucosa en plasma) en los 6s y fue elogiado por sus médicos por su gran control de la glucosa en sangre, sin embargo, a pesar de que los mantuvo por debajo de los recomendados por la Asociación Americana de Diabetes (un máximo de HbA1c del 7%) , Antonio en realidad estaba en el rango de alto riesgo para la enfermedad cardiovascular, como se muestra en la siguiente tabla. Durante este tiempo él siempre fue informado por sus médicos de que su A1c estaba entre 6 y 7 se encontraba dentro de las directrices médicas.
Si bien los medicamentos antidiabéticos ayudan a disminuir los niveles de glucosa en la sangre (es decir, el de los síntomas) estos datos que se muestran a continuación muestran que los medicamentos no reducen necesariamente el riesgo de enfermedades o permiten que la grasa de sus órganos puedan ser lanzados para restaurar la sensibilidad a la insulina (es decir, la solución).
Como se muestra en la tabla a continuación, la insulina es una hormona anabólica que permite que el cuerpo construya reservas de energía en el cuerpo. Sin embargo, si su problema es la hiperinsulina, la diabetes tipo 2 o hígado graso, entonces su objetivo debe ser reducir el nivel de glucosa en la sangre y los niveles de insulina para permitir que la grasa almacenada se metabolice a energía. Parece que simplemente tomando medicamentos para reducir el alto nivel de glucosa en la sangre sin cambios en la dieta va a conducir la energía de nuevo en el almacenamiento en forma de grasa, incluso dentro el corazón, el hígado y el páncreas.
El siguiente diagrama del Dr. Ted Naiman ayuda a explicar cómo la resistencia a la insulina, los niveles altos de insulina (hiperinsulina) y azúcar en la sangre (hiperglucemia) están interelacionados y ambas cosas son malas noticias.
Lamentablemente el 28 de marzo de 2014 Antonio sufrió un ataque al corazón, razón por la cual le colocaron un stent en una arteria. A su ingreso en el hospital pesaba 158 libras y tenía una HbA1c del 7%. Después de su ataque cardíaco, Antonio se le indicó tomar aspirina, medicamentos para la presión arterial, una estatina, un anticoagulante y un bloqueador beta. En poco tiempo comenzó a sentir los efectos secundarios de las medicaciones múltiples. Frustrado, volvió a leer una serie de materiales de salud y medicina y dijo a sus médicos que no estaría tomando medicamentos para el resto de su vida. También vio el documental “Cereal Killers – Asesinos del Cereales”, que fue como una luz en su camino para seguir dando los pasos necesarios en los cambios de sus hábitos para su restablecimiento.
En julio de 2014 Antonio dijo a su médico de cabecera y a su cardiólogo que iba hacer una dieta baja en carbohidratos y rica en grasas. Mientras que sus médicos no le aconsejaron nada en contra de ella, eran escépticos y le advirtieron que tendría que hacerse un análisis hecho con frecuencia para controlar el impacto de la dieta. A continuación, para septiembre de 2014 Antonio recibió una llamada de su médico quien le dijo: “¡felicidades, lo que sea que está haciendo, sígalo haciendo, tiene usted un HbA1c normal!, por lo que le recomendaron dejar de tomar el medicamento Janumet y como forma de control que siguiera tomando el Metformin”. Como se muestra a continuación, el HbA1c de Antonio había bajado del 6,6% al 4,9% con el enfoque de la dieta baja en carbohidratos, también había rebajado trece libras, por lo que se encontraba ahora con 145 libras, mientras que su presión arterial se había normalizado, su HDL aumentó en 20 puntos y sus triglicéridos habían disminuido por debajo de 100 mg / dl.
ELIMINANDO EL FENOMENO DEL ALBA EN LA DIABETES TIPO II
A pesar de comer sólo dos comidas bajas en carbohidratos por día, Antonio observó que a finales del 2015 sus niveles de azúcar en sangre comenzaban a dispararse hacia arriba en horas de la mañana.
El fenómeno del amanecer es el proceso en el que el cuerpo segrega una serie de hormonas y la glucosa en el torrente sanguíneo, en preparación para el día, sin embargo, si usted es resistente a la insulina entonces la respuesta de la insulina puede no ser adecuada para mantener los niveles normales de glucosa en la sangre, por lo que Antonio después de haber sufrido un ataque al corazón se tomó esto en serio y estaba dispuesto a hacer lo que fuese necesario para revertir esta situación, así que para poner en marcha el nuevo año, Antonio adoptó un régimen regular de ayuno intermitente que involucró a ir a la cama sin cenar el domingo por la noche y luego no comer hasta el martes por la noche, ofreciéndole esto una ventana de ayuno de 44 a 48 horas cada semana. La siguiente tabla muestra los números de glucosa en la sangre de Antonio hasta diciembre antes del protocolo de ayuno y luego a través de enero y febrero con el protocolo de ayuno en su lugar.
La vida real de los números de la glucosa en la sangre siempre van a rebotar, sin embargo, se puede ver que los valores promedio de glucosa en sangre de Antonio han mejorado mucho. Sus números de glucosa en sangre por la mañana se muestran a continuación. “Estoy consiguiendo los mejores números que he tenido y sin fenómeno del amanecer”, dice Antonio.
Mientras que los ayunos más largos están trabajando bien para Antonio, también puede utilizar períodos de ayuno más cortos regulares para mantener su glucosa en la sangre hacia abajo. Echa un vistazo a la sección: usandoel medidor de glucosa en su artículo como un indicador de combustible para que obtengan algunas ideas sobre cómo puede asegurarse de que su glucosa en sangre promedio sea una tendencia en la dirección correcta.
Una forma de ver los niveles de glucosa en la sangre y el fenómeno del amanecer es la manera del cuerpo de liberar el exceso de energía almacenada en el torrente sanguíneo para ser utilizado. Si usted es resistente a la insulina del cuerpo va a utilizar un proceso llamado gluconeogénesis para convertir el exceso de proteínas, grasas e incluso hasta cierto punto, en glucosa. Una vez que el exceso de grasa de las personas disminuye, la frecuencia será más sensible a la insulina y el cuerpo detendrá el bombeo de este exceso de glucosa en el torrente sanguíneo.
Comenzando con una HbA1c de 5,1% se notaba que Antonio ya había realizado buenas modificaciones con los cambios en su dieta debido a su baja ingesta en carbohidratos bajo un enfoque disciplinado. Sin embargo, la adición del protocolo de ayuno le ayudó a fundar sobre una buena base y a hacer posible que sus niveles de glucosa en la sangre disminuyeran aún más que los niveles óptimos y en base a esto sus valores de glucosa en sangre ahora tienen un HbA1c de alrededor del 4,6%.
Las cetonas de Antonio son estables, pero en realidad con tendencia a la baja después de la introducción del régimen de ayuno. El hecho de que Antonio tiene valores más bajos de cetonas no es realmente una preocupación dado que él está probablemente utilizando sus cetonas de manera más eficaz de la energía en lugar de dejar que se acumulen en la sangre como podría ser el caso con una dieta alta en grasa y sin ayuno.
Creo que muchas personas se meten en problemas persiguiendo a altos valores de cetona, añadiendo más grasa dietética sin mejorar su metabolismo y la sensibilidad a la insulina, hasta el punto en que realmente puede utilizar las cetonas. El ayuno da fuerzas al cuerpo para aprender a usar cetonas como combustible.
GLUCOSA: INDICE DE CETONA
La relación entre la glucosa y las cetonas (GKI) pueden ser una medida más útil cuando los niveles de glucosa en la sangre se están reduciendo. Un GKI reductor es una indicación de que los niveles de insulina están disminuyendo y su salud metabólica está mejorando. Podemos ver en el gráfico a continuación la glucosa de Antonio: relación de cetona (GKI) que mejora cada vez que ayuna y que está en una baja tendencia con el tiempo. Estos valores bajos GKI indican que él está logrando una excelente salud metabólica.
Thomas Seyfried GKI es una herramienta útil para el seguimiento de su salud metabólica una vez que sus valores de glucosa en sangre están acercando a los niveles óptimos. Seyfried apunta a sus pacientes de cáncer para tienen una GKI de 1,0, aunque un GKI debajo de 10 se considera que es un estado de insulina bastante bajo y que en menos de tres es excelente para la salud metabólica de alguien que no esté persiguiendo una cetosis terapéutica.
¿NO HAY VUELTA A ATRÁS?
Antonio sigue disfrutando de los ayunos semanales durante el cual se centra en beber grandes cantidades de té, café y un poco de caldo de hueso, ingiere también varios suplementos dietéticos y una aspirina diaria. Su peso ahora se ha reducido a 141 libras y ha vuelto a usar la misma talla de ropa que solía llevar durante estuvo en la universidad.
Cuando sus amigos le preguntan cómo ha logrado revertir su diabetes tipo 2 y cómo ha logrado perder peso, él responde: “lo he logrado al comer una dieta baja en carbohidratos y rica en grasas en base a comer comida de verdad. Yo trabajo para mantener la mayor cantidad de mis alimentos en el rango del 70% de grasa, 20% por ciento de proteínas y un10% de carbohidratos como mis objetivos ideales. Yo miro mi ingesta de proteínas, porque el exceso convertirá a través de la gluconeogénesis. “Yo me propongo mantener este enfoque para el resto de mi vida, pues amo los resultados que esta dieta ha proporcionado a mi nuevo estilo de vida! ”
Antonio dice: Otra manera de mirar la resistencia a la insulina es su cuerpo, ya que éste le dice que usted está comiendo en exceso, ya sean demasiadas cosas inadecuadas o simplemente comer demasiado a menudo. Nuestros antepasados eran cazadores recolectores cuyos hábitos de alimentación eran más como escasez y abundancia, no de tres comidas con bocadillos. Conozca y respete la insulina, ya que ésta le dirá cómo puedo hacerlo y si no atiende a sus señales le podrá causar estragos en su salud metabólica.
También puede pensar en su medidor de glucosa en sangre como indicador de combustible. Si sus niveles de glucosa en la sangre son altos, entonces podría ser el momento de dejar de llenar el depósito de combustible por un tiempo. El ayuno intermitente es como ir a un gimnasio metabólico y de trabajo. El cuerpo obtiene la oportunidad de reparar, recuperar y regenerarse si se utiliza de forma inteligente lo que hará la diferencia para su salud y para los sensibilizadores a la insulina.
Estoy decepcionado en el establecimiento médico, ya que deben saber mejor que yo lo que hay que hacer y no lo hacen. ¿Por qué no es la educación en nutrición clínica y terapéutica obligatoria en la escuela de medicina y no es enseñado con el mismo énfasis que la farmacología?
Con el ex líder de la mayoría del Senado EE.UU, Tom Daschle (SD) en Washington DC, febrero 2016.
¿Antonio está curado de su diabetes tipo 2? La respuesta depende de su definición de “curado”.
¿Antonio va a ser capaz de comer comida chatarra y alimentos procesados cinco veces al día? Probablemente, no, sin embargo, si Antonio mantiene este protocolo en ayunas junto con su enfoque bajo en carbohidratos entonces él podría ser capaz de mantener los niveles óptimos de glucosa en sangre sin temor a otro ataque al corazón. Si ese es su definición de “curado”, la respuesta podría ser sí.
Can fasting improve blood glucose levels and reduce the need for diabetes medications? Antonio Martinez was eager to find out, so he set out on his own n = 1 experiment.
Antonio is an Attorney at Law (Martindale Hubbard Distinguished Rating and in The Legal Network Top Lawyers in New York) and businessman who worked for the late Dr Robert C. Atkins MD in government relations and appeared on his radio show in the 90s.
Antonio was one of the principal lobbyists and strategists involved in the passage of the Dietary Supplement Health and Education Act of 1994 (DSHEA) and has been involved in health care issues in law and policy throughout his career.
Back in the 90s Antonio adopted a low carb approach to lose weight for a time but says he then resumed a more moderate diet. It wasn’t until Antonio started to have his own health issues, including type 2 diabetes and a heart attack, that he realised he needed to intensify his efforts.
type 2 diabetes diagnosis
Antonio has a family history of Type 2 Diabetes, with both his mother and father suffering from the condition. Diagnosed with Type 2 Diabetes in 2002, Antonio was initially put on Metformin and eventually Janumet in 2008.
With the help of anti diabetic medications Antonio maintained a HbA1c in the 6s and was commended for his great blood glucose control. However even though he kept his blood glucose under the American Diabetes Association recommended maximum HbA1c of 7% Antonio was still at risk for cardiovascular disease.
As shown in the chart below, people with a HbA1c of less than 5.0% have the lowest risk of cardiovascular disease and stroke, however it doesn’t seem to count if you are using anti-diabetes medications to reduce blood glucose levels as they simply drive the excess energy back into storage as fat.
While anti-diabetic medications help to lower blood glucose levels (the symptom) these medications do not necessarily reduce your disease risk or allow the fat in your organs (the cause) to be released to restore insulin sensitivity (the solution).
Insulin is an anabolic hormone which means that it enables the body to build energy stores. If your problem is hyperinsulinemia, Type 2 Diabetes or fatty liver then your goal should be to lower your blood glucose and insulin levels to enable your stored body fat to be used for energy. Medicating high blood glucose without dietary changes will drive the energy back into storage as fat (including in your heart, liver and pancreas).
The diagram below from Dr Ted Naiman helps to explain how both high insulin levels (hyperinsulinemia) and high blood glucose levels (hyperglycemia) are interrelated and both bad news.
Sadly, on March 28, 2014, Antonio suffered a heart attack and had a stent placed in one artery.
Upon admission to the hospital he weighed 158 lbs and had a HbA1c of 7%. After the heart attack Antonio was prescribed aspirin, blood pressure medication, a statin, an anti-coagulant, and a beta blocker. Within a short time he began to experience side effects from the multiple medications.
Frustrated, he re-read a number of health and medical materials and told his doctors he would not be taking medications for the rest of his life. He also watched the documentary “Cereal Killers” which was a light bulb moment for him.
reduced carbohydrate approach
In July 2014, Antonio told his doctor and cardiologist that he was going on a high fat low carbohydrate diet. While his doctors did not advise against it, they were skeptical and warned him that he would have to have labs done frequently to monitor the impact of the diet.
Then in September 2014 Antonio received a call from his doctor who said
Congratulations. Whatever you are doing, keep doing it. You have a normal HbA1c! I’m taking you off Janumet. Take Metformin at the lowest dose as a control.
As shown below, Antonio’s HbA1c had come down from 6.6% to 4.9% with the low carbohydrate dietary approach. He had also dropped thirteen pounds to 145 lbs, his blood pressure had normalized, his HDL increased by 20 points and his triglycerides dropped below 100 mg/dL.
tackling dawn phenomenon
Despite eating only two low carb meals per day Antonio became concerned towards the end of 2015 that his morning blood sugar levels were starting to drift up.
Dawn Phenomenon is the process where the body secretes a range of hormones and glucose in preparation for the day, however if you are insulin resistant then the insulin response may not be adequate to maintain normal blood glucose levels. Having already experienced a heart attack he took this seriously and was eager to do whatever he could to reverse the situation.
So to kick off the new year Antonio adopted a regular fasting regime which involved going to bed without dinner on Sunday night and then not eating until Tuesday evening. This gives him a 44 to 48 hour fasting window each week.
The chart below shows Antonio’s blood glucose numbers through December before the fasting protocol and then through January and February with the fasting protocol in place.
Real life blood glucose numbers are always going to bounce around, however you can see that Antonio’s average blood glucose values have really improved.
I am getting the best numbers that I’ve ever had and no Dawn Phenomenon.
While the longer fasts are working well for Antonio he could also use shorter more regular fasting periods to keep his blood glucose down. Check out the Using your glucose meter as a fuel gaugearticle for some ideas on how you can make sure your average blood glucose is trending in the right direction.
One way of viewing high blood glucose levels and Dawn Phenomenon is the body’s way of releasing excess stored energy into the bloodstream to be used. If you are insulin resistant the body will use a process called gluconeogenesis to convert excess protein, and even fat to an extent, into glucose.
Once the excess fat decreases people will often become more insulin sensitive and the body will stop pumping out this extra glucose.
Starting out with an HbA1c of 5.1% Antonio was already doing pretty well due to his disciplined low carb approach. However the addition of the fasting protocol helped him break through the plateau and bring his blood glucose levels down even further towards optimal levels. Based on his blood glucose values he now has an HbA1c of around 4.6% which is pretty much optimal.
Antonio’s ketones are solid but actually trending down after introducing the fasting regime. The fact that Antonio has lower ketones values is not really a concern given that he’s likely using his ketones more effectively for energy rather than letting them build up in the blood as might be the case with a high fat diet without fasting.
I think many people get themselves into trouble chasing high ketone values by adding more dietary fat without improving their metabolism and insulin sensitivity to the point that they can actually use the ketones. Fasting forces your body to learn to use ketones for fuel.
glucose : ketone index
The ratio between glucose and ketones (GKI) can be a more useful measure when your blood glucose levels are reducing. A reducing GKI is an indication that your insulin levels are decreasing and your metabolic health is improving.
Antonio’s glucose : ketone ratio (GKI) improves each time he fasts and that it is trending down over time. These low GKI values indicate that he is achieving excellent metabolic health.
Thomas Seyfried’s GKI is a useful tool to track your metabolic health once your blood glucose values are approaching optimal levels. Seyfried aims for his cancer patients to have a GKI of 1.0, though a GKI below 10 is considered to be a fairly low insulin state and less than three is excellent metabolic health for someone not chasing therapeutic ketosis.
no turning back?
Antonio continues to enjoy the weekly fasts during which he focuses on drinking lots of different teas, coffee, and some bone broth. His weight has now dropped to 141 pounds and he is wearing the same size clothes as he wore in college.
When his friends ask him how he reversed his type 2 diabetes and got skinny. He replies,
By eating a high fat low carbohydrate diet based upon eating real food.
I work to keep my food macros in the range of 70 percent fat, 20 percent protein, 10 percent carbs as my ideal targets. I do watch my protein intake because excess will convert via gluconeogenesis.
I will likely maintain this approach for the rest of my life. I am loving my results!
Another way to look at insulin resistance is your body telling you that you’re eating too much, eating too much of the wrong things or just eating too often. Our ancestors were hunter foragers whose eating habits were more like feast and famine, not three meals with snacks. Know and respect your insulin because it will command you to do so or otherwise wreak metabolic havoc on your health.
You can also think of your blood glucose meter as a fuel gauge. If your blood glucose levels are high then it might be time to stop filling the fuel tank for a while.
Intermittent fasting is like going to a metabolic gym and working out. Your body gets the opportunity to repair, recover, regenerate. Used intelligently, it will make the difference for your health and insulin sensitizing.
I am disappointed in the medical establishment because they should know better and they do not. Why isn’t clinical and therapeutic nutrition education mandatory in medical school and taught with the same emphasis as pharmacology?
It has been a transformational journey for RD Dikeman since his son Dave was diagnosed with Type 1 Diabetes, both as a parent and for himself as he has implemented a regimen of what he likes to call “meal skipping” (a.k.a. intermittent fasting) guided by his own blood glucose levels.
I came across Dave Dikeman, a young man with Type 1 Diabetes, in Episode 831 of Jimmy Moore’s LLVLC Show. I still remember ten year old Dave saying “finger pricks now or amputations later, the choice is pretty simple”. Dave’s pragmatic attitude to his condition was another light bulb moment in our family’s journey to learning to manage diabetes.
It has also been quite a journey for RD Dikeman, Dave’s dad, who recently posted a few comments on the Optimising Nutrition Facebook Group that I thought were worth capturing.
I’ll tell you a quick story about how this whole low carb thing started.
Dave is near death, in the hospital, diagnosed with T1. The doctor rolls in to meet us. A kindly doctor – no Bernstein – but a very kindly man (he took an injection of insulin to show Dave not to be afraid).
So the doctor is talking to Dave and finds out they both went to the same school. So there’s some kinship. And the doctor recognizes that Dave is a pretty sharp guy and Dave starts asking questions ‘will I die young?’ And Doc is brutally honest ‘you have to control your blood sugars – amputations, blindness and those things are on the table’. And doc starts to give us a lecture on how to do that.
He has an easel and a sharpie. Anyway, he draws a rollercoaster blood sugar graph and he says ‘carbo makes blood sugar go up and insulin go down and you want to be between 80 and 180 (sigh) mg/dL.’
And Dave goes ‘I just won’t eat carbo’. TRUE STORY.!
And ME!! I interrupt and say (throw me down and kerb stomp me everyone) ‘You need carbo for… ENERGY’. LOL!
So I spent the next month force feeding Dave oatmeal. I am heckled daily for this. Every time there is oatmeal. Oatmeal on a TV commercial. Oatmeal at restaurant. Heckled!
About a month later guess who discovered ‘The Bernstein Book‘!!! NOT ME!! It was Roxanne (my wife). So that is two fails for me.
I will say the happiest moment of my life was reading Bernstein’s ‘law of small numbers’. I knew then that we had a way out of this mess.
Being 100% wrong never felt so good. I have a good leader. The whole thing was his idea.
Since then, RD has become passionate about the low carb way of eating and helping other people learn more about diabetes. He is an admin on the Type One Grit Facebook Page which is a great source of support and inspiration for people with Type One Diabetes. He and Dave also produce Dr Bernstein’s Diabetes University which captures nuggets from Dr B on YouTube.
RD lives low carb theory…
I don’t eat any carbohydrate-glucose foods. No sugar, manipulated sugar fruits, grains or starch. Ever. Carbs are only from fibrous veggies and nuts.
…and it seems to be working.
Dr Bernstein’s recommended target blood glucose is 83mg/dL (or 4.6mmol/L) with a recommendation that people with Type 1 Diabetes actively work to keep within a ten point range of this target number (i.e. 73 to 93mg/dL or 4.0 to 5.2mmol/L).
Dr B tells the story of how, back in the day, blood glucose meter sales reps would come to his office. He would get them to demonstrate how it worked by testing it on themselves so he could see their blood glucose number. Sure enough, the blood glucose levels of these healthy young non-diabetic sales reps was always around 83mg/dL.
Since then there has been plenty of research that showing the benefits of having an average blood glucose level of around 83mg/dL including reducing your risk of cancer, obesity, heart disease and a range of other metabolic issues.
Some people operate happily at the lower end of this range, particularly if they are younger and / or insulin sensitive and producing ketones. Generally though, the body of someone with a healthy metabolism will bring them back to a blood sugar of around 83mg/dL (or 4.6mmol/L).
Not too high. Not too low. Just right.
The table below shows a generalised relationship between blood glucose, ketones, HbA1c and the glucose : ketone ratio (GKI). There’s no perfect number for everyone, however typically the lower your HbA1c, without using blood glucose lowering medications, the lower your risk of metabolic syndrome and related diseases (see the Diabetes 102 article for more details).
RD is not technically diabetic himself however he understands the dangers of high blood glucose levels. RD found that the low carb way of eating helped him lower his own blood glucose, however he still wasn’t consistently achieving Dr Bernstein’s target blood glucose level of 83mg/dL.
What he did find was that when he waited to eat his blood glucose would come down as the body used up the glucose in his blood. Over time RD developed a practice of meal timing guided by his glucose meter that finally enabled him to optimize his own blood glucose levels.
My blood sugar tells me when it’s time to get some insulin sensitizing exercise at the gym also.
I would say if blood sugar is above normal (83 mg/dL) then beta cells are ‘on’ and insulin is a fat storage hormone (obviously other functions).