Category Archives: diabetes

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.

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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.

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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!

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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.

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

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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 very interesting, 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.

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

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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.

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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.

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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!

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context

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).

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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.

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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.

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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!

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

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

Seven days later I had some spectacular ketone readings.

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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.

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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).

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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.

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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).

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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.

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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]

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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.

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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]

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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.

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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.

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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.

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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.

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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]

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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!

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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.

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

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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.

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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).

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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!]

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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?

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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

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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

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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.


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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

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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
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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

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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]
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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

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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.
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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

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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!

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the alkaline diet vs acidic ketones | optimising nutrition
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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 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.

P.P.S.

Elizma and I have been talking about kicking off an occasional Q&A podcast.  So, if you have any questions in the area of functional medicine, MTHFR, nutrigenomics / 23andme (Elizma) or diabetes and nutrition (me) then feel free to leave some questions below to kick off our first one.  It could be a fun adventure.

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‘.

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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.

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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.

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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.

 

zero carb

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]

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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.

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The chart below is a comparison of the average amount of nutrients (as a percentage of the daily recommended intake) for a range of dietary approaches.  A zero carb approach can provide you with a solid amount of nutrients, and likely more than a plant only based approach, though not as much as dietary approaches that incorporates both plant and animal based foods.[6]

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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.

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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.

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).

You can see from this comparison that 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.

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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
lamb liver 18 20 168 1.9
lamb kidney 19 15 112 1.9
chicken liver 15 13 119 1.7
veal liver 16 26 192 1.5
turkey liver 14 21 189 1.5
beef brains 8 8 151 1.5
chicken liver 14 20 172 1.5
beef liver 16 25 175 1.5
beef kidney 13 20 157 1.4
chicken liver pate 7 17 201 1.2
lamb brains 5 10 154 1.1
turkey heart 8 20 174 1.0
lamb heart 8 19 161 1.0
pork liver 10 23 165 1.0
liver sausage 0 10 331 0.9
beef heart 8 23 179 0.9
beef heart 5 16 165 0.9
lamb sweetbread 4 15 144 0.8
sweetbread -3 9 318 0.7
beef tripe 6 14 103 0.7
liver pate -4 13 319 0.5

animal products

food ND insulin load (g/100g) calories/100g MCA
ground turkey 4 19 258 1.0
ham 11 17 113 1.0
salami 1 17 378 1.0
pepperoni -1 16 504 0.9
lamb chop 5 25 234 0.9
rib eye steak 5 21 210 0.9
roast pork 5 20 199 0.9
roast beef 4 21 219 0.9
meatballs 0 14 286 0.9
T-bone steak 2 19 294 0.8
turkey bacon 0 11 226 0.8
lean beef 9 23 149 0.8
park sausage 1 13 217 0.8
turkey 0 21 414 0.8
kielbasa -1 12 325 0.8
pork sausage -0 16 325 0.8
pork ribs -1 16 361 0.8
bacon -2 11 417 0.8
turkey meat 6 21 158 0.8
turkey drumstick 6 21 158 0.8
roast ham 4 18 178 0.8
chicken 7 22 148 0.7
veal 8 24 151 0.7
pork chop 6 23 172 0.7
ground pork 6 25 185 0.7
bratwurst -2 13 333 0.7

seafood

food ND insulin load (g/100g) calories/100g MCA
caviar 14 23 264 1.8
fish roe 16 18 143 1.7
salmon 17 20 156 1.7
oyster 18 14 102 1.6
trout 14 18 168 1.6
mackerel 7 10 305 1.6
anchovy 13 22 210 1.5
cisco 7 13 177 1.3
sturgeon 11 16 135 1.2
sardines 8 16 185 1.2
crab 15 14 83 1.2
sardine 8 19 208 1.2
herring 7 19 217 1.2
flounder 11 12 86 1.1
halibut 12 17 111 1.0
tuna 9 23 184 1.0
shrimp 12 19 119 0.9
lobster 12 15 89 0.9
rockfish 11 17 109 0.9
crayfish 11 13 82 0.9
pollock 11 18 111 0.9
cod 11 48 290 0.8
perch 8 14 96 0.7
octopus 9 28 164 0.7
haddock 9 19 116 0.6
whiting 8 18 116 0.6
white fish 8 18 108 0.5

dairy and egg

food ND insulin load (g/100g) calories/100g MCA
egg yolk 8 12 275 1.6
cream 4 5 340 1.4
butter 3 3 718 1.4
cheddar cheese 7 20 410 1.4
Swiss cheese 7 22 393 1.4
cream cheese 4 10 350 1.3
sour cream 4 6 198 1.3
whole egg 7 10 143 1.3
feta cheese 5 15 264 1.2
mozzarella 8 26 304 1.2
parmesan cheese 6 35 420 1.1
limburger cheese 2 15 327 1.1
camembert 2 16 300 1.0
Greek yogurt 6 9 97 1.0
goat cheese 2 14 264 1.0
gouda cheese 3 21 356 1.0
gruyere cheese 2 23 413 1.0
blue cheese 2 19 353 1.0
edam cheese 2 21 357 0.9
brie 1 16 334 0.9
Monterey cheese 1 19 373 0.9
muenster cheese 1 19 368 0.8
kefir 10 7 41 0.8
Colby 0 20 394 0.8
ricotta -0 12 174 0.7
sour cream (light) -1 9 136 0.6
cottage cheese (low fat) 6 13 81 0.6
Greek yogurt (low fat) 6 11 73 0.6

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.

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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.

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

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

Then in 2013, Jason Fung emerged onto the low carb scene with his epic six part Aetiology of Obesity YouTube Series in which he detailed a wide range of theories relating to obesity and diabetes.

Essentially, Jason’s key points are that:

  • simply treating Type 2 diabetes with more insulin to suppress blood glucose levels while continuing to eat the diet that caused the diabetes is futile,
  • people with Type 2 diabetes are already secreting plenty of insulin, and
  • insulin resistance is the real problem that needs to be addressed.

Jason’s Intensive Dietary Management blog has explored a lot of concepts that made their way into his March 2016 book, The Obesity Code.  However surprisingly, given that Jason is the fasting guy, the book didn’t talk much about fasting.

my experience with fasting

I have benefited personally from implementing an intermittent fasting routine after getting my head around Jason’s work.  I like the way I look and perform, both mentally and physically, after a few days of not eating.  I also like the way my belt feels looser and my clothes fit better.

Complete abstinence is easier than perfect moderation.

St Augustine

I recently did a seven day fast and since then I’ve done a series of four day fasts, testing my glucose and blood and breath ketones with a range of different supplements (e.g. alkaline mineral mix, exogenous ketones, bulletproof coffee / fat fast and Nicotinamide Riboside) to see if they made any difference to how I feel and perform, both mentally and physically.

Fasting does become easier with practice as your body gets used to accessing fat for fuel.

I love the mental clarity!   My workout performance and capacity even seems to be better when I’ve fasted for a few days.

My key fasting takeaways are:

  1. Fasting is not that hard. Give it a try.
  2. You can build up slowly.
  3. If you don’t feel good. Eat!

The more I learn about health and nutrition, the more I realise how critical it is to be able to burn fat and conserve glucose for occasional use.  We get into all sorts of trouble when we get stuck burning glucose.

Our body is like a hybrid car with a slow burning fat motor (with a big fuel tank) and high octane glucose motor (with a small fuel tank).  If you’re always filling the small high octane fuel tank to overflowing, you’ll always be stuck burning glucose and your fat burning engine will start to seize up (i.e. insulin resistance and diabetes).

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Reducing the processed carbs in our diet enables us to lower our insulin levels and retrain our body to burn fat again.  But nothing lowers insulin as aggressively and effectively as not eating.

Even though lots of Jason’s thoughts on fasting seem self-evident, his blog elucidating them has been very popular, perhaps because the concept of fasting is novel in the context of our current nutritional education.

We’ve been trained, or at least given permission, to eat as often as we want by the people that are selling food or sponsored by them.[1]

context

Jason’s angle on obesity and diabetes comes from his background as a nephrologist (kidney specialist) who deals with chronically ill people who are a long way down the wrong track before they come to his office.  Jason also talks about how he had tried to educate his patients about reducing their carbs, however after eating the same thing for 70 years this is just too hard for many people to change.

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Desperate times call for desperate measures!

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Many of these patients come to him jamming in hundreds of units a day of insulin to suppress blood glucose levels, even though their own pancreas is still likely secreting more than enough insulin.

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Rather than continuing to hammer more insulin to suppress the symptom (high blood glucose), the solution, according to Jason, is to attack the ultimate cause (insulin resistance) directly.

Jimmy Moore is well known to most people that have an interest in low carb or ketogenic diets.  Whether you agree with his approach, it’s safe to say that low carb and keto would not be as popular today without his role.

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Meanwhile Jason talks about trying to educate people about reducing the processed carbs from their diet not working, not because of the science but more due to people not being able to change their eating habits after 70 years.

the Complete Guide to Fasting

You’ve probably heard by now that Jason has teamed up with Jimmy to write The Complete  Guide to Fasting which captures Jason’s extensive thoughts on fasting from the blog along with Jimmy’s n=1 experiences and wraps them up in a cohesive comprehensive manual with a colourful bow.

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

Similar to The Obesity Code, TCGTF is a compilation of ideas that Jason has developed on his Intensive Dietary Management blog.  Blogging is a great way to get the ideas together and thrash them out in a public forum.   Some people love to read the latest blog posts and debate the minutiae, however most people would rather spend the $9 and sit down with a comprehensive book and get the full story.

Unlike The Obesity Code, TCGTF is a bright, full colour production with great graphics that will make it worth buying the hard copy to have and to hold.

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

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

The book covers:

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

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

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

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

my additional 2c…

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

target glucose levels

Jason has come under attack for using the word ‘cured’ in relation to HbAc1 values that most diabetes associations would consider non-diabetic,[2] though are not yet optimal.[3]

In the book Jason does discuss relaxing target blood glucose levels during fasting.  This makes sense for someone taking a slew of diabetic medications.   They’re probably not going to continue the journey if they end up in a hypoglycaemic coma on day one.

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The chart below shows the real life blood glucose variability for someone with Type 1 Diabetes on a standard diet.  With such massive fluctuations in glucose levels, it’s impossible to target ideal blood glucose levels (e.g. Dr Bernstein’s magic target blood glucose number of 4.6 mmol/L or 83 mg/dL).

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.

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Pretty much everyone agrees that it’s dumb to be eating crap food and dosing with industrial levels of insulin to manage blood glucose levels.   High levels of exogenous insulin just drive the sugar that is not being used to be stored as fat in your belly, then your organs, and then in the more fragile places like your eyes and the brain.

Jason’s perspective is that people who are chronically insulin resistant and morbidly obese are likely producing more than enough insulin.  The last thing they need is exogenous insulin which will keep the fat locked up in their belly and vital organs.  Dropping insulin levels as low as possible using a low insulin load diet and fasting coupled with reducing medications will let the fat flow out.

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fasting to optimise blood glucose levels

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

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.

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In a similar way, a disciplined fasting routine can help optimise blood glucose levels in the long term.  The chart below shows a plot of Rebecca Latham’s blood glucose levels over three months where she used her fasting blood glucose numbers AND body weight to decide if she would eat on any given day.

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While there is some scatter in the blood glucose levels, you can see that regular fasting does help to reduce blood glucose levels over the long term.

Once you’ve lost your weight , broken the back of your insulin resistance and stopped eating crap food, you may find that you still need some exogenous insulin or other diabetic medication to optimise blood glucose levels if you have burned out your pancreas.

fasting frequency

The TGTF book covers off on several fasting regimens such as intermittent fasting, 24 hours, 36 hours, 42 hours and 7 to 14 days.  One concept that I’m intrigued by, similar to the idea of using your glucose meter as a fuel gauge, is using your bathroom scale as a fuel gauge.

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.

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Again, Rebecca Latham has done a great job building an online community around the concept of using weight as a signal to fast through her Facebook group  My Low Carb Road – Fasting Support.

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The chart below shows Rebecca’s weight loss journey through 2016 where she initially targeted a weight loss of 0.2 pounds AND a reduction of 0.25 mg/dL in blood glucose per day.   After three months, she stabilized for a period (during a period when she had a number of major family issues to look after).  She is now using a less aggressive weight loss goal as she heads for her long-term target weight at the end of the year.

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The chart below shows the fasting frequency required to achieve her goals during 2016.  Tracking her weight against her target rate of weight loss has required her to fast a little more than one day in three to stay on track.

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Eating quality food is part of the battle, but managing how often you eat is also an important consideration.  After you’ve fasted for a few days, you can easily excuse yourself for eating more when you feast again.  And maybe it’s OK to enjoy your food when you do eat rather than tracking every calorie and trying to consciously limit them.

The obvious caveat is that there are a lot of other things that influence your scale weight such as muscle gain, water, GI tract contents etc, but this is another way to keep yourself accountable over the long term.

FAST WELL, FEED WELL

Fasting is a key component of the metabolic healing process, but it’s only one part of the story.

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Fasting is like ripping out your kitchen to put in a new one.   You have to demolish and remove the old stovetop to put the new shiny one back in.  You don’t sticky tape the new marble bench top over the crappy old Laminex.  You have to clean out the old junk before you implement the new, latest, and greatest model.

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In fasting, the demolition process is called autophagy, where the body ‘self eats’ the old proteins and aging body parts.   The great thing about minimising all food intake is that you get a deeper cleanse than other options such as fat fast, 500 calories per day or a protein sparing modified fast (PSMF).

But keep in mind that it’s the feast after the fast that builds up the shiny, new body parts that will help you live a longer, healthier, and happier life.

“Fasting without proper refeeding is called anorexia.” 

Mike Julian

Even fasting guru Valter Longo is now talking about the importance of feast / fast cycles rather than chronic restriction.  In the end you need to find the right balance of feasting / fasting, insulin / glucagon, mTOR / AMPK that is right for you.

In TCGTF, Jason and Jimmy talk about prioritising nutrient dense, natural, unprocessed,  low carb, moderate protein foods after the fast.  I’d like to reiterate that principle and emphasise that nutrient density becomes even more important if you are fasting regularly or for longer periods.

In the long term, I think your body will drive you to seek out more food if you’re not giving it the nutrients it needs to thrive.  Conversely, I think if you are providing your body with the nutrients it needs with the minimum of calories I think you will have a better chance of accessing your own body fat and reaching your fat loss goals.

optimising insulin levels AND nutrient density

It’s been great to see the concept of the food insulin index and insulin load being used by so many people!  In theory, when people reduce the insulin load of their diet they more easily access their own body fat and thus normalizes appetite.

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.

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While lowering carbs and improving food quality is the first step, I think that, as soon as possible you should start focusing on building up your metabolic machinery (i.e.  muscles and mitochondria).   A low carb nutrient dense diet is part of the story, but I don’t see many people with amazing insulin sensitivity that don’t also have a good amount of lean muscle mass which is critical to ‘glucose disposal’, good blood sugar levels and metabolic health.

This recent IHMC video from Doug McGuff provides a stark reminder of why we should all be focusing on maximising strength and lean muscle mass to slow aging.

The chart below shows a comparison of the nutrient density of the various dietary approaches.  Unfortunately, a super high fat diet is not necessarily going to be as nutrient dense and thus support muscle growth, weight loss, or optimal mitochondrial function as well as other options.

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The chart below (click to enlarge) shows a comparison of the various essential nutrients provided by a high fat therapeutic ketogenic dietary approach versus a nutrient dense approach that would suit someone who is insulin sensitive.

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I developed a range of lists of optimal foods that will help people in different situations with different goals to maximise the nutrient density that should be delivered in the feast after the fast.   The table below contains links to separate blog posts and printable .pdfs.  The table is sorted from highest to lowest nutrient density.   In time, you may be able to progress to a more nutrient dense set of foods as your insulin resistance improves.

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

protein

Jason had  a “robust discussion” with Steve Phinney over the topic of ideal protein levels recently during the Q&A session at the recent Low Carb Vail Conference.

To give some context again, Phinney is used to dealing with athletes who require optimal performance and are looking to optimise strength.  Meanwhile Jason’s patient population is typically morbidly obese people who are on kidney dialysis and probably have some excess protein, as well as a lot of fat that they could donate to the cause of losing weight.

I also know that Jimmy is a fan of Ron Rosedale’s approach of minimising protein to minimise stimulation of mTOR.  Jimmy and Ron are currently working on another book (mTOR Clarity?).  Protein also stimulates mTOR which regulates growth which is great when you’re young but perhaps is not so great when you’ve grown more than enough.

The typical concern that people have with protein in a ketogenic context is that it raises blood insulin in people who are insulin resistant.  ‘Excess protein’ can be converted to blood glucose via gluconeogenesis in people who are insulin resistant and can’t metabolise fat very well.

Managing insulin dosing for someone with Type 1 Diabetes like my wife Monica is a real issue, though she doesn’t actively avoid protein.  She just needs to dose with adequate insulin for the protein being eaten to manage the glucose rise.

The chart below shows the difference in glucose and insulin response to protein in people who have Type 2 Diabetes (yellow lines) versus insulin sensitive (white lines) showing that someone who is insulin resistant will need more insulin to deal with the protein.

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As well as insulin resistance, these people are also “anabolic resistant” meaning that some of the protein that they eat is turned into glucose rather than muscle leaving them with muscles that are wasting away.

People who are insulin resistant are leaching protein into their bloodstream as glucose because they can’t mobilise their fat stores for fuel.  They are dependent on glucose and they’ll even catabolise their own muscle to get the glucose they need if they stop eating glucose.

While it’s nice to minimise insulin levels, I wonder whether people who are in this situation may actually need more protein to make up for the protein that is being lost by the conversion to glucose to enable them to maintain lean muscle mass.  Perhaps it’s actually the people who are insulin sensitive that can get away with lower levels of protein?

As well as improving diet quality which will reduce insulin and thus improve insulin resistance, in the long term it’s also very important to maintain and build muscle to be able to dispose of glucose efficiently and also improve insulin resistance.

In TCGTF Jason talks about the fact that the rate of the use of protein for fuel is reduced during a fast and someone becomes more insulin sensitive.  He goes to great lengths to point out that concern over muscle loss shouldn’t stop you trying out fasting (which is a valid point).

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A big part of the magic of fasting is that you clean out some of your oldest and dodgiest proteins in your body and set the stage for rebuilding back new high quality parts.   But the reality is that you will lose some protein from your body during a fast (though this is not altogether a bad thing).[5] [6]

Bodybuilders often talk about the “anabolic window” after a workout where they can maximise muscle growth after a workout.  Similarly, one of the awesome things about fasting is that you reduce your insulin resistance and anabolic resistance meaning that when at the end of your fast your body is primed to allocate the high quality nutrients you eat in the right place (i.e. your muscles not your belly or blood stream).

In the end, I think optimal protein intake has to be guided to some extent by appetite.  You’ll want more if you need it, and less if you don’t.

I think if we focus on eating from a shortlist of nutrient dense unprocessed foods we won’t have to worry too much about whether we should be eating 0.8 or 2.2 g/kg of lean body mass.

However, avoiding nutrient dense, protein-containing foods and instead “feasting” on processed fat when you break your fast will be counter-productive if your goal is weight loss and waste a golden opportunity to build new muscle.

are you really insulin resistant?

Insulin resistance and obesity is a continuum.

Not everyone who is obese is necessarily insulin resistant.

If you are really insulin resistant, then fasting, reducing carbs, and maybe increasing the fat content of your diet will enable you to improve your insulin resistance.  This will then help with appetite regulation because your ketones will kick in when your blood glucose levels drop.

However, if you continue to overdo your energy intake (e.g. by chasing high ketones with a super high fat, low protein diet), then chances are, just like your body is primed to store protein as muscle, you will be very effective at storing that dietary fat as body fat.

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I fear there are a lot of people who are obese but actually insulin sensitive who are pursuing a therapeutic ketogenic dietary approach in the belief that it will lead to weight loss.  If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help you identify your optimal dietary approach.

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optimal ketone levels

Measuring ketones is really fascinating but confusing as well.

“Don’t be a purple peetone chaser.”

Carrie Brown, The Ketovangelist Podcast Ep 78

Urine ketones strips have limited use and will disappear as you start to actually use the ketones for energy.

In a similar way blood ketones can be fleeting.  Some is better than none, but more is not necessarily better.  As shown in the chart of my seven day fast below I have had amazing ketones and felt really buzzed at that point but since then I haven’t been able to repeat this.  I think sometimes as your body adapts to burning fat for fuel the ketones may be really high but then as it becomes efficient it will stabilise and run at lower ketone levels even when fasting.

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If your ketone levels are high when fasting then that’s great.  Keep it up.  They might stay high.  They might decrease.  But don’t chase super high ketones in the fed state unless you are about to race the Tour de France or if you want your body to pump out some extra insulin to bring them back down and store them as fat.

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The chart below shows the sum of 1200 data points of ketones and blood glucose levels from about 30 people living a ketogenic lifestyle.  Some of the time they have really high blood ketone levels but I think the real magic of fasting happens when the energy in our bloodstream decreases and we force our body to rely on our own body fat stores.

the root cause of insulin resistance is…

So we’ve worked out that large amounts of processed carbs drive high blood glucose and insulin levels which is bad.

We’ve also worked out that insulin resistance drives insulin levels higher, which is bad.

But what is the root cause of insulin resistance?

I think Jason has touched on a key component in that, as with many things, resistance is caused by excess.  If we can normalise insulin levels, then our sensitivity to insulin will return, similar to our exposure to caffeine or alcohol.

However, at the same time, I think insulin resistance is potentially more fundamentally caused by our sluggish mitochondria that don’t have enough capacity (number or strength) to process the energy we are throwing at them, regardless of whether they come from protein, carbs, or fat.

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A low carb diet lowers the bar to enable us to normalise our blood glucose levels.  However, the other end of the spectrum is focusing on training our body and our mitochondria to be able to jump higher.  In the long term this is achieved through, among other things, maximising nutrient dense foods and building lean body mass through resistance exercise.

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summary

  1. The Complete Guide to Fasting is, as per the title, the complete guide to fasting. It’s the most comprehensive guide to the nuances of fasting out there and there’s a good balance between the technical detail, while still being accessible for the general public.
  2. Fasting can help optimise blood glucose and weight in the long term, with a disciplined regimen.
  3. Fasting makes the body more insulin sensitive and primes it for growth. When you feast after you fast, it is ideal to make sure you maximise nutrient density of the food you eat as much as possible while maintaining reasonable blood glucose levels.
  4. Understanding your current degree of insulin resistance can help you decide which nutritional approach is right for you. As you implement a fasting routine and transition from insulin resistance to insulin sensitivity you will likely benefit from transitioning from a low insulin load approach to a more nutrient dense approach.

 

references

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

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

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

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

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

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

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

I’m looking forward to Robb Wolf’s new book Wired to Eat in which 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]

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[yes, I may be a Robb Wolf fan boy.]

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.

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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.

So 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…

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… gone to extraordinary lengths to obtain energy dense honey …

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

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OFT in captivity

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

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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.

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These days we have are surrounded by energy dense hyperpalatable foods that are designed to taste good without providing substantial levels of nutrients.

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When these foods are available our primal programming leaves us defenceless.

Our willpower or our calorie counting apps are no match for engineered foods with an optimised bliss point.

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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 research into 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 1000kJ of different foods (see the low energy density high nutrient density foods for weight loss article for more on this complex and intriguing topic).

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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.

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

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Maybe a little too well.

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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.

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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 to rebel and eliminate all carbohydrates because low fat was such a failure.  Right?

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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.

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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.

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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.

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what happens when we go paleo?

So if ‘paleo foods’ 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?

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Well, maybe.  Maybe not.

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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.

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

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

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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.

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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 sugar hit for energy (Cori cycle).

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

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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.

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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 get 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).

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

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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!

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.

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

food ND % insulinogenic insulin load (g/100g) calories/100g
watercress 31 65% 2 11
broccoli 27 36% 3 22
spinach 25 49% 4 23
spirulina 22 70% 6 26
turnip greens 19 44% 4 29
asparagus 19 50% 3 22
portabella mushrooms 18 55% 5 29
Chinese cabbage 18 54% 2 12
white mushroom 18 65% 5 22
chard 16 51% 3 19
zucchini 16 40% 2 17
cauliflower 15 50% 4 25
parsley 14 48% 5 36
lettuce 14 50% 2 15
chives 13 48% 4 30
endive 13 23% 1 17
mung beans 13 74% 4 19
collards 12 38% 4 32
chicory greens 12 23% 2 23
okra 11 50% 3 22
seaweed (wakame) 11 79% 11 45
beet greens 11 35% 2 22
soybeans (sprouted) 10 49% 12 81
shitake mushroom 10 58% 7 39
alfalfa 10 19% 1 23
escarole 9 24% 1 19
summer squash 9 45% 2 19
brown mushrooms 8 73% 5 22
edamame 8 41% 13 121
radicchio 7 67% 4 23
Brussel sprouts 6 50% 6 42
bamboo shoots 6 60% 5 27
kale 6 60% 5 28
celery 6 50% 3 18
peas 6 65% 7 42
seaweed (kelp) 5 77% 10 43
radishes 3 43% 2 16
cabbage 3 55% 4 23
snap beans 3 58% 3 15
onions 3 65% 6 32
shiitake mushrooms 3 82% 72 296
arugula 3 45% 3 25
carrots 3 61% 4 23
turnips 2 51% 3 21
sauerkraut 2 39% 2 19
pickles 2 39% 1 12
cucumber 2 39% 1 12
red peppers 1 40% 3 31
eggplant 1 35% 3 25
chayote 1 40% 3 24
jalapeno peppers 1 37% 3 27
radishes 1 60% 3 18
cucumber 1 67% 3 15
pumpkin 1 76% 4 20
lima beans 1 70% 20 113
dandelion greens 0 54% 7 45
mustard greens 0 36% 3 27
yeast extract spread 0 59% 27 185

Spices

food ND % insulinogenic insulin load (g/100g) calories/100g
basil 22 47% 3 23
parsley 21 49% 44 292
paprika 6 27% 26 282
cloves 5 35% 35 274
mustard seed 3 27% 37 508
curry powder 2 13% 14 325
caraway seed 1 27% 28 333
turmeric 0 61% 52 312
sage -0 26% 26 315
thyme -0 34% 31 276
dill seed -0 42% 43 305
coriander -1 64% 54 279

Fruits

food ND % insulinogenic insulin load (g/100g) calories/100g
carambola -5 56% 5 31
avocado -5 8% 3 160
rhubarb -5 55% 3 21
Guava -5 57% 11 68
jackfruit -6 61% 16 95
cantaloupe -7 70% 7 34
apricots -7 71% 10 48
strawberries -7 49% 4 32
kiwifruit -7 55% 9 61
blackberries -7 27% 3 43
peaches -8 70% 8 39
grapefruit -8 85% 8 33
boysenberries -8 54% 8 50
honeydew melon -8 66% 7 36
lemon peel -8 34% 6 47
mango -9 63% 11 60

Legumes

food ND % insulinogenic insulin load (g/100g) calories/100g
soy protein isolate 16 72% 69 335
tofu 13 34% 8 83
soy sauce 13 78% 12 57
soybeans 6 44% 49 446
natto 3 39% 22 211
lupin seeds 3 51% 50 371
cowpeas 3 79% 68 336
lima beans 3 70% 61 338
lentils 2 64% 19 116
mung beans 2 73% 65 347
navy beans 1 72% 63 337
broad beans 1 61% 54 341
kidney beans 0 74% 63 337
black beans 0 73% 63 341
pinto beans -0 73% 64 347

Nuts and seeds

food ND % insulinogenic insulin load (g/100g) calories/100g
pumpkin seeds 2 19% 29 559
sunflower seeds 0 15% 22 546
coconut water -0 66% 3 19
sesame butter -3 21% 33 586
brazil nuts -3 9% 16 659
cashews -3 26% 40 580
walnuts -4 13% 22 619
flax seed -4 11% 16 534
sesame seeds -4 10% 17 631
pistachio nuts -4 22% 34 569
almond butter -4 16% 26 614
almonds -4 15% 25 607
butternuts -6 17% 28 612
hazel nuts -6 10% 17 629
macadamia nuts -7 6% 12 718
pine nuts -8 11% 21 673
coconut milk -9 8% 5 230
coconut -9 10% 9 354
coconut cream -9 8% 7 330
gingko nuts -9 52% 15 111

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.

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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.

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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.

diabetic friendly plant based foods

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 % insulinogenic insulin load (g/100g) calories/100g MCA
alfalfa 12 19% 1 23 1.47
endive 15 23% 1 17 1.38
chicory greens 14 23% 2 23 1.37
escarole 10 24% 1 19 1.27
broccoli 30 36% 3 22 1.14
coriander 10 30% 2 23 1.07
beet greens 15 35% 2 22 0.97
zucchini 18 40% 2 17 0.81
collards 7 37% 4 33 0.77
eggplant 1 35% 3 25 0.77
mustard greens 2 36% 3 27 0.72
banana pepper 1 36% 3 27 0.71
jalapeno peppers 3 37% 3 27 0.71
turnip greens 20 44% 4 29 0.71
spinach 30 49% 4 23 0.70
pickles 6 39% 1 12 0.67
sauerkraut 4 39% 2 19 0.66
edamame 8 41% 13 121 0.65
cucumber 4 39% 1 12 0.64
red peppers 2 40% 3 31 0.58
asparagus 23 50% 3 22 0.56
chayote 1 40% 3 24 0.55
radishes 3 43% 2 16 0.52
summer squash 9 45% 2 19 0.52
parsley 15 48% 5 36 0.50
chives 15 48% 4 30 0.48
lettuce 17 50% 2 15 0.47
chard 19 51% 3 19 0.45
arugula 4 45% 3 25 0.43
cauliflower 15 50% 4 25 0.43
okra 13 50% 3 22 0.40

spices

food ND % insulinogenic insulin load (g/100g) calories/100g MCA
curry powder 1 13% 14 325 1.52
poppy seeds -5 17% 23 525 1.32
paprika 7 27% 26 282 1.14
mustard seed 2 27% 37 508 1.05
sage -0 26% 26 315 1.04
caraway seed 1 27% 28 333 1.03
nutmeg -15 23% 32 525 0.93
mace -13 26% 34 475 0.86
marjoram -4 31% 27 271 0.83
cloves 4 35% 35 274 0.79
thyme -0 34% 31 276 0.76
pepper -4 34% 36 318 0.73
cinnamon -8 34% 30 247 0.65
basil 22 47% 3 23 0.63
cumin -6 39% 44 375 0.51
dill seed -1 42% 43 305 0.48
bay leaf -10 52% 53 313 -0.01
pepper -4 57% 47 251 -0.11
turmeric -1 61% 52 312 -0.21

nuts and seeds 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 % insulinogenic insulin load (g/100g) calories/100g MCA
macadamia nuts -7 6% 12 718 1.65
brazil nuts -4 9% 16 659 1.59
pecans -11 6% 12 691 1.59
sesame seeds -5 10% 17 631 1.55
coconut milk -10 8% 5 230 1.53
coconut cream -11 8% 7 330 1.52
flax seed -4 11% 16 534 1.52
hazelnuts -8 10% 17 629 1.50
coconut meat -10 10% 9 354 1.49
sunflower seeds 1 15% 22 546 1.46
pine nuts -9 11% 21 673 1.44
walnuts -5 13% 22 619 1.43
almonds -5 15% 25 607 1.37
almond butter -5 16% 26 614 1.35
pumpkin seeds 1 19% 29 559 1.31
butternuts -7 17% 28 612 1.29
sesame butter -4 21% 33 586 1.17
pistachio nuts -5 22% 34 569 1.12
cashews -5 26% 40 580 0.99
coconut -11 34% 39 443 0.61
gingko nuts -10 52% 15 111 -0.02

fruits

The list of diabetic friendly fruits with a lower proportion of insulinogenic calories ends up being quite short.

food ND % insulinogenic insulin load (g/100g) calories/100g MCA
olives -11 3% 1 145 1.72
avocado -6 8% 3 160 1.62
blackberries -8 27% 3 43 0.89
raspberries -10 30% 4 52 0.78
strawberries -8 49% 4 32 0.13
apples -15 50% 7 52 -0.01
gooseberries -12 52% 6 44 -0.02
rhubarb -6 55% 3 21 -0.06
boysenberries -9 54% 8 50 -0.07
passionfruit -14 52% 14 97 -0.08
carambola -6 56% 5 31 -0.08
kiwifruit -8 55% 9 61 -0.09

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 % insulinogenic insulin load (g/100g) calories/100g MCA
peanut butter -5 17% 27 593 1.31
peanuts -3 18% 29 599 1.30
tofu 12 34% 8 83 0.94
natto 2 39% 22 211 0.63
soybeans 6 44% 49 446 0.50
hummus -7 45% 20 177 0.27
Miso -2 49% 25 198 0.21
lupin seeds 2 51% 50 371 0.20
garbanzo beans -2 57% 13 88 -0.07
broad beans 1 61% 54 341 -0.18
navy beans -1 61% 22 140 -0.21
lentils 2 64% 19 116 -0.27

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.

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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 % insulinogenic net carbs/100g insulin load (g/100g) calories/100g
butter 0.00 0% 0 1 734
egg yolk 0.04 19% 4 15 317
cream cheese 0.01 10% 4 8 348
sour cream 0.00 9% 3 4 197
goat cheese 0.03 22% 2 25 451
limburger cheese 0.02 18% 0 15 327
blue cheese 0.02 20% 2 18 354
gruyere cheese 0.02 21% 0 22 412
edam cheese 0.02 22% 1 20 356
cream -0.01 5% 4 5 431
cheddar cheese 0.02 20% 1 20 403
camembert cheese 0.02 20% 0 15 299
muenster cheese 0.02 20% 1 18 368
Monterey 0.02 20% 1 19 373
gouda cheese 0.02 23% 2 20 356
Colby 0.02 20% 3 20 394
feta cheese 0.02 22% 4 14 265
provolone 0.02 24% 2 21 350
brie cheese 0.01 19% 0 16 334
Swiss cheese 0.02 26% 5 25 379
parmesan cheese 0.03 30% 3 31 411
mozzarella 0.01 23% 2 18 318
whole egg 0.03 29% 1 10 138
ricotta cheese -0.02 25% 3 11 174
Greek Yogurt -0.05 27% 6 9 130
cottage cheese -0.06 39% 3 9 93

seafood

food ND % insulinogenic insulin load (g/100g) calories/100g
caviar 0.09 32% 22 276
anchovy 0.10 42% 21 203
herring 0.07 34% 18 210
sardine 0.05 36% 18 202
trout 0.08 43% 17 162
mackerel 0.07 45% 17 149
oyster 0.11 57% 14 98
tuna 0.08 50% 17 137
salmon 0.07 50% 15 122
sturgeon 0.06 47% 15 129
squid 0.02 50% 21 170
halibut 0.06 63% 16 105
mussel 0.05 61% 25 165
shrimp 0.07 66% 19 113
lobster 0.08 69% 14 84
Pollock 0.06 66% 17 105
whitefish 0.06 67% 17 102
octopus 0.06 69% 27 156
snapper 0.05 64% 15 94
crab 0.07 69% 13 78
whiting 0.03 63% 17 109
haddock 0.04 67% 18 110
crayfish 0.03 64% 12 78
perch 0.01 59% 13 91
haddock 0.02 69% 15 85
clam 0.03 71% 24 135
cod 0.01 67% 17 99
abalone 0.03 76% 19 99

comparison of essential micronutrients

The charts below show the level of vitamins, minerals and amino acids for each of the approaches including for the most nutrient dense foods (without the plant based constraint).  All of the reduced insulin load (IL) approaches do well compared to the average of all the foods in the USDA database.

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The plot below shows the amino acids and essential fatty acids of the various approaches.  This analysis indicates that you can achieve the daily recommended intake of protein from a nutrient dense plant based approach.  The area that suffers when it comes to an exclusively plant based approach is the essential fatty acids EPA and DHA which many vegetarians choose to supplement with.

However, with the high levels of omega 3s in seafood it appears that you could probably obtain adequate essential fatty acids from around 200 calories of nutrient dense seafood (or around 10% of your energy intake).

image12

In an effort to simplify things, the chart below shows a comparison of the average of the nutrient density provided by the various lower insulin load diabetic friendly approaches.

image10

When we look at the average (blue bars) the pescetarian approach (i.e. plant based plus seafood, no eggs, no dairy) wins out.

A more useful way to identify the approach that will maximise the nutrient density of all the nutrients is to look at the average minus the standard deviation (orange bars).  When we look at it from this perspective the pescetarian approach (i.e. plant based plus seafood without eggs or dairy) wins out again.

So it appears that the optimal approach from a nutrient density perspective is to focus on nutrient dense plant foods with some seafood.

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.

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how to make endogenous ketones at home

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

image23

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

Different glucose : ketone relationships for different people

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

image02

Characterisation of different metabolic states

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

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

Type 2 Diabetes

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

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

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

Hyperinsulinemia and metabolic disorders

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

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

Exciting research is currently underway looking at the use of EXOGENOUS ketones as an adjunct treatment for cancer or to provide energy directly to the mitochondria for people with epilepsy, dementia, Alzheimer’s and the like.[6]  [7]  

2016-08-11.png

Patrick Arnold, who worked with Dr Dominic D’Agostino to develop the first ketone esters and BHB salts, has noted that exogenous ketones may help alleviate the symptoms of the ‘keto flu’ during the transition from a high carb to a low carb dietary approach.


However, as noted by Robb Wolf, once you have successfully transitioned to a lower carb eating style you would need to reduce or eliminate the exogenous ketones to enable your body to fully up-regulate lipolysis (fat burning), maximise ENDOGENOUS ketone production and access your ENDOGENOUS FAT stores.

2016-08-08.png

Insulin resistant

Someone with diabetes who persists with a nutrient dense low insulin load dietary approach may be able to successfully normalise their blood glucose and insulin levels.  When this happens your body will be able to more easily release ENDOGENOUS ketones which will help improve satiety between meals, and decrease appetite which will in turn lead to weight loss.  Exercising to train your body to do more with less is also helpful.

image20

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

image27

I enthusiastically started adding unrestricted amounts of fat from all the yummy stuff (cheese, butter, cream, peanut butter, BPC etc) in the hope of achieving higher ketone levels and therefore weight loss, but I just got fatter and more inflamed as you can see in the photo on the left.  My blood tests suggested I was developing fatty liver in my mid 30s!  And I thought I was doing it right with the bacon and BPC?!?!?

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

image05

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

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

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

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

2016-08-10

I did find it had an amazing impact on my appetite.  While it was in my system I didn’t care as much about food.  However once the ketones were used up my appetite came flooding back.  It was like I had ‘bonked’ all of a sudden and needed LOTS OF FOOD NOW!

image17

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

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

image30

The Pruvit FAQ says that one of the benefits of Keto//OS is weight loss, however no reference to the research studies was provided to Pruve this claim.

AVPageView 11082016 13036 PM.bmp.jpg

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

Princess_Bride_That_Word

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

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

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

image06

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

image25

 

image28

image16 [13]

Confused yet?  I don’t blame you.

Metabolically healthy

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

image32

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

2016-08-10 (2).png

RD has achieved a spectacular HbA1c of 4.4%.  Perhaps a two or three day water only fast testing blood glucose and ketones with no exercise would be a useful test of your insulin status?  You could use RD’s line as the gold standard.

image04

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

RD also told me that when he is not fasting and is eating his regular nutrient dense higher protein meals his ketone levels are not particularly high. While RD fairly easily produces ketones, it seems they are also quickly metabolised so they do not build up in his bloodstream.

I know Luis Villasenor of Ketogains finds the same thing.

image10

Total energy = ketones + glucose

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

2016-08-12 (11)

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

When the TOTAL ENERGY in our bloodstream increases outside of the normal range it appears the body raises insulin to store the excess energy.  That is, unless you have untreated Type 1 Diabetes, in which case you end up in diabetic ketoacidosis with high blood glucose and high ketones.

Regardless of whether your energy takes the form of glucose, ketones or free fatty acids they all contribute to acetyl-coA which is oxidized to produce energy.  Forcing excess unused energy to build up in the bloodstream is typically not desirable and can lead to long term issues (gyration, oxidized LDL etc).

I’m not sure if ketones can be converted to glucose or body fat, but it makes sense that excess glucose would be converted to body fat via de novo lip genesis to decrease the TOTAL ENERGY in the blood stream to normal levels.

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

Ketone bodies have effects on insulin and glucagon secretions that potentially contribute to the control of the rate of their own formation because of antilipolytic and lipolytic hormones, respectively.  Ketones also have a direct inhibitory effect on lipolysis in adipose tissue.[15]

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

image26

Looking at the glucose and ketones together in terms of TOTAL ENERGY was a bit of an ‘ah ha’ moment for me.  It helped me to understand why people like Seyfried and D’Agostino always talk about the therapeutic benefits and the insulin lowering effects of a calorie restricted ketogenic diet. [19] [20] [21] [22]

Dealing with high ketones and high glucose typically a concern fro the body because it just doesn’t happen in nature with real whole foods.  But now we have refined grains, HFCS, processed fats and exogenous ketones to ‘bio-hack’ our metabolism and send it into overdrive.

While fat doesn’t normally trigger an insulin response, it seems that excess unused energy in the blood stream, regardless of the source, will trigger an increase in insulin to reduce the TOTAL ENERGY in the blood stream.

I am concerned that if people continue to enthusiastically zealously focus on pursuing higher blood ketones “through whatever means you can”[24] in an  effort to amplify fat loss they will promote excess energy in the bloodstream which will lead to insulin resistance and hyperinsulinemia.

Using multi-level marketing tactics to distribute therapeutic supplements to the uneducated masses who are desperate to lose weight with a ‘more is better’ approach also troubles me deeply.

My heart sank when I saw this video.

MORE investigation required?

There are anecdotal reports that use of exogenous ketones provide mental clarity, enhanced focus and athletic performance benefits.  At the same time there are also people who have been taking these products for a while that don’t appear to be doing so well.

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

Recently, ketone body supplements (ketone salts and esters) have emerged and may be used to rapidly increase ketone body availability, without the need to first adapt to a ketogenic diet. However, the extent to which ketone bodies regulate skeletal muscle bioenergetics and substrate metabolism during prolonged endurance-type exercise of varying intensity and duration remains unknown. Therefore, at present there are no data available to suggest that ingestion of ketone bodies during exercise improves athletes’ performance under conditions where evidence-based nutritional strategies are applied appropriately.

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

Ketosis decreased muscle glycolysis and plasma lactate concentrations, while providing an alternative substrate for oxidative phosphorylation. Ketosis increased intramuscular triacylglycerol oxidation during exercise, even in the presence of normal muscle glycogen, co-ingested carbohydrate and elevated insulin. These findings may hold clues to greater human potential and a better understanding of fuel metabolism in health and disease.

I can understand how exogenous ketones could be beneficial for someone who is metabolically healthy and consuming a disciplined hypo-caloric nutrient dense diet.  They would likely be able to auto regulate their appetite to easily offset the energy from the EXOGENOUS ketones with less food intake.

While it seems that EXOGENOUS ketones assist in relieving the symptoms of metabolic disorders I’m yet to be convinced that a someone who is obese and / or has Type 2 Diabetes would do as well in the long term, especially if they were hammering MOAR fat and MORE exogenous ketones (along with maybe some sneaky processed carbs on the side) in an effort to get their blood ketones as higher in the hope of losing body fat.

Some questions that I couldn’t find addressed in the Pruvit FAQ that I think would be interesting to study in a long term controlled environment in the in the future are:

  1. What is the a safe dose limit of EXOGENOUS ketones for a young child?  How would you adjust their maximum intake based on age and weight?
  2. IF EXOGENOUS ketones do have a long term weight loss effect what is the upper limit  of intake of EXOGENOUS ketones to avoid stunting a child’s growth?
  3. Is there a difference in the way EXOGENOUS ketones are processed in someone is metabolically healthy versus someone who is very insulin resistant?
  4. Does the affect on appetite continue beyond the point that the ketones are out of your system?
  5. Do you need to take EXOGENOUS ketones continuously to maintain appetite suppression?  Does the effect of ENDOGENOUS wear off as your own ENDOGENOUS ketone production down regulates?  Do you need to keep taking more and more EXOGENOUS ketones to maintain healthy appetite control?
  6. How should someone with Type 2 Diabetes adjust their medication and insulin dose based on their dose of EXOGENOUS ketones?  Should they be under medical supervision during this period?
  7. Is there a difference in health outcome if you are taking EXOGENOUS ketones in the context of a hypo-caloric ketogenic diet versus a hyper-caloric ketogenic diet?  What about a diet high in processed carbs?
  8. Is there a minimum effective dose to achieve optimal long term benefits to your metabolic health or is MORE better?
  9. Are the long term health benefits of EXOGENOUS ketones equivalent to a calorie restricted ketogenic diet?

Unfortunately, I think we will find the answers to these questions sooner rather than later with the large scale experiment that now seems to be well underway.

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

The lower the better?

Alessandro Ferretti recently made the observation that metabolically healthy people tend to have lower TOTAL ENERGY levels at rest (and hence have a lower HbA1c), but are able to quickly mobilise glycogen and fat easily when required (e.g. when fasting or a sprint). They are metabolically flexible[25] and metabolically efficient.[26]   

These people would have been able to both conserve energy during a famine and run away from a tiger and live to become our ancestors, while the ones who couldn’t didn’t.

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

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He is also committed to improving his metabolic fitness to be more competitive in ice hockey.  His resting heart rate is now a spectacular 45 bpm!

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

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

It seems excellent metabolic health is actually characterised by lower TOTAL ENERGY.

MORE is not necessarily BETTER when it comes to health.

Fast well, feed well

To clean up the data a little I removed the ketones vs glucose data points for a couple of people who I thought might be suffering from pancreatic beta cell burnout and one person that was taking exogenous ketones during their fast that had a higher TOTAL ENERGY.  I also removed the top 30% of points that I thought were likely high due to measuring after high fat meals.

So now the chart below represents the glucose and ketone values for a group of reasonably metabolically healthy people following a strict ketogenic dietary approach, excluding for the effect of high fat meals, BPC, fat bombs and the like.

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The average ketone value for this group of healthy people trying to live a ketogenic lifestyle is 0.7mmol/L. Their average glucose is 4.8mmol/L (or 87mg/dL). The average TOTAL ENERGY is 5.5mmol/L or 99mg/dL.

ketones (mmol/L)

blood glucose (mmol/L)

total energy (mmol/L)

average

0.7

4.8

5.5

30th percentile

0.4

4.6

5.2

70th percentile

0.9

5.1

5.8

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

ketones
(mmol/L)

blood
glucose (mg/dL)

total
energy (mg/dL)

average

0.7

86

99

30th percentile

0.4

83

94

70th percentile

0.9

92

104

It seems we may not necessarily see really high ketone levels in our blood even if we follow a strict ketogenic diet, particularly if we are metabolically healthy and our body is using to ketones efficiently.

The real ketone magic

When we deplete glucose we train our body to produce ketones.

This is where autophagy, increased NAD+ and SIRT1 kicks in to trigger mitochondrial biogenesis and ENDOGENOUS ketone production (i.e. the free ones).[27]   The REAL magic of ketosis happens when all these things happen and ketones are release as a byproduct.  I do not believe that simply adding EXOGENOUS ketones will have nearly as much benefit to your mitochondria, metabolism and insulin resistance as training your body to produce ENDOGENOUS ketones in a low energy state.

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Everything improves when we train our bodies to do more with less (e.g. fasting, high intensity exercise, or even better fasted HIIT).  Resistance to insulin will improve as your insulin receptors are no longer drowning in insulin caused by high TOTAL ENERGY building up in your bloodstream.

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Driving up ketones artificially through EXOGENOUS inputs (treating the symptom) does NOT lead to increased metabolic health and mitochondrial biogenesis (cure) particularly if you are driving them higher than normal levels and not using them up with activity.

You may be able to artificially mimic the buzz that you would get when the body produces ketones ENDOGENOUSLY, however it seems you may just be driving insulin resistance and hyperinsulinemia if you follow a “MORE is better” approach.

Simply managing symptoms with patented products for profit without addressing the underlying cause often doesn’t end well.

Just like having low blood glucose is not necessarily good if it is primarily caused by high levels of EXOGENOUS insulin couple with a poor diet, or having lower cholesterol due to statins, having high blood ketone values is not necessarily a good thing if it is achieved it by driving up the TOTAL ENERGY in your blood stream with high levels of purified fat and EXOGENOUS ketones.

Nutrient density

When we feed our body with quality nutrients we maximise ATP production which will make us feel energised and satisfied.  Nutrient dense foods will nourish our mitochondria and reduce our drive to keep on seeking out nutrients from more food.  Greater metabolic efficiency will lead to higher satiety, which leads to less food intake, which leads to a lower TOTAL ENERGY, greater mitochondrial biogenesis, improved insulin sensitivity and lower blood glucose levels.

Prioritising nutrient dense real food is even more important in a ketogenic context.[28]  While we can always take supplements, separating nutrients from our energy source is never a great idea, whether it be soda, processed grains, sugar, glucose gels, HFCS, protein powders, processed oils or exogenous ketones.

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

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

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Intermittent fasting

If your goal is metabolic health, weight loss and improving your ability to produce ENDOGENOUS ketones, then developing a practice of FEASTING and FASTING is important.

To start out, experiment by extending your fasting periods until your TOTAL ENERGY is decreasing over time.  This will cause your circulating insulin levels to decrease which will force your body to produce ENDOGENOUS ketones from your ENDOGENOUS fat stores.

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

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If you really want to measure something, see how low you can get your glucose levels before your next meal.  Then when you do eat, make sure you choose the most nutrient dense foods you possibly can to build your metabolic machinery and give your mitochondria the best chance of supporting a vibrant, active and happy life.

As my wise friend Raymund Edwards keeps reminding me, FAST WELL, FEED WELL.

 

 

Epilogue

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

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

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

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

This was mid-morning after a kettlebell session.

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

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

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

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

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

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

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

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

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

 

references

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

salad and salmon lunch

This is one of my favourite work lunches.

We often go to the markets on the weekend and then prepare a bunch of ready made lunches for the rest of the week.

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(note: by “we” I mean my amazing wife Monica who knows how to make healthy food look and taste incredible…  I just tag along, take some photos and enjoy eating it).

This one has chorizo, spinach, cherry tomatoes, beans and a fig.

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We will also make up some little containers of balsamic vinegar or olive oil with perhaps some feta cheese that you can add to it.

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At work I throw a can of salmon, tuna or sardines on it with some balsamic vinegar and viola a spectacularly yummy lunch!

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This meal does well on the nutritional completeness, both in terms of vitamins and amino acids.

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net carbs

insulin load carb insulin fat protein

fibre

6g 27g 22% 58% 34%

3g

More recently I’ve started having sardines instead of the salmon because it’s cheaper and even more nutrient dense.   Together with the salad it gives an even higher protein score.  Tuna is another option but it doesn’t do as well as the sardines or salmon on the vitamins and minerals.

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Sometimes when we don’t get around to doing the salads or taking a lunch I’ll just grab a quick can of the sardines which I’ve grown to like by themselves these days.  They’re filling, cheap and pack quite a nutritional punch all by themselves.

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