Category Archives: blood sugar

the complete guide to fasting (review)

Considering the massive amount of research and interest in the idea of fasting, not a lot has been written for the general population on the topic.

Brad Pilon’s 2009 e-book Eat Stop Eat was a great, though fairly concise, resource on the mechanisms and benefits of fasting.

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Martin Berkhan’s LeanGains blog had a cult following for a while in the bodybuilding community.

image17Michael Mosley’s 2012 documentary Eat, Fast and Live Longer documentary piqued the public interest and was followed by the popular 5:2 Diet book.

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.

St Augustine

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 seems to be better when I’ve fasted for a few days.

My key fasting takeaways are:

  1. Fasting is not that hard. Give it a try.
  2. You can build up slowly.
  3. 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).

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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.[1]

context

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.

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Desperate times call for desperate measures!

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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.

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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.

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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 Complete  Guide 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.

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Jason and Jimmy both sent me a copy of their new 304 page book, The Complete Guide to Fasting, to review (thanks guys).   So here goes…

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, full colour production 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,[2] though are not yet optimal.[3]

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.

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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).

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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.[4]  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.

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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.

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fasting to optimise blood glucose levels

In the long run, neither high insulin nor high glucose levels are optimal.

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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.

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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.

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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.

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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.

fasting frequency

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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.” 

Mike Julian

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.

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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.

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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.

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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.

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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.

dietary approach printable .pdf
weight loss (insulin sensitive) download
autoimmune (nutrient dense) download
alkaline foods download
nutrient dense bulking download
nutrient dense (maintenance) download
weight loss (insulin resistant) download
autoimmune (diabetes friendly) download
zero carb download
diabetes and nutritional ketosis download
vegan (nutrient dense) download
vegan (diabetic friendly) download
therapeutic ketosis download
avoid download

protein

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.

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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).

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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).[5] [6]

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.

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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.

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optimal ketone levels

Measuring ketones is really fascinating but confusing as well.

“Don’t be a purple peetone chaser.”

Carrie Brown, The Ketovangelist Podcast Ep 78

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.

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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.

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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.

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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.

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summary

  1. 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.
  2. Fasting can help optimise blood glucose and weight in the long term, with a disciplined regimen.
  3. 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.
  4. 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.

 

references

[1] https://intensivedietarymanagement.com/of-traitors-and-truths/

[2] https://www.diabetes.org.uk/About_us/What-we-say/Diagnosis-ongoing-management-monitoring/New_diagnostic_criteria_for_diabetes/

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

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

[5] https://www.dropbox.com/s/h3pi53njcfu4czl/Physiological%20adaptation%20to%20prolonged%20starvation%20-%20Deranged%20Physiology.pdf?dl=0

[6] https://www.facebook.com/groups/optimisingnutrition/permalink/1602953576672351/?comment_id=1603210273313348&comment_tracking=%7B%22tn%22%3A%22R9%22%7D

how to make endogenous ketones at home

I’ve spent some time lately analysing these 1100 ketone vs glucose data points looking for the secret to achieving optimal ketone values for weight loss and health.

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As you can see from this chart, there is a relationship between ketones and glucose.  As your blood glucose levels decrease your blood ketones rise to compensate.

Different glucose : ketone relationships for different people

It seems that each person has a unique relationship between their blood glucose and ketone values that gives us an insight to understand their insulin resistance status and metabolic health.

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Characterisation of different metabolic states

Similar to Dr Kraft’s insulin curves, we can characterise different levels of insulin resistance metabolic health using the relationship between glucose and ketones.

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If you want to know why hyperinsulinemia is the “unifying theory of chronic disease” it’s worth taking the time to read up on it to provide some more context for the discussion later in this article. [1] [2] [3] [4] [5]

Type 2 Diabetes

If you have type 2 diabetes and your blood glucose levels are consistently high, you are not metabolising carbohydrates well, and will likely benefit from a lower insulin load dietary approach.

When you go a long time between meals, your ketones don’t kick in because of high insulin levels and / or your mitochondria are not functioning optimally.  You feel tired and hangry.

Particularly in the early stages when someone is still insulin resistant, a lower insulin load dietary approach will help with satiety and carb cravings while keeping blood glucose levels under control.

Hyperinsulinemia and metabolic disorders

If your blood glucose levels are very low and ketone levels are also very low, you may have an infection or a metabolic disorder that is stopping you from producing enough energy.

The yellow line in the chart above is based on an actual person who is suffering from a range of metabolic related issues including obesity, PCOS, depression, etc.  For these people, EXOGENOUS ketones may help to relieve the debilitating symptoms of acute Hyperinsulinemia.

Exciting research is currently 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.[6]  [7]  

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Patrick Arnold, who worked with Dr Dominic D’Agostino to develop the first ketone esters and BHB 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, as noted by Robb Wolf, once you have successfully transitioned to a lower carb eating style you would need 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 ENDOGENOUS FAT stores.

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Insulin resistant

Someone with diabetes who persists 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 body will be able to more easily release 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.

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If you are insulin resistant you are probably not able to metabolise carbohydrates, protein or fats very well.  The light blue “mild insulin resistance” line is based on my ketone and glucose values when I started trying to wrap my head around this ketosis thing.

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I enthusiastically started adding unrestricted 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 the bacon and BPC?!?!?

The photo on the right is after I worked out how to decrease the insulin load of my diet and learning about intermittent fasting from Jason Fung.  I realised that ENDOGENOUS ketosis and weight loss is caused by a lower dietary insulin load, not more EXOGENOUS fat on your plate or in your coffee cup.

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I recently had my HbA1c tested at 4.9%.  It’s getting there.  But knowing what I know now about the importance of glucose control,  I would love to lose a bit more weight and see my HbA1c even lower.

I recently purchased a couple of bottles of KetoCaNa from the USA after hearing a number of podcast interviews with Dominic D’Agostino and Patrick Arnold.[8] [9]

This metabolic jet fuel is definitely fascinating stuff!  My experience is that it gives me the buzz like a BPC, but also has an acute diuretic effect (meaning I need to stay close to a toilet and long drives to work in slow traffic were sometimes humiliating).

I had hoped it would have a weight loss effect like some people seemed to be saying it would.

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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.  It was like I had ‘bonked’ all of a sudden and needed LOTS OF FOOD NOW!

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Unfortunately my hunger and subsequent binge eating seemed to offset the short term appetite suppression.  And it was not going to be financially viable for me to maintain a constant level of artificially elevated ketone levels.

I asked around to see if anyone had come across studies demonstrating long term weight loss effects of exogenous ketones.[11]   It was a VERY enlightening discussion if you want to check it out here.  Wow!

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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 Pruve this claim.

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Also, the studies that were referenced in the Pruvit FAQ all appear to relate to the benefits of ENDOGENOUS or nutritional ketosis rather than EXOGENOUS ketone supplementation.

Princess_Bride_That_Word

According to a Pruvit tele-seminar the EXOGENOUS ketone salts were not designed to be a weight loss product and hence have not been studied for weight loss.

The only studies that we could find that mentioned EXOGENOUS ketone supplementation and weight loss were on rats an they found that there was no long term effect on weight loss.[12]   

So in spite of my hopeful $250 outlay it seems that exogenous ketones ARE just a fuel source after all.

image06

Even the experts don’t seem to think exogenous ketones help with fat loss.

image25

 

image28

image16 [13]

Confused yet?  I don’t blame you.

Metabolically healthy

The “metabolically healthy” line in the chart above is based on RD Dike man’s ketone and glucose data when he recently did a 21 day fast.

image32

Due to his hard earned metabolic health and improved insulin resistance he has developed the ability to fairly easily release ketones when goes longer periods between meals.

2016-08-10 (2).png

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 line as the gold standard.

image04

In spite of his improvement in insulin resistance and blood glucose control, he still says the “siren” of hunger is incredibility difficult to resist and mastering appetite is more challenging than particle physics.  As a Chief Scientist at Lockheed Martin, he would know.

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, it seems they are also quickly metabolised so they do not build up in his bloodstream.

I know Luis Villasenor of Ketogains finds the same thing.

image10

Total energy = ketones + glucose

Where this gets even more interesting is when we look at the glucose and ketone data in terms of TOTAL ENERGY.  That is, from both glucose and ketones.

2016-08-12 (11)

The average TOTAL ENERGY of the 1100 data points from these 26 fairly healthy people working hard to achieve nutritional ketosis is 6.1mmol/L. It seems the body works to maintain homeostasis around this level.

When the TOTAL ENERGY in our bloodstream increases outside of the normal range it appears 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.

Regardless of whether your energy takes the form of glucose, ketones or free fatty acids they all contribute to acetyl-coA which is oxidized to produce energy.  Forcing excess unused energy to build up in the bloodstream is typically not desirable and can lead to long term issues (gyration, oxidized 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 lip genesis to decrease the TOTAL ENERGY in the blood stream to normal levels.

A number of studies seem to support this view including Roger Unger’s 1964 paper the Hypoglycemic Action of Ketones.  Evidence for a Stimulatory Feedback of Ketones on the Pancreatic Beta Cells.[14]

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.[15]

This guy seems to agree too.  But what would he know? [16]  [17] [18]

image26

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 Seyfried and D’Agostino always talk about the therapeutic benefits and the insulin lowering effects of a calorie restricted ketogenic diet. [19] [20] [21] [22]

Dealing with high ketones and high glucose typically a concern fro the body because it just doesn’t happen in nature with real 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 in the blood stream, 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”[24] 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 use of 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.

A July 2016 study Ketone Bodies and Exercise Performance: The Next Magic Bullet or Merely Hype? didn’t find that EXOGENOUS ketones were very exciting.

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.

Another study by Veech et al (who is trying to bring his own ketone ester to market) from August 2016 Nutritional Ketosis Alters Fuel Preference and Thereby Endurance Performance in Athletes found in favour of ketones.

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 MOAR fat and MORE 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 study in a long term controlled environment in the in the future are:

  1. What is the a safe dose limit of EXOGENOUS ketones for a young child?  How would you adjust their maximum intake based on age and weight?
  2. 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?
  3. Is there a difference in the way EXOGENOUS ketones are processed in someone is metabolically healthy versus someone who is very insulin resistant?
  4. Does the affect on appetite continue beyond the point that the ketones are out of your system?
  5. 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?
  6. 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?
  7. Is there a difference in health outcome if you are taking EXOGENOUS ketones in the context of a hypo-caloric ketogenic diet versus a hyper-caloric ketogenic diet?  What about a diet high in processed carbs?
  8. Is there a minimum effective dose to achieve optimal long term benefits to your metabolic health or is MORE better?
  9. 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.

Perhaps the burden of proof is actually on Pruvit to prove it rather getting their Pruvers to demonstrate that within 59 minutes they are successfully peeing out the product they’ve just paid some serious money for!

The lower the better?

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 mobilise glycogen and fat easily when required (e.g. when fasting or a sprint). They are metabolically flexible[25] and metabolically efficient.[26]   

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.

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Similar to RD Dikeman, John Halloran is an interesting case.  Recently he has been putting a lot of effort into eating nutrient dense foods, intermittent fasting and high intensity exercise.

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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!

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And he’s been able to lose 10kg (22lb) during July 2016!

image12

At 5.2mmol/L (i.e. glucose of 4.0mmol/L plus ketones of 1.2mmol/L) John’s TOTAL ENERGY is lower than the average of the 26 people shown in the glucose + ketone chart above.  Looking good John!

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.

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.

image22

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.

ketones (mmol/L)

blood glucose (mmol/L)

total energy (mmol/L)

average

0.7

4.8

5.5

30th percentile

0.4

4.6

5.2

70th percentile

0.9

5.1

5.8

The table below shows this in US units (mg/dL).

ketones
(mmol/L)

blood
glucose (mg/dL)

total
energy (mg/dL)

average

0.7

86

99

30th percentile

0.4

83

94

70th percentile

0.9

92

104

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 ketone magic

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).[27]   The REAL magic of ketosis happens when all these things happen and ketones are release 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.

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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 drowning in insulin caused by high TOTAL ENERGY building up in your bloodstream.

image01

Driving up ketones artificially through EXOGENOUS inputs (treating the symptom) does NOT lead to increased metabolic health and 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.

Just like having low blood glucose is not necessarily good if it is primarily caused by high levels of EXOGENOUS insulin couple 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 EXOGENOUS ketones.

Nutrient density

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, greater mitochondrial biogenesis, improved insulin sensitivity and lower blood glucose levels.

Prioritising nutrient dense real food is even more important in a ketogenic context.[28]  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.

Based on my analysis of nutrient density I don’t think you should be trying to avoid protein and carbohydrates in the pursuit of higher ketone levels unless you have a legitimate medical reason for perusing therapeutic ketosis (e.g. cancer, Alzheimer’s, epilepsy, dementia etc).

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I believe the best approach is to maximise nutrient density as much as possible while working within the limits of your metabolic health and your pancreas’ ability to maintain normal blood glucose levels.

image14

Intermittent fasting

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.

image03

Check out the how to use your glucose meter as a fuel gauge article or Jason Fung’s Intensive Dietary Management blog for some more ideas on how to get started with fasting.   Rebecca Skvorc Latham has also developed a fasting protocol using weight to guide your eating schedule if your primary goal is weight loss rather than blood glucose control.

image24

If you really 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.

 

 

Epilogue

Like most people dabbling in this low carb thing, I’m still on a journey.

I’d love to be able to share shirtless photos like Ted and Dom but I’m still working to overcome my own genetic propensity for diabetes, obesity, Alzheimer’s and Parkinson’s.  I’m still learning and working out how to apply these things in my own life.

Although I do sometimes check blood glucose levels before meals to see how I’m tracking I haven’t been testing ketones much for a year or so after I realised chasing high ketones with more dietary fat wasn’t helping me lose weight.

However after writing this article using other peoples’ data, I was intrigued to see how my ketones were travelling.

This was mid-morning after a kettlebell session.

I was able to get my heart rate up to 190 bpm which is my highest ever!  My daughter joined me today so there was some downtime between sets.  Usually I do an exercise until my heart rate gets up to at least 170 bpm.  I then stop and wait until it drops back down to 140 bpm and then go again.

My aim is to train my mitochondria to pump out more power with less energy (i.e. fasted) to improve insulin sensitivity as well as mitochondrial efficiency and drive  mitochondrial bio-genesis.

You can get a lot of work done in an intense 25 to 30-minute session with these weapons of torture that I keep downstairs in my garage (although I don’t think it really matters what you do as long as you push your body to do more with less).

My appetite today was great so I didn’t feel the need to eat until I had dinner with my family.

Previously I would have not been happy with these ketone readings and would have wanted to drive my ketones higher to get into the ‘optimal ketone zone’.  I would have wondered “Maybe I should have eaten some MORE butter or had a BPC to drive ketones higher to facilitate fat loss?”

But given I’d still like to lose some more body fat I’m pretty happy with these numbers.

  • My total energy is low (4.5mmol/L and 5.1mmol/L).  Check.
  • Ketones are present but not too high which means I’m able to mobilise fat but not building it up in my bloodstream.  Check.
  • Blood glucose is low.  Check.

All good!  Feeling crisp, happy and vibrant thanks to ENDOGENOUS ketones!

(Sorry.   I can’t sell you mine.  You’ll have to make your own.)

 

references

[1] http://www.thefatemperor.com/blog/2015/5/6/the-incredible-dr-joseph-kraft-his-work-on-type-2-diabetes-insulin-reigns-disease

[2] http://www.thefatemperor.com/blog/2015/5/10/lchf-the-genius-of-dr-joseph-r-kraft-exposing-the-true-extent-of-diabetes

[3] https://profgrant.com/2013/08/16/joseph-kraft-why-hyperinsulinemia-matters/

[4] https://www.amazon.com/Diabetes-Epidemic-You-Joseph-Kraft/dp/1425168094

[5] https://www.youtube.com/watch?v=193BP6aORwY

[6] http://fourhourworkweek.com/2016/07/06/dom-dagostino-part-2/

[7] http://www.thelivinlowcarbshow.com/shownotes/10568/848-dr-dominic-dagostino-keto-clarity-expert-interview/

[8] http://superhumanradio.com/579-shr-exclusive-patrick-arnold-back-in-the-supplement-business.html

[9] http://superhumanradio.com/shr-1330-best-practices-for-using-ketone-salts-for-dieting-performance-and-therapeutic-purposes.html

[10] http://docmuscles.shopketo.com/

[11] https://www.facebook.com/groups/optimisingnutrition/permalink/1574631349504574/

[12] https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/s12986-016-0069-y

[13] https://www.facebook.com/groups/optimisingnutrition/permalink/1574631349504574/

[14] https://www.dropbox.com/s/287bftreipfpf29/jcinvest00459-0078.pdf?dl=0

[15] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2129159/

[16] https://www.facebook.com/BurnFatNotSugar/

[17] http://www.dietdoctor.com/obesity-caused-much-insulin

[18] http://www.lowcarbcruiseinfo.com/2016/2016-presentations/Hyperinsulinemia.pptx

[19] http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0115147

[20] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819381/

[21] http://healthimpactnews.com/2013/ketogenic-diet-in-combination-with-calorie-restriction-and-hyperbaric-treatment-offer-new-hope-in-quest-for-non-toxic-cancer-treatment/

[22] https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwjK8Jvku7DOAhUJspQKHS5-DkwQFggbMAA&url=http%3A%2F%2Fwww.rsg1foundation.com%2Fdocs%2Fpatient-resources%2FThe%2520Restricted%2520Ketogenic%2520Diet%2520An%2520Alternative.pdf&usg=AFQjCNFuTA7xmWX1pFr6wBTV_hsS7C5j_w&sig2=pcBN_f_kCLSgFKYUy–uug&bvm=bv.129391328,d.dGo

[23] https://www.facebook.com/DocMuscles/videos/10210426555960535/?comment_id=10210431467003308&comment_tracking=%7B%22tn%22%3A%22R9%22%7D&pnref=story&hc_location=ufi

[24] https://www.facebook.com/DocMuscles/videos/10210426555960535/?comment_id=10210431467003308&comment_tracking=%7B%22tn%22%3A%22R4%22%7D&hc_location=ufi

[25] http://guruperformance.com/episode-3-metabolic-flexibility-with-mike-t-nelson-phd/

[26] http://guruperformance.com/tag/metabolic-efficiency/

[27] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852209/

[28] http://ketotalk.com/2016/06/23-responding-to-the-paleo-mom-dr-sarah-ballantynes-claims-against-the-ketogenic-diet/

REVERSION Y REMISION DE LA DIABETES TIPO 2 CASO DE ANTONIO C. MARTINEZ II

¿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.

[for the English version of this post click here]

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.

image07

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.

image05

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).

image09

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.

image04

ATAQUE CARDIACO

image03

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.

Ver este video a continuación:

https://www.youtube.com/watch?v=dON-fPp5Hy0

DIETA BAJA EN CARBOHIDRATOS

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.

image00

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.

image06

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.

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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: usando el 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.

HBA1C

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%.

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CETONAS

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.

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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?

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Con el ex líder de la mayoría del Senado EE.UU, Tom Daschle (SD) en Washington DC, febrero  2016.

¿CURADO?

¿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.

Felicidades Antonio y mantener el gran trabajo!

Referencias:

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

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

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

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

Contacto:

Si usted está atravesando por una experiencia similar a la de Antonio, a él le encanta oír de usted a través de su correo email acmartinezlaw@gmail.com o su página web en www.acmartinez2.com

Agradecimientos:  A la Ing. Julia Angelica Mariñez por la traducción del ingles al español.

 

Antonio C. Martinez II’s type 2 diabetes reversal

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

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

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

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

type 2 diabetes diagnosis

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

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

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

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

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

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

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heart attack!  

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

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

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

reduced carbohydrate approach

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

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

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

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

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tackling dawn phenomenon  

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

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

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

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

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

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

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

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

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

HbA1c

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

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ketones

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

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

glucose : ketone index

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

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

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

no turning back?

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

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

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

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

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

Antonio says:

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

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

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

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

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

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… Brussell sprouts salad…

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..some pate…

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…and Le Côte de Beouf.

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

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

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

cured?

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

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

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

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

Congratulations Antonio and keep up the great work!

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

references

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

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

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

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

contact

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

optimising blood sugars with RD Dikeman

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

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

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

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

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

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

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

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

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

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

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

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

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

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

RD lives low carb theory…

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

and it seems to be working.

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

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

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

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

Not too high.  Not too low.  Just right.

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

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

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

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

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

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

It’s your table exactly Marty Kendall!

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

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

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

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

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

Decreasing average blood glucose = winning!

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

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

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

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

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

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

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

I worked out plenty in 2006.  Same gym.

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

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

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

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

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

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

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

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

Congrats RD!

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

fine tuning your diet to suit your goals – Jane

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

background

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

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

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

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nutritional analysis of base case diet

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

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

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with added spinach and mushroom

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

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with egg

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

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

weight loss approach – reduced calorie density and increased fibre

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

Jane says,

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

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

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

image011.png

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

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

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

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

discussion

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

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

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

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

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

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

 

references

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

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

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

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

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

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

the most nutritious low carb meals

If you are struggling with insulin resistance or diabetes you need to reduce the insulin load of your meals to achieve normal blood glucose levels.  But at the same time you also need to maximize the nutrient density of the food you eat.

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After analysing more than 400 meals I have listed below the highest ranking low carb nutrient dense meals.

Click on each of the photos below to see more details for each recipe.

Be sure to subscribe to the blog and / or on Facebook to receive fornightlightly updates.

Also be sure to check out:

Check out this article for more details about basis of the ranking ranking system.

curried egg with cows brains

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eggs benedict

spinach, cheddar and scrambled eggs

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bacon, eggs, avocado and spinach

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low carb breakfast stax

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steak, broccoli, spinach & halloumi

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spinach, egg and avocado

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spinach, egg, cheese and cream

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Terry’s Wahls’ lamb skillet meal

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Chris Froome’s rest day breakfast

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egg, spinach, avocado and tomato

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baked creamed spinach

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slow cooked pork with veggies 

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spinach, onion and goat cheese omelette

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bacon, egg, cheese and cream

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Dom’s breakfast of sardines, oysters, eggs and broccoli

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asparagus, egg and sauerkraut

Dr Rhonda Patrick’s Ultimate Micronutrient Smoothie vs Zero Carb Gregg

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kale with chorizo and eggs

kale with chorizo and eggs

bulletproof coffee with egg

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baked eggs with sardines

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bacon wrapped salmon

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Five Sisters Greek omelette

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coffee with cream and stevia

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slow-cooked heart on fire with kale

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salad and salmon lunch

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broccoli, cheddar & bacon chowder

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spicy fish tacos

White Fish Fillets being prepared for Cooking

zucchini and feta fritters

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cheesy garlic bread with bacon, beans and tomato

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chia seed pudding

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keto chocolate cake in a mug

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the most nutrient dense foods for different goals

While a lot of attention is often given to macronutrient balance, quantifying the vitamin and mineral sufficiency of our diet is typically done by guesswork.  This article lists the foods that are highest in amino acids, vitamins, minerals or omega 3 refined to suit people with different goals (e.g. diabetes management, weight loss, therapeutic ketosis or a metabolically healthy athlete).

I’ve spent some time lately analysing people’s food diaries, noting nutritional deficiencies, and suggesting specific foods to fill nutritional gaps while still being mindful of the capacity of the individual to process glucose based on their individual insulin sensitivity and pancreatic function.  The output from nutritiondata.self.com below shows an example of the nutrient balance and protein quality analysis.

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In this instance the meal has plenty of protein but is lacking in vitamins and minerals, which is not uncommon for people who are trying to reduce their carbohydrates to minimise their blood glucose levels.

The pink spokes of the nutrient balance plot on the left shows the vitamins while the white shows the minerals.  On the right hand side the individual spokes of the protein quality score represent individual amino acids.

A score of 100 means that you will meet the recommended daily intake (RDI) for all the nutrients with 1000 calories, so a score of 40 in the nutrient balance as shown is less than desirable if we are trying to maximise nutrition. [1]

I thought it would be useful to develop a ‘shortlist’ of foods to enable people to find foods with high levels of particular nutrients to fill in possible deficiencies while being mindful of their ability to deal with glucose.

essential nutrients

The list of essential nutrients below is the basis of the nutrient density scoring system used in the Your Personal Food Ranking System article, with equal weighting given to each of these essential nutrients. [2]

The only essential nutrients not included in this list are the omega-6 fatty acids which we typically get more than enough of in our western diet.  [3]

essential fatty acids

  1. alpha-Linolenic acid (omega-3) (18:3)
  2. docosahexaenoic acid (omega-3) (22:6)

amino acids

  1. cysteine
  2. isoleucine
  3. leucine
  4. lysine
  5. phenylalanine
  6. threonine
  7. tryptophan
  8. tyrosine
  9. valine
  10. methionine
  11. histidine

vitamins

  1. choline
  2. thiamine
  3. riboflavin
  4. niacin
  5. pantothenic acid
  6. vitamin A
  7. vitamin B12
  8. vitamin B6
  9. vitamin C
  10. vitamin D
  11. vitamin E
  12. vitamin K

minerals

  1. calcium
  2. copper
  3. iron
  4. magnesium
  5. manganese
  6. phosphorus
  7. potassium
  8. selenium
  9. sodium
  10. zinc

the lists

Previously I’ve developed short lists of nutrient dense foods also based on their insulin load or other parameters (see optimal foods lists).

But what if we want to get more specific and find the optimal foods for a diabetic who is getting adequate protein but needs more vitamins or minerals?  What about someone whose goal is nutritional ketosis who is trying to maximise their omega-3 fats to nurture their brain?

To this end the next step is to develop more specific lists of nutrient dense foods in specific categories (i.e. omega-3, vitamins, minerals and amino acids) which can be tailored to individual carbohydrate tolerance levels.

I’ve exported the top foods using each of the ranking criteria from the 8000 foods in the database.  You can click on the ‘download’ link to open the .pdf to see the full list.  Each .pdf file shows the relative weighting of the various components of the multi criteria ranking system.  The top five are highlighted in the following discussion below.

It’s worth noting that the ranking system is based on both nutrient density / calorie, and calorie density / weight.  Considering nutrient density / calorie will preference low calorie density foods such as leafy veggies and herbs.  Considering calorie density / weight tends to prioritise animal foods.  Evenly balancing both parameters seems to be a logical approach.

You’re probably not going to get your daily energy requirements from basil and parsley so you’ll realistically need to move down the list to the more calorie dense foods once you’ve eaten as much of the green leafy veggies as you can.  The same also applies if some foods listed are not available in your area.

weighting all nutrients omega-3 vitamins minerals aminos
no insulin index contribution download download download download download
athlete download download download download download
weight loss download download download download download
diabetes and nutritional ketosis download download download download download
therapeutic ketosis download download download download download

all nutrients

This section looks at the most nutrient dense foods across all of the essential nutrients shown above.  Consider including the weighting tables.

no insulin index contribution

If we do not consider insulin load then we get the following highly nutrient dense foods:

  1. liver,
  2. cod,
  3. parsley,
  4. white fish, and
  5. spirulina / seaweed

Liver tops the list.  This aligns with Matt Lalonde’s analysis of nutrient density as detailed in his AHS 2012 presentation.

It’s likely the nutrient density of cod, which is second on the list of the most nutrient dense foods, is the reason that Dwayne Johnson (a.k.a. The Rock) eats an inordinate amount of it. [4]

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It certainly seems to be working for him.

Duane Johnson 2 - Copy

athlete and metabolically healthy

If you have no issue with obesity or insulin resistance then you’ll likely want to simply select foods at the top of the nutrient dense foods list.  However most people will also benefit from considering their insulin load along with fibre and calorie density.   Most of us mere mortals aren’t as active or metabolically healthy as Dwayne.

When we consider insulin load we get the following foods at the top of the list:

  1. basil,
  2. parsley,
  3. spearmint,
  4. paprika, and
  5. liver

We grow basil in a little herb garden and use it to make a pesto with pine nuts, parmesan and olive oil.  It’s so delicious!   (And when I say ‘we’ I mean my amazing wife Monica.)

Aaron Tait Photography

You’ll note that spices and herbs typically rank highly in a lot of these lists.  The good news is that they typically have a very low calorie density, high nutrient density and are high in fibre.

The challenge again is that it’s hard to get all your energy needs from herbs alone, so after you’ve included as many herbs and green leafy veggies as you can fit in, go further down the list to select other more calorie dense foods to meet your required intake.

weight loss

If we reduce calorie density, increase fibre and pay some attention to insulin load for the weight loss scenario we get the following foods:

  1. wax gourd (winter melon),
  2. basil,
  3. endive,
  4. chicory, and
  5. dock

If you’re wondering what a winter melon looks like (like I was), here it is.

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The winter melon does well in this ranking because it is very fibrous, has a very low calorie density and a very low 8% insulinogenic calories which means that it has very few digestible carbohydrates.

Again, basil does pretty well along with a range of nutrient dense herbs.  Basil is more nutrient dense than the winter melon while still having a very low calorie density.

diabetes and nutritional ketosis

If we factor carbohydrate tolerance into the mix and want to keep the insulin load of our diet low we get the following foods:

  1. wax gourd (winter melon),
  2. chia seeds,
  3. flax seeds,
  4. avocado, and
  5. olives

Wax gourd does well again due to its high fibre and low calorie density; however if you’re looking for excellent nutrient density as well, then chia seeds and flax seeds may be better choices.  When it comes to flax seeds are best eaten ‘fresh ground’ (in a bullet grinder) for digestibility and also freshness and that over consumption may be problematic when it comes to increasing estrogens.

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therapeutic ketosis

Then if we’re looking for the most nutrient dense foods that will support therapeutic ketosis we get the following list:

  1. flax seeds,
  2. fish oils,
  3. wax gourd,
  4. avocado, and
  5. brazil nuts.

Good nutrition is about more than simply eating more fat.  When you look at the top foods using this ranking you’ll see that you will need to use a little more discretion (e.g. avoiding vegetable oils, margarine and fortified products) due to the fact that nutrients and fibre have such a low ranking.

ganze und halbe reife avocado isoliert auf weissem hintergrund

fatty acids

Omega-3 fats are important and most of us generally don’t get enough, but rather get too many omega-6 fats from grain based processed foods.

Along with high levels of processed carbohydrates, excess levels of processed omega-6 fats are now being blamed for the current obesity epidemic. [5]

The foods highlighted in the following section will help you get more omega-3 to correct the balance.

no insulin index contribution

If we’re looking for the foods that are the highest in omega 3 fatty acids without consideration of insulin load we get:

  1. salmon,
  2. whitefish,
  3. shad,
  4. fish oil, and
  5. herring

I like salmon, but it’s not cheap.  I find sardines are still pretty amazing but much more cost effective. [6]  If you’re going to pay for salmon to get omega 3 fatty acids then you should make sure it’s wild caught to avoid the omega 6 oils and antibiotics in the grain fed farmed salmon.

Sardines have a very high nutrient density but still not as much omega 3 fatty (i.e. 1480mg per 100g for sardines versus 2586mg per 100g for salmon).

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athlete and metabolically healthy

If we factor in some consideration of insulin load, fibre and calorie density we get:

  1. salmon,
  2. marjoram,
  3. chia seeds,
  4. shad, and
  5. white fish

It’s interesting to see that there are also  excellent vegetarian sources of omega-3 fatty acids such as marjoram (pictured below) and chia seeds (though some may argue that the bio-availability of the omega 3 in the salmon is better than the plant products).

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weight loss

Some of the top ranking foods with omega-3 fatty acids for weight loss are:

  1. brain,
  2. chia seeds,
  3. sablefish,
  4. mackerel, and
  5. herring

While seafood is expensive, brain is cheap, though a little higher on the gross factor.

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Cancer survivor Andrew Scarborough tries to maximise omega 3 fatty acids to keep his brain tumour and epilepsy at bay and makes sure he eats as much brain as he can.

diabetes, nutritional ketosis and therapeutic ketosis

And if you wanted to know the oils with the highest omega-3 content, here they are:

  1. Fish oil – menhaden,
  2. Fish oil – sardine,
  3. Fish oil – salmon,
  4. Fish oil – cod liver, and
  5. Oil – seal

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amino acids

This section will be of interest to people trying to build muscle by highlighting the foods highest in amino acids.

no insulin index contribution

So what are the best sources of protein, regardless of insulin load?

  1. cod,
  2. egg white,
  3. soy protein isolate,
  4. whitefish, and
  5. whole egg

Again, Dwayne Johnson’s cod does well, but so does the humble egg, either the whites or the whole thing.

We have been told to limit egg consumption over the last few decades, but now, in case you didn’t get the memo, saturated fat is no longer a nutrient of concern so they’re OK again.

And while egg whites do well if you’re only looking for amino acids, however if you are also chasing vitamins, minerals and good fats I’d prefer to eat the whole egg.

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athlete and metabolically healthy

If you have some regard for the insulin load of your diet you end up with this list of higher fat foods:

  1. parmesan cheese,
  2. beef,
  3. tofu,
  4. whole egg, and
  5. cod.

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weight loss

If we aim for lower calorie density foods for weight loss we get this list:

  1. bratwurst,
  2. basil,
  3. beef,
  4. chia seeds, and
  5. parmesan cheese

The bratwurst sausage does really well in the nutrition analysis because it is nutrient dense both in amino acids and high fat which keeps the insulin load down.

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diabetes and nutritional ketosis

If you’re concerned about your blood glucose levels then this list of foods may be useful:

  1. chia seeds,
  2. flax seed,
  3. pork sausage,
  4. bratwurst, and
  5. sesame seeds

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Therapeutic ketosis

And those who are aiming for therapeutic ketosis who want to keep their insulin load from low protein may find these foods useful:

  1. flax seed,
  2. pork sausage,
  3. sesame seeds,
  4. chia seeds, and
  5. pork

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vitamins

People focusing on reducing their carbohydrate load will sometimes neglect vitamins and minerals, especially if they are counting total carbs rather than net carbs which can lead to neglecting veggies.

I think most people should be trying to increase the levels of indigestible fibre as it decreases the insulin load of their diet, [7] feeds good gut bacteria, leaves you feeling fuller for longer and generally comes packaged with heaps of good vitamins and minerals.

At the same time it is true that some high fibre foods also come with digestible carbohydrates which may not be desirable for someone who is trying to manage the insulin load of their diet.

The foods listed in this section will enable you to increase your vitamins while managing the insulin load of your diet to suit your goals.

no insulin index contribution

These foods will give you the biggest bang for your buck in the vitamin and mineral department if insulin resistance is not an issue for you:

  1. red peppers,
  2. liver,
  3. chilli powder,
  4. coriander, and
  5. egg yolk

Peppers (or capsicums as they’re called in Australia) are great in omelettes. image031

Liver is also very high in vitamins if you just can’t tolerate veggies.

athlete and metabolically healthy

If we bring the insulin load of your diet into consideration then these foods come to the top of the list:

  1. paprika,
  2. chilli powder,
  3. liver,
  4. red peppers, and
  5. sage

It’s interesting to see so many spices ranking so highly in these lists.  Not only are they nutrient dense but they also make the foods taste better and are more satisfying.

image034

Good food doesn’t have to taste bland!

weight loss

If weight loss is of interest to you then this list of lower calorie density foods might be useful:

  1. chilli powder,
  2. chicory greens,
  3. paprika,
  4. liver, and
  5. spinach

It will be very challenging to eat too many calories with these foods.  We find spinach to be pretty versatile whether it is in a salad or an omelette.

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diabetes and nutritional ketosis

These foods will give you lots of vitamins if you are trying to manage your blood glucose levels:

  1. chilli powder,
  2. endive,
  3. paprika
  4. turnip greens, and
  5. liver

Most green leafy veggies will be great for people with diabetes as well as providing excellent nutrient density and heaps of fibre.

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therapeutic ketosis

If you really need to keep your blood sugars down then getting your vitamins from these foods may be helpful:

  1. chilli powder,
  2. liver,
  3. liver sausage,
  4. egg yolk, and
  5. avocado

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minerals

no insulin index contribution

Ever wondered which real whole foods would give you the most minerals per calorie without resorting to supplements?

Here’s your answer:

  1. coriander,
  2. celery seed,
  3. basil,
  4. parsley, and
  5. spearmint

Even if you found a vitamin and mineral supplement that ticked off on all the essential nutrients there’s no guarantee that they will be absorbed by your body, or that you’re not missing a nutrient that is not currently deemed ‘essential’.  Real foods will always trump supplements!

As you look down these lists you may notice that herbs and spices top the list of foods that have a lot of minerals.  Once you have eaten as much coriander, basil, parsley and spearmint as you can and still feel hungry keep doing down the list and you will find more calorie dense foods such as spinach, eggs, sunflower seeds, and sesame seeds etc which are more common and easier to fill up on.

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athlete and metabolically healthy

If we factor in some consideration of insulin load then we get this list:

  1. basil,
  2. spearmint,
  3. wheat bran (crude),
  4. parsley, and
  5. marjoram

Wheat bran (crude) features in this list but it’s very rarely eaten in this natural state.  Most of the value is lost when you remove the husk from the wheat.

As much as we’re told that we shouldn’t eliminate whole food groups, grain based products just don’t rate well when you prioritise foods in terms of nutrient density.

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weight loss

If you’re looking for some lower calorie density options the list changes slightly:

  1. basil,
  2. caraway seed,
  3. marjoram,
  4. wheat bran (crude), and
  5. chilli powder

image044

diabetes and nutritional ketosis

If you’re trying to manage your blood sugars then this is your list of foods that are packed with minerals:

  1. basil,
  2. caraway seed,
  3. flax seed,
  4. chilli powder, and
  5. rosemary.

image045

therapeutic ketosis

If you’re aiming for therapeutic ketosis then the higher fat nuts come into the picture to get your minerals:

  1. flaxseed,
  2. sesame seed,
  3. pine / pinon nuts,
  4. sunflower seeds, and
  5. hazel nuts.

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application

So what does all this mean and how can we apply it?

I don’t think it’s necessary or ideal to track your food all the time, however it’s well worth taking a typical day of food and entering it into the recipe builder at nutritiondata.self.com to see where you might be lacking.

Are your vitamins or minerals low?  Protein?  What about fibre.

If you find these are lacking you can use these food lists to fill nutritional gaps while keeping in mind your ability to process carbohydrates and attaining your personal goals.

references

[1] http://nutritiondata.self.com/help/analysis-help

[2] http://ketopia.com/nutrient-density-sticking-to-the-essentials-mathieu-lalonde-ahs12/

[3] The omega 6 fatty acids are also classed as essential however it is generally recognised that we have more omega omega 6 than omega 3.

[4] http://www.muscleandfitness.com/nutrition/meal-plans/smell-what-rock-cooking

[5] http://ebm.sagepub.com/content/233/6/674.short

[6] http://nutritiondata.self.com/facts/finfish-and-shellfish-products/4114/2

[7] https://optimisingnutrition.wordpress.com/2015/03/30/what-about-fibre-net-carbs-or-total-carbs/

fine tuning your diet to suit your goals – Chris Kelly

I’m a big fan of Chris Kelly’s Nourish Balance Thrive podcast[1]

It’s sort of like listening to Jimmy Moore, Dave Asprey and Ben Greenfield all rolled into one, but even nerdier and more intellectually challenging.

I first heard the term “glucogenic protein” on one of Chris’s podcasts [2] and went searching  to learn more and the epic Insulin Index V2 article was the result.

I also have really enjoyed Chris’ discussion about heart rate variability (HRV), gut health and a range of other intriguing subjects. [3]

Chris is a software engineer who used to work for a hedge fund and has now chosen to go into full time nutritional therapy counselling with a bit of pro-mountain biking on the side!  He’s also into kettlebells.

He has basically mastered all my passions and hobbies and taken them to the elite level!  I’m not that jealous, really.

Chris is another endurance athlete who found he had pre-diabetic blood sugars (like Tim Noakes, Ben Greenfield and Sami Inkenen), and has turned to the ketogenic diet to normalise his blood sugars.

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Chris’s diet

Chris posted his daily food dairy outputs from cron-o-metre [4] on Facebook recently and gave me permission to run the numbers on it to see what we could learn.

image003

Using cron-o-metre is superior to MyFitnessPal because it tracks your micronutrients in addition to calories and macronutrients.

As shown in nutritional analysis below, Chris’s nutrient dense diet has achieved the RDI for all of the key micronutrients.   His protein intake is solid but not high at about 1.5g/kg LBM.

Chris uses MCT oil to fuel his cycling with some slow release Superstarch to top off his glycogen stores for races without throwing him out of ketosis.

image005

The plot of Chris’s macronutrients from his daily food diary shows that his diet is certainly ketogenic.  When he occasionally measures his blood ketones they’re pretty high at around 2.1mmol/L. [5]

At the same time he gets a really solid 46g of fibre per day (compared to the RDI of 30g for men), with a low 5% net carbs and a very low 16% insulinogenic calories.  One of the issues I see for a lot of people trying to reduce their carbohydrates is that they struggle to get enough fibre for digestion and good gut health.

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nutritional analysis

But can a diet that is so highly ketogenic also provide adequate nutrition?   I ran his daily food diary though nutrientdata.self.com and the results are solid.

image009

The nutritional content would depend heavily on the source of his beef ground  beef  which makes up most of his protein on the day I have analysed.  I know Chris also goes out of his way to eat organ meats, and the locally sourced grain feed beef that he gets would likely have a higher protein quality score than the ground beef profile in the USDA database.

It should also be noted that the data from his daily food diary entered into nutritiondata.self.com hasn’t captured everything given, because it didn’t seem to have yerba mate tea, kim chi and bone broth which would have a bunch more nutrients.

increasing the protein score

The table below shows how Chris’s food diary stacks up against the 200 or so other meals and daily diaries that I have analysed.  I have used the diabetic / nutritional ketosis weighting in the ranking which prioritises a low insulin load with solid vitamins, minerals and protein.

image011

The only area where the “base” food diary is lacking compared to the other meals is the protein score.  The score of 0.01 for protein means that it is about average for the 200 meals analysed.

The calorie density score is low, however this is not a problem given that Chris is already quite lean (as you can see from the photo above).

Chris uses MCT oil to fuel his cycling, and weight loss is not a goal.  Trying to get him to reduce the calorie density of his diet with more broccoli and mushrooms would mean that he just couldn’t physically get in enough fuel!

You can see from the comparison of the nutrients and amino acids from various protein sources below that muscle meat is not necessarily the most nutrient dense source of protein.

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If we replace the ground beef with sardines which have a higher quality of amino acids we get the updated nutritional profile shown below.  Both the protein score and the vitamin score has increased with the sardines.

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So overall, Chris’s diet is currently well suited to his goals; however, refining the quality of the protein source could further improve the vitamin and mineral content of his diet.

Overall, I think Chris’s diet is a great example of how someone can get great nutrition and high amounts of fibre while still achieving ketosis.

references

[1] http://www.nourishbalancethrive.com/podcasts

[2] http://www.nourishbalancethrive.com/blog/2014/12/29/protein-transcription/

[3] http://www.nourishbalancethrive.com/blog/2014/12/16/how-track-hrv-measure-progress/

[4] https://cronometer.com/

[5] https://www.facebook.com/groups/optimisingnutrition/permalink/1462501844050859/

fine tuning your diet to suit your goals – Wendy

  • There is no single dietary template that works for everyone.
  • Different individuals have particular needs and goals, and nutrition should be adjusted accordingly.
  • It can be useful to compare how your diet stacks up against other dietary approaches to identify where you might further refine and improve your diet.
  • The insulin load of your diet should not exceed the capacity of your pancreas to keep up and achieve normal blood glucose levels.
  • Once excellent blood glucose levels are achieved, reviewing your nutrient density, calorie density and fibre intake can be a useful  refinement to optimise your diet to achieve your goals.

keeping it simple…

Eating should not be complex!

I could understand how some people might find all this discussion about nutrition a bit daunting and / or irrelevant.

If all this talk about food is confusing and leaves you a bit perplexed then I apologise.

The reality is that if most people ate a range of whole foods from natural sources they would be pretty much OK.   Most people will not turn into ripped physique competitors with bulging six packs without meticulously tracking food intake, however most would be able to achieve good health and vitality.

A good diet is something that people will stick to and enjoy without tracking and obsessing over too much.  At the point it becomes enjoyable, effortless and normal it stops being a diet and becomes just a way of eating!

To this end I’ve created a list of optimal foods and optimal meals to suit different goals that people can just run with without too much hassle or conscious thought.

finding your path in all the noise

Unfortunately many of us have spent too long either eating poorly and need some more intense intervention, or have more specific dietary needs (e.g. diabetes, cancer, epilepsy etc) that require more targeted approaches.

My key aim in all of this is to demonstrate how a nutrient dense diet with a managed glucose load can be optimal, and modified to suit a person’s goals.  Rather than giving general platitudes I hope I can add something to the discussion and help people tweak their diet to achieve specific goals.

There is a lot of sometimes-conflicting dietary guidance out there that makes it hard to synthesise it all into a coherent plan that’s right for you.  You may be ketogenic, vegetarian, LCHF, LCHP, Paleo, ‘peagan’, or zero carb, or just do ‘everything in moderation’ (whatever that means).

taking it to the next level

No one eats optimally all the time, however it’s useful to know what can be done to improve things if you want to move further in a particular direction.

If you’re not getting the results from your current approach, you might be motivated enough to refine your current regimen to move further forward in the desired direction.   Unfortunately a lot of people fall into this category and are left looking for a bit more specific guidance on what they can do to reach their goals.

Some people are already putting a lot of thought and effort into what they eat, but sometimes not getting everything they hoped for, whether it be athletic performance, blood sugar control or weight loss.

Quantification of insulin load, nutrient density and fibre are powerful tools to further manipulate your diet in the pursuit of specific goals.  In this article we look at how we can review and refine our current diet to suit specific goals.

I hope that reviewing the application of a number of tools to real life examples can demonstrate how we can manage the glucose load of our diet while at the same time optimising the vitamins, minerals and amino acids.

I think it’s useful to review, refine and tweak someone’s existing diet rather than trying to get them to adopt a whole new way of eating that might be hard to stick to in the long term.  So to this end I’ve reviewed a number of people’s actual food diaries to see what the system would tell us about how they can move forward in a particular direction.

The plan is to profile a dietary analysis every couple of weeks to see how we might apply the tools detailed throughout this blog to optimise their nutrition while keeping in mind their insulin load.

so let’s meet Wendy…

Wendy describes herself as being obese for her entire adult life, except for a few short-lived diet-induced periods (using “eat less, move more” diet templates).  Despite obesity, Wendy had good blood lipids and fasting glucose until early 2014, when fasting glucose crept into the pre-diabetic range.  She had been hypertensive since her mid-20’s, diagnosed as essential or idiopathic hypertension (i.e. no known cause), but was advised it was caused by her obesity.

In early 2014, at age 44, Wendy began exercising regularly and then changed her diet first to lower-carb (inspired by Robert Lustig) and then ultimately low-carb.  She lost over 70 pounds over eighteen months, going from a BMI of 39 to 27.  Wendy says she is comfortable with low-carb eating as a life-long proposition, along with regular exercise (mostly yoga and strength training, with some HIIT).

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Wendy had some insulin resistance before making these changes, but now has blood sugars that are “typically in the 70s, 80s or 90s” and a fasting insulin of 5.1mIU/ml (i.e. upper end of the excellent range).

Wendy’s most recent HbA1C was 5.2% which is pretty good (see Diabetes 102 for more details of target blood sugar and HbA1c levels), so it appears that her insulin resistance has improved with her recent weight loss or at least is in remission with her improved diet and exercise regimen.  Wendy has also been able to drop all hypertension medications and now regularly home-tests blood pressure at slightly-below-normal levels.

Wendy has been very active on the Optimising Nutrition, Managing Insulin blog with a heap of insightful questions and comments.  Lately she’s also been helping me with reviewing and editing of some of the posts on the blog.  She’s certainly an educated, motivated and seasoned nutrition nerd.  You can also read more about Wendy’s journey on her own blog https://fitteratfortyish.wordpress.com/.

If you look at her food diaries you’ll see that the reason she’s lost so much weight already is that she’s eating pretty darn well!  But let’s look at what she could do to further move towards her weight loss goals.

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review of glucose load

First up I’ve analysed Wendy’s macronutrients to determine the insulin load, percentage insulinogenic calories and macronutrient split as shown in the table below.

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With less than 20g net carbohydrates per day, an average of 5% calories from carbohydrates and 23% insulinogenic calories, Wendy’s diet definitely qualifies as low carb!

I’ve plotted the macronutrients from her daily diaries in the chart below (labelled 8, 9 and 10 June).  Two of the three days sit just outside the threshold of Steve Phinney’s well formulated ketogenic diet triangle (i.e. the orange line in the figure below).  This analysis would indicate that Wendy is eating a good diet that would be great for normalisation of blood glucose.

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If Wendy was still having blood sugar issues (say average of greater than 97mg/dL or 5.3mmol/L) she might benefit from reducing her protein to bring her macros back towards the bottom left corner of this chart in order to reduce the total glucose load of the diet and make it more ketogenic.

This is not the case for Wendy though as her blood sugars are now reasonably well controlled, with her insulin resistance improved after her already significant weight loss.  So reducing the insulin load of her diet is not the primary issue.

nutritional analysis – diabetes weighting

I’ve written before about the theory of balancing glucose load while maximising nutrition.  I thought it would be interesting to look at how we could apply this in practice with Wendy’s food diary data.

Using the nutritiondata.self.com recipe analyser I have compared a range of meals and daily food diaries as discussed in the article The Most Nutritious Diabetic Friendly Meals [1] and dietary approaches as discussed in the article Diet Wars…  Which One is Optimal? [2]  In line with this I’ve analysed Wendy’s food diary from 9 June 2015.  The results of the analysis are shown below.

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A score of 100 in either the “nutrient balance” or “protein quality” scores means that you’re covering the recommended daily intake of each of the nutrients with 1000 calories.   What this means in Wendy’s case is that she’s doing pretty well with her protein score at 140.  However there are some possible deficiencies with her vitamins and minerals which are only at 52.

The table below shows a comparison of scores for the 9 June 2015 food diary with the suggested refinements discussed below.  Based on the diabetes weighting (which prioritises low insulin load) Wendy’s diet from 9 June ranks at #77 of 175 which is fairly solid, however there is some room for improvement.

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A score of zero would mean that it is average in comparison to the other meals, greater than zero (blue) means that it is better, while less than zero (red) means that it is worse than average.

The areas that the food from the 9 June 2015 food diary doesn’t do so well is calorie density, vitamins and minerals, and fibre.

so why is fibre and calorie density important?

Every individual is different.  What will work for one person may not work so well for another.  For example, simply applying a body builder or a diabetes dietary approach to Wendy’s situation may not be appropriate given that she wants to continue on her weight loss journey.

The comparison of Wendly’s base diet to the other diets analysed indicates that she could benefit from adding fibre and reducing her calorie density. But why would increasing fibre and reducing calorie density be useful for someone trying to lose weight, particularly when the low carbohydrate approaches advocated by Westman and Eades may likely recommend continuing to focus on a low total carbohydrates (i.e. not net carbohydrates) until goal weight is achieved.

I think the “magic” of the low carbohydrate dietary approach is that it normalises blood glucose levels and reduces insulin so that you can release rather than store fat.  For more detail on the importance of insulin in fat loss check out the article why we get fat and what to do about it v2.

Without a reduction in insulin levels it is difficult to unlock the fat stores for energy. It get frustrated when I hear ‘experts’ in the body building scene just saying that fat people need to achieve a calorie deficit and they’ll be all good, apparently not understanding the effect that a highly insulinogenic diet can have on fat loss and appetite for people who are insulin resistant.

Chris Gardner’s A to Z trial [3] identified that people who are insulin resistant typically only lose weight on a low carbohydrate diet.[4]  The reduced insulin load allows energy to be released from fat stores which in turn leads to increased satiety and decreased calories.  However people who don’t have insulin resistance issues can lose weight with reduced calories regardless of the carbohydrate level as long as they create a calorie deficit.

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However, once you’ve normalised your blood glucose levels and insulin I think all bets are off.  There may be a limit to how far a diet with liberal quantities of added fat will take you when it comes to weight loss.  Somehow you do need to work out a sustainable way to burn more calories than you consume.  However I don’t think this is as simple as just counting calories and maintaining deficit.

While a low carbohydrate / ketogenic diet in maintenance mode involves high levels of dietary fat, you don’t necessarily need to be adding extra dietary fat while you’re trying to lose weight.  If you’re trying to lose weight ideally the energy from fat can come from your body fat stores as shown diagrammatically below in Steve Phinney’s four phases of a ketogenic diet diagram.

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I’ve got a lot of time for Jonathan Bailor who isn’t a big fan of calorie counting.  He prefers rather to manipulate diet so that you naturally feel satiated with fewer calories.  As noted in this video he advocates for nutrient dense foods that have plenty of water, fibre and protein to naturally feel full so you don’t need to manually track calories.  This video gives a good overview of Bailor’s philosophy which I think makes sense for most people.

In my food ranking system I have tried to codify Bailor’s approach using the USDA foods database, and have used a similar approach in the meal ranking system.  The highest ranking meal using the weight loss weighting is Terry Wahls’ lamb skillet meal which is shown below.

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While this meal might have 24g of total carbohydrate there is 16g of fibre, meaning that there is only 8g of net carbs.  So if we abandon the concept of total carbohydrate and focus on net carbohydrates when it comes to real unprocessed whole foods, we can keep our insulin load low and achieve satiety naturally by eating a larger volume of nutrient dense high fibre foods.  This will ideally allow us stop worrying about counting calories while still keeping our insulin load fairly low.

One of the criticisms of Terry Wahls’ diet approach is that there is just so much food and it’s hard to eat it all to get your calories.  If you do not want to lose weight Wahls recommends adding MCT or coconut oil to increase the calorie density.  However you can see how not being able to fit in enough calories (as opposed to just counting calories) would help you to sustain a lower calorie approach without as much conscious effort.

Similarly, Dave Asprey criticises Joel Fuhrman’s ANDI score as a recipe for starvation, which is sort of what we’re after if we are trying to lose weight. [5]  So sure, maybe you’re not going to feel full eating parsley and watercress, but that doesn’t mean you shouldn’t try to eat as many non-starchy veggies as you possibly can as your first priority, and then fill up on the other foods.

While counting calories can be useful and effective as an educational tool, I your appetite will probably win out in the long run unless you find a way of eating that will naturally keep you satiated.  I believe a high fibre, nutrient dense, lower calorie density approach can be helpful to achieve this goal.

See the optimal foods for weight loss article for more details on this topic or this list of foods that are ranked based on these criteria.

improved calorie density and nutrient density

So in Wendy’s case, in order to improve the vitamin and mineral score I’ve reduced the chicken from lunch and added in some spinach and mushroom.  This has raised the “Nutrient Balance” score from 52 to 75.  The chicken is quite calorie dense in comparison to the spinach and mushroom, and you can eat a lot of these veggies without increasing calories very much.

This updated food diary then ranks at #50 of 175 meals analysed (previously #77) based on the diabetes weighting as shown above.  The overall fibre increases from a fairly low 13g to a more reasonable 21g.  This is closer to the recommended daily minimum fibre intake of 25g for women and 30g for men [6]).

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This change does increase the net carbohydrates from 11g to 32g and the insulin load from 60g to 77g, so someone who did have serious insulin resistance or diabetes should monitor their blood sugars to make sure they were not adversely affected by shifting to this approach.

For most people this increase in net carbohydrates would not be a major concern, particularly as the increase in carbohydrates is from low glycemic whole foods which tend to raise blood sugars much less than manufactured products.   You might also find that you end up naturally eating fewer calories because of the high volume of food and the high nutrient density which might leave you satisfied with fewer calories.

reducing calorie density for weight loss

For Wendy, though, blood glucose / insulin resistance is not the primary issue.  Her current priority is to move forward with her weight loss which has now stalled, more than a year into continuous weight loss.

Eliminating processed carbohydrates is critical to the success of the low carbohydrate approach but what do you replace them with?  As per Terry Wahls’ approach I would recommend trying to maximise nutrient dense non-starchy veggies in the first instance and then supplementing with added fats (if required) to make sure you’re satiated.  If we focus on eating as much high fibre, nutrient dense, low calorie density foods as we can we no longer have to worry about limiting how much we eat!

So if we want to tweak Wendy’s meal plan more towards the weight loss goal by decreasing calorie density we can:

  • use a whole avocado rather than half an avocado to increase the fibre,
  • drop the added olive oil (to the extent that is practical for cooking),
  • drop the “half and half” cream to one tablespoon rather than four in the coffee, and
  • drop the calorie dense macadamias.

If we sort the meal revisions based on the weight loss weighting (which emphasises high fibre and low calorie density) we can see that the revised diabetes diet has a ranking of 43.

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With these changes we’ve nearly doubled the weight of the food for the day while keeping the total calories the same.  Fibre has gone up from 13 to 26g which meets the minimum recommended minimum fibre intake.  This approach will be a lot more filling, which is useful if weight loss is the goal.

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Net carbs have gone from 10g in the original scenario to 50g per day.  This is still considered low carbohydrate; however Wendy should keep an eye on her blood sugars as her HbA1c is good but not yet in the excellent range.  If they go outside the normal range (see criteria here), she should revert to the nutrient dense diabetes approach (see criteria and foods here).

Different people will have different carbohydrate tolerances, and these can change as your body heals and releases fat from your belly, liver and pancreas.  Most reasonably healthy people would be able to deal with this level of carbohydrate, particularly given that it is from low calorie density, low GI carbohydrates from vegetables.

As shown in the updated nutritional analysis below, the protein quality score is still pretty high at 135 (down from 140) and the quantity of protein is still quite high at 26% of calories (down from 27%).  The only way to increase the protein quality score without increasing calories further would be to incorporate organ meats, which is not everyone’s cup of tea.   The nutritional completeness score has increased to 88 which is a significant change from the base diet that had 52!

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Reducing excess insulin (as indicated by poor blood sugar control and high body fat levels) is the first priority, however once blood glucose and insulin are stabilised, targeting high fibre nutrient dense foods (while still keeping the insulin load as low as possible) is likely to be the next step when it comes to weight loss.

If there were any nutritional issues that were causing the body to hold onto weight, these may be improved with the highly nutrient dense diet and possibly help to break through the weight stall.

references

[1] https://optimisingnutrition.wordpress.com/2015/03/22/the-most-nutritious-diabetic-friendly-meals/

[2] https://optimisingnutrition.wordpress.com/2015/03/22/best_diet/

[3] http://jama.jamanetwork.com/article.aspx?articleid=205916

[4] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3504183/

[5] https://www.bulletproofexec.com/cdc-superfoods-andi-score-debunked/

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