Category Archives: diabetes

vegan vs keto for diabetes… which is one optimal?

I recently watched the Mastering Diabetes teleseminar on ketogenic diets with high hopes of picking up some gems of wisdom from the rising stars of the plant-based diabetes community.

Unfortunately, I was underwhelmed with what I heard.

I shared my frustration on Facebook.

Robb Wolf suggested I put together a response to some of the misinformation in the teleseminar.  Hence this post.  [Robb did an excellent breakdown on the claims in the What the Health Netflix doco, What the Health: A Wolf’s Eye View, which I highly recommend checking out if you haven’t already.]

What’s actually wrong with the keto diet for diabetes?

Cyrus Khambatta (aka Mangoman) and Robby Barbaro (The Mindful Diabetic) should be uniquely qualified, both academically and experientially having themselves lived with type 1 diabetes for decades.

If I were was going to attack keto for diabetes management, then there would have been a couple of ‘free kicks’ I think they could have taken.  So, in fairness to both sides, I’ll touch on a few of what I see as legitimate issues with ‘popular keto’ before I dissect the Mastering Diabetes presentation.

Giving fat a free pass

Humans like things to be straightforward and binary.

Yes or No.

Black or white.

High fat or low fat.

Low carb or high fat.

High protein or low protein.

Plants only or animals only.

For the last four decades, we have been told that fat, particularly saturated fat, is bad because it causes heart diseases and should be avoided.

The tide is now turning.  However, there will always be people who take things to the extreme.

Now fat is healthy.  But is more is better?

Ketones are good.  So more is better?

For many people, a higher fat diet will be more satiating, particularly compared to processed grains and sugars.  However, not everyone can ‘eat fat to satiety’ without some level of restraint and self-discipline.  We can’t all trust our appetite to kick in to effortlessly provide the lean and chiselled body that they dream of.

null

My personal experience is that you can overdo the fat and drive insulin resistance by pushing fat too hard.  If you exceed your ‘personal fat threshold’[1], your adipose tissues will become insulin resistant, and the body will start pushing excess energy to the vital organs.

While there is no need to fear fat, there is no reason to go hog wild to compensate for the butter and bacon deficiencies that we all developed over the past four decades.

When it comes to nutrition, you need to get your big rocks in place first (i.e. the nutrient dense foods).  You can then fill up with fuel such as fattier foods if you do not want to burn any body fat.  You could even add some starchy carbs if your blood sugars all.

Having some level ketones is an indication that your insulin levels aren’t too high and your metabolism is working.  However, if you are not yet metabolically healthy, chasing ‘fauxtosis’ by loading up on butter, coconut oil, cream and exogenous ketones to achieve high blood ketone levels can be a recipe for hypercaloric metabolic disaster that will drive insulin resistance.

People with type 1 diabetes (such as the Mastering Diabetes guys and my wife Monica) have a unique insight into the various factors that affect their insulin sensitivity.  They can monitor their daily insulin dose.

I know some people with type 1 diabetes who have made an effort to chase higher ketones with more refined fat and less protein but found that they ended up needing more insulin.  Retreating to a moderate to high protein approach with less added fat (as per Dr Bernstein’s recommended approach for Type 1 diabetes) enabled them to improve their insulin sensitivity (e.g. check out Allison’s Nutrient Optimiser analysis here).

This phenomenon is not unique to people with type 1 diabetes.  There seem to be more and more people start out believing calories don’t count, only hormones.  They then put their faith in the ‘magic ketone fairy’ and end up driving insulin resistance and obesity chasing ‘optimal ketone levels’ with more and more added fat.[2]

I have a dream

Before we get into the nutritional analysis, permit me this indulgence to share my vision (with a hat tip to Martin Luther King) from Martin Laurence Kendall.

I have a dream that one-day nutrition will be defined by the nutrients that a food contains and the health benefits that it confers rather than religious and ethical beliefs or commercial interests.

I have a dream that all people, mothers and children, fathers and brothers, would be able to clearly understand the foods that are truly optimal for them.

I have a dream that one day all people afflicted with diabetes will be able to choose foods that will enable them to achieve normal blood sugars and restore the health and vitality that they deserve. 

Further, that they will be able to choose optimal foods, with engineering precision, without being affiliated with the needless ridicule that they will needlessly die of a heart attack due to unnecessary fears about ‘artery clogging saturated fat’ or ‘harmful animal proteins’. 

I have a dream that one day people will have, freely in their grasp, quality nutritional information that enables them to make informed choices that will, in turn, bring about a new day in the commercial food environment. 

I dream that one day all people, obese, diabetic, children and athletes alike,  will be free from the corruption of Big Food and Big Pharma working through diabetes educators, diabetes associations, heart associations, medical institutions and animal welfare advocates.   

Free at least.  Free at last. 

I hope that one day we will be free at last. 

Indulgence over.  On with the data.

On with the data.

Nutrient deficiencies in a high-fat diet

Another fact that I thought Cyrus and Robby would mention was that very high-fat foods tend to have a weak nutrient profile, especially compared to non-starchy vegetables.

The chart below shows the nutrients provided by the 800 highest fat foods out of the 8000 foods in the USDA database.   If we prioritise fat, we will likely be lacking in around half of the essential nutrients.

A summary of some of the highest fat foods is shown below.

[For some real life examples of the poor nutrient profiles achieved by people chasing high ketone levels in the misguided pursuit of weight loss check out the Nutrient Optimiser reports here, here, here here and here.]

Vitamins and minerals,  in particularly electrolytes such as potassium, magnesium and calcium are critical to support our mitochondria, enabling them to produce energy and maximise insulin sensitivity.

People in the keto community are conscious that electrolytes are essential and go out of their way to supplement with magnesium, calcium, sodium and potassium as well as taking bone broth.

The kidneys let go of water and electrolytes when insulin levels drop.  A ketogenic diet without attention to green leafy veggies is at risk of being very low in electrolytes.  This will cause the pancreas to secrete more insulin to hold onto the scarce electrolytes.  This increase in insulin levels may[3] ironically drive insulin resistance.

Whether you call them electrolytes or alkaline foods[5], our bodies need enough substrate to allow our kidneys to maintain a good acid/base balance without having to work too hard.  Focussing on minerals can helps us maximise insulin sensitivity and ensure oxygen is efficiently be carried around our bloodstream.

There are plenty of foods available to provide the micronutrients that you need if you actually require therapeutic ketosis as an adjunct to cancer, epilepsy or dementia.  We can achieve the Daily Recommended Intake (DRI) for most of the nutrients while still maintaining a low dietary insulin load.

The short list of foods that comprise a ‘well formulated ketogenic diet’ are shown below.

However, if you just need to manage diabetes with a low carb diet (rather than therapeutic ketosis), you can achieve even higher levels of nutrition while maintaining stable blood sugars.

Given my family history of Type 2 and my wife Monica’s Type 1 diabetes, we generally focus on the foods listed below.  Lots of people have found these lists useful.  You can pin them to the fridge as a reminder of what you should focus on or print it out to take shopping next time when you need some inspiration.   (There is a complete list of nutrient dense foods to suit different goals at the end of this article.)

Now my blood glucose levels are more stable, I’ve been trying to back off on the higher fat foods and focus on more nutrient dense foods to build muscle and lose fat.

The ‘problem’ with the most nutrient dense foods (as shown below) is that they typically have a very low energy density, so it will be nearly impossible to get enough energy to prevent rapid weight loss.

Prioritising nutrient dense foods is the secret to obtaining the nutrients you need with the lowest energy intake.  If you don’t want to keep losing weight or want to run a marathon then adding some higher energy density foods will be useful.

High carbohydrate foods are not  nutritious

After watching the Mastering Diabetes teleseminar, you will get the feeling that the Mastering Diabetes guys believe carbohydrate can do no wrong and we should only fear fat.

The reality, however, is that the foods with the least fat are generally even more nutritionally corrupt than the highest fat foods.

Not all of the low-fat foods are going to be beneficial.

Defining your nutritional approach as ‘high carbohydrate’ is not wise, especially if you are trying to manage diabetes.  The foods with the most carbohydrates in our food system are typically very nutritionally deficient as well as highly insulinogenic.

If a ‘low carb diet’ leads you to avoid processed foods you may be better off.  However, I don’t think defining nutrition in terms of macronutrient extremes is particularly useful. [6]

Plant based versus animal based

One area where vegans potentially have it over carnivores is vitamins and minerals.  As shown in the chart below, a zero carb diet does not provide really high levels of many nutrients.

2017-06-26-5[1]

At the same time, there are plenty of people who appear to be thriving on a zero carb dietary approach.  Many people with severe autoimmune related digestive issues succeed when they switch to a zero carb approach.   Zero carb advocates will also tell you that they don’t need the recommended daily intake levels of the various micro nutrients that are based on limited data or deficiency studies in people eating a standard high carb western diet.

2017-06-26-4[1]

A plant based diet can provide a reasonably nutrient dense outcome.  However, it will be hard to get adequate levels of omega 3, vitamin D and vitamin B-12.  People following a strictly plant based approach may need to supplement with these nutrients.

Achieving the minimum protein intake levels is possible.  However, many people have concerns about reduced bioavailability of plant based proteins and whether or not the minimum protein intake levels are actually optimal, particularly if you are active or older.

It’s also worth noting that other nutrients such as iron, vitamin A and omega 3 will be more bioavailable from animal based sources.  So it’s not as simple as comparing the nutrients in the food, what gets into your body is what really matters.

If you are going to follow a plant based diet then prioritising the food listed below will give you the best chance of success.  Most people are going to do best somewhere on the spectrum between exclusively plant based and solely animal based foods.

The real problem comes when we start to heavily process our food.  Rather than prioritising the most nutrient dense and minimally processed vegetables, fruits and legumes, many vegans end up living on processed grains, cereal, sugar and soy products that have been treated with a host of fertilisers and pesticides.  Meanwhile, many zero carbers or keto peeps end up living on nothing but bacon or processed meats from animals that were fed nutrient poor corn and grains with added antibiotics to make them grow quicker.

The vegan echo chamber

I have spent a good chunk of time hanging out in many vegan or plant based groups trying to understand their position and gain insights about nutrient density.  I have learned a lot from people like Professor Christopher Gardner, Ray Cronise and Dr Joel Fuhrman.  Much of the analysis in this is based on the integration of my learnings their work with Dr Richard Bernstein and Dr Matt Lalonde.

Unfortunately, it seems that the vast majority of vegan/plant based education comes from Dr Michael Greger through his sanitised, highly processed and hyper palatable “Nutrition Facts” videos.

While Greger covers a lot of relevant research and raises some valid points, a lot of the time he seems to twist the science to ensure that the moral of the story is always ‘eat plants, not animals’.  Plant based is better.  Eating animals will be bad for your health.

Without evolutionary context, we are asked again and again to believe that fat (particularly saturated fat) and ‘animal protein’ (whatever the hell that is!) is the primary cause of heart disease, the complications of diabetes and practically every other modern health ill.

There is no demonstrated biochemical mechanism provided as to how we suddenly became allergic to animal products.  Meanwhile, vegans advocates generally give a free pass to sugar and processed grains.

With more than six million views and an estimated earnings of more than $100k per year from YouTube[7] (not to mention donations[8]), there appear to be a LOT of people eager to lap up the nutritional and medical justification of their ethical position.

Greger’s unique ‘interpretation’ of the scientific data all starts to make sense once you understand that he is the Director for Public Health and Human Agriculture for the Humane Society International.[9]

The mission of the Humane Society is to celebrate animals, confront cruelty and shape public opinion.

I wonder if Greger does his researching, writing, filming and editing the Nutrition Facts videos as a hobby after he gets home after working 50 hours a week and commuting?   Or perhaps he creates these videos as an employee of the Humane Society as part of their stated goal to shape public opinion on animal cruelty?

It seems Mangoman and Robby are pretty tight with Greger.[10]  Makes me wonder if Mastering Diabetes is a coordinated and strategic assault by the Humane Society on the low carb/keto/diabetes community who have become immune to Dr Greger.

I am by no means advocating animal cruelty.  However, as a human,  if you are looking for the best advice on human nutrition, is it wise to put your blind faith and unswerving trust in someone whose explicitly stated primary goal is animal welfare?

Do you really want to save the planet?

Worrying about whether we eat plants or animals exclusively is a modern luxury, an intellectual indulgence of sorts.

For the majority of human history, we have been opportunistic omnivores.  When plants were the only thing that was available, we would eat them.  When we could, we would chase down an animal to get the protein we need to thrive.  We never had to worry about nutrient density because the foods we ate grew in fertile soil without pesticides.  The animals we ate were eating their natural foods which were also nutritious for them.

Humans thrived and were able to populate the world because we learned to hunt, store, cook and process food.  We became very good at getting the nutrients we needed with the minimum amount of effort.[11][12] [13]

Unfortunately, we have now become too good at processing food.

Many of us are now fantasising nostalgically about Paleo times.

Related image

It’s one thing to worry about saving animals, but ultimately we need to save the planet and our human race from accelerated extinction.

Our newfound ability to harvest fossil fuels enables us to move around in cars and grow a massive amount of food with chemical fertilisers.  These foods grow quickly and give us plenty of energy, but few nutrients that we then process and feed to animals or humans.[14]

Take a moment to think about how your life would be different if we had never discovered fossil fuels (e.g. coal or oil).  For as long as it lasts we are gorging ourselves on stored energy that is making us lazy and obese and driving not just us, but life as we know it to an early grave. If you want to care about something it should be the sustainability of the global environment (including animals and humans).

If you want to care about something it should be the sustainability of the global environment (including animals and humans).

While humans are probably the biggest threat to the long term sustainability of earth as we know it, most of us aren’t willing to volunteer ourselves or our family as the first ones to check out to save the planet.

[If you want some challenging thoughts on this topic you should check out Daniel Vitalis’ Why I Hunt podcast.]

The plural of anecdote is not data

So, finally, onto the Mastering Diabetes video.

Cyrus and Robbie look like genuinely nice guys.

They are both living with type 1 diabetes.

They look like they’re happy and thriving on a plant based diet full of fruits and vegetables.

To be honest, they look a lot healthier than many recovering diabetics in the low carb scene.

But at the same time, the zero carbers will hold up anecdotes of people who have not eaten a plant for decades and look as great as the Johnson Family.

Or Dr Shawn Baker who is setting world records as a masters athlete since cutting plants out of his diet.

Then the keto folks will point to Dr Dominic D’Agostino who thrives on high fat and exogenous ketones and is exceptionally smart and can lift very heavy stuff at the same time.

 [15]

While it’s useful to look at populations of people following a particular diet to look for trends, anecdote does not equal data.

It is more useful to look at underlying metrics (such as nutrient density and insulin load) that we can use to identify the optimal diet for humans.

I thought they would know better

Cyrus Khambatta is a smart guy.  He was studying mechanical engineering at Stanford before he got type 1 and changed course to study nutritional biochemistry.

However, for all his ability in nutrition, engineering and mathematics (I took those classes, and I know how hard they are!), I thought he would have more to offer than what was presented!

People with diabetes get screwed around by the mainstream medical system and ‘diabetes education’ system.  The system doesn’t really understand how it works, so they give them bad advice (e.g. “just eat like we tell everyone else to and cover it with insulin”)!

I remember clearly the anxiety and confusion we experienced after going to an appointment with the hospital endocrinologist when my wife Monica was pregnant with our daughter.

At her visits, she would routinely be told that she needed to reduce her blood sugars to avoid the many serious risks and complications and risks for her and the baby.  Monica asked what else she could do to get the blood sugars down, but they had no advice.  They just wanted to see them lower.

We now have two healthy and wonderful kids, but I if I can I would love to see other people spared the anxiety as well as minimise the genuine health risks related to diabetes.  Hence my quest to understand how we can make intelligent food choices to optimise blood sugar and insulin levels.

What is the actual relationship between insulin and the food we eat?

The food insulin index data is a highly valuable resource that helps us to understand what causes us to secrete insulin and our blood sugars to rise.   The chart below shows the results of the food insulin index testing on more than 100 different foods (click to enlarge).

The food insulin index testing demonstrates clearly that we have the lowest insulin response to fats and oils while we have the highest insulin response to high carbohydrate foods like jelly beans and rice bubbles.   However, when we plot this data, we see that carbohydrate does not fully explain our insulin response.

We get a much better prediction of our insulin response when we account for protein (which requires insulin to metabolise) and non-digestible fibre.

Eating more fat will decrease the amount of insulin required to keep our blood sugars stable.

Eating more protein will reduce the amount of insulin your pancreas has to produce because it will push the more insulinogenic processed carbohydrates and sugar out of your diet.

How to improve your insulin sensitivity

If you reduce your intake of processed carbs and sugars, your insulin requirements will come down.  Once your organs and muscles are no longer swimming in insulin, you will become more insulin sensitive (just like you become more sensitive to coffee or alcohol if you cut back your intake).

If you are injecting insulin, reducing the insulin load of your diet will enable you to significantly reduce your insulin dosage which will, in turn, allow you to more easily access your own body fat stores for fuel.[16]

This data is an inconvenient truth for both high carb vegans or the nutritional recommendations such Food Pyramid / My Plate generated by the US Dept of Agriculture.  But I think it could be beneficial for people who want to effectively manage their diabetes.

Granted, if you switch your processed grains and sugar for fruits and vegetables, you will do better.  But is it really optimal?

If you can’t win, move the goalposts!!!!

So what do you do if you can’t win with science?

You change the rules!  You move the goalposts.

It was Cyrus and Robby’s unique definition of insulin resistance that really frustrated me.

So you can understand my frustration, I need to explain the difference between basal and bolus insulin which is a daily reality for someone with type 1 diabetes.

  • Bolus insulin is taken with food and is proportional to the insulin load of the food they eat (i.e. carbs – fibre + half protein)[17].
  • Basal insulin is the insulin that your pancreas would produce through the day and night whether or not you eat anything.  It’s the basal insulin that keeps your fat in storage and your muscles from being used for fuel.

You need both, but their function is different.

For someone eating a standard western diet about one-third to a half of their insulin will be basal insulin with the majority being bolus insulin for the food you eat.

When you switch to a low carb or keto diet this ratio flips and the majority of your insulin is basal insulin.  You only need a little bit of bolus insulin to cover the small amount of carbohydrates and protein that you eat.   With less glucose to deal with, you don’t need as much insulin, and your blood sugars stabilise.[18]

A significant portion of the Mastering Diabetes video was devoted to explaining their new creative definition of insulin sensitivity.  The fundamental problem with this central piece of the Mastering Diabetes argument is that it conflates basal and bolus insulin.  Your basal insulin is irrelevant if you are trying to do this sort of insulin sensitivity calculation!

It’s just the bolus insulin (i.e. for food) that matters when it comes to insulin sensitivity.  The calculations in the table below demonstrate my point.   If you take the denominator to your insulin sensitivity calculations to be the basal + bolus insulin then the high carb approach has a better insulin sensitivity.  If you only consider the bolus insulin (the only sensible approach in my view), then you declare the low carb approach to be the winner.

  low carb high carb conclusion
ISF (g carb/unit insulin) 6 5
carbs (g) 50 500
bolus insulin (units) 8.3 100
basal insulin (units) 20 20
total daily insulin (per day) 28 120
24 carb / 24-hour insulin (basal + bolus) 1.8 4.2 High carb is better
24 carb / 24-hour insulin (bolus only) 6.0 5.0 Low carb is better

The chart below shows the difference in the daily blood sugar fluctuations of someone on a standard western diet and then after switching to a lower carb diet.  The difference in the blood sugar levels is night and day!  The difference in the quality of life between these two situations when it comes to energy levels, anxiety, depression, mood etc is also immensely different.

I pinged Mastering Diabetes on their Facebook page to clarify if the cornerstone of their whole argument includes basal and bolus insulin.  Unfortunately, my fears were confirmed (though they have since deleted their response and kicked me out of their Facebook Group).

Tight blood sugar control isn’t that important after all?

The next argument they try to run is that tight blood sugars really aren’t that necessary.

Cyrus (who is very active and practices intermittent fasting) has a Hba1c in the high 5s.

Robbie has a Hb1c in the low 6s.

Granted, this is good compared to the majority of the Type 1 population. They’ll have a better chance of thriving with good blood sugars if they are eating lots of vegetables and fruit compared to more processed grains and sugars that make up the typical diet.  But it’s still a far cry from the blood sugar control of people following the type of low carb approach advocated by Dr Richard Bernstein.

The problem I see with defining your diet as vegan or plant based is that most people don’t have the self-discipline to stick with eating only vegetables and fruit and end up filling up on more processed (but still technically vegan) processed junk food.

Cyrus and Robbie argue that normal blood glucose fluctuations are between 70mg/dL to 145 mg/dL or 3.8 to 8.0mmol/L.

The problem with this argument is that what currently passes for ‘normal’ is far from optimal.[19]  Complications from diabetes start to kick in well below what is widely considered “normal”.


Just because it’s normal for most people to do Facebook on their phone while they drive doesn’t mean it’s ideal or optimal.  Just because it’s normal to have poor blood sugar and most people are dying of metabolic diseases doesn’t sound like a persuasive argument for plant based diet being optimal to me!

If you’re happy to settle for less than optimal blood sugar control because you have a strong ethical position, then that’s fine, but don’t construe it as optimal for everyone when it’s not.

The reality is that many people over at Type 1 Grit following Dr Bernstein’s approach are doing fabulously!  Not everyone will achieve optimal, but it’s useful to know what to aim for and how to get there.

If you had a child or loved one with Type 1 diabetes would you want the opportunity to choose the approach that would yield the best results or would you prefer your advice to be tainted with ethical or commercial bias?

Check out the video the Type 1 Grit group put together for Dr B’s 83rd birthday to thank him for changing their lives.

Insulin resistance and metabolic syndrome are a big deal, so let’s not ruin more lives than we need to with bad advice that is based on bad math or putting ethical convictions or religious beliefs ahead of human health.

Understanding physiological insulin resistance

Cyrus and Robbie argue that someone on a low carb diet won’t deal with carbohydrate well when they are exposed to them.  This phenomenon is real, but is typically due to what is termed ‘physiological insulin resistance’.

Someone who eats a lot of carbohydrates will have high levels of insulin floating around in their bloodstream.  Then when they eat a carb bolus, their pancreas is primed to shoot out some more insulin to mop up the glucose and stop more glucose being released into the bloodstream via the liver.  By contrast, someone who doesn’t eat a lot of carbohydrates will have low levels of insulin in their bloodstream and need to wind up their pancreas to produce insulin to bring down the glucose.

This phenomenon is also referred to the first phase versus second insulin response.  Someone who is not eating a lot of carbs will have a slower first phase insulin response.

It’s like comparing someone’s time over 100m when they are starting from a standstill versus someone using a rolling start.  It’s not a relevant comparison.  This phenomenon will go away after a few days on a high carb diet.

At the same time though, micronutrients such as potassium, magnesium and calcium are critical to maintaining healthy insulin sensitivity and glucose uptake.   Metabolic acidosis (caused by a lack of dietary electrolytes) appears to cause an upregulation in insulin by the pancreas to hold onto precious electrolytes.  Over the long term, this could be another driver of insulin resistance, metabolic syndrome and diabetes. [20]

Getting adequate dietary electrolytes from green leafy vegetables will make it easier for our body to maintain acid/base balance.  However, I don’t think we need to feed all diabetics a high carbohydrate exclusively plant based diet to achieve this.

Eating fat makes you fat?

The vegan community seems to confuse eating fat and storing fat.  The Ancel Keys / vegan story is that we store fat in our body because we overeat dietary fat.  However, the reality is that we get fat because we eat more than we burn.

As shown in the graphic from Ray Cronise’s Oxidative Priority paper, we will only burn fat (from our body or diet) once we’ve burned through the alcohol, ketones, protein and carbohydrate and fat that we eat (in that order).[21]

When we eat our body prioritises the refilling of our glucose and glycogen stores in our blood stream and liver (which can hold about 1200 to 2000 calories) before we start to store the excess energy in our adipose tissue.  Our body fat stores can hold a lot more energy, but not an unlimited amount.  Once our fat stores are full and can hold no more, they become insulin resistant.  We then start to store the excess energy in our vital organs such as our liver, kidney, brain, eyes, heart, etc.

The trick to weight loss is to keep your blood sugar levels low enough so that your liver glycogen is being replenished from your body fat rather than always having overfull glycogen stores, so we need to offload excess energy to our fat stores.[22]

One of the many roles of insulin is to shut off the flow of stored energy from the liver into the blood stream.  If energy is coming in the pancreas will upregulate insulin to stop the flow of glucose from the liver back into the blood stream (regardless of whether you’re eating carbs, fat or protein from animal or plant based sources).  The best way to reduce insulin is to stop eating and let your stored energy flow back into your blood stream.

In a way, you can think of your liver as your fuel tank and you your blood glucose meter as the fuel gauge.  If your blood sugars are high, you should think twice about whether you really need more fuel now.

If you are insulin sensitive, the bad news is that you can easily store excess energy as body fat very effectively.  Insulin is an anabolic hormone that will help you to grow.  However, when you are insulin sensitive, you can lose fat relatively easily when you reduce energy intake.  If you are insulin sensitive your circulating insulin levels will be low, and fuel will more easily flow from storage.  Hence you won’t be such a mindless slave to your uncontrollable appetite.

If you are insulin resistant and have high levels of circulating insulin, you may struggle to release your stored body fat.  Your appetite will drive you to seek out food because you can’t efficiently access it from your body stores.   You won’t be able to go very long between meals.

A low carb diet can be helpful for someone who is insulin resistant because it can help lower insulin which in turn help them to normalise their appetite.  Teaching that we get fat because we eat fat is just outdated science.

Even Dr Joel Fuhman will tell you that actively avoiding fat is stupid.  He will also tell you that there is some value in eating fish on a regular basis to ensure you get adequate amounts of omega 3s and vitamin B-12.

Complications on a ketogenic diet

There are plenty of studies that show the shortcomings of a ketogenic diet.  Sarah Ballantyne did a great job of summarising these on her Paleo Mom Blog here.

When you look in detail however you find that the adverse reactions the ketogenic diet are typically due to ‘keto in a can’ formula products.

While these food substitutes will help achieve therapeutic ketosis to help manage epilepsy or other chronic conditions, many of these keto formula products end up being very low in micronutrients.[23]

Obtaining a significant amount of your energy intake from processed food-like products that have been separated from nutrients is not a good idea (e.g. whether it be sugar, processed grains, refined oils or exogenous ketones).

Is a low carb diet actually good for diabetes?

Unfortunately, Cyrus and Robby didn’t mention the benefits of a low carb diet for people with diabetes which are fairly well documented.  The seminal paper that summarises much of the latest work in this area is documented in Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base.

Anyone who is on the fence about using a low carb diet to manage diabetes should check out this paper which shows that a low carb diet is better for weight, HbA1c, glucose, HDL and triglycerides compared to low GI or a grain based diet.

Another well-known study is Christopher Gardener’s A to Z trial[24]  where they found that the Atkins diet did much better than the low fat, particularly if you were already insulin resistant.[25]

Image result for atkins at to z

What should you eat if you are a vegan with diabetes?

So, after all this, what should we eat to maintain optimal blood sugar levels?  Cyrus and Robby’s view is shown below.    Unfortunately, it appears that their recommendations are driven more by their philosophical and ethical views rather than the nutrient content of the food or their ability to stabilise blood sugars.

  • In the green column, most people with diabetes aren’t going to do too well with a lot of fruits, starchy veggies, and beans. Intact whole grains do contain substantial nutrients but are very hard to find in our modern food system.  Who actually eats wheat bran as a substantial part of their diet?  The vast majority of grains are processed with the nutrients discarded so they are tasty and shelf stable.
  • In the red column, dairy eggs, meat, fish and poultry can be nutrient dense and keep your blood sugars stable (as long as you’re not afraid of fat in whole foods or ‘animal protein’).
  • In the orange column, higher fat foods like nuts, seeds, avocados, coconut and olives can be useful to help stabilise your blood sugars, but it is possible to overconsume them if your goal is to lose weight.

We want to maximise nutrient density as much as possible while keeping the insulin load of our diet down to the point that we keep blood sugars stable.

This does not end up being super high fat or super low fat.  Fat just comes along with nutritious whole foods.

If you have diabetes, then a little more dietary fat initially may help to stabilise blood sugars.  Once your blood glucose levels have stabilised, you can start to decrease the dietary fat and increase nutrient density as much as you can while still maintaining excellent blood sugar levels.

A low insulin load diabetes-friendly plant based nutritional approach will be lacking omega 3 and vitamin B-12.

The shortlist of nutrient dense low insulin load plant based foods is shown below.  The foods at the top of each section should be reasonably safe for most people with diabetes.  You should test your blood sugars to see how you respond to some of the foods further down the list.

Many people who are conscious of animal welfare will eat fish (i.e. pescetarian).  Adding some fish will provide a much better nutritional profile than eating plants alone, with plenty of vitamin B12 and omega 3 available from the seafood.

I hope this is helpful for people who want to choose a plant based approach to maximise nutrient density and maintain excellent blood sugar control.

If you’re still confused, I have designed the Nutrient Optimiser to identify what foods you should add or remove from your diet to ensure you are getting the nutrients you need while maintaining excellent blood sugar levels.

So which approach is optimal?

It depends.

The optimal approach for you will depend on your situation and goals.

Going plant based may be an improvement if your diet is currently full of sugar and processed grains, but it is not the singular solution to every ill.  (For an excellent example of a very nutrient dense plant based dietary approach check out David’s Nutrient Optimiser analysis here.)

To help you make more informed food choices I have devised two different ways of measuring food quality:

  • Proportion of insulinogenic calories, and
  • Nutrient density.

The proportion of insulinogenic calories is the percentage of the food you eat that will require insulin to metabolise.  The table below lists a range of nutritional approaches ranked by the percentage of insulinogenic calories (right-hand column).

If you’re interested in any of these approaches you can download the list and save it to your phone or print it out to take shopping for some inspiration.

approach pdf foods nutrient profile % insulinogenic
well formulated ketogenic diet pdf foods profile 21
low carb pdf foods profile 34
plant based (diabetes friendly) pdf foods profile 56
weight loss and insulin resistance pdf foods profile 59
low carb pescitarian pdf foods profile 61
the most nutrient dense foods pdf foods profile 67
plant based pdf foods profile 68
plant based (without ND) profile 73

Simply switching to a plant based nutritional approach will leave you with 73% of your diet requiring insulin to metabolise.  The diabetes friendly plant based approach will be an improvement, but a low carb or ketogenic diet may be better if your goal is stable blood glucose levels.

Another way to look at things is nutrient density.  You may have noticed the nutrient profiles shown above have a red dotted box.  If a particular nutritional approach provides two times the Daily Recommended Intake for all essential nutrients then you would get a perfect score of 100%.  You can see below that the most nutritious foods below are pretty close to 100%.

By contrast, if we only focus on ‘plant based foods’ nutritional outcome is not so flash.  Thinking only in terms of plant based is not automatically nutrient dense.

I have sorted the various food lists in the table below based on their nutrient score.  My suggestion is to start at the top with the most nutrient dense foods and work your way down until you find an approach that suits your ethical framework or religious beliefs that will also enable you to stabilise your blood glucose levels (i.e. lower % insulinogenic calories).

approach score pdf foods nutrient profile % insulinogenic
the most nutrient dense foods 99.7% pdf foods profile 67
weight loss and insulin resistance 99.3% pdf foods profile 59
low carb pescitarian 94.5% pdf foods profile 61
low carbohydrate 81.0% pdf foods profile 34
plant based 78.0% pdf foods profile 68
plant based (diabetes friendly) 76.0% pdf foods profile 56
well formulated ketogenic diet 74.0% pdf foods profile 21
plant based (without ND) 57.0% profile 73

Summary

  • While many people chose exclusively plant based foods, they are not necessarily a better dietary choice compared to a more varied diet.
  • Someone following an exclusively plant based approach will require supplementation with vitamin B-12, vitamin D and omega 3s.
  • Fat is not necessarily good or bad. Swinging to macronutrient extremes will not lead to an optimal outcome.
  • Reducing the insulin load of your diet will help to normalise your blood sugar and insulin levels.
  • Ideally, you should aim to achieve the blood sugars of a metabolically healthy person while maximising nutrient density at the same time.

 

references

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

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

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

[4]https://www.quackwatch.org/01QuackeryRelatedTopics/DSH/coral2.html

[5]https://authoritynutrition.com/the-alkaline-diet-myth/

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

[7]https://socialblade.com/youtube/user/nutritionfactsorg

[8]https://nutritionfacts.org/donate/

[9]http://www.hsi.org/about/who_we_are/leadership/subject_experts/michael_greger.html

[10]https://www.facebook.com/mangomannutrition/videos/656469947843978/

[11]https://optimisingnutrition.com/2016/10/23/energy-density-food-hyper-palatability-and-reverse-engineering-optimal-foraging-theory/

[12]https://en.wikipedia.org/wiki/Optimal_foraging_theory

[13]http://www.hoajonline.com/obesity/2052-5966/2/2

[14]https://www.amazon.com/Dorito-Effect-Surprising-Truth-Flavor/dp/1476724237

[15]https://fineartamerica.com/featured/8-muscleart-marius-poser-classic-jake-hartz.html

[16]https://www.ncbi.nlm.nih.gov/pubmed/21241239

[17]https://optimisingnutrition.com/2015/08/10/insulin-dosing-options-for-type-1-diabetes/

[18]https://www.facebook.com/Type1Grit/

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

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

[21]http://online.liebertpub.com/doi/full/10.1089/met.2016.0108

[22]https://optimisingnutrition.com/2016/02/15/how-to-use-your-glucose-meter-as-a-fuel-gauge/

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

[24]http://jamanetwork.com/journals/jama/fullarticle/205916

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

analysis of what a nutritionist eats and hospital food

An article in Business Insider, A Nutritionist Shares Pictures of Everything She Eats in a Day, caught my eye recently.  I thought it would be interesting to run the numbers to see how the food diary logged by this nutritionist compared to the four hundred or so meals that I’ve analysed.

Check out the original article if you want to see the daily food log chronicled in photos by the popular and published “Registered Dietician”, who claims to specialise in diabetes and is “passionate about being a good role model.”[1]

The quantities and foods that I analysed in the recipe builder at SELFNutritionData are shown below.  Besides the fact that the only green things she ate during the day were M&M’s, the food log is not particularly divergent from mainstream dietary advice (i.e. no full-strength Coke or McDonald’s).  The nutritional analysis would be much worse if it was a diet full of junk food, which is pretty common for a lot of people these days in this fast-paced convenience-loving world.

image10

This dietician is a national media spokesperson for the Academy of Nutrition and Dietetics.  She has published books and written for several magazines.[2]  Like most nutritionists, she argues for less fat and more whole grains.[3]

image00

So, let’s see how her daily diet stacks up.  The analysis below shows that, when we compare this daily diet against mainstream dietary advice that nutritionists prescribe, it ticks the following boxes:

  1. avoids trans fats,
  2. is low in fat, and
  3. is low in cholesterol.

image05

However, even though the diet is fairly low in fat, it has 29g of saturated fat which is greater than the Heart Association’s recommendation for a maximum of 16g of saturated fat per day.[4]   Unfortunately, the recommended limit of saturated fat is actually quite hard to achieve without relying on low fat highly processed foods.

Ironically, due to the focus on avoiding fat and trying to incorporate more “heart healthy whole grains”, the food recommended by nutritionists ironically tends to be lacking in nutrients.  It makes no sense!

The registered nutritionist’s daily food log also contains more than 400 grams of carbohydrates which will be a massive challenge to someone who is insulin resistant, would likely generate insulin resistance and eventually diabetes in someone who isn’t there yet.

For comparison, check out the analysis shown below of one of my regular meals (stir-fry veggies with some butter and sardines) which has a much higher vitamin and mineral score (94 compared to 55) and better protein score (139 compared to 66).

image03

image18

When it comes to nutrient density and being diabetic friendly, this nutritionist’s daily food log ends up at the bottom of the pile of the four hundred meals that I’ve analysed!

It’s sad that this myopic one-size-fits-all dietary advice is forced on anyone who asks what they should be eating, or anyone whose food is influenced by government nutritional guidelines (e.g. hospitals, schools, jails, nursing homes etc).

Then we are told that dieticians are the only ones that are qualified to give dietary advice, even though the dietary advice that they give revolves around avoidance of saturated fat and more “heart healthy whole grains” and does not actually lead to high levels of micronutrition.

image12

Where it gets even sadder is that this sort of short sighted advice is also given to the people who are the most vulnerable.  The photo below is of Lucy Smith in hospital after being diagnosed with Type 1 Diabetes.  The diet given to her, as a newly diagnosed Type 1 Diabetic, is Weet-Bix, low fat milk, bananas, low fat toast, orange juice, and peaches.

image26

The analysis for Lucy’s hospital-provided breakfast is shown below.

image17

This single meal contains more than 200 grams of carbohydrates (82% of calories).  This breakfast would require a ton of insulin to be injected into her little body, and she would be on a blood glucose / insulin rollercoaster for days to come.

image16

When it comes to nutrient density, this meal has an even lower score than the day in the life of the nutritionist’s own diet discussed above!  Ironically, this hospital prescribed meal ranks at the very bottom of the list of four hundred meals when ranked to identify the best recipes for people with diabetes!

image14

Unfortunately, things don’t seem to have changed much from thirty years ago when my wife Monica was diagnosed with Type 1 Diabetes.  In hospital, after diagnosis, she was given so many carbs that she hid the food in pot plants in her hospital ward room because she just couldn’t eat anymore!  Twenty-five years later, she learned about the low carb dietary approach and she was finally able to reduce the high levels of insulin required to cover her food.

I’ve witnessed firsthand the massive improvements in quality of life (body composition, inflammation, energy levels, dental health etc) when someone comes off the blood glucose/insulin roller coaster!

Monica has been able to halve her daily insulin dose since no longer ascribing to the dietary advice she has been given by the dieticians and diabetes educators.  Her blood glucose levels are now better than ever and when she goes to the dentist, podiatrist and optometrist they tell her she’s doing great and they wouldn’t even know she’s diabetic.  And I get to have my wife around for an extra decade or two!

image04

By the way, Lucy is doing well now too.  Her parents are some of the most knowledgeable people I know when it comes to optimal foods for diabetics and monitoring blood glucose (as shown in this video from her father Paul).

My friend, Troy Stapleton, is another example of someone living with Type 1 Diabetes who has benefited immensely from a low carbohydrate dietary approach that aligns with his metabolic health.  His story and approach have been an inspiration to me.  You can also check out the Standing on the Shoulders of Giants article for a few more encouraging stories of people with Type 1 who got their life back after going against nutritionists orders.

As detailed in the article How to optimise your diet for your insulin resistance, if you have the luxury of being more metabolically healthy (i.e. not diabetic) you can focus on more nutrient dense foods or lower energy density if you’re looking to lose some weight.

image24

It amazes me that dieticians can be so militant and belligerent when they are largely passing on the recommendations of the US Department of AGRICULTURE (i.e. the USDA, also known as “Big Ag”), whose mission it is to promote the economic opportunity and production of AGRICULTURE[5] (i.e. grains and seed oils).  Talk about putting the fox in charge of the hen house!

image09

Speaking of conflicts of interest, it’s worth noting that major nutritionist organisations funding ‘partners’ are big food manufacturers.[6]  Does this influence the recommendations they give?  They claim not.

It’s hard to believe their published research or dietary recommendations could be impartial when so heavily sponsored by the food industry.

image06

Despite these conflicts of interest and a poor track record of success over the past four decades, I don’t think we should be gagging the Accredited Dietitians from publishing poor nutritional advice.  Everyone should be entitled to their freedom of speech and freedom to choose what they eat.

image23

What I do find ironic is that dieticians can bring spurious cases of malpractice against doctors to their governing bodies when they are acting in line with the latest research and their personal, professional and clinical observations (e.g. Tim Noakes in South Africa and Gary Fettke in Australia).  At the same time, the Registered Dieticians have no governing body to report to, only their board of directors[7] and their ‘partners’.

image13

image07

While they purport to be protecting the public interest, one could be excused for thinking that the dieticians’ associations are another marketing arm for big food companies and are protecting commercial interest rather than acting on behalf of public health.

16864248_10158266373295383_2174911756581917873_n

Is it just a coincidence that Nestle’s Milo, which is half sugar, is prescribed by hospital dieticians for pregnant and breastfeeding mothers with diabetes?

image30

Unfortunately, the situation isn’t that much different with the diabetes associations.[8]  Why would these institutions ever make recommendations to their members that reduced the amount of medications they needed or reduce the amount of processed food when their financial partners are pharmaceutical companies who manufacture insulin and drugs for diabetes?

image01

What would happen to this financial structure if a significant amount of people started eating whole unprocessed food without a bar code?  The share price of these massive medical and pharmaceutical companies would tank!

image22

After battling cancer himself and studying the role of nutrition in metabolic and mitochondrial disease in depth, Gary Fettke now spends his days as an orthopaedic surgeon amputating limbs mainly due to the complications of diabetes.

No, it’s not pretty, but unfortunately it’s very very real.

image19

Each year Gary volunteers as an orthopaedic surgeon in Vanuatu.[9] [10]  The contrast between the native people living in their natural environment, eating their native foods, and their relatives in town, eating processed foods, is stark.

I took this photo in a traditional village during our holiday in Vanuatu a couple of years ago.  These people eat lots of coconuts (which contains plenty of saturated fat, one of the remaining nutrients that Registered Dieticians still say we should avoid) and fish. These Vanuatu natives are some of the most beautiful, healthiest and happiest people I have ever seen!

image11

Unfortunately, in the capital Port Vila, it’s not so pretty.  The diabetes rates are the third highest in the world.  One in fifty Vanuatu natives have had an amputation!

It is such a big problem. Their diet has changed quite rapidly over the years, so instead of eating their island’s food, they now eat very large quantities of white rice and of course all the liquid sugar, like Coca-Cola and Fanta, and it’s literally killing them.[11]

After seeing the impact of diet, Gary has been outspoken in Australia, bringing attention to the quality of food that people are eating, especially in hospitals.[12]

image27

Gary and his Nutrition for Life Centre also worked with Chef Pete Evans on the “Saving Australia Diet” on national TV with great results achieved.[13]

image20

Then, in return for his efforts, Gary has been reported by the certified dieticians to the Australian Health Practitioner Regulation Agency; and he has been told he can no longer tell his patients to limit sugar even if they have just had their leg amputated due to the complications of diabetes.

Similarly, Tim Noakes has developed a massive following after realising that he needed to go against his own previous publications and advice when he found he was developing diabetes. The recipe book that he helped write, The Real Meal Revolution, is filled with nutrient dense low carb meals that help people with diabetes achieve normal blood glucose levels, has been massively popular.

image21

Despite his impressive track record of real results, which goes against the general trend of the explosion of diabetes and obesity in western society, Professor Noakes has been reported to the Health Professionals Council of South Africa (HPCSA) and charged with unprofessional conduct, after suggesting that a mother wean her baby on to whole foods rather than processed “baby food”.

image15

This has led to a long and expensive court case which really appears to be more about maintaining the status quo on the supermarket shelves rather than public health.[14]

I think most nutritionists believe that they are doing the right thing by advising their clients to prioritise the avoidance of fat, cholesterol and saturated fat, and eat “heart healthy whole grains”.  However, the foundation of this advice seems to be crumbling from underneath them with the most recent updates to the US Dietary Guidelines that now remove the upper limit on fat and removing cholesterol a nutrient of concern.[15] [16]

However, if we have to rely on Big Food to provide processed food products to achieve the reduced saturated fat aspirations of the dietary guidelines (and in so doing produce very otherwise nutrient poor foods), then perhaps we need to declare them broken and look for new ones?

image02

Makes you wonder how we survived (let alone thrived) with the food that was available to us before the highly-processed foods and the low fat dietary guidelines that came to dominate our food choices in the 1970s.

Unfortunately though, fear of saturated fat still dominates the majority of mainstream dietary recommendations out there and leads to nonsensical food rankings that only suit the grain based food industry.[17] [18]

For example, the simplistic Australian Health Star Rating is based on the energy, saturated fat, sodium, sugar content along with the amount of fruits and vegetables in a product.[19]  This avoidance-based process gives little consideration for the amount of essential nutrients in a product, regardless of where they came from, and hence often returns nonsensical results.

image29

It’s hard to tell whether the attacks on people like Fettke and Noakes are motivated by:

  1. Well-meaning nutritionists who earnestly believe that higher levels of fat and a lack of “heart healthy whole grains” is going to harm people,
  2. Nutritional institutions sensing that they are becoming irrelevant and making a last-ditch attack at their adversaries in an effort to hold onto their jobs,
  3. Processed food manufacturers (i.e. big food) using their “partner organisations” to attack these outspoken thought leaders so they can maintain their strangle hold on nutritional advice that suits them and sells more of their product (i.e. it’s not a conspiracy, it’s just business), or
  4. Some combination of each of these options.

To cut through the confusion and conflicts of interest, wouldn’t it be great if there was an unbiased quantitative way to judge whether a particular food or meal was optimal based its nutrient density?  Perhaps we could even tailor food choices based on blood glucose and metabolic health (i.e. using insulin load), or by manipulating energy density of someone who is insulin sensitive but just needs to lose weight.

If you’ve been following this blog, you may have seen the optimal food lists tailored to specific goals.  To this end, I have devised a system to identify foods for different goals and situations. The table below will help you choose your ideal dietary approach and optimal foods based on your blood glucose levels and waist to height ratio.

approach average glucose waist : height
(mg/dL) (mmol/L)
therapeutic ketosis > 140 > 7.8
diabetes and nutritional ketosis 108 to 140 6.0 to 7.8
weight loss (insulin resistant) 100 to 108 5.4 to 6.0 > 0.5
weight loss (insulin sensitive) < 97 < 5.4 > 0.5
nutrient dense maintenance < 97 < 5.4 < 0.5

The first step in improving your nutrition is to minimise processed food that is laced with sugar.  These food lists can help you further optimise your food choices to suit your goals whether they be blood glucose management, weight loss or just maintaining optimal health.

Once you normalise your blood glucose levels, you can then start to focus more on nutrient density.  If you still have weight to lose, then you can focus on foods with a lower energy density to force more energy to come from your body while still maximising nutrition.   You can also find the highest ranking of the four hundred meals that I have analysed listed here.

Several people recently have suggested that I turn the nutrient density ranking system into a mobile app for easy implementation of the ideas and theories outlined on the blog in the real world.

So, my current project is to develop a Nutrient Optimiser that would rank the foods you have eaten based on your current goals (e.g. therapeutic ketosis, diabetes management, weight loss or maximising nutrient density) and recommend new foods to try.  The Nutrient Optimiser would progressively retrain your eating patterns towards ideal by helping you to maximise the more optimal foods, and progressively eliminate the foods that don’t align with your goals.   Whether you are trying to eat less Maccas, or you are practising Calorie Restriction with Optimal Nutrition (CRON) and trying to live to 120, the Nutrient Optimiser would push you forward to truly optimise your nutrition.

The idea is not to simply create another calorie counting app.  There are plenty of those out there already.  Rather, the Nutrient Optimiser will help you to maximise nutrient density as much as you can while catering to your other goals.

Rather than being centred on outdated “science” and avoiding boogeymen such as cholesterol, fat and saturated fat, or serving the interest of “financial partners” (e.g. BigFood and BigPharma), the Nutrient Optimiser uses a quantitative algorithm that will help you maximise the nutritional value of the food you eat.

The Nutrient Optimiser, based on the foods logged in the past few weeks, helps you to identify foods that would provide the nutrients that you haven’t been getting as much of.  Rather than just tracking calories, the app will continually adapt to what you eat, ensure that you are getting a broad range of foods that contain the nutrients you need, and ensure you don’t get stuck in a nutritional rut.

For people just starting out, it will help them gently move forward, without the judgement of someone looking over their shoulder.  It will suggest foods they should buy more of, new foods to try, and maybe which foods they should bin and never buy again.

For people who are truly wanting optimal nutrition, it will hopefully be the ultimate tool to continue to refine their food choices to maximise nutrient density while optimising blood glucose, insulin and body fat levels.

As you continue to log your weight, blood glucose levels and whatever other metrics you want to track, the app will progressively prompt you to “level up” to a more optimal nutritional approach.  Then, with your nutritional deficiencies filled, the cravings will dissipate and you will naturally be satisfied with less food.[20] [21]

If something like this is of interest to you and you want to be an early adopter or just check it out the nutritional analysis of other people food logs that have been done so far then then take a look at the Nutrient Optimiser Facebook page and to stay posted as things develop.

 

references

[1] https://www.amazon.com/Ruth-Frechman/e/B007HDN5IW

[2] http://www.ruthfrechman.com/Meet_Ruth.html

[3] https://www.youtube.com/watch?v=LAugDpr16Jg

[4] http://www.heart.org/HEARTORG/Conditions/Cholesterol/PreventionTreatmentofHighCholesterol/Know-Your-Fats_UCM_305628_Article.jsp#

[5] https://www.usda.gov/documents/usda-strategic-plan-fy-2014-2018.pdf

[6] http://daa.asn.au/advertising-corporate-partners/program-partners/

[7] http://daa.asn.au/?page_id=136

[8] https://www.diabetesaustralia.com.au/corporate-partners

[9] http://www.hopeforhealthvanuatu.com/volunteers/

[10] https://www.facebook.com/permalink.php?story_fbid=857965770964542&id=393958287365295

[11] http://www.radionz.co.nz/international/programmes/datelinepacific/audio/201818486/hope-given-to-amputees-in-vanuatu

[12] http://www.nofructose.com/2014/12/19/hospital-food-is-crap-and-its-killing-my-patients-and-what-to-do-about-it/

[13] https://au.news.yahoo.com/sunday-night/features/a/31538041/the-saving-australia-diet/#page1

[14] http://foodmed.net/tag/tim-noakes/

[15] http://time.com/3705734/cholesterol-dietary-guidelines/

[16] https://therussells.crossfit.com/2017/01/05/big-food-vs-tim-noakes-the-final-crusade/

[17] http://healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/Content/How-to-use-health-stars

[18] http://www.nuval.com/

[19] http://healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/Content/excel-calculator

[20] http://sydney.edu.au/news/84.html?newsstoryid=12632

[21] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988700/

 

post last updated July 2017 

micronutrient flax crackers

Who would have thought crackers could be so ketogenic and nutrient dense at the same time.

This another recipe from the Ketogenic Edge Cookbook by Jessica Haggard.

2016-11-18-1

There are a ton of seeds and spices that soak up a liberal amount of butter or coconut oil which is what makes them so ketogenic.

2016-11-19

While the recipe comes out to be 20% total carbs, once you account for the massive amount of fibre the net carbs are negligible.  And the nutrient density from the herb and spices is awesome!

2016-11-19-1

If you like this sort of thing make sure you check out Jessica’s cookbook where she has created a whole range of real food ketogenic and diabetic friendly meals that won’t boost your blood sugars!

The table below shows the nutritional data per 500 calorie serving.

net carbs

Insulin load

carb insulin

fat

protein

fibre

4g

11g

34%

70%

13g

21

spinach and egg

I’m a pretty simple cook, but sometimes the simple things in life are the best.   You don’t have to achieve great feats of molecular gastronomy to get a hearty nutrient dense start to the day.

This recipe is a simply egg and spinach fried up with some dill, some cream with the egg and coconut oil with the spinach for cooking.

img_6295-copy

The ‘secret’ here is to go heavy on the spinach.  Spinach always gives an amazing nutritional profile.

2016-11-19-5

Even with four eggs and 300g of spinach the end result is still very much ketogenic as well as being nutrient dense!

For some extra taste and you could throw in some mozzarella with the egg.

For all it’s simplicity, this recipe ends up ranking at #9 in the diabetes and nutritional ketosis ranking and #17 in the therapeutic ketogenic meals ranking.

The table below shows the nutritional data per 500 calorie serving.

net carbs insulin load carb insulin fat protein fibre
5g 18g 28% 72% 24g 6g

 

 

the alkaline diet vs acidic ketones

  • Whether you think eating alkaline foods is useful or woo woo junk it appears that metabolic acidosis is a thing.
  • Metabolic acidosis seems to be interrelated with insulin resistance, Type 2 Diabetes, and retention of muscle mass.
  • To prevent metabolic acidosis, it appears prudent to ensure that your body has adequate minerals to enable your kidneys to balance pH over the long term. This can be achieved by eating plenty of veggies and/or supplementing with alkaline minerals (e.g. magnesium, sodium, potassium, zinc etc).
  • If you eat plenty of veggies you’re probably getting enough alkalising minerals, however, you can easily test your urine to see if your dietary acid load is high.
  • If you are targeting a high fat therapeutic ketogenic diet, following a zero-carb dietary approach and/or taking exogenous ketones it seems then it may be even more important to be mindful of your acid load and consider mineral supplementation.

some unique ketone and blood glucose results

Recently I had a fascinating, surprising and exciting experience during a fast.  The chart below shows my ketones, glucose and ‘total energy’ (i.e. glucose plus ketones) over the seven days.

image03

My ketones increased to above 8.0 mmol/L.  They even couldn’t be read on my ketone metre!

image14

I really did feel sky high on ketones!

It was the full keto brochure experience.  It was like my body fat was effortlessly feeding my brain with delicious, succulent ketones!  I felt great.

This chart shows my glucose : ketone index (GKI) dropping to below 0.5 after a few days.

image07

The orange dots in this chart shows the relationship between glucose and ketones about 18 months ago when I first started trying this keto thing (after I read ‘Jimmy’s Moore’s Keto Clarity’).  The blue dots show the relationship between my glucose and ketones during the recent fast.  As you can see from the much flatter line, my blood glucose levels were lower, and I could more easily access my body fat for fuel to manage my appetite.

image21

The frustrating thing is that, thinking I was now a bonafide keto super hero, I’ve tried to repeat this feat of super ketones and perfect blood glucose levels without any luck!   My ketones just didn’t go as high again!

So, what’s the go?  What changed?  What gives?  What was it that let me trip with the magic ketone fairies in Keto Land for such a short period!

image53

are ketones acidic?

So let’s rewind the story a little and give some context…

In July 2016, I got some blood tests.  I’d been good with my diet, eating nutrient dense foods, with some fasting and intense exercise.

My HbA1c was great at 4.9% and the cholesterol markers were all good.

I went to see Elizma Lambert (pictured below), my family doctor / naturopath / friend / mentor / hero, with the simple request that I wanted to feel superhuman.  I felt like I had been doing all the right things (e.g. good food, exercise etc) but not quite getting results that I was after (e.g. weight loss, energy levels, higher ketone levels).

image00

Elizma said everything looked good but my blood tests indicated that I was acidic.  But what does this mean?

  • You can see in the test results shown below that my uric acid levels are at the top of the normal range. High uric acid levels can be affected by fasting and exercise (i.e. lactic acid)[1] which may have influenced my test results.
  • My “other anions” test was at the top of the normal range.
  • I had also been using exogenous ketones occasionally around workouts leading up to these tests. I wondered whether they might contribute to the acidity.
  • My bicarbonate levels were on the low end which I’ve now learned suggests that I was running low on alkalising minerals (i.e. magnesium, calcium and potassium) for my kidneys to balance the acid load I was serving up with my exercise, diet and fasting.
  • My calcium and potassium were also on the lower end of the normal range.

image01

So Elizma sent me away with a mineral mix of magnesium, potassium, N-acetyl Cysteine and Calcium-D-Glucarate to help with the acidity issue that she had observed in my tests and to help improve my fat metabolism.

image25

I wasn’t sure what to expect, if anything.  But after a couple of weeks of taking this stuff my brain felt really clear and sharp and I felt full of energy.  I actually felt the superhuman energy and crispness that I’d been hoping for!

image38

My blood glucose and ketone levels were spot on.  And my hunger seemed to be massively reduced.

image51

So, just for interest, I decided to see how long I could go without eating.

Seven days later I had some spectacular ketone readings.

image03

As well as the alkalizing mineral mix, I was also taking some Celtic sea salt, Carnitine, Creatine and some alkalising green powder to keep my micronutrients up during the seven days.  I was aware of keto experts like Steve Phinney advocating adequate electrolytes during keto or fasting and I wanted to give myself the best chance of surviving and keeping up with my day job as well as riding to work.  I also started taking Nicotinamide Riboside which arrived on day four of the fast.

image36

So unfortunately, it wasn’t a really well controlled experiment to understand which supplement during my ‘fasting’ had the biggest effect.

Towards the end, I ran out of the alkalising mineral mix and I spent the day in the sun at a birthday party with my daughter (pictured below on the last day…  she knows how to pose for better for photos than me).

image42

I started to feel a bit shabby, so I decided to eat.

I figured seven days was a good ‘achievement’.

Since then I’ve tried a number of four-day fasts with various supplements (i.e. the alkalising minerals, Nicotinamide Riboside, exogenous ketones, a ‘fat fast’ and Robert Miller’s MitoFuel) to understand what the magic ingredient was, but I haven’t been able to repeat the phenomenal ketone excursions.

15204045_10154380499344807_1281857376_o.jpg

I quizzed Elizma about what she thought might have happened.  Could it simply be the alkalising mineral mix that causes the magic ketone fairies to visit me?  She said:

Whether you call it resistance or stuck, the alkalizing minerals can open up a lot of enzyme pathways that work at more neutral pH levels, which means it’s like opening the door with a massive crowd outside.

Once the door is open everyone just rushes through (giving you those big readings), but the crowd eventually thins out and becomes a regular stream of customers walking through the door again.

Very interesting though.  Every single person on ketogenic diet that I have tested have high acidity levels, which is natural considering that ketones are highly acidic, but it does mean it’s something to really look out for when ketogenic.

Hmmm…  intriguing.

Then I came across a Ben Greenfield podcast with Yuri Elkaim where he talked about alkaline diets.  It got interesting when Yuri started talking about the Potential Renal Acid Load which is based around the balance between the foods that leave an acidic residue (i.e. sulphur from protein and phosphorus) versus the foods that leave an alkaline residue once metabolised (i.e. magnesium, calcium and potassium).

image35

Previously when I’d heard talk of alkaline foods I’d written it off as woo woo.  But maybe this might explain the symptoms what I’d experienced (e.g. loss of appetite, high ketones, perfect blood glucose etc)?   Given the fact that taking the magnesium, potassium and calcium supplements had worked wonders for me I was interested and thought I’d dig into the topic a little further.

Here’s a video from Yuri on the pros of the alkaline dietary approach.  I’m not saying I’m advocating 100% of this, but it’ll give you an overview of some of the theory on alkaline diets from one of the less fringe advocates of the concept of alkalising.

let’s start with the basics

As I am prone to do, I went down a bit of a ‘rabbit hole’ looking at the research on this topic looking for answers trying to understand and explain my experience.   In this article I have tried to explain my journey and learnings along the way.

So let’s start with the less controversial stuff.  Basic biochem.

pH (or “potential hydrogen”) is a measure of the number of negatively charged hydrogen ions (H+).[2]

More formally, “pH is the negative of the logarithm to base 10 of the molar concentration, measured in units of moles per liter, of hydrogen ions.”

But why should we care about pH?

Well, when it comes down to it, your entire metabolism exists to pass around hydrogen ions.

You call it energy.  It’s important.

image30

maintaining pH homeostasis

The body goes to great lengths via a range of different systems to keep different parts of your body at a specific pH to enable the chemical reactions that fuel metabolism to continue function.

A pH of 7.0 is “neutral”, however the blood is slightly alkaline at somewhere between a pH of 7.35 and 7.45.  It’s virtually impossible to change the pH of your blood outside this range.

If your pH drops to 6.9, you’re in a coma.  At 6.8 you’re dead.[3]

image46

At this point many people simply say “see, we can’t change the pH of our blood so worrying about alkalinity is bogus garbage” (or something to that effect) and walk away.  Conversation over.

image24

However, I think it’s interesting to think about how the body actually maintains this tight homeostasis and whether a pH of 7.35 is different (more acidic) to a pH of 7.45 (more alkaline).

The body has so many different buffers and so many different systems and ways of mitigating pH.   Intracellularly, it has phosphate; extracellularly, hydrogen types of proteins. The lungs get involved, the kidneys get involved.   Which just tells you is the more processes or mechanisms in the body, or systems, devoted to a certain subject or topic of process, the more important that process is.

Bryan Walsh, Keto Summit Interview[4]

Part of the body’s pH balance involves our kidneys which use the various minerals that it obtains from our food to keep a tight rein on the acid / base balance of our blood.

The minerals that can donate acid forming negative charge are:

  • Bromine (Br-)
  • Chlorine (Cl-)
  • Copper (Cu-)
  • Fluorine (Fl-)
  • Iodine (I-)
  • Phosphorus (P-)
  • Silicon (Si-)
  • Sulphur (Su-)

The minerals that can donate alkaline positive charge are:

  • Boron (B+)
  • Calcium (Ca+)
  • Iron (Fe+)
  • Magnesium (Mg+)
  • Manganese (Mn+)
  • Nickel (Ni+)
  • Potassium (P+)
  • Sodium (Na+)
  • Zinc (Zn+)

alkalinity, carbon dioxide and oxygen

In Australia, one of our premier tourist attractions, Great Barrier Reef, is dying as the ocean absorbs CO2 from the atmosphere and becomes more acidic.[5]  It’s not hard to see how an increasing environmental acid load could similarly be affecting our internal microbiome.[6]

image33

Every farmer knows the importance of getting the pH of the soil right before planting a crop.  A higher pH is achieved by adding extra potassium and lime which is taken up by the plant.   The pH of the soil in which plants are grown can have considerable influence on the mineral content of the food we eat.

When it comes to the pH and net acid load in the human diet, there has been considerable change from the hunter gather civilization to the present.[7]

As we continue to grow mono crops in the same field year after year with farmers relying on chemical fertiliser to provide nutrients for the plant, it’s understandable that our veggies are also decreasing in nutrient content, particularly the alkalising minerals.

With the agricultural revolution (last 10,000 years) and even more recently with industrialization (last 200 years), there has been a decrease in potassium (K) compared to sodium (Na) and an increase in chloride compared to bicarbonate found in the diet.

It is generally accepted that agricultural humans today have a diet poor in magnesium and potassium as well as fibre and rich in saturated fat, simple sugars, sodium, and chloride as compared to the pre-agricultural period. [8]

This results in a diet that may induce metabolic acidosis which is mismatched to the genetically determined nutritional requirements. With aging, there is a gradual loss of renal acid-base regulatory function and a resultant increase in diet-induced metabolic acidosis while on the modern diet.[9]

Even if you don’t like veggies, it’s not hard to see how the meat from animals fed with grains (which contain less alkalising minerals than grass) grown with chemical fertilisers could be leading to a higher acid load compared to animals that are able to eat grass and other natural stuff.

image47

When the pH of something is higher (more alkaline) it can hold more dissolved oxygen.  If it is more acidic (lower pH) it can hold less oxygen.  Blood with a pH of 7.3 (more acidic) and can carry 65% less oxygen than blood at a pH of 7.45 (more alkaline).[10]

Good things happen when there is more oxygen available.  For example, when there is more oxygen the body is able to utilise the fat burning Krebs Cycle based / aerobic metabolism (with oxygen) and less on the sugar based Cori cycle / anaerobic metabolism (without oxygen).

Conversely, more acidic = not so good.

image05[11] [12]

While still controversial, in the 1930s Otto Warburg (pictured below, with poodle) suggested that “cancer cells live in hypoxic, very low oxygen, and acidic conditions and derive energy from sugars by fermenting them the way yeast does.” [13] From this, he theorized that these low-oxygen and more acidic conditions caused cancer.

image18

So low oxygen = bad.  Lots of oxygen = good.

Wim Hof, Iceman Extraordinaire, achieves superhuman feats essentially by hyperventilating to increase the oxygen in his blood.

image41

the effect of food and alkalinity

There is some indication that this ability to absorb more oxygen is also affected by the food we eat.

The chart below shows how athletes on a lower acid load dietary approach appear to be burning more fat (as indicated by a lower respiratory exchange ratio or RER[14]) and have a longer lead time to exhaustion.[15]

image45

The study Effects of Dietary Acid Load on Exercise Metabolism and Anaerobic Exercise Performance (Caciano et al, 2015) noted that:

An alkaline promoting (low-PRAL) diet increases anaerobic exercise performance, as evidenced by greater time-to-exhaustion during high-intensity treadmill running.

Preliminary evidence suggests that an alkaline promoting (low-PRAL) diet increases lipid oxidation and may have a carbohydrate-sparing effect during submaximal endurance exercise, although further studies are needed.[16]

More fat burning = winning!

image26

This aligns with my personal experience.  During a good workout it feels like my cells can “breath better”.  My stamina and performance in my cycling or kettlebell workouts is not so much limited by my strength but more by my ability to recover my breath quickly.  When everything is working just right I seem to be able to maintain a high heart rate easily for a longer time without running out of breath.

image02

The chart below shows my heart rate during a good kettlebell session.

image10

It seems that a lower insulin load (i.e. low carb / ketogenic) diet with lower levels of insulin enables us to tap into our fat stores more easily.  However, in addition, it seems that a more alkaline pH also helps us burn more fat by enabling us to access more oxygen as well.

potential renal acid load

So how does all this this relate to nutrition and optimising our food choices?

Well, back in the late 1870s a scientist named Marcellin Berthelot used the Bomb Calorimeter to study the amount of heat produced or absorbed during chemical reactions.[17]  This machine consisted of a cylinder-shaped chamber, pressurized oxygen, and a small amount of water.

image04

Berthelot would take various food substances and incinerate them within this device which turned the item into an ash-type substance. When this ash was mixed with water, Berthelot could check the pH of each item to determine whether a food was acidic or alkaline after it had been burned.

The Potential Renal Acid Load (PRAL) revolves around the idea that there is a residual ash remaining after a food is metabolised in our body that is either acidic or basic.  This residual ash, which has a net acidic or alkaline property, then needs to be cleared from the body to maintain optimal pH.[18] [19] [20]

A simplified PRAL value can be calculated based on the most dominant nutrients affecting pH.  That is, protein (which forms sulphur) and phosphorus (acidic) minus the magnesium, calcium and potassium (alkaline).

Potential renal acid load (PRAL) = [0.49 x grams of protein + 0.037 x mg of phosphorus]  – [0.026 x mg magnesium + 0.013 x mg calcium + 0.021 x mg potassium] 

If the PRAL value is negative, then you are left with an alkaline residue.

If the PRAL number is positive, then you are left with a net acidic residue that needs to be cleared by the kidneys.

urine ph

While significantly changing the pH of the blood is controversial, the food we eat does seem to have an impact on the pH of our urine as the kidneys clear the excess acid load that is not used up in balancing our pH.[21] [22]  The theory is that pH of our urine changes based on whether the residual ash from our food after it is metabolised is either acidic or alkaline.

The chart below shows the urine pH of the test subjects in the Effects of Dietary Acid Load on Exercise Metabolism and Anaerobic Exercise Performance study mentioned above.  In the cross over trial participants performed the best when they had a more alkaline urine pH greater than 7.0 (alkaline) in comparison to when they had a pH less than 6.0 (acidic).

image19

balancing electrolytes

If you’re a die hard low carber / ketonian congratulations in getting this far into the article before switching off and writing me off as a vegan tree hugging hippie.

You’ll also likely be aware that in The Art and Science of Low Carbohydrate Performance Volek and Phinney talk a lot about how important it is to manage minerals and electrolytes when following a low carb / ketogenic dietary approach.  Chapter 9 of The Art and Science of Low Carbohydrate Performance is all about how important it is to make sure you keep up your electrolytes in the form of sodium, potassium, magnesium and zinc.

[Steve was recently in Brisbane and we had the privilege of having him stay at our place.  Not only did he make us his famous blue cheese dressing (see action shot below) I also got to pick his brains for a day!]

2016-11-15-10-58-17

You get bonus points if you realised that these critical electrolytes that Volek and Phinney talk about are the same as the alkalising minerals in the PRAL formula (i.e. magnesium, calcium and potassium)!  Maybe erring on the side of being alkaline and ensuring good mineral / electrolyte management in a keto diet are two sides of the same coin?

image34

We can get this critical electrolytes from supplements or more ideally from real food.

As you dig further you quickly find that the discussions around PRAL can go sideways really quickly and turn into a keto / carnivore vs vegan / plant based argument.

I have tried to wade through the science versus woo woo, which I’ll try to summarise later in this article.  But for now let’s jump into what the analysis of PRAL could mean for our choices around what we should eat.

the most alkaline foods

The table below shows the most alkaline foods with their nutrient density (ND), and PRAL value per 100g and PRAL / 2000 calories.[23]

Most lists I’ve seen use PRAL per 100 calories.  However, I think it’s more useful to think of it in terms of the amount as a proportion of your daily energy intake (i.e. per 2000 calories).

To make the lists more concise I’ve filtered for the most nutrient dense foods for each category.

vegetables and spices

image15

The PRAL values of the most nutrient dense vegetables are listed below.  Overall vegetables are quite alkaline (i.e. negative PRAL values).  Only alfalfa has a positive PRAL value due to high levels of phosphorus.

The other observation here is that nutrient density and alkalinity don’t necessarily go hand in hand.  It’s not as simple as saying ‘eat your veggies’ because there is a wide range of nutrient density and PRAL values within the vegetables.

If you are striving for optimal in terms of ND and PRAL then some veggies are better than others.

food ND PRAL / 2000 cal PRAL / 100g
beet greens 19 -1,523 -17
Chinese cabbage 20 -1,241 -7
watercress 24 -1,034 -6
spinach 25 -895 -10
chard 19 -857 -8
coriander 23 -841 -10
chicory greens 18 -724 -8
dill 16 -721 -15
endive 19 -707 -6
arugula 16 -629 -8
parsley 19 -618 -11
celery 12 -610 -5
basil 22 -569 -7
mustard greens 16 -507 -7
escarole 15 -495 -5
zucchini 20 -489 -4
pickles 11 -424 -3
lettuce 19 -419 -3
summer squash 13 -397 -4
brown mushrooms 16 -383 -4
yeast extract spread 12 -369 -34
dandelion greens 16 -353 -8
cauliflower 15 -351 -4
sauerkraut 11 -328 -3
chives 16 -317 -5
turnip greens 13 -307 -4
banana pepper 10 -296 -4
sage 13 -295 -46
cabbage 10 -286 -3
paprika 11 -262 -37
okra 15 -243 -3
seaweed (kelp) 12 -224 -5
cloves 13 -216 -30
snap beans 11 -215 -2
white mushroom 13 -205 -2
portabella mushrooms 13 -204 -3
asparagus 20 -199 -2
broccoli 27 -167 -2
collards 11 -141 -2
shiitake mushroom 11 -80 -2
mung beans 13 -64 -1
seaweed (wakame) 17 -59 -1
spirulina 11 -1 -0
alfalfa 12 154 2

dairy

image08

Dairy is widely regarded to be some of the most acidic of foods.   As you can see below there are a wide range of PRAL values, from slightly alkaline high fat cream and butter to the low fat cheeses which are quite acidic.

Even though dairy can be nutrient dense, many people seem to do better with their weight or allergies when they limit dairy.

Personally, I know I lost some weight when I reduced dairy for a period.  I thought it might be related to the energy density.  Maybe the minerals and pH balance plays a role too and living on a low carb diet primarily comprised of cheese could be a problem for some people in the long term.
https://s0.wp.com/wp-content/themes/pub/twentyfourteen/js/html5.js

 

 

food ND PRAL/2000 cal PRAL/100g
sour cream 4 -2 0
low fat milk 4 -1 0
milk (full fat) 2 0 0
butter 3 0 0
cream 4 3 1
milk 5 5 0
kefir 10 14 0
cream cheese 4 15 3
brie 1 66 11
blue cheese 2 68 12
Colby 0 83 16
cheddar cheese 7 85 17
feta cheese 5 85 11
muenster cheese 1 87 16
camembert 2 87 13
Monterey cheese 1 88 16
limburger cheese 2 90 15
edam cheese 2 100 18
Greek yogurt 6 100 5
parmesan cheese 6 102 21
gruyere cheese 2 103 21
Swiss cheese 7 104 21
gouda cheese 3 113 20
goat cheese 2 119 16
mozzarella 8 123 19
egg yolk 8 133 18
whole egg 7 133 10
Greek yogurt (low fat) 6 143 5
cottage cheese (low fat) 6 157 6
cheddar (non-fat) 2 262 23
cream cheese (low fat) 8 306 16

baked products, cereals and grains

image04

Baked products, cereals and grains, in addition to generally having quite poor nutrient density values are also typically highly insulinogenic.

Baking soda or bicarbonate is a powerful alkaline supplement that can be used to aggressively shift pH.

Other than wheat bran and baker’s yeast (think vegemite, marmite or brewer’s yeast), processed grains have a poor nutritional value while also being quite alkaline AND insulinogenic.

According to Bill Davis the phytates in grains also make it harder to absorb alkalising minerals.[24]

No wonder processed grains are problematic for so many people.

the alkaline diet vs acidic ketones | optimising nutrition
https://s0.wp.com/wp-content/themes/pub/twentyfourteen/js/html5.js

 

 

food ND PRAL/2000 cal PRAL/100g
baking soda 0 -309 -15
oat bran muffins -4 13 2
crackers -3 18 4
croissant -2 22 5
blueberry muffins -4 23 4
bagels -4 23 3
wheat bran bread -4 27 3
rice bran bread -3 28 3
egg bread -4 31 4
wheat bran 12 32 3
bread roll -4 32 4
quinoa -2 38 2
rye flour -3 40 7
English muffins -3 50 5
baker’s yeast 15 50 3
wild rice -4 53 9
pancakes -4 128 22
oat bran 3 137 17

seafood

image21

Seafood is typically acidic due to the protein though also nutrient dense.  However, as we’ll see later, it’s not as simple as avoiding protein, as protein seems to help with calcium absorption.[25]
https://s0.wp.com/wp-content/themes/pub/twentyfourteen/js/html5.js

 

 

food ND PRAL/2000 cal PRAL/100g
mackerel 7 34 5
anchovy 13 69 7
cisco 7 75 7
caviar 14 76 10
octopus 9 107 9
herring 7 114 12
white fish 8 123 7
trout 14 131 11
sardines 8 136 13
oyster 18 146 7
sardine 8 153 16
sturgeon 11 165 11
pollock 11 168 9
rockfish 11 168 9
halibut 12 175 10
salmon 17 180 14
haddock 9 188 11
whiting 8 197 11
tuna 9 197 18
lobster 12 201 9
cod 11 205 30
crab 15 238 10
crayfish 11 253 10
shrimp 12 282 17
fish roe 16 285 20
perch 8 297 14
flounder 11 322 14

animal foods

image09

Animal products have a high PRAL values due to their protein content.     Grain fed animals are likely to be even worse than animals able to eat their natural diet.

food ND PRAL/2000 cal PRAL/100g
chicken liver pate 7 105 11
rib eye steak 5 130 14
lamb chop 5 139 16
bison 5 166 14
beef brains 8 166 13
ground pork 6 168 16
ground beef 6 171 12
leg ham 6 175 14
pork shoulder 6 178 14
turkey heart 8 182 16
turkey meat 6 188 15
turkey drumstick 6 188 15
chicken 7 189 14
pork chop 6 195 17
beef tripe 6 208 11
lamb heart 8 212 17
lean beef 9 216 16
turkey liver 14 218 21
pork liver 10 218 18
beef heart 5 220 18
beef heart 8 229 21
turkey 6 230 16
chicken liver 15 233 14
ham 11 239 13
veal 8 239 18
veal liver 16 244 23
chicken liver 14 250 22
beef liver 16 262 23
lamb kidney 19 267 15
lamb liver 18 274 23
beef kidney 13 283 22

fruits

fruits-and-vegetables

Fruits are typically quite alkaline, however the nutrient density value is typically less than ideal.  Fruits are also typically quite insulinogenic.  So I don’t think it’s a matter of simply  saying that we should eat a ton of “fruits and vegetables” if nutrient density or insulin load are also an issue.
https://s0.wp.com/wp-content/themes/pub/twentyfourteen/js/html5.js

 

 

food ND PRAL/2000 cal PRAL/100g
rhubarb 3 -621 -7
cantaloupe -2 -298 -5
honeydew melon -4 -247 -4
jackfruit -3 -186 -9
kiwifruit -2 -184 -6
apricots -4 -180 -4
grapefruit -4 -174 -3
peaches -4 -160 -3
strawberries -1 -159 -3
oranges -4 -156 -4
carambola -2 -138 -2
blueberries -0 -137 -3
blackberries -1 -130 -3
limes -3 -115 -2
avocado -1 -102 -8
raspberries -2 -93 -2
boysenberries -2 -86 -2
blackberries -4 -69 -2

legumes

image11

Legumes have a range of PRAL values, though again the nutrient density values are not that great compared to the veggies, seafood or animal products.

food ND PRAL/2000 cal PRAL/100g
navy beans 0 -32 -5
soybeans 2 -21 -5
cowpeas 1 -14 -2
peanut butter 2 -5 -1
broad beans -1 -2 -0
lentils 0 37 2
tofu 4 41 2
soy protein isolate 0 400 67

nuts and seeds

nuts_seeds

There are a range of PRAL values when it comes to nuts and seeds depending on the mineral content.

Anything based on coconut seems to do well in terms of nutrient density and alkalinity.  There’s nothing quite like fresh coconut water.  The photo below shows how we finished our recent holiday in Fiji!

image44

the alkaline diet vs acidic ketones | optimising nutrition
https://s0.wp.com/wp-content/themes/pub/twentyfourteen/js/html5.js

 

 

food ND PRAL/2000 cal PRAL/100g
coconut water 4 -539 -5
gingko nuts -6 -20 -1
coconut milk 0 -16 -2
coconut meat -1 -15 -3
coconut -1 -13 -3
coconut cream -1 -9 -1
hazelnuts -3 -6 -2
macadamia nuts -2 -4 -1
sesame butter -1 -3 -1
almond butter -2 5 2
pecans -6 6 2
almonds -2 7 2
flax seed -2 8 2
pistachio nuts -3 8 2
cashews -2 24 7
brazil nuts -3 25 8
pine nuts -4 26 9
butternuts -6 43 13
walnuts -3 44 14
sesame seeds -3 54 17
pumpkin seeds 1 98 27
sunflower seeds 2 110 30

balancing alkalinity and nutrient density

So my big takeaway from the analysis above is that alkalinity and nutrient density are not necessarily related.  You can’t just say ‘eat your fruits and vegetables and avoid protein’ to manage your alkalinity and maximise nutrients at the same time.  Particularly given that protein is the one macronutrient that seems to be correlated with nutrient density.

Recent clinical studies and a meta-analysis have indicated either no effect or a modest benefit associated with higher protein intakes. These contradictory considerations may be explained by the existence of a two-faced relationship between protein and bone, with simultaneous positive and negative pathways. In opposition to the negative effects of dietary acid load, protein may exert positive effects related to improving calcium absorption, increasing insulin-like growth factor 1, or improving lean body mass, which, in turn, improves bone strength.[26]

The chart below shows  a comparison of the nutrient density of the top 10% of the USDA food database for a range of dietary approaches.  If we prioritise our food choices based on low PRAL values alone we end up with a lower nutrient density.

image52

Most things in nutrition are not binary.  We can’t just take one parameter and use it to guide ALL our decisions about nutrition.  That includes protein, carbs, fat, energy density, nutrient density or alkalinity.

Where it gets gets is when we mix and match a number of factors to prioritise our food choices to suit our goals.

image20

Nutrient dense low alkaline foods typically have quite a low energy density so we don’t have to worry too much about that.  To develop the list of more alkaline nutrient dense in the following section I have factored in:

  • nutrient density,
  • PRAL, and
  • insulin load.

The chart below shows a comparison of the nutrients provided by the top 10% of foods for the following approaches:

  • low PRAL,
  • nutrient dense alkaline, and
  • nutrient dense maintenance.

image31

If we just prioritise low PRAL (grey bars) then the amino acids drop.  However, if we prioritise low PRAL and nutrient density we get a better balance of alkalinity and nutrient density across the board.

  • The chart below shows a comparison of macronutrients.
  • The nutrient dense approach is quite high in protein while the more alkaline approach has less protein and more carbs from more veggies.
  • If we only look at minimising PRAL we get a lot of fibre and less protein.
  • The nutrient dense alkaline approach provides a reasonable balance in terms of macronutrients.

image50

From an insulin load perspective, the low PRAL approach is relatively insulinogenic.  Considering insulin load in the multi criteria analysis gives us a little bit of additional dietary fat which is useful for blood glucose regulation or satiety, particularly if we’re not trying to lose weight.  Moderate amounts of dietary fat help with the absorption of the fat-soluble vitamins A, D, E and K).

image11

The chart below shows a comparison of some of the key minerals provided by a number of dietary approaches (note: phosphorus is acidic while the magnesium, calcium, potassium and sodium are alkaline).

  • The therapeutic ketosis and the average of all foods do not have a lot of alkalising magnesium, calcium, potassium and sodium to balance the acid forming phosphorus.
  • By comparison, the nutrient dense alkaline and low PRAL foods have a lot more alkalising minerals to balance the acidic phosphorus.

image16

Rather than worrying about actively balancing our pH I think we focus on maximising nutrient density our body will have what it needs to do what is necessary to balance pH.  Maximising nutrient density will also minimise nutrient hunger so our bodies will be satisfied with less and our kidneys won’t have to process as much.

The chart below shows that after Vitamin D and Vitamin E, many people are getting less than the recommended intake of magnesium, calcium and zinc (i.e. alkalising minerals).

image13

PRAL value of different nutritional approaches

The chart shows the PRAL value for thirteen different nutritional approaches outlined on this blog.

  • The nutrient dense vegan approach the is the most alkaline while the zero-carb approach is the most acidic.
  • The nutrient dense alkaline foods (listed below) end up being nearly as alkaline as the vegan.
  • On average, the 8000 foods in the USDA database have a net acid load.
  • The zero carb, high insulin load and therapeutic ketogenic approaches have net acid load.
  • Most of the other approaches that focus on nutrient density have adequate vegetables to ensure that they are alkaline overall.

image12

If the alkalinity of our diet does actually have a bearing on insulin resistance, oxygen availability / hypoxia, insulin sensitivity I wonder if people pursuing a therapeutic ketogenic approach should actually be considering prioritising their veggies and / or or mineral supplements that will balance their alkalinity to balance out their diet.

Results of recent observational studies confirm an association between insulin resistance and metabolic acidosis markers, including low serum bicarbonate, high serum anion gap, hypocitraturia, and low urine pH.[27]

image28

nutrient dense alkaline foods

The list of foods is prioritised for nutrient density, alkalinity and a lower insulin load.

vegetables, spices and fruit

image19

The list of vegetables and fruit below are both nutrient dense and highly alkaline.  Whether you buy into this alkaline food theory it will be hard to go wrong if you eat more of these foods which are nutrient dense and have a low insulin load.

If you are concerned that your body is lacking alkalising minerals, focusing on the green leafies at the top of this list will be a good first step.   Real food is always going to be a better option than supplements.

food ND insulin load (g/100g) PRAL/2000cal MCA
watercress 13 2 -1,034 2.8
spinach 11 4 -895 2.7
endive 9 1 -707 2.7
chicory greens 8 2 -724 2.5
basil 9 3 -569 2.3
coriander 7 2 -841 2.3
chard 9 3 -857 2.3
beet greens 7 2 -1,523 2.2
escarole 6 1 -495 2.2
zucchini 7 2 -489 2.2
Chinese cabbage 8 2 -1,241 2.1
lettuce 8 2 -419 2.0
mustard greens 6 3 -507 2.0
parsley 7 5 -618 2.0
arugula 7 3 -629 2.0
dandelion greens 8 7 -353 1.9
sage 6 26 -295 1.9
asparagus 9 3 -199 1.9
turnip greens 7 4 -307 1.8
summer squash 6 2 -397 1.8
okra 7 3 -243 1.7
alfalfa 8 1 154 1.6
thyme 5 31 -257 1.6
cloves 6 35 -216 1.6
curry powder 5 14 -107 1.6
collards 6 4 -141 1.6
paprika 4 26 -262 1.6
cucumber 4 1 -424 1.5
pickles 4 1 -424 1.5
celery 4 3 -610 1.5
chives 5 4 -317 1.5
brown mushrooms 7 5 -383 1.5
broccoli 6 5 -204 1.4
marjoram 3 27 -364 1.4
cauliflower 4 4 -351 1.4
bamboo shoots 4 5 -591 1.3
banana pepper 3 3 -296 1.2
celery flakes 3 42 -530 1.2
sauerkraut 3 2 -328 1.2
seaweed (wakame) 8 11 -59 1.2
cabbage 4 4 -286 1.2
dill 3 8 -721 1.2
radicchio 4 4 -413 1.2
radishes 2 2 -551 1.2
rhubarb 3 3 -621 1.2
seaweed (kelp) 6 10 -224 1.2
portabella mushrooms 5 5 -204 1.2
edamame 5 13 7 1.1
artichokes 4 7 -211 1.1
kale 4 5 -302 1.1
poppy seeds 3 23 -7 1.1
white mushroom 5 5 -205 1.1
snap beans 4 3 -215 1.0
eggplant 1 3 -314 1.0
caraway seed 3 28 -80 1.0
yeast extract spread 3 27 -369 1.0
dill seed 2 43 -218 0.9
cumin 2 44 -171 0.9
turnips 2 3 -275 0.9
shiitake mushroom 5 7 -80 0.9
onions 3 6 -312 0.9
jalapeno peppers 1 3 -269 0.9
soybeans (sprouted) 4 12 -16 0.9
tarragon 2 56 -437 0.9
pumpkin 3 4 -380 0.9
spirulina 6 6 -1 0.9
red peppers 2 3 -219 0.8
chayote 1 3 -228 0.8

nuts and seeds

image15

Coconuts do pretty well.  Some of the other nuts are not so nutrient dense or alkaline, so this list isn’t too long.  Keep in mind that drinking a lot of coconut water might not be ideal for someone with diabetes due to the carbohydrate content.

food ND insulin load (g/100g) PRAL/2000cal MCA
coconut water 2 3 -539 1.0
coconut milk 1 5 -16 0.9
flax seed 1 16 8 0.9
coconut meat 1 9 -15 0.9
coconut cream 1 7 -9 0.8
almond butter 1 26 5 0.8
pumpkin seeds 2 29 98 0.8
almonds 1 25 7 0.8
sunflower seeds 1 22 110 0.7

seafood

image21

If you are eating plenty of veggies I think you can so afford to also eat plenty of nutrient dense seafood as the acid / alkaline will balance each other out in the long run.   While there have been some concerns that a high protein diet will cause acidity that will, in turn, cause osteoporosis due to calcium being used to buffer the acid, more recent research indicates that protein has a net positive effect on bone health.[28] [29]

food ND insulin load (g/100g) PRAL/2000cal MCA
fish roe 11 18 285 1.6
caviar 7 23 76 1.5
trout 8 18 131 1.3
salmon 8 20 180 1.3
sturgeon 8 16 165 1.2
sardine 6 19 153 1.2
oyster 8 14 146 1.1
halibut 9 17 175 1.1
mackerel 3 10 34 1.1
anchovy 6 22 69 1.1
cisco 5 13 75 1.1
cod 9 48 205 1.1
flounder 9 12 322 1.1
crab 9 14 238 1.1
crayfish 9 13 253 1.1
pollock 8 18 168 1.1
rockfish 8 17 168 1.0
lobster 8 15 201 1.0
perch 8 14 297 0.9
herring 4 19 114 0.9
white fish 7 18 123 0.9
whiting 7 18 197 0.9
shrimp 8 19 282 0.9
haddock 7 19 188 0.8
clam 7 25 128 0.8

dairy and egg

image08

A number of cheeses make it onto the list due to their nutrient density along with egg, butter and cream.  Cheese are typically acidic however, in moderation, they can potentially form part of a well-rounded diet.

The problem, I think, is a that a lot of people looking for a low carb / keto dietary approach (me included) end up eating large quantities of dairy (e.g. cream, cheese and butter) and end up struggling to keep the weight off or find that they are “allergic to dairy”.   Perhaps excess acid load without adequate minerals to balance it from green leafy veggies may be playing a role here?

food ND insulin load (g/100g) PRAL/2000cal MCA
egg yolk 4 12 133 1.1
feta cheese 4 15 85 1.1
whole egg 5 10 133 1.0
milk 5 7 5 1.0
Swiss cheese 4 22 104 1.0
cheddar cheese 3 20 85 1.0
gruyere cheese 3 23 103 1.0
gouda cheese 4 21 113 0.9
Eggnog 5 11 14 0.9
kefir 6 7 14 0.9
edam cheese 3 21 100 0.9
mozzarella 4 26 123 0.9
cream 1 5 3 0.9
Monterey cheese 3 19 88 0.8
limburger cheese 2 15 90 0.8
butter 0 3 -0 0.8
muenster cheese 3 19 87 0.8
goat cheese 3 14 119 0.8
sour cream 1 6 -2 0.8
cream cheese 1 10 15 0.8
Colby 2 20 83 0.8
camembert 2 16 87 0.8
low fat milk 5 8 -1 0.8
blue cheese 2 19 68 0.8
cream cheese (low fat) 8 19 306 0.7
parmesan cheese 3 35 102 0.7
ricotta 2 12 71 0.7

animal products

image09

Several animal products make the list even though they carry an acid load.  I don’t think “animal protein” is really a concern if you are also eating your alkalising veggies.  Seafood and animal products are also nutrient dense and have beneficial properties, including lean body mass[30] and bone health.    If you can, it’s going to be ideal to consume seafood and animals that aren’t fed more acidic grains.

food ND insulin load (g/100g) PRAL/2000cal MCA
lamb liver 7 20 274 0.9
beef brains 3 8 166 0.9
ham (lean only) 7 17 239 0.8
lamb kidney 6 15 267 0.8
turkey liver 5 21 218 0.7
ground turkey 3 19 115 0.7
turkey heart 4 20 182 0.6
pork 3 22 128 0.6
roast ham 3 18 137 0.6
lamb brains 2 10 197 0.6
beef kidney 5 20 283 0.6
roast pork 3 20 130 0.6
chicken liver 5 20 250 0.6
lamb sweetbread 4 15 313 0.5
turkey drumstick 4 21 188 0.5
turkey meat 4 21 188 0.5
pork chop 5 23 195 0.5
leg ham 4 22 175 0.5

other dietary approaches

I’ve added this list to the various dietary in the table below.  If you’re already getting plenty of veggies then acidity probably won’t be a problem with your acid balance.  But if you already have metabolic acidosis, gout or kidney concerns they you may want to focus on getting more of the alkaline foods.

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

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.

image43

am I getting enough veggies?

If you have blood tests handy you can see if they show any of the following signs that may suggest that your diet is more acidic and / or you are struggling to balance your acid load:

  • high uric acid levels,
  • low bicarbonate levels / CO2 levels,
  • a high anion gap,[31]
  • high potassium, or
  • low sodium / potassium ratio,

These values will give you an indication whether your kidneys are keeping up and you might need to review your diet.

If you don’t have the blood tests available, you can test your urine pH which gives you an indication of how much acid versus alkaline ash your kidneys are clearing after digestion.  This will not necessarily tell you how alkaline your blood is, but rather whether your body is having to excrete alkaline or acidic waste products after digestion which appears to still be a relevant guide.

The chart below shows the urine pH of people in the Caciano et al study noted above when they changed their diet to a low PRAL (alkaline) or high PRAL (acidic) dietary approach.   Most participants could achieve the high PRAL acidic target of greater than a pH of 6.0 within four days.  However, it took some participants up to nine days of changing their diet to achieve an alkaline pH of greater than 7.0.

image19

If you’re interested, you can grab some pH test tape and see where you are currently at.  If you find your urine is more acidic (i.e.  pH lower than 6.0) you could consider manipulating your diet and / or use mineral supplements until you are achieving a pH of greater than 6.8 or so.

image15

supplementation

Obviously eating real food such as the ones listed above is preferable.  However, if simply adding more non-starchy veggies listed above doesn’t work for you there are a number of other more aggressive options that you can turn to.

One popular approach is to use a greens powder.  On the positive side, a few spoonful’s of this will quickly give you lots of micronutrients and alkalising minerals.  However, real veggies are always going to be better and it will give you about one gram of carbohydrates per serving.

image40

Another option is to use baking soda which is highly alkaline and has been shown to improve athletic performance in a range of studies (check out the plethora of study reviews on Adel’s SuppVersity site if you are interested in seeing how the alkalinity provided by Bicarbonate can affect exercise performance).[32] [33] [34]

image39

In situations that result in acute acidosis, supplementing younger patients with sodium bicarbonate prior to exhaustive exercise resulted in significantly less acidosis in the blood than those that were not supplemented with sodium bicarbonate.[35]

The pros of baking soda is that it is cheap and effective and will turn your urine pee sticks blue very quickly (see picture below).  It may also cause gut distress if you have a sensitive gut (as many people with diabetes do).  And you’ll also be missing out on all the other benefits of eating whole veggies.

image08

Elizma says:

I prefer citrate minerals since taking bicarb soda can dilute stomach acid when taken with meals whereas citrate minerals can be taken at any time.  Using citrate minerals has a ‘bicarbonate sparing’ effect without necessarily taking bicarbonate.

By reducing the workload on the pancreas more ATP is available to produce insulin.   The lungs can only deal with volatile acids that can be excreted via CO2, but the kidneys have to do the rest via ammonia.

I think people try and simplify it for themselves by talking about acid / alkaline diets when it’s more to do with minerals imbalances and other factors that shift metabolic acid production.

But does it really matter what we call it if people eat better?

In our house what we’re trying to do is maximise the green leafy veggies, not overdo the dairy, perhaps increase the coconut intake as well as taking the a little and then take the potassium, calcium and magnesium citrate mineral supplement mix until the urine pH consistently is above 6.8.

are ketones acidic ketones?

If you are taking exogenous ketone supplements, then making sure you get your green leafies or taking a mineral supplement may be even more important.

Your body will likely secrete some insulin to bring down the total energy in your bloodstream if you have really high ketones, particularly in a fed state.  A recent study indicated that the pancreas does not secrete insulin in response to ketones alone, but rather when glucose is greater than 5.0 mmol/L or 90 mg/dL and you add in additional ketones.

So, I wondered if adding exogenous ketones to a diet that is not already ketogenic (i.e. high blood glucose levels) is a recipe for accelerated hyperinsulinemia and acidity?

image22

I had some exogenous ketones lying around the house so I thought it would be interesting to test at what point they become acidic.

Seems the answer is yes for the ketone salts…

image06

2016-11-19 11.03.08.jpg

… and so is the Ketone Aid ketone ester.

image37

So maybe some of the acidity that I saw on my blood tests could also have been contributed to by me dabbling with exogenous ketones?

image49 [36]

So are exogenous ketones also acidic inside the body?  In the name of science I downed two packets of Keto//OS.  My ketone value went from 0.6 to 0.8mmol/L and the increased insulin released to clear the exogenous ketones also brought the blood glucose levels down over a period of about five hours.

2016-11-19 10.49.07.jpg

But the pH of my urine also went from alkaline to acidic as my kidneys worked to clear the acid load from the exogenous ketones.  I sure hope all those people with the recurring order of Keto//OS are also taking mineral supplements and ideally eating lots of green leafy veggies.

2016-11-19 12.57.53.jpg

I also wonder what the long term effects of high levels of exogenous ketones will be on people who are taking them for cancer and other conditions which appear to be exacerbated by insulin and acidity.  I suppose time will tell.

Interestingly there are some people who feel that increased ketones are more a downstream symptom of increased NAD+.  It’s actually the increased NAD+ that occurs in fasting and carb restriction and the upregulated Sitruins that is causing the positive outcomes and not actually the ketones themselves.

2016-11-20 03.04.20.png

endogenous ketones

Endogenous ketones are acidic too,[37] [38] though this is not really a problem in someone who has a functioning pancreas and is producing adequate insulin to keep ketone levels under control.  When the pancreas fails to produce adequate insulin in (i.e. Type 1 Diabetes) it is called ketoacidosis and it can be very dangerous.

In a metabolically healthy person, alkalising minerals play a role in balancing out the acid load of the ketones and actually neutralising them.  Perhaps this is part of the reason that many metabolically fit athletes do not tend to see really high blood ketones even if they have been following a ketogenic diet for a long time?  If their kidneys and pancreas are functioning well, they have adequate minerals to balance their acidity they will be able to happily operate most of the time with very low glucose and ketone values (i.e. low total energy).

Perhaps the reverse could be an interesting “hack” if you really wanted to achieve higher blood ketone values without fasting?

In his Keto Summit interview, Bryan Walsh (pictured below) raised some interesting questions about pH balance on a long term ketogenic diet.

Can we deplete our buffering capacity by being in this chronically acidic state all the time, a self-induced acidic state, meaning a ketogenic diet?  Long term can we deplete our body’s ability to mitigate this pH shift? 

The body will still maintain an incredibly tight pH.  But at what expense? What are we using up that we may have used for something else to try to maintain this golden egg of pH in the body?

I don’t think over time you’d see somebody’s pH shift.  But what I do think is that other things would suffer as a consequence.

image32

metabolic acidosis and insulin resistance

When you dig into the literature, there seem to be a lot of parallels between Type 2 Diabetes and metabolic acidosis.[39] [40] [41]  Type 2 Diabetes and kidney disease often occur together.

“[The] dietary acid load is directly associated with an increased risk of type 2 diabetes. From a public health perspective, dietary recommendations should not only incriminate specific food groups but also include recommendations on the overall quality of the diet, notably the need to maintain an adequate acid/base balance.”[42]

image09

The pancreas’ job is to maintain normal blood glucose levels within a tight range.  The adipose tissue continues to store the excess energy from processed carbs through de novo lipogenesis until it can’t take anymore and we become insulin resistant in order to slow the storage of fat in the adipose tissue.  Then, in the long run the pancreas burns out and we require exogenous insulin.

Similar to the pancreas’ role with glucose, it seems the kidneys maintain our pH within a tight range.  But then over time if it is subjected to excessive acid load, just like excessive glucose in our pancreas, our tight grip on pH may slip, even a little.  Then the kidneys start to burn out.  They no longer maintain optimal acid levels, but rather slightly more acidic levels and then lose their grip on optimal oxygenation of the blood which leads to a plethora of metabolic issues.

Similar to maintaining tight blood glucose control, part of the solution to slow the decline in our kidney function may be to eat some more leafy greens while minimizing the acidic load from nutrient poor foods such as sugar and processed grains.

muscle loss

Another parallel between Type 2 Diabetes and metabolic acidosis is muscle loss.  Our ability to optimise lean muscle mass is critical to maintaining good glucose disposal and insulin sensitivity.

Recent insights indicate that several consequences of metabolic acidosis including the development of insulin resistance can stimulate muscle protein degradation.[43]

So if we don’t eat our veggies, maybe we risk losing our gainz?!?!?

In Type 2 Diabetes we often see excess gluconeogenesis when the body can’t burn fat due to high insulin / insulin resistance and instead to protein in our diet and body for energy.

Evidence increasingly suggests that acidosis promotes muscle protein wasting by both increasing protein degradation and inhibiting protein synthesis.

Correction of acidosis may therefore help to preserve muscle mass and improve the health of patients with pathological conditions associated with acidosis.[44]

The chart below shows that people with the highest amount of potassium excretion in the urine (i.e. most alkaline) had a greater percentage of lean body mass.  Perhaps the quickest way to get buff is to get adequate protein AND eat your veggies to enhance fat burning and reduce your reliance on glucose and protein for energy.

image27

It has been demonstrated that even the slightest degree of metabolic acidosis produces insulin resistance in healthy humans. Many recent epidemiological studies link metabolic acidosis indicators with insulin resistance and systemic hypertension.

The strongly acidogenic diet consumed in developed countries produces a lifetime acidotic state, exacerbated by excess body weight and aging, which may result in insulin resistance, metabolic syndrome, and Type 2 diabetes, contributing to cardiovascular risk, along with genetic causes, lack of physical exercise, and other factors… 

Even very slight levels of chronic kidney insufficiency are associated with increased cardiovascular risk, which may be explained at least in part by deficient acid excretory capacity of the kidney and consequent metabolic acidosis-induced insulin resistance.[45]

image23 [46]

As we age, there is a loss of muscle mass, which may predispose us to falls and fractures. A three-year study looking at a diet rich in potassium, such as fruits and vegetables, as well
as a reduced acid load, resulted in preservation of muscle mass in older men and women. Conditions such as chronic renal failure that result in chronic metabolic acidosis result in accelerated breakdown in skeletal muscle. 

Correction of acidosis may preserve muscle mass in conditions where muscle wasting is common such as diabetic ketosis, trauma, sepsis, chronic obstructive lung disease, and renal failure.[47]

summary

  • Whether you think eating alkaline foods is useful or woo woo junk it appears that metabolic acidosis is a thing.
  • Metabolic acidosis seems to be interrelated with insulin resistance, Type 2 Diabetes and retention of muscle mass.
  • To prevent metabolic acidosis it appears prudent to ensure that your body has adequate minerals to enable your kidneys to balance pH over the long term. This can be achieved by eating plenty of veggies and / or supplementing with alkaline minerals (e.g. magnesium, sodium, potassium, zinc etc.).
  • If you eat plenty of veggies you’re probably getting enough alkalising minerals, however you can easily test your urine to see if your dietary acid load is high.
  • If you are targeting a high fat therapeutic ketogenic diet, following a zero carb dietary approach and / or taking exogenous ketones it seems then it may be even more important to be mindful of your acid load and consider mineral supplementation.

epilogue

So, you may be wondering how my ketones are going these days with the alkalising minerals on board.  They seem to be a little lower now with the mineral supplementation.   When I fast for a few days they kick in and might get to around 2.0mmol/L and hunger is not a big deal.  I think the ketones are doing what they’re meant to do.

I’m still not exactly sure why my ketone spiked off the chart that brief period.  I think Elizma’s explanation makes sense.  That is, my insulin sensitivity improved and the flood gate of free fatty acids was released for a time and then settled down.  In time though I think the alkalising minerals balance out the ketones and keep them from getting too high.

I have also been taking the Niacel on an ongoing basis to increase NAD+ which in appears to increase the breath acetone (fat burning) and decreases the ketones in the blood (BHB).  But more on that in future posts.  This one is already too long.

The ratio of β-OHB to AcAc depends on the NADH/NAD+ ratio inside mitochondria; if NADH concentration is high, the liver releases a higher proportion of β-OHB.[48]

I think being able to run with a lower total energy (i.e. glucose plus ketones) in the blood most of the time might be a good thing.  When high levels of glucose or ketone are required (e.g. fasting or explosive exercise) they can be easily accessed if we have good insulin sensitivity.

post updated May 2017

references

[1] https://www.ncbi.nlm.nih.gov/pubmed/8396707

[2] https://en.wikipedia.org/wiki/PH

[3] http://www.forbes.com/sites/quora/2016/03/11/how-our-bodies-go-to-extraordinary-lengths-to-maintain-safe-ph-levels/#4dd8545c208a http://www.forbes.com/sites/quora/2016/03/11/how-our-bodies-go-to-extraordinary-lengths-to-maintain-safe-ph-levels/#667262df208a

[4] http://ketosummit.com/

[5] http://www.gbrmpa.gov.au/managing-the-reef/threats-to-the-reef/climate-change/how-climate-change-can-affect-the-reef/ocean-acidification

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

[7] http://thepaleodiet.com/acidbase-balance/

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

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

[10] http://christinecronau.com/wp-content/uploads/2014/01/pH.pdf

[11] https://www.facebook.com/drjackkruse/posts/1537554709642211

[12] http://www.nature.com/articles/srep35907

[13] https://en.wikipedia.org/wiki/Warburg_hypothesis

[14] https://en.wikipedia.org/wiki/Respiratory_exchange_ratio

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

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

[17] http://www.madehow.com/inventorbios/32/Pierre-Eug-ne-Marcellin-Berthelot.html

[18] https://www.ncbi.nlm.nih.gov/pubmed/7797810

[19] http://www.precisionnutrition.com/acid-base

[20] http://thepaleodiet.com/acidbase-balance/

[21] https://www.ncbi.nlm.nih.gov/pubmed/7797810

[22] https://www.ncbi.nlm.nih.gov/m/pubmed/23439373/

[23] https://www.ncbi.nlm.nih.gov/pubmed/7797810

[24] http://www.wheatbellyblog.com/2015/02/mind-minerals/

[25] https://www.ncbi.nlm.nih.gov/pubmed/21248199

[26] https://www.ncbi.nlm.nih.gov/m/pubmed/21457266/

[27] https://www.ncbi.nlm.nih.gov/m/pubmed/21481501/

[28] http://nutritionfacts.org/video/alkaline-diets-animal-protein-and-calcium-loss/

[29] https://www.ncbi.nlm.nih.gov/pubmed/15546911

[30] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597402/

[31] https://en.wikipedia.org/wiki/High_anion_gap_metabolic_acidosis

[32] http://firstendurance.com/the-ph-of-foods-and-their-effect-on-performance/

[33] https://www.facebook.com/groups/optimisingnutrition/permalink/1607541596213549/?comment_id=1608380926129616&comment_tracking=%7B%22tn%22%3A%22R%22%7D

[34] https://www.facebook.com/groups/optimisingnutrition/permalink/1607541596213549/?comment_id=1608380926129616&comment_tracking=%7B%22tn%22%3A%22R%22%7D

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

[36] https://www.facebook.com/livinlowcarbman/photos/a.145604576319.138059.91566951319/10154770616481320/?type=3&comment_id=10154788120686320&comment_tracking=%7B%22tn%22%3A%22R%22%7D

[37] http://chemistry.stackexchange.com/questions/54459/why-are-ketones-acidic

[38] http://answers.wikia.com/wiki/Is_a_ketone_an_acid_or_a_base

[39] http://l.facebook.com/l.php?u=http%3A%2F%2Fsuppversity.blogspot.com.au%2F2013%2F04%2Fscience-round-up-seconds-macro-mineral.html&h=sAQHCVlPJ

[40] https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/diet-induced-acidosis-is-it-real-and-clinically-relevant/D7F03DFEF497996E90BB6DA487C777B8/core-reader

[41] https://www.ncbi.nlm.nih.gov/pubmed/21481501

[42] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4935236/

[43] https://www.ncbi.nlm.nih.gov/pubmed/16736444

[44] https://www.ncbi.nlm.nih.gov/pubmed/15586003

[45] https://www.ncbi.nlm.nih.gov/pubmed/21352078

[46] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3155690/

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

[48] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709699/

curried egg with cows brain

Considering how very nutrient dense offal is, it’s been surprisingly hard to find organ meat recipes that do really well in the nutrition ranking because so many of the recipes are ‘diluted’ with lots of sweet stuff to mask the taste.

That is, until Tristan Haggard sent me their long awaited ‘ketogenic edge cookbook‘.

2016-11-18-1

Tristan and Jessica Haggard from Primal Edge Health moved from California to Ecuador to seek a healthier place to live and raise their family.

Clean water.  More sunshine.  Closer to the equator.

These guys are the real deal.

The recipes in their new cookbook document’s how Jessica lovingly makes sure they ensure they ensure they thrive with their food.  It’s not all offal, but it’s clean, nutrient dense and simple, even when it comes to the deserts.

2016-11-18

This recipe for curried eggs with cows brains does spectacularly  well with the vitamins and minerals as well as the amino acids while still being 68% fat.

2016-11-18-3

The table below shows the nutritional data per 500 calorie serving.

net carbs Insulin load carb insulin fat protein fibre
4g 16g 27% 68% 21g 14g

Combining the brains  with the egg, spinach and avocado makes for a pretty unbeatable combination when it comes to nutrient density.  In fact it ranks at:

The only thing really missing from the book is a family photo to show how health these nutrient dense whole foods are making them.  So here you go.

I  also recommend you check out their YouTube Channel, blog and podcast for some pragmatic nutrition and lifestyle advice.

 

no carb foods

For most people, the optimal dietary approach seems to include a balance of plant and animal based foods.  Some people prefer more (or all) plants due to ethical or religious reasons, while others prefer to avoid vegetables and grains.

Some people just don’t like veggies, while others struggle to digest plant fibres and find relief from debilitating digestive, mental health[1] or other symptoms when they avoid plant based foods and even dairy.[2] [3] [4]

Others feel that the nutrients in plant based foods are less bioavailable and that the nutrients in animal based foods will be more easily absorbed.[5]

image04

The chart below shows a comparison of the nutrients provided by:

  • the most nutrient dense zero carb foods,
  • the most nutrient dense plant based foods, and
  • the most nutrient dense foods available.

As you might expect, the zero carb foods (red bars) do well in the proteins and fatty acids while the plant based foods (blue bars) generally contain more vitamins and minerals.

image07

Going zero carb will reduce the insulin load compared to most dietary approaches, although the higher levels of protein may mean that you won’t necessarily be ‘ketogenic’ or showing high levels of blood ketones.

2016-11-07-1

While the recommended daily intake values for various nutrients is debatable, it appears that it is more difficult to obtain the recommended quantity of calcium, magnesium, potassium, vitamin E and vitamin C on a zero carb approach compared to others that contain plant based foods and hence it may be useful to supplement these nutrients.

2017-02-26 (19).png

You’ll notice the most nutrient dense zero carb foods listed below contain a solid amount of organ meats which are very nutrient dense.  The chart below shows the nutrient density of the highest ranking zero carb foods with and without organ meats (cutting out all carbohydrate containing foods narrows the list of available foods from 8000 to 2887 and removing offal narrows the list to 2784 available foods).  Organ meats makes a significant difference to the levels of copper, manganese, selenium, vitamin A and vitamin B-12.  So if you are going to go with a zero carb approach it makes sense to maximise your organ meats.

image03

The zero carb foods below are sorted using both nutrient density and insulin load (to make sure you’re not just eating lean protein).  Also included in the table are the nutrient density scores, percentage of insulinogenic calories, insulin load, energy density and the multicriteria analysis score (MCA) that combines all these factors (see the building a better nutrient density index article for more details on the MCA process).

offal

food ND insulin load (g/100g) calories/100g MCA
turkey liver 9 21 189 1.6
lamb liver 9 20 168 1.4
chicken liver 9 20 172 1.4
beef brains 5 8 151 1.4
lamb kidney 8 15 112 1.3
veal liver 8 26 192 1.2
beef liver 9 25 175 1.2
chicken liver pate 4 17 201 1.1
lamb brains 3 10 154 1.0
beef kidney 5 20 157 0.8
pork liver 5 23 165 0.7
beef heart 3 16 165 0.7
lamb sweetbread 3 15 144 0.7
liver sausage -2 10 331 0.7
turkey heart 3 20 174 0.7
lamb heart 3 19 161 0.6
sweetbread -2 9 318 0.6
beef tripe 3 14 103 0.6
beef heart 2 23 179 0.5

animal products

food ND insulin load (g/100g) calories/100g MCA
ham (lean only) 8 17 113 1.1
ground turkey 2 19 258 0.8
chicken breast 6 22 148 0.8
pork chop 5 23 172 0.8
roast ham 3 18 178 0.7
roast pork 3 20 199 0.7
turkey ham 3 14 124 0.7
ham 1 11 149 0.7
turkey drumstick 4 21 158 0.7
turkey meat 4 21 158 0.7
turkey (skinless) 2 16 170 0.6
turkey bacon -1 11 226 0.6
turkey drumstick (with skin) 0 15 221 0.6
chicken (leg with skin) 2 18 184 0.6
pork ribs 2 21 216 0.6
pork loin 2 19 193 0.6
pork shoulder 4 22 162 0.6
pork sausage -0 13 217 0.6
turkey -1 21 414 0.6
leg ham 4 22 165 0.6
pork 2 22 209 0.6
meatballs -1 14 286 0.6
veal loin 3 20 175 0.6
ground pork 3 25 185 0.6
salami -2 17 378 0.6
turkey 3 23 189 0.6
bratwurst -2 13 333 0.5
kielbasa -2 12 325 0.5
bologna -1 11 172 0.5
pork sausage -2 16 325 0.5
bacon -3 11 417 0.5
pork ribs -2 16 361 0.5
lean beef 3 23 149 0.5
veal 4 24 151 0.5

seafood

food ND insulin load (g/100g) calories/100g MCA
fish roe 10 18 143 1.6
caviar 7 23 264 1.5
salmon 9 20 156 1.5
trout 8 18 168 1.4
sturgeon 8 16 135 1.4
mackerel 3 10 305 1.2
crab 10 14 83 1.2
anchovy 6 22 210 1.2
halibut 9 17 111 1.2
crayfish 9 13 82 1.2
sardine 5 19 208 1.2
oyster 7 14 102 1.0
cisco 3 13 177 1.0
cod 8 48 290 1.0
lobster 8 15 89 1.0
flounder 7 12 86 1.0
herring 3 19 217 0.9
pollock 8 18 111 0.9
rockfish 7 17 109 0.8
perch 6 14 96 0.8
shrimp 6 19 119 0.7
haddock 6 19 116 0.7
tuna 4 23 184 0.7
whiting 5 18 116 0.6
white fish 5 18 108 0.5
octopus 5 28 164 0.5
clam 4 25 142 0.4
scallop 5 22 111 0.3

dairy and egg

food ND insulin load (g/100g) calories/100g MCA
egg yolk 4 12 275 1.4
whole egg 4 10 143 1.2
kefir 5 7 41 0.7
whey powder 9 82 339 0.6
cream -4 5 340 0.5
sour cream -3 6 198 0.5
feta cheese -2 15 264 0.4
butter -5 3 718 0.4
cheddar cheese -2 20 410 0.4
limburger cheese -2 15 327 0.4
camembert -2 16 300 0.4
blue cheese -2 19 353 0.4
Swiss cheese -2 22 393 0.4
cream cheese -4 10 350 0.4
gruyere cheese -2 23 413 0.4
cream cheese (low fat) 5 19 105 0.4
edam cheese -3 21 357 0.3
muenster cheese -3 19 368 0.3
Monterey cheese -3 19 373 0.3
gouda cheese -3 21 356 0.3

other dietary approaches

The table below contains links to separate blog posts and printable .pdfs for a range of dietary approaches (sorted from most to least nutrient dense) that may be of interest depending on your situation and goals.   You can print them out to stick to your fridge or take on your next shopping expedition for some inspiration.

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

If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help identify the optimal dietary approach for you.

image02

 

notes

[1] https://zerocarbzen.com/2016/10/04/zero-carb-interview-amber-ohearn/

[2] https://www.gutsense.org/fiber-menace/about-fiber-menace-book.html

[3] https://optimisingnutrition.com/2015/10/05/ketogenic-fibre/

[4] https://zerocarbzen.com/

[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3153292/

[6] However, keep in mind that this analysis is based on the USDA database that includes all the nutrients in the food rather than what will be absorbed.  Species specific nutrient bioavailability is still an emerging area.  While we can measure the nutrient in a food, it is hard to quantify how much of those nutrients are digested and absorbed into the body.

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.

image08

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 seem 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).

image25

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.

2016-10-29-6

Desperate times call for desperate measures!

image11

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.

image07

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.

image06

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.

image01

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, ffull-colourproduction with great graphics that will make it worth buying the hard copy to have and to hold.

TCGTF did originally have the working title Fasting Clarity as a follow on from Jimmy’s previous Cholesterol Clarity and Keto Clarity.   However, other than Jimmy’s discussion of his n=1 fasting experiences, TCGTF is predominantly written in Jason’s voice building from his blog, so it wouldn’t be appropriate for it to have become the third in Jimmy’s Clarity series.

What is similar to Jimmy’s clarity series is that it’s easy to read and accessible for people who are looking for an entry level resource.  This book will be great for people who are interested in the idea of fasting.  It is indeed the complete guide to fasting and is full of references to studies, however, it doesn’t go into so much depth as to lose the average reader with scientific detail and jargon.

The book covers:

  • Jimmy’s n=1 experience with fasting,
  • Dr George Cahill’s seminal work on the effects of fasting on metabolism, glucose, ghrelin, insulin, and electrolytes,
  • the history of fasting over the centuries,
  • myth busting about fasting,
  • fasting in weight loss,
  • fasting and diabetes, physical health, and mental clarity,
  • managing hunger during a fast,
  • when not to fast, and
  • when fasting can go wrong.

The book is complete with a section on fasting fluids (water, coffee, tea, broth) and a range of different protocols that you can use depending on what suits you.  What did seem out of place are the recipes for proper meals.  Apparently, the publisher insisted they include these to widen the appeal (If you don’t like the fasting bit you’ve still got some new recipes?)

Overall, the book will be an obvious addition to the library (or Kindle) of people who are already fans of Jason and / or Jimmy and want a polished, consolidated presentation of all their previous work with a bunch of new material added.

TCGTF will also be a great read for someone who is interested learning more about fasting and wants to start at the beginning.   TCGTF is the most comprehensive book on the topic of fasting that I’m aware of.

my additional 2c…

Jason doesn’t mind weighing into a controversial argument, using some hyperbole or dropping the occasional F-bomb for effect and Jimmy’s no stranger to controversy either, so I thought I’d take this opportunity to give you my 2c on some of the topical issues at the fringe that aren’t specifically unpacked in the book.  We learn more as we thrash out the controversial issues at the fringes.   Many arguments come down to context.

target glucose levels

Jason has come under attack for using the word ‘cured’ in relation to HbAc1 values that most diabetes associations would consider non-diabetic,[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.

image12

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).

image31

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.

image24

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.

image00

fasting to optimise blood glucose levels

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

image10

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.

image04

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.

image26

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.

image09

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.

image02

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.

14633142_10209291396354349_7869008000126784615_o

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.

image28

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.

image15

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.

image16

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.

image29

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.

image32

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.

image30

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.

image22

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.

image03

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.

image33

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.

image14

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).

image18

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.

image05

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.

image19

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.

image27

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.

image20

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.

image13

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.

image23

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

energy density, food hyper-palatability and reverse engineering optimal foraging theory

In Robb Wolf’s new book Wired to Eat he talks about the dilemma of optimal foraging theory (OFT) and how it’s a miracle in our modern environment that even more of us aren’t fat, sick and nearly dead.[1]

But what is  optimal foraging theory[2]?   In essence it is the concept that we’re programmed to hunt and gather and ingest as much energy us we can with the least amount of energy expenditure or order to maximise survival of the species.

In engineering or economics this is akin to a cost : benefit analysis.  Essentially we want maximum benefit for minimum investment.

image13

In a hunter gatherer / paleo / evolutionary context this would mean that we would make an investment (i.e. effort / time / hassle that we could have otherwise spent having fun, procreating or looking after our family) to travel to new places where food was plentiful and easier to obtain.

In these new areas we could spend as little time as possible hunting and gathering and more time relaxing.  Once the food became scarce again we would move on to find another ‘land of plenty’.

The people who were good at obtaining the maximum amount of food with the minimum amount of effort survived and thrived and populated the world, and thus became our ancestors.  Those that didnt’ didn’t.

You can see how the OFT paradigm would be well imprinted on our psyche.

OFT in the wild

In the wild, OFT means that native hunter gatherers would have gone bananas for bananas when they were available…

image28

… gone to extraordinary lengths to obtain energy dense honey …

image16

… and eaten the fattiest cuts of meat and offal, giving the muscle meat to the dogs.

image02

OFT in captivity

But what happens when we translate OFT into a modern context?

image09

Until recently we have never had the situation where nutrition and energy could be separated.

In nature, if something tastes good it is generally good for you.

Our ancestors, at least the ones that survived, grew to understand that as a general rule:

 sweet = good = energy to survive winter

But now we have entered a brave new world.

image19

We are now surrounded by energy dense hyperpalatable foods that are designed to taste good without providing substantial levels of nutrients.

image05

Our primal programming is defenceless to these foods.  Our willpower or our calorie counting apps are no match for engineered foods optimised for bliss point.

image14

These days diabetes is becoming a bigger problem than starvation in the developing world due to a lack of nutritional value in the the foods they are eating.[3]

The recent industrialisation of the world food system has resulted in a nutritional transition in which developing nations are simultaneously experiencing undernutrition and obesity.

In addition, an abundance of inexpensive, high-density foods laden with sugar and fats is available to a population that expends little energy to obtain such large numbers of calories.

Furthermore, the abundant variety of ultra processed foods overrides the sensory-specific satiety mechanism, thus leading to overconsumption.”[4]

what happens when we go low fat?

So if the problem is simply that we eat too many calories, one solution is to reduce the energy density of our food by avoiding fat, which is the most energy dense of the macronutrients.

Sounds logical, right?

The satiety index demonstrates that there is some basis to the concept that we feel more full with lower energy density, high fibre, high protein foods.[5] [6]   The chart below shows how hungry people report being in the two hours after being fed 1000 kJ of different foods (see the low energy density high nutrient density foods for weight loss article for more on this complex and intriguing topic).

image21

However the problem comes when we focus on reducing fat (along with perhaps reduced cost, increased shelf life and palatability combined with an attempt to reach that optimal bliss point[7]), we end up with cheap manufactured food like products that have little nutritional value.

image10

Grain subsidies were brought in to establish and promote cheap ways to feed people to prevent starvation with cheap calories.[8]  It seems now they’ve achieved that goal.[9]

image07

Maybe a little too well.

image01

The foods lowest in fat however are not necessarily the most nutrient dense.     Nutritional excellence and macronutrients are are not necessarily related.

In his blog post Overeating and Brain Evolution: The Omnivore’s REAL Dilemma Robb Wolf says:

I am pretty burned out on the protein, carbs, fat shindig. I’m starting to think that framework creates more confusion than answers.

Thinking about optimum foraging theory, palate novelty and a few related topics will (hopefully) provide a much better framework for folks to affect positive change. 

The chart below shows a comparison of the micronutrients provided by the least nutrient dense 10% of foods versus the most nutrient dense foods compared to the average of all foods available in the USDA foods database.

image18

The quantity of essential nutrients you can get with the same amount of energy is massive!  If eating is about obtaining adequate nutrients then the quality of our food, not just macronutrients or calories matters greatly!

Another problem with simply avoiding fat is that the foods lowest in fat are also the most insulinogenic, so we’re left with foods that don’t satiate us with nutrients and also raise our insulin levels.  The chart below shows that the least nutrient dense food are also the most insulinogenic.


what happens when we go low carb?

So the obvious thing to do is eliminate all carbohydrates because low fat was such a failure.  Right?

image20

So we swing to the other extreme and avoid all carbohydrates and enjoy fat ad libitum to make up for lost time.

The problem again is that at the other extreme of the macronutrient pendulum we may find that we have limited nutrients.

The chart below shows a comparison of the nutrient density of different dietary approaches showing that a super high fat therapeutic ketogenic approach may not be ideal for everyone, at least in terms of nutrient density.  High fat foods are not always the most nutrient dense and can also, just like low fat foods, be engineered to be hyperpalatable to help us to eat more of them.

image24

The chart below shows the relationship (or lack thereof) between the percentage of fat in our food and the nutrient density.   Simply avoiding or binging on fat does not ensure we are optimising our nutrition.

image12

While many people find that their appetite is normalised whey they reduce the insulin load of their diet high fat foods are more energy dense so it can be easy to overdo the high fat dairy and nuts if you’re one of the unlucky people whose appetite doesn’t disappear.

image08

what happens when we go paleo?

So if the ‘paleo diet’ worked so well for paleo peeps then maybe we should retreat back there?  Back to the plantains, the honey and the fattiest cuts of meat?

image27

Well, maybe.  Maybe not.

image06

For some people ‘going paleo’ works really well.  Particularly if you’re really active.

Nutrient dense, energy dense whole foods work really well if you’re also going to the CrossFit Box to hang out with your best buds five times a week.

image11

But for the rest of us that aren’t insanely active, then maybe simply ‘going paleo’ is not the best option…

image25

… particularly if we start tucking into the energy dense ‘paleo comfort foods’.

image03

If we’re not so active, then intentionally limiting our exposure to highly energy dense hyperpalatable foods can be a useful way to manage our OFT programming.

enter nutrient density

A lot of people find that nutrient dense non-starchy veggies, or even simply going “plant based”, works really well, particularly if you have some excess body fat (and maybe even stored protein) that you want to contribute to your daily energy expenditure.

image15

Limiting ourselves to the most nutrient dense foods (in terms of nutrients per calorie) enables us to sidestep the trap of modern foods which have separated nutrients and energy.  Nutrient dense foods also boost our mitochondrial function, and fuel the fat burning Krebs cycle so we can be less dependent on a regular sugar hit to make us feel good (Cori cycle).

Limiting yourself to nutrient dense foods (i.e. nutrients per calorie) is a great way to reverse engineer optimal foraging theory.

image04

If your problem is that energy dense low nutrient density hyperpalatable foods are just too easy to overeat, then actively constraining your foods to those that have the highest nutrients per calorie could help manage the negative effects of OFT that are engrained in our system by imposing an external constraint.

image22

But if you’re a lean Ironman triathlete these foods are probably not going to get you through.  You will need more energy than you can easily obtain from nutrient dense spinach and broccoli.

optimal rehabilitation plan?

So while there is no one size fits all solution, it seems that we have some useful principles that we can use to shortlist our food selection.

  1. We are hardwired to get the maximum amount of energy with the least amount of effort (i.e. optimal foraging theory).
  2. Commercialised manufactured foods have separated nutrients from food and made it very easy to obtain a lot of energy with a small investment.
  3. Eliminating fat can leave us with cheap hyperpalatable grain-based fat free highly insulinogenic foods that will leave us with spiralling insulin and blood glucose levels.
  4. Eating nutrient dense whole foods is a great discipline, but we still need to tailor our energy density to our situation (i.e. weight loss vs athlete).

the solution

So I think we have three useful quantitative parameters with which to optimise our food choices to suit our current situation:

  1. insulin load (which helps as to normalise our blood glucose levels),
  2. nutrient density (which helps us make sure we are getting the most nutrients per calorie possible), and
  3. energy density (helps us to manage the impulses of OFT in the modern world).

image30

I have used a multi criteria analysis to rank the foods for each goal.  The chart below shows the weightings used for each approach.

image23

The lists of optimal foods below have been developed to help you manage your primal impulses.  The table below contains links to seperate blog posts and printable .pdfs for a range of dietary approaches that may be of interest depending on your goals and situation.

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

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.

survey

I hope this helps.  Good luck out there!

post last updated May 2017

references

[1] http://ketosummit.com/

[2] https://en.wikipedia.org/wiki/Optimal_foraging_theory

[3] http://www.hoajonline.com/obesity/2052-5966/2/2

[4] https://www.ncbi.nlm.nih.gov/pubmed/24564590

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

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

[7] https://www.nextnature.net/2013/02/how-food-scientists-engineer-the-bliss-point-in-junk-food/

[8] https://en.wikipedia.org/wiki/Agricultural_subsidy

[9] http://blog.diabeticcare.com/diabetes-obesity-growth-trend-u-s/

nutrient dense diabetic friendly vegan foods

  • Eating plant-based foods can be a great way to improve nutrient density and reduce the amount of highly insulinogenic processed carbohydrates in your diet.
  • This article looks at how we can optimize a plant-based diet for nutrient density as well as diabetic friendly by reducing insulin load.
  • Finally, we will look at whether adding additional food groups such as seafood, dairy or eggs would diminish or improve the nutrient density of a plant based approach.

nutrient density

A nutrient dense diet is key to maximizing health and satiety with a minimum of calories.  Maximising nutrient density enables our mitochondria to do more with less.

If our world is full of beneficial nutrients our body realises that there is no longer an energy crisis and is more likely to stop searching for more nutrients and lets go of our stored body fat and decrease appetite.

As detailed in the ‘Building a Better Nutrient Density Index’ article, quantifying nutrient density enables us to prioritise foods that contain the highest amount of essential nutrients that are harder to obtain.[1]

The chart below (click to enlarge) shows the percentage of the recommended daily intake of various essential nutrients provided by:

  • all 7000+ foods in the USDA foods database,
  • plant based foods, and
  • the most nutrient dense plant based foods.

2016-10-22

Restricting ourselves to ‘plant based’ foods will improve the vitamin and mineral content of the foods we eat.  However, focusing on the most nutrient dense plant based foods allows us to improve nutrient density even further

most nutrient dense plant based foods

Listed below is a summary of the most nutrient dense plant based foods sorted by their nutrient density score.  The nutrient density score (ND) is shown for each of the foods.

As you can see from the plot below from Nutrition Data, celery, which has a very high nutrient density score (ND), will provide you with a range of vitamins and minerals equivalent to 92% of your recommended daily intake with 1000 calories and 83% of your protein intake with 1000 calories.  Keep in mind though that you would need to eat five bunches of celery to get that 1000 calories though.

2016-10-22-1

The fact that broccoli has a low energy density may be a benefit if you are trying to lose weight, but perhaps would not be so helpful if you are fueling for an Ironman Triathlon.

Also shown in the tables below is the net carbohydrates and calories per 100g for each of the foods listed.

The great thing about most of these foods is that they will provide you with heaps of nutrients while having a low energy density which will make it hard to over consume them to a point that they will spike your blood glucose levels.

Listed below are the most nutrient dense plant based foods.  In the second half of this article we will look at how we can choose foods that will be more gentle on blood glucose levels for those of us that are more insulin resistant.

vegetables and spices 

food ND insulin load (g/100g) calories/100g MCA
watercress 13 2 11 2.2
white mushroom 10 5 22 1.8
spinach 10 4 23 1.7
portabella mushrooms 10 5 29 1.7
asparagus 10 3 22 1.7
spirulina 9 6 26 1.5
alfalfa 9 1 23 1.5
brown mushrooms 8 5 22 1.3
basil 8 3 23 1.3
chard 8 3 19 1.3
endive 7 1 17 1.2
shiitake mushroom 7 7 39 1.2
seaweed (wakame) 7 11 45 1.1
zucchini 6 2 17 1.0
cauliflower 6 4 25 1.0
Chinese cabbage 6 2 12 1.0
turnip greens 5 4 29 0.9
chicory greens 5 2 23 0.9
escarole 5 1 19 0.9
mung beans 5 4 19 0.9
lettuce 5 2 15 0.9
parsley 5 5 36 0.8
radicchio 4 4 23 0.7
edamame 4 13 121 0.7
bamboo shoots 4 5 27 0.7
peas 4 7 42 0.7
soybeans (sprouted) 4 12 81 0.7
seaweed (kelp) 4 10 43 0.6
shiitake mushrooms 3 72 296 0.6
chives 3 4 30 0.6
paprika 3 26 282 0.6
coriander 3 2 23 0.6
collards 3 4 33 0.5
summer squash 3 2 19 0.5
beet greens 3 2 22 0.5
okra 3 3 22 0.5
mustard seed 3 37 508 0.5
celery 2 3 18 0.5
curry powder 2 14 325 0.4
arugula 2 3 25 0.4
Brussel sprouts 2 6 42 0.4
pumpkin 2 4 20 0.3
snap beans 1 3 15 0.3
carrots 1 4 23 0.2
chayote 1 3 24 0.2
cabbage 1 4 23 0.2
cloves 1 35 274 0.2
kale 1 5 28 0.2
radishes 0 2 16 0.1
jalapeno peppers 0 3 27 0.1
dandelion greens 0 7 45 0.1
pickles 0 1 12 0.1
cucumber 0 1 12 0.1
turnips 0 3 21 0.1
eggplant -0 3 25 0.1
red peppers -0 3 31 0.0
lima beans -0 20 113 0.0
yeast extract spread -0 27 185 0.0
sauerkraut -0 2 19 0.0

legumes

food ND insulin load (g/100g) calories/100g MCA
tofu 5 8 83 0.9
soybeans 2 49 446 0.3
lentils 1 19 116 0.2
natto 1 22 211 0.2
navy beans 1 22 140 0.2
cowpeas 0 68 336 0.1
broad beans -0 54 341 0.0
peas -0 57 352 0.0

nuts and seeds

food ND insulin load (g/100g) calories/100g MCA
sunflower seeds 3 22 546 0.6
pumpkin seeds -0 29 559 0.0
brazil nuts -0 16 659 0.0
walnuts -1 22 619 -0.1
almond butter -2 26 614 -0.2
almonds -2 25 607 -0.2
flax seed -2 16 534 -0.3
pistachio nuts -2 34 569 -0.3
sesame seeds -3 17 631 -0.4
coconut water -3 3 19 -0.4
hazelnuts -3 17 629 -0.4
cashews -3 40 580 -0.4
sesame butter -3 33 586 -0.4
pine nuts -3 21 673 -0.4
butternuts -3 28 612 -0.5

fruit

food ND insulin load (g/100g) calories/100g MCA
carambola -1 5 31 -0.1
blackberries -2 3 43 -0.3
cranberries -2 8 46 -0.3
avocado -2 3 160 -0.3
kiwifruit -2 9 61 -0.3
apricots -3 10 48 -0.4
raspberries -3 4 52 -0.4
peaches -3 8 39 -0.4
grapefruit -3 8 33 -0.4
mulberries -3 9 43 -0.5
boysenberries -3 8 50 -0.5
strawberries -3 4 32 -0.5
nectarines -3 9 44 -0.5

diabetic friendly nutrient dense vegan foods

While the foods listed above would represent a significant dietary improvement for most people, those who are insulin resistant may struggle to keep their blood glucose levels stable if they eat too much non-fibre carbohydrate that can be found in plant based foods (e.g. bread, sweet potato, quinoa, rice, beans or spaghetti).

It is hard to get too many calories and / or spike your glucose levels if you restrict yourself to vegetables like celery, broccoli and spinach.

The problem comes if you are still hungry after you have eaten your fill of non-starchy veggies and are not wanting to lose more weight.  People using a plant based approach may end up filling up on energy dense higher carbohydrate foods which are more likely to raise their blood glucose and insulin levels.

As shown in the chart below, our insulin response to food is only partially explained by the quantity of carbohydrates in our food.

image01

The analysis of the food insulin index data indicates that our insulin response is also influenced by the fibre and the protein in the foods we eat.

image02

We can use the formula below to estimate the amount of insulin that our food will require as shown by the formula below.  Foods with a lower insulin load will enable your pancreas to keep up with demand and maintain normal blood glucose levels without the ‘blood glucose roller coaster’.

insulin load (g)=carbohydrates (g)-fiber (g) + 0.56*protein (g)

The higher fat foods actually have a lower nutrient density than the most nutrient dense vegetarian foods listed above.  Ideally in time someone with insulin resistance would be able to restore their insulin sensitivity through eating nutrient dense, low insulin load foods along with perhaps intermittent fasting and exercise.  However, in the meantime the lower insulin load foods will enable you to maintain normal blood glucose levels.

The list of foods below is prioritised by both nutrient density and the proportion of insulinogenic calories.  These foods will provide high levels of nutrition while also being gentle on your blood glucose levels with lower levels of insulin required.

vegetables

The vegetables in this list have a lower percentage of insulinogenic calories, lower amounts of net carbohydrates and a low energy density and therefore will have a minimal impact on blood glucose levels.   While the percentage of insulinogenic calories is often high, the net carbohydrates is low so the effect on blood glucose will be minimal.

food ND insulin load (g/100g) calories/100g MCA
curry powder 2 14 325 1.5
alfalfa 9 1 23 1.5
endive 8 1 17 1.3
poppy seeds -2 23 525 1.3
chicory greens 5 2 23 1.3
escarole 6 1 19 1.2
paprika 3 26 282 1.1
mustard seed 3 37 508 1.1
caraway seed -0 28 333 1.0
coriander 2 2 23 1.0
nutmeg -8 32 525 0.9
sage -5 26 315 0.9
mace -8 34 475 0.8
beet greens 3 2 22 0.8
marjoram -6 27 271 0.7
collards 3 4 33 0.7
eggplant -0 3 25 0.7
cloves -0 35 274 0.7
zucchini 6 2 17 0.7
thyme -2 31 276 0.7
banana pepper -2 3 27 0.6
edamame 5 13 121 0.6
jalapeno peppers -1 3 27 0.6
mustard greens -2 3 27 0.6
cinnamon -5 30 247 0.6
turnip greens 8 4 29 0.6
spinach 13 4 23 0.6
sauerkraut -1 2 19 0.6
pickles -1 1 12 0.6
cucumber -1 1 12 0.6
chayote 0 3 24 0.5
basil 9 3 23 0.5
red peppers -1 3 31 0.5
asparagus 11 3 22 0.5
radishes -1 2 16 0.4
cumin -6 44 375 0.4
summer squash 3 2 19 0.4
dill seed -3 43 305 0.4
parsley 5 5 36 0.4
chard 9 3 19 0.4
chives 5 4 30 0.4
arugula 0 3 25 0.4
lettuce 6 2 15 0.4
soybeans (sprouted) 5 12 81 0.4
cauliflower 6 4 25 0.3
portabella mushrooms 11 5 29 0.3
okra 4 3 22 0.3
Chinese cabbage 8 2 12 0.3
Brussel sprouts 1 6 42 0.2
carrots -1 5 37 0.2
celery 2 3 18 0.2
turnips -0 3 21 0.2
artichokes -2 7 47 0.2
shiitake mushroom 7 7 39 0.1
watercress 17 2 11 0.1
dandelion greens -1 7 45 0.0
cabbage 0 4 23 0.0
celery flakes -4 42 319 -0.0
red cabbage -3 5 29 -0.0
white mushroom 11 5 22 -0.1
snap beans 1 3 15 -0.1
bay leaf -7 53 313 -0.1
bamboo shoots 4 5 27 -0.1
rhubarb -4 3 21 -0.1
pepper -2 47 251 -0.1
kale 1 5 28 -0.1
yeast extract spread -2 27 185 -0.2
carrots 1 4 23 -0.2
spirulina 13 6 26 -0.2
peas 5 7 42 -0.2
turnips -3 4 22 -0.3
turmeric -2 52 312 -0.3
radicchio 4 4 23 -0.3
onions -0 6 32 -0.3
carrots -1 7 41 -0.3
potatoes -4 26 158 -0.4

nuts and seeds

Nuts and seeds have a lower proportion of insulinogenic calories as well as being lower in net carbs which makes them diabetic friendly.  They do have a considerably higher energy density and hence, unlike the veggies, it is possible to overeat nuts and seeds if you’re keeping an eye on your weight.

food ND insulin load (g/100g) calories/100g MCA
brazil nuts -1 16 659 1.6
pecans -6 12 691 1.6
macadamia nuts -7 12 718 1.6
sesame seeds -3 17 631 1.5
sunflower seeds 3 22 546 1.5
hazelnuts -4 17 629 1.5
coconut milk -6 5 230 1.5
coconut cream -7 7 330 1.5
flax seed -3 16 534 1.5
coconut meat -7 9 354 1.5
walnuts -1 22 619 1.5
pine nuts -4 21 673 1.5
almonds -3 25 607 1.4
almond butter -2 26 614 1.3
butternuts -3 28 612 1.3
pumpkin seeds -0 29 559 1.3
sesame butter -4 33 586 1.1
pistachio nuts -3 34 569 1.1
cashews -4 40 580 0.9
coconut -7 39 443 0.6
gingko nuts -6 15 111 -0.0
coconut water -3 3 19 -0.4

fruits

The list of diabetic friendly fruits with a lower proportion of insulinogenic calories ends up being quite short.  Some of these fruits will raise your blood glucose levels if you eat enough of them.  So if you are particularly insulin resistant then you will want to limit your quantity of fruit or stick to the lower insulin load fruits (e.g. olives and avocados rather than mango).

food ND insulin load (g/100g) calories/100g MCA
olives -6 1 145 1.7
avocado -4 3 160 1.6
blackberries -4 3 43 0.9
raspberries -4 4 52 0.8
strawberries -4 4 32 0.1
apples -7 7 52 0.0
gooseberries -6 6 44 -0.0
carambola -1 5 31 -0.0
kiwifruit -3 9 61 -0.1
boysenberries -5 8 50 -0.1
passionfruit -7 14 97 -0.1
apples -7 7 48 -0.1
pears -7 7 50 -0.1
blueberries -6 9 57 -0.2
blueberries -7 14 88 -0.3
watermelon -5 5 30 -0.3
cherries -7 9 50 -0.4
mango -5 11 60 -0.4
cranberries -3 8 46 -0.4

legumes

These legumes have a lower proportion of insulinogenic calories and lower carbohydrates, however there may still be some impact on blood glucose with the moderate levels of carbohydrates, so you may want to keep an eye on your blood glucose levels when you try these foods to see how you react to them.

food ND insulin load (g/100g) calories/100g MCA
tofu 9 8 83 1.1
peanuts -3 29 599 0.5
natto 2 22 211 0.5
soybeans 3 49 446 0.5
peanut butter -4 27 593 0.4
lupin seeds 1 50 371 0.2
miso -1 25 198 0.1
lentils 1 19 116 -0.0
navy beans 0 22 140 -0.0
broad beans 0 54 341 -0.1
hummus -4 20 177 -0.1
peas -0 57 352 -0.1
chick peas -2 27 164 -0.2
kidney beans -0 63 337 -0.3
black beans -1 63 341 -0.3
cowpeas 1 68 336 -0.4
garbanzo beans -2 67 378 -0.4
pinto beans -1 64 347 -0.4

what about pescetarian, lacto, ovo options?

In the development of this article I spoke with Barry Erdman who runs the Vegetarian Low Carb Diabetic Healthy Diet Society Facebook group.

Barry has been a strict vegetarian since 1970 and was diagnosed with Type 1 Diabetes nine years ago.  Barry maintained a nutrient dense plant based diet after his diagnosis, however found that he needed to incorporate dairy, eggs and some oils (e.g. MCT, coconut) into his vegetarian diet in order to achieve acceptable blood glucose control.  Barry told me that when he lost 30 lbs when he switched from a vegetarian diet to a LCHF keto lacto ovo vegetarian diet eliminating all grains, bad oils and fruit (except berries).

Barry also came to the conclusion that he would need to incorporate some fish oil into his diet in order to provide adequate levels of essential fatty acids which are not available in significant quantities in plant based products.

Barry asked me to have a look at how a lacto, ovo, pescitarian diet would stack up against the straight vegan approach.  So listed below are the most nutrient dense lacto (dairy), ovo (eggs), and pescetarian (seafood) diabetic friendly foods.

image11

For those who are interested in adding eggs or seafood I have listed them based on their nutrient density and proportion of insulinogenic calories.

eggs and dairy

food ND insulin load (g/100g) calories/100g MCA
butter -6 3 718 1.7
cream -5 5 340 1.6
egg yolk 5 12 275 1.5
cream cheese -4 10 350 1.4
sour cream -4 6 198 1.4
limburger cheese -2 15 327 1.2
cheddar cheese -2 20 410 1.2
camembert -2 16 300 1.2
whole egg 5 10 143 1.2
blue cheese -2 19 353 1.1
Monterey cheese -2 19 373 1.1
muenster cheese -2 19 368 1.1
brie -3 16 334 1.1
Swiss cheese -1 22 393 1.1
gruyere cheese -1 23 413 1.1
feta cheese -1 15 264 1.1
Colby -3 20 394 1.1
edam cheese -2 21 357 1.1
goat cheese -3 14 264 1.1
gouda cheese -2 21 356 1.1
ricotta -3 12 174 0.9
sour cream (light) -4 9 136 0.9
mozzarella -0 26 304 0.8
parmesan cheese -2 35 420 0.7
Greek yogurt -2 9 97 0.6
milk (full fat) -1 7 64 0.4

seafood

food ND insulin load (g/100g) calories/100g MCA
mackerel 2 10 305 1.6
caviar 8 23 264 1.1
cisco 4 13 177 1.1
sardine 6 19 208 0.9
herring 5 19 217 0.9
fish roe 12 18 143 0.8
trout 10 18 168 0.8
anchovy 8 22 210 0.8
sturgeon 10 16 135 0.7
salmon 11 20 156 0.6
tuna 5 23 184 0.4
oyster 10 14 102 0.3
flounder 9 12 86 0.3
halibut 11 17 111 0.1
crayfish 12 13 82 0.1
perch 8 14 96 0.1
crab 14 14 83 0.1
rockfish 9 17 109 0.0

macronutrient comparison

The image below shows a comparison of the macronutrients of these different approaches compared to the average of all of the foods in the USDA foods database.

The nutrient dense vegan approach will provide a lot of of fibre which will make these foods very filling and hard to overeat, however perhaps not particularly diabetes friendly.

The diabetes friendly approach has more protein and only 30% net carbohydrates so it will have are more gentle effect on blood glucose levels.

With higher levels of fat from fish, dairy and eggs, the pescetarian approach is 40% fat which will be more gentle on the blood glucose levels of someone with diabetes.

2017-02-26 (10).png

comparison of essential micronutrients

This chart shows the nutrients provided by the vegan approach compared to the average of all the foods in the USDA database.  We get a lot of vitamin K, vitamin C and vitamin A but no omega 3 fatty acids and lower quantities of vitamin B-12.

2017-02-26 (12).png

This chart shows the nutrients contained in the diabetes friendly vegan approach.  While this approach has more fat and less carbohydrates the nutrient density is lower overall.

2017-02-26 (14).png

This chart shows the nutrient density of the pescetarian approach which is higher overall.

2017-02-26 (15).png

summary

So in summary, there are some great nutrient dense options for people with diabetes who choose to follow a plant based dietary approach.  Supplementing a plant based diet with some seafood will provide essential fatty acids and boost protein levels.

more information

If you’re interested in learning more about the nutrient density ranking system check out:

other approaches

The table below contains links to separate blog posts and printable .pdfs detailing optimal foods for a range of dietary approaches (sorted from most to least nutrient dense) that may be of interest depending on your situation and goals.   You can print them out to stick to your fridge or take on your next shopping expedition for some inspiration.

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

If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help identify the optimal dietary approach for you.

image02