Category Archives: insulin resistance

how optimize your diet for your insulin resistance

Lately I’ve seen a number of common themes come up at low carb conferences and online.  The contentious questions tend to run along the lines of:

  1. I did really well on a low carb diet initially, but my fat loss seems to have stalled. What gives?  What should I do now?
  2. If protein is insulinogenic should I actively avoid protein as well as carbs if my goal is to reduce insulin because low insulin = weight loss?
  3. If eating more fat helped kick start my weight loss journey, then why does eating more fat seem to make me gain weight now?

This article outlines some quantitative parameters around these contentious questions and helps you chose the most appropriate nutritional approach.

The importance of monitoring blood glucose levels

Coming from a diabetes headspace, I’ve seen firsthand the power of a low carb diet in reducing blood glucose and insulin levels.  As a Type 1 Diabetic, my wife Moni has been above to halve her insulin dose with a massive improvement in energy levels, body composition and mood.

If your blood glucose levels are high, then chances are your insulin levels are also high.  Insulin is the hormonal “switch” that causes us to store excess energy as body fat in times of plenty.[1]  Lower levels of insulin in times of food scarcity then enable us to access to the stored energy on our body.[2]

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You can actively manage the fat storing potential of your diet by managing the insulin load of the food you eat.

The chart below shows that our glucose response is fairly well predicted by the carbohydrates we eat.  (note: The “glucose score” is the area under the curve of glucose response to various foods tested over the three hours relative to glucose which gets a score of 100%.) [3] [4]

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Having high blood glucose levels is bad news.[5]  The chart below shows the correlation between HbA1c (a measure of your average glucose levels over three months) and the diseases that will kill most of us, cardiovascular disease, coronary heart disease and stroke.[6]  It makes a lot of sense to do whatever it takes to reduce our blood glucose to the levels of a metabolically healthy person to postpone the major diseases of aging.

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Optimal ketone levels

Ketones in our blood rise when our insulin levels are low.[7]  As shown in the chart below, even better than carbohydrates, insulin levels are better predicted by the net carbohydrates plus about half the protein we eat.[8] [9]

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You may have seen this ‘optimal ketone zone’ chart from Volek and Phinney’s ‘Art and Science of Low Carb Living’.

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The problem however with this chart is that it is difficult for most people to achieve “optimal ketone levels” (i.e. 1.5 to 3.0mmol/L) without fasting for a number of days or making a special effort to eat a lot of additional dietary fat (which may be counterproductive in the long run if you’re trying to lose weight).

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Recently I had the privilege of having Steve Phinney stay at our house when he spoke at a Low Carb Down Under event in Brisbane (btw, he’s also a passionate cook if you let him lose in the kitchen).  I quizzed Steve about the background to his optimal ketosis chart.  He said it was based on two studies, one with cyclists who the adapted to ketosis over a period of six weeks and another ketogenic weight loss study.  In both cases these ‘optimal ketone levels’ (i.e. between 1.5 to 3.0mmol/L) were observed in people who were transitioning into a state of nutritional ketosis.

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Since the publication of this chart in the Art and Science books, Phinney has noted that well trained athletes who are long term fat adapted (e.g. the low carb athletes in the FASTER study[10]) actually show lower levels of ketones than might be expected.  It appears that over time many people, particularly athletes, move beyond simple keto adaption and are able to utilise fat as fuel even more efficiently and their ketone levels reduce further.

Metabolically flexible people are able to access and burn fat efficiently and hence only release free fatty acids or ketones into the bloodstream when they need the energy.  If you’re metabolically healthy and can call on your fat stores as required there’s no need to be walking around with super high levels of glucose or ketones.

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If you’ve been following a ketogenic diet for a while and / or are metabolically healthy then your ketone levels may not be as high as you might expect from looking at Volek and Phinney’s “optimal ketone zone” chart.

And as discussed in my Alkaline Diet vs Acidic Ketones article, higher ketone levels could even be an indication that you have some level of metabolic acidosis.  People with untreated Type 1 Diabetes have very high ketone as well as blood glucose levels at the same time (i.e. ketoacidosis).

Phinney says he does not condone the “adolescent behaviour” of competing to see how high you can get your ketone levels and warns that you can risk loss of lean body mass by chasing high ketone levels with an inappropriately low insulin load approach (i.e. very low carb and very low protein).[11]

People with higher NAD+ levels (an important coenzyme which declines with aging[12]) and lower NADH levels are more likely to produce more breath acetone (which can be measured with the Ketonix) and less BHB ketones in the blood.   Hence, higher consistent levels of breath acetone may be a more useful indication than blood ketones that you are burning fat rather than just eating fat.[13]

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“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.”[14]

While I think it’s good to have some ketones in the blood as an indication that your insulin levels aren’t too high, it can be hard to interpret what high or low level of blood ketones mean.

As noted in Peter Attia’s Fat Flux article, the BHB ketones you measure in your blood is a function of:

  • the dietary fat that you’re eating,
  • plus the fat being liberated from your body fat (lipolysis),
  • minus the BHB being used by your muscles, heart and brain.

High blood ketones could mean that your insulin levels are low and your level of lipolysis is high (i.e. lots of fat is being released from your body).  In this case, high ketones are an indicator of metabolic health and may facilitate healthy appetite regulation and enable you to burn your stored body fat.

However, high blood ketone levels could also mean that you are eating a lot of dietary fat (or consuming a lot exogenous ketones) and your body isn’t well adapted to using ketones for fuel and hence unused ketones are building up in your blood stream.  If this is the case, then loading up with more dietary fat in the pursuit of higher ketone levels may cause you to become more insulin resistant and inflamed as your ketone levels rise but the fat is not yet able to be efficiently oxidised for fuel.

The plot below shows a compilation of glucose and ketone values from a range of people following a low carb or “ketogenic” diet.  It seems that the most metabolically healthy people have low blood glucose levels and moderate ketones at rest, however they can easily access plenty of glucose and fat from the body when required.

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It makes sense to me from an evolutionary perspective that someone who is healthy would be able to conserve energy when not active (i.e. hiding in a cave) but then be able to quickly access stored energy when required (i.e. when being chased by a sabre-toothed tiger).  The body doesn’t always need super high blood ketone levels and hence we secrete insulin to remove both glucose and ketones back into storage.

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The exception to this seems to be in periods of extended fasting when the body is on high alert and we are in a super-fuelled state ready to chase down some food at a moment’s notice.

So, unless you’re fasting or exercising intensely, it seems that having a lower total energy (i.e. blood glucose plus blood ketones) might be a better place to be rather than having super high ketone levels.

There is also interesting emerging research suggesting that as we become more fat adapted we can obtain more fuel from fat and hence do not need to rely on ketones which are more of an emergency fuel source during starvation.  It’s as if, just like in time we no longer measure high ketones in the urine as we utilise them better, we also start to show less ketones in the blood.  Quoting my friend Mike Julian:

I think we become less ketogenic with further adaptation simply because as we improve our ability to utilize the fat we create spin off glucose from both glycerol and acetone that goes to restore beta oxidation of fatty acids.

The spin of glucose provides oxaloacetate and restores Krebs function in the liver and reduces ketogenesis in favour of complete oxidation of acetyl-CoA. In short, ketogenesis is a transitional state, not the end goal.

Ketones will be lower if you’re fit.  Even Phinney has said that very adapted individuals are in ketosis starting at 0.3mmol.  Look at how robust the GNG is in the low carb guys in the FASTER study. It is a direct result of the nearly doubled rate of fat oxidation.

All of the glycerol when fat is oxidised has to go somewhere and it is used to make glucose. This glucose is then used to restore the Krebs cycle which means that the can make even better use of fat etc, but reduces GNG via traditional means and in turn reduces ketogenesis.

It’s a system that feeds into itself.  The better fat burner you are, the more glucose you make from fat, the better you are at fat burning and so on.

As we get better at fat utilisation we also get better at deriving glucose from fat metabolism. This source of glucose reduces the need for ketogenesis.[15] [16]

So overall, measuring blood ketones is intriguing, but not always the most reliable measure of where your metabolic health status.  Moreover, eating more dietary fat in an effort to raise your blood ketone levels is no guarantee that you’re going to lose body fat.[17]

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You may be “ketogenic” in that you are able to generate ketones, though they may not necessarily show up in high levels in the blood if you are also athletic and able to use your blood glucose and ketones effectively for energy.

The relationship between ketones and glucose

The chart below shows the generalised relationship between blood glucose and blood ketones for different people with:

  • Type 2 Diabetes,
  • Pre-diabetes,
  • Mild insulin resistance, and
  • someone who is metabolically healthy.

(note: Someone with uncontrolled Type 1 Diabetes would be literally ‘off the chart’ with high blood glucose and high blood ketones.)

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The table below shows the HbA1c incident rates for cardiovascular disease, stroke and coronary heart disease from the chart above to average blood glucose levels and the corresponding ketone levels and glucose : ketone index values.   This gives us a useful understanding of what different HbA1c risk levels look like in terms of average blood glucose levels, ketones and the glucose : ketone index.

metabolic health level HbA1c average blood glucose ketones GKI
 (%)  (mmol/L)  (mg/dL)  (mmol/L)
low normal 4.1 3.9 70 2.1 1.9
optimal 4.5 4.6 83 1.3 3.5
excellent < 5.0 < 5.4 < 97 > 0.5 11
good < 5.4 < 6 < 108 < 0.3 30
danger zone > 6.5 7.8 > 140 < 0.3 39

While it can be interesting to measure ketones, as a general rule, if you have consistently high blood glucose levels you are likely to be insulin resistant and hence will benefit from a higher fat dietary approach.

If you have high insulin and glucose levels, when transitioning to a high fat diet your glucose and insulin levels will likely plummet to be closer to the levels of a metabolically healthy person and suddenly you will be able to access your body fat stores for fuel.  You might quickly find yourself losing weight like it was magic and you’ll think the keto diet is the best thing ever!  Amazingly, lots of people find that they can “eat fat to satiety” and still lose weight (at least during this initial stage).

For the last four decades we’ve been told to avoid fat, particularly saturated fat.  Imagine the excitement, enthusiasm, and maybe even anger, when someone who has been avoiding fat finds that they suddenly start losing weight when the do the opposite to what they’ve been told to do!

But it works until it doesn’t

The problem with adding more dietary fat is that it works until it doesn’t.

Let’s say (based on the levels of metabolic health in the table above) you are able to successfully “level up” from the “danger zone” though “good” blood glucose control to “excellent” blood glucose levels with a high fat dietary approach, but then your weight loss slows and then stops well short of your optimal body fat levels.

What gives?

What do you do now?

Do you listen to the people who say you should eat more fat or the people who say you should eat less fat?

It can be confusing on the interwebs!

I think the answer depends largely on whether you are insulin resistant or insulin sensitive.  You should ‘level up’ to the most nutrient dense nutritional approach that your current level of insulin sensitivity allows.

It’s worth noting that while many people can achieve ‘excellent’ blood glucose levels through dietary manipulation, the people that I’ve seen get to truly optimal blood glucose control tend to be working hard with both their nutrition and training to maximise their lean body mass.

What is insulin resistance anyway?

In order to understand what we need to do when we stop losing weight on keto I think it’s important to understand what causes insulin resistance.

Many people think that people who are fat are simply insulin resistant.  This is partly true.   However, while insulin resistance and obesity are related, it’s not quite that simple.  It’s useful to understand the difference.

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A metabolically flexible insulin sensitive person stores excess energy eaten for later use in the fat stores on the body (i.e. adipose tissue).  When they stop eating, someone who is insulin sensitive will experience a drop in blood glucose and insulin levels and stored body fat will be released.   For the lucky people who are insulin sensitive, calories in calories out (CICO) largely works as advertised.  They find it difficult to depart far from a healthy set point weight without a change in diet quality or insulin load.

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However, as we keep eating more and more low nutrient density foods to obtain the micronutrients we need, we get to a point where the adipose tissue can no longer hold all that excess energy and starts to channel it into the organs because the fat stores are full.

The body knows that this isn’t such a great idea though because our vital organs are, well, vital, so the body becomes insulin resistant as a defence mechanism to avoid damage to vital organs, and hence the levels of sugar in our blood rise to avoid storing the extra energy in the organs.   The body even starts dumping the excess sugar into the urine to avoid having to pump it into the liver, pancreas, eyes and brain.

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The a of the major problems with insulin resistance is appetite dysregulation.  That is, when you are insulin resistant your insulin levels stay higher for longer which then makes it harder for you to access your body fat for fuel between meals.   As shown in this chart, if your blood glucose levels are high the release of fat from your body (ketones) will be low, ghrelin will kick in[18], and it will be hard to go very long without food.  Your appetite will be more likely to win out over your willpower and thus make it hard to lose weight if your insulin levels are high.

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Eating “low carb” or “keto” enables us to lower insulin levels to the point that our appetite works more in line with the way it’s meant to when we were metabolically healthy / insulin sensitive / metabolically flexible.  Our appetite drives us to seek out nutrients and energy when required and stop when we have had enough.   (note: keep in mind though that lower insulin levels are due to eating a lower dietary insulin load, not necessarily due to more dietary fat.)

Once our appetite is restored and we can more easily access our own body fat I think we need to change focus, especially if adding more fat isn’t moving you toward your weight loss goals.

Be a nutrient chaser

Once your blood glucose levels are normalised but you’re stuck on a plateau and not sure where to turn I think it’s a good idea to turn your focus to chasing nutrients rather than ketones or even worrying about blood glucose levels quite so much.

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As your blood glucose and insulin levels decrease, you should be able to release more body fat stores and hence have less need for dietary fat.  When we focus on balancing micronutrients macronutrients largely look after themselves.

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As well as adequate energy, the body works hard to make sure it gets the nutrients it needs to thrive.  The vitamins and minerals that come with whole foods are like the spark that ignites the fuel they contain.[19]  We always get ourselves into trouble when we separate nutrients from energy.  While refined sugars and grains are particularly problematic because they spike insulin, neither refined sugars or purified fats contain the same level of nutrients necessary to power our mitochondria that whole foods do.

The problem comes when we eat nutrient poor foods.  We are left with a residual need for nutrients that are required to convert our food into energy (ATP).  Our appetite will drive us to seek out more food to obtain the required nutrients.

“Added sugars displace nutritionally superior foods from the diet and at the same time increase nutritional requirements. Specifically, vitamins such as thiamine, riboflavin and niacin are necessary for the oxidation of glucose, and phosphates are stripped from ATP in order to metabolise fructose, which leads to cellular ATP depletion. The metabolism of fructose also leads to oxidative stress, inflammation and damage to the mitochondria, causing a state of ATP depletion. Hence, the liberation of calories from added sugars requires nutrients, and increases nutritional demands, but these sugars provide no additional nutrients. Thus, the more added sugars one consumes, the more nutritionally depleted one may become. This may be particularly extreme in individuals whose habitual diet is already lacking in key micronutrients.”[20]

“A nourishing, balanced diet that provides all the required nutrients in the right proportions is the key to minimising appetite and eliminating hunger at minimal caloric intake.”[21]

“To produce ATP efficiently, the mitochondria need particular things.  Glucose or ketone bodies from fat and oxygen are primary.   Your mitochondria can limp along, producing a few ATP on only these three things, but to really do the job right and produce the most ATP, your mitochondria also need thiamine, riboflavin, niacin, pantothenic acid, minerals (especially sulfur, zinc, magnesium, iron and manganese) and antioxidants.   Mitochondria also need plenty of L-carnitine, alpha-lipoic acid, creatine, and ubiquinone (also called coenzyme Q) for peak efficiency.”[22]

If we don’t get enough amino acids to prevent loss of lean muscle mass the body will also up-regulate appetite (i.e. protein leverage hypothesis).[23] [24]   While we can track our food intake to try to actively manage our energy intake, in the end, appetite, driven by the body’s need for nutrients, tends to win out.

Even if we are successful in limiting our intake, our body senses an energy crisis and slows down to make sure it has enough energy and stored fat to run our inefficient metabolism.  However, when we consume whole foods with a higher nutrient density our appetite tends to be satisfied with less energy because it can run more efficiently with an optimal balance of the nutrients it needs.[25]

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If we want to lose weight we need to find a way to provide the body with the nutrients it needs to function optimally with the minimum amount of energy intake while still maintaining low enough blood glucose and insulin levels to allow energy to flow out of our fat stores. 

Ask the experts

There was an interesting panel discussion in Episode 1161 of Jimmy Moore’s Livin La Vida Low Carb Show “Q&A Medical Panel – 2016 Low Carb Cruise” where someone asked:

LCHF says calories don’t matter.  But I still gain weight even when in ketosis.  What’s up with that?

There was a range of responses from the panel of medical doctors, not all in agreement, but my favourite answer was from Dr Ted Naiman (pictured below on the cruise) who said:

I have tons of patients who absolutely plateau out on this diet.   Everyone who goes on LCHF loses a ton of weight, and then hits a plateau.  This is extremely common.  Almost universal.  

If you eat enough fat, the flow of fat into your adipose sites will equal the flow of fat out of your adipose sites and you’re just going to plateau. 

My number one priority is nutrient density.  Eat less fat bombs and instead eat the highest nutrient density foods you possibly can and then more of the fat that you’re burning comes from your internal body stores. 

I recommend really high fat diets for people who are really glucose dependent to help them get fat adapted.  Then, once you have reached your ideal body weight you have to eat a high fat diet then as well because you’re burning fat.  But there is a period in the middle when you’re plateaued when you do want to eat less fat because you want your fat to come off stored body fat.  

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Are you really insulin resistant?

I think the critical question here is whether you are really insulin resistant.  The most useful measure is simply to test your blood glucose levels.

If you have been diagnosed with diabetes, then you will have a glucose meter and you’ll be able to easily test your blood glucose levels to know where you’re at.  Glucometers are fairly cheap to purchase and often come with a rebate.

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There are many people who are fatter than they want to be but still have reasonable insulin sensitivity and normal blood glucose.  For these people, eating more fat doesn’t always get them where they want to be.[26] [27]

At the same time, many skinny people are actually insulin resistant (TOFI).  It of depends on how much energy your belly is willing to store before it starts pumping the excess fat into your vital organs.

The irony here is that you may look healthier if you are skinny, but it may mean that your adipose tissue is able to store less energy before it transitions to start storing excess energy in your vital organs.

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For those of you that don’t like testing your blood glucose level I have outlined a number of other ways to determine whether you are actually insulin resistant.  This understanding can then be used to understand whether you may need more or less dietary fat.

Oral glucose tolerance test

An Oral Glucose Tolerance Test (OGTT) is the generally accepted medical test for insulin resistance and diabetes.  An OGTT measures someone’s rise in blood glucose in response to a large amount of ingested glucose.   If it goes up too much after a standard amount of glucose then you are deemed to be insulin resistant.

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The problem is most people following a low carb approach will likely fail an OGTT because of physiological insulin resistance.  Someone following a low carb diet won’t have a lot of insulin circulating in their body, so when they ingest a large amount of fast acting glucose their pancreas will respond from a “standing start” and has to pump out a lot of insulin to respond to the glucose.  The glucose levels of someone following a low carb dietary approach may rise quite a lot before the pancreas can catch up.

By comparison, someone eating more carbohydrates would have higher levels of insulin circulating that will act on the glucose as soon as it was ingested with only a little bit of extra insulin needing to be secreted in response to the food and hence the glucose response would be lower.

Kraft test

A Kraft Insulin Assay, which measures insulin response over time to a certain amount of glucose, will give you an accurate idea of whether you’re insulin resistant, however these tests are expensive and fairly hard to obtain.  A Kraft Test might be a useful way to see if your are becoming insulin resistant even if your glucose levels are keeping up, for now.

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Oral protein tolerance test

Whether or not your blood glucose levels rise or decrease in response to a high protein meal with no carbohydrate is also a useful way to understand if you are insulin resistant.

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Someone who is metabolically healthy will release glucagon and insulin in response to protein as it is metabolised to maintain a stable glucose level.[28]  Someone who is insulin resistant may not produce adequate insulin to counteract the glucagon released by the liver and hence they may see their blood glucose levels rise.

If you find your glucose levels do rise significantly response to protein, it may be a sign that you need to slow down a little on the protein (or at least limit processed protein powders and opt for whole food sources of protein which are harder to overeat).

Realistically though, unless you’re severely insulin resistant, have Type 1 Diabetes or are using therapeutic ketosis to manage a chronic health condition such as cancer, epilepsy, alzheimers or dementia, most people don’t need to micromanage their protein intake if they are eating a range of unprocessed whole foods.

Your ability to handle protein may improve with time as your insulin resistance improves or you build a bit more muscle mass.  Actively avoiding protein to minimise insulin may be counterproductive in the long term if it leads to loss of lean body mass.

Optimal dietary approach survey

While testing blood glucose is a pretty good indicator of your insulin resistance status, there are a number of reasons that you may not want to test, including:

  • you don’t yet own a blood glucose meter,
  • you don’t like the sight of your own blood, or
  • test strips can be expensive, especially if not covered by insurance.

Beyond testing your blood glucose and / or ketone levels, there are a wide range of other indicators that you may be insulin resistant and may need a higher fat dietary approach.   I have prepared this multiple choice survey to help people better understand which dietary approach might be ideal for them based on their situation and goals.

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You may be insulin resistant and / or benefit from a higher fat diet if you answer yes to most of these of these questions.[29]   If you answer no to most of these questions then you may do better if you focus on nutrient dense foods rather than more fat.

  1. Do you have a chronic health condition such as cancer, epilepsy, dementia, Alzheimer’s, Parkinson’s, severe insulin resistance or traumatic brain injury?
  2. Have you been diagnosed with diabetes?
  3. Is your HbA1c greater than 6.4%?
  4. Is your fasting glucose greater than 7.0 mmol/L?
  5. Is your post meal glucose level greater than 11.0mmol/L or 200 mg/dL?
  6. Is your triglyceride : HDL ratio greater than 3.0?
  7. Are your triglycerides greater than 1.1mmol/L or 100mg/dL?
  8. Are your blood ketone levels less than 0.3mmol/L?
  9. Is your fasting insulin greater than 20 uIU/mL or 120 pmol/L?
  10. Is your C-reactive protein greater than 1.0 mg/dL?
  11. Does your blood glucose level rise significant after eating a large protein only meal?
  12. Do you have a big hard belly (fat stored around the organs not on the surface)?

Can I take my insulin levels to zero?

You cannot eliminate your need for insulin by eating a 100% fat diet, or even not eating at all.

Back in the 70s Dr Richard Bernstein worked out by self experimentation that people with Type 1 Diabetes require both basal and bolus insulin.  Basal insulin is required, regardless of food intake, to stop the body from breaking down its own lean body mass.  Bolus insulin is required to metabolise the food eaten.[30]

Someone on a typical western diet has about a 50:50 ratio of basal to bolus insulin.  Someone on a low carb diet will require less insulin, however 80% of their insulin dose required as basal insulin and the remaining 20% for their food.  While the body typically doesn’t secrete insulin in response to fat, and appetite is often reduced on a high fat diet, if we force an energy excess with high levels of processed fats there will always be enough basal insulin circulating in the blood to remove the excess energy to our fat stores.

Someone with Type 1 will modify their insulin sensitivity factor in their insulin pump to match their insulin sensitivity to optimise their blood glucose control.  People without Type 1 Diabetes can change their insulin sensitivity (and hence require less insulin) by, amongst other things, being exposed to less insulin[31] and improving our level of lean body mass (muscle) and mitochondrial function.  It is important to ensure your diet has adequate protein to build muscle as well as exercising that muscle to make sure our body is well trained and efficient at using that energy.

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Having well trained lean muscle mass is critical to glucose disposal and insulin action and thus reducing overall insulin levels.[32]  In addition to avoiding foods that quickly raise our blood glucose levels, we need to train our body to dispose of the glucose effectively and efficiently with less reliance on large amounts of insulin through building lean body mass.  This is achieved by (amongst other things like sleep, sunlight, reduced stress etc) eating nutrient dense foods that power up the mitochondria to enable us to burn the energy efficiently.

So just tell me what to eat!

I have prepared the table below to guide people to the most optimal foods based on their blood glucose levels and current level of insulin resistance and whether you need to lose weight (based on your waist to height ratio[33]).

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

There’s no nutrient poor processed grains or added sugars in any of these lists.

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The therapeutic ketosis foods have higher levels of added fat.  The nutrient dense weight loss foods contain more lean proteins and non-starchy veggies and less added fat.

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Someone with poorly controlled Type 2 Diabetes may start out on a high fat ketogenic approach (say 2:1 fat to protein by weight), in time they should be able to progressively ‘level up’ to more nutrient dense foods as their insulin sensitivity improves and they find their blood glucose levels can tolerate it.

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Someone who has long standing diabetes or who has Type 1 Diabetes may settle on a 1:1 for maintenance.  Someone who becomes more insulin sensitive may be able to cut their dietary fat down even more as they are more easily able to release fat from their body fat stores.  Even if someone wanting to lose weight got down to a 1:0.5 protein to fat ratio by weight the majority of their energy is still coming from fat, they’re just given their body a better chance of needing to use dietary fat.

I hope this helps you find the optimal approach for you.  I would love to hear how it goes.

references

[1] https://optimisingnutrition.com/2015/06/22/why-we-get-fat-and-what-to-do-about-it-v2/

[2] http://bja.oxfordjournals.org/content/85/1/69.long

[3] https://optimisingnutrition.com/2015/06/29/trends-outliers-insulin-and-protein/

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

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

[6] http://cardiab.biomedcentral.com/articles/10.1186/1475-2840-12-164

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

[8] https://optimisingnutrition.com/2015/06/29/trends-outliers-insulin-and-protein/

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

[10] http://www.sciencedirect.com/science/article/pii/S0026049515003340

[11] https://youtu.be/r8uSv6OgHJE?t=2080

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

[13] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737348/pdf/OBY-23-2327.pdf

[14] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4102118/

[15] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140964/

[16] https://www.facebook.com/groups/198981013851366/permalink/261051057644361/?comment_id=261276760955124&comment_tracking=%7B%22tn%22%3A%22R4%22%7D

[17] https://www.youtube.com/watch?v=r8uSv6OgHJE&feature=youtu.be

[18] http://www.nature.com/ejcn/journal/v67/n7/abs/ejcn201390a.html

[19] https://www.amazon.com/Nutritional-Approach-Revised-Model-Medicine-ebook/dp/B00CXECDI8/ref=tmm_kin_swatch_0?_encoding=UTF8&qid=&sr=

[20] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975866/

[21] http://perfecthealthdiet.com/

[22] http://terrywahls.com/about-the-wahls-protocol/

[23] http://sydney.edu.au/science/outreach/inspiring/news/cpc.shtml

[24] http://www.nature.com/ejcn/journal/vaop/ncurrent/full/ejcn2016256a.html

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

[26] https://optimisingnutrition.com/2016/06/13/low-energy-density-high-nutrient-density-foods-for-weight-loss/

[27] https://www.dropbox.com/s/n8tzuiixb1n1cxi/Weight%20Loss%20on%20Low-Fat%20vs.%20Low-Carbohydrate%20Diets%20by%20Insulin%20Resistance%20Status%20Among%20Overweight%20Adults%20and%20Adults%20With%20Obesity-%20A%20Randomized%20Pilot%20Trial%20(1).pdf?dl=0

[28] https://optimisingnutrition.com/2015/06/15/the-blood-glucose-glucagon-and-insulin-response-to-protein/

[29] http://www.thebloodcode.com/

[30] https://www.youtube.com/watch?v=6lrbxITXAVA

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

[32] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2343294/

[33] https://en.wikipedia.org/wiki/Waist-to-height_ratio

the complete guide to fasting (review)

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

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

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

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

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

Essentially, Jason’s key points are that:

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

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

my experience with fasting

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

Complete abstinence is easier than perfect moderation.

St Augustine

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

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

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

My key fasting takeaways are:

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

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

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

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

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

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

context

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

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Desperate times call for desperate measures!

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

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

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

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

the Complete Guide to Fasting

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

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

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

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

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

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

The book covers:

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

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

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

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

my additional 2c…

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

target glucose levels

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

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

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

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If your glucose levels are swinging wildly due to a poor diet coupled with lots of medication, your glucose levels are simply going to tank when you stop eating.  Hence, a safe approach is to back off the medication, at least initially, until your glucose levels have normalized.

Being married to someone with Type 1 Diabetes, I have learned the practical realities of getting blood glucose levels as low as possible while still avoiding dangerous lows.[4]  My wife Monica doesn’t feel well when her blood glucose levels are too low, but neither does she feel good with high blood glucose levels.  Balancing insulin and food to get blood glucose levels as low as possible without experiencing lows requires constant monitoring.

The chart below shows how scattered blood glucose levels can be even if you’re fairly well controlled.   Ideally you want the average blood glucose level to be as low as possible while minimising the number of hypoglycaemic episodes (i.e. below the red line).  If you can’t reduce the variability you just can’t bring the average blood glucose level down.  The last thing you want is to be eating to raise your blood glucose levels because you had too much blood glucose lowering medication.

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

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

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fasting to optimise blood glucose levels

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

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Once you’ve broken the back of your insulin resistance with fasting, you can continue to drive your blood glucose levels down towards optimal levels.

One of the most popular articles on the Optimising Nutrition blog is how to use your glucose meter as a fuel gauge which details how you can time your fasting based on your blood glucose levels to ensure they continue to reduce.

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Your blood glucose levels can help calibrate your hunger and help you to understand if you really need to eat.  I think this is a great approach for people whose main issue is high blood glucose levels and who aren’t ready to launch into longer multi day fasts.

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

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

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

fasting frequency

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

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The reality, at least in my experience, is that we can overcompensate for our fasting during our feasting and end up not moving forward toward our goal.

If your goal is to lose weight I like the idea of tracking your weight and not eating on days that your weight is above your goal weight for that day.

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

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

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

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

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

FAST WELL, FEED WELL

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

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

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

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

“Fasting without proper refeeding is called anorexia.” 

Mike Julian

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

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

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

optimising insulin levels AND nutrient density

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

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Some people who are very insulin resistant do well, at least initially, on a very high fat diet.  However, as glycogen levels are depleted and blood glucose levels start to normalise, I think it is prudent to transition to the most nutrient dense foods possible while still maintaining good (though maybe not yet optimal) blood glucose levels.

The problem with doubling down on reducing insulin by fasting combined with eating only ultra-low insulinogenic foods is that you end up “refeeding” with refined fat after your fast.

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

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

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

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

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

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

protein

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

are you really insulin resistant?

Insulin resistance and obesity is a continuum.

Not everyone who is obese is necessarily insulin resistant.

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

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

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

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optimal ketone levels

Measuring ketones is really fascinating but confusing as well.

“Don’t be a purple peetone chaser.”

Carrie Brown, The Ketovangelist Podcast Ep 78

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

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

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

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

the root cause of insulin resistance is…

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

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

But what is the root cause of insulin resistance?

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

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

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

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summary

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

references

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

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

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

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

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

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

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

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

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

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

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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.

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

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

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

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

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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 regular sugar hit to make us feel good (Cori cycle).

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

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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 easily obtain from nutrient dense spinach and broccoli.

optimal rehabilitation plan?

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

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

the solution

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

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

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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!

post last updated May 2017

references

[1] http://ketosummit.com/

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

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

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

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

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

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

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

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

nutrient dense foods for weight loss and insulin resistance

I found a number of people that were using the a combination of the optimal foods for diabetes and nutritional ketosis and the optimal foods for weight loss lists.  So I thought it would be useful to combine the two approaches into a single list of foods for people who want to lose weight but who were still somewhat insulin resistant.

optimal foods for diabetes and nutritional ketosis

The food ranking system revolves around manipulating these three parameters to suit different goals:

The optimal foods for diabetes and nutritional ketosis list has a low insulin load, is fairly low in non-fibre carbs and moderately high fat while still being as nutrient dense as possible.

This approach suits someone who has Type 1 Diabetes or is lean and looking to achieve nutritional ketosis.  People who are at their goal weight can afford to eat a little more added dietary fat.

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While  most people looking to manage their blood glucose levels limit their carbohydrates to some arbitrary number that works for them, maximising nutrient density as well will help you to improve your mitochondrial function and increase your energy levels to ideally overcome your insulin resistance.  Maximising nutrient density also means that your body won’t keep on seeking out more and more food to obtain the nutrients it requires.

People who are very insulin resistant often do well on a higher fat dietary approach initially to let the insulin levels drop, however they often find further success in the long term if they drop their dietary fat to let more fat come from their body.

optimal foods for weight loss

The optimal foods for weight loss list is fairly low in dietary fat to allow for to come form the body during weight loss.  It’s heavy in lean proteins and non-starchy veggies and is VERY nutrient dense.  The chart below shows a comparison of a range of dietary approaches with the insulin sensitive weight loss approach being having the highest nutrient density while the diabetes and nutritional ketosis approach comes in at #8 of thirteen.

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This list of foods may look like a low fat dietary approach, but it’s not really low fat once you factor in your body fat.  The chart from Steve Phinney illustrates how your body fat makes a contribution to the weight loss phase of a well formulated ketogenic diet.

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The weight loss list of foods is also quite bulky (i.e. lots of fibre and water) so they would be very hard to overeat if you stick to just these foods.  The chart below show a comparison of the various approaches with the weight loss approach having the lowest energy density.

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Eating from the weight loss foods basically equates to a protein sparing modified fast (which is widely held to be the most effect way to lose weight in the long term) meaning that will fill you up so much you won’t be above to overeat while at the same time providing enough protein to preserve lean muscle mass during the weight loss phase.

The “problem” with the aggressive weight loss approach is that it is very low in energy dense comfort foods and it is higher in carbohydrates and protein than most low carbers might be used to, so it might be harder to stick to.  It may also raise your blood glucose levels if you’re still somewhat insulin resistant.

finding the optimal balance between the extremes

I have designed this list of foods for people who are insulin resistant and also looking to lose weight provides a balance between both extremes – high nutrient density, lowish levels of dietary fat and lower energy density.

The foods listed below represent the top 10% of the USDA food database using this ranking system.  I’ve included the nutrient density score, percentage of insulinogenic calories, insulin load (per 100g), energy density (per 100g) and the multicriteria analysis score score (MCA) that combines all these factors.

The chart below shows the amount of each nutrient provided by the more balanced approach compared to average of all the foods in the USDA food database.  As you can see you will still be able to obtain heaps of nutrients while the fat comes from your body.

weight-loss-insulin-resistant

vegetables

food ND % insulinogenic insulin load (g/100g) calories/100g MCA
broccoli 23 36% 3 22 2.07
endive 15 23% 1 17 1.84
coriander 16 30% 2 23 1.79
zucchini 18 40% 2 17 1.75
chicory greens 14 23% 2 23 1.74
spinach 20 49% 4 23 1.66
escarole 11 24% 1 19 1.58
basil 17 47% 3 23 1.55
alfalfa 9 19% 1 23 1.51
watercress 22 65% 2 11 1.51
beet greens 13 35% 2 22 1.49
asparagus 16 50% 3 22 1.44
lettuce 14 50% 2 15 1.33
Chinese cabbage 15 54% 2 12 1.29
summer squash 12 45% 2 19 1.26
okra 13 50% 3 22 1.26
parsley 13 48% 5 36 1.25
cauliflower 13 50% 4 25 1.23
chard 13 51% 3 19 1.22
portabella mushrooms 14 55% 5 29 1.20
mustard greens 9 36% 3 27 1.20
arugula 11 45% 3 25 1.17
turnip greens 10 44% 4 29 1.17
chives 11 48% 4 30 1.14
banana pepper 8 36% 3 27 1.13
paprika 9 27% 26 282 1.11
cucumber 7 39% 1 12 1.08
pickles 7 39% 1 12 1.08
collards 7 37% 4 33 1.07
celery 10 50% 3 18 1.03
brown mushrooms 16 73% 5 22 1.01
avocado -0 8% 3 160 0.99
white mushroom 13 65% 5 22 0.99
shitake mushroom 12 58% 7 39 0.98
red peppers 6 40% 3 31 0.98
dandelion greens 10 54% 7 45 0.97
sauerkraut 5 39% 2 19 0.96
dill 11 59% 8 43 0.96
eggplant 4 35% 3 25 0.95
cloves 9 35% 35 274 0.95
radishes 6 43% 2 16 0.94
sage 7 26% 26 315 0.93
jalapeno peppers 5 37% 3 27 0.93
curry powder 3 13% 14 325 0.92
edamame 7 41% 13 121 0.89
chayote 5 40% 3 24 0.88
olives -5 3% 1 145 0.80
Brussel sprouts 6 50% 6 42 0.78
spirulina 11 70% 6 26 0.76
soybeans (sprouted) 6 49% 12 81 0.76
cabbage 7 55% 4 23 0.75
blackberries -1 27% 3 43 0.71
artichokes 5 49% 7 47 0.71

seafood

food ND % insulinogenic insulin load (g/100g) calories/100g MCA
fish roe 18 47% 18 143 1.45
salmon 19 52% 20 156 1.44
trout 16 45% 18 168 1.36
caviar 13 33% 23 264 1.25
oyster 16 59% 14 102 1.19
cisco 9 29% 13 177 1.17
sturgeon 13 49% 16 135 1.13
mackerel 6 14% 10 305 1.08
anchovy 12 44% 22 210 1.08
crab 17 71% 14 83 1.01
sardines 9 36% 16 185 1.01
flounder 13 57% 12 86 1.01
herring 9 36% 19 217 0.97
sardine 9 37% 19 208 1.0
halibut 15 66% 17 111 0.96
tuna 12 52% 23 184 0.91
rockfish 13 66% 17 109 0.86
lobster 14 71% 15 89 0.85
crayfish 12 67% 13 82 0.82
shrimp 13 69% 19 119 0.81
pollock 13 69% 18 111 0.79
perch 10 62% 14 96 0.73

animal products

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food ND % insulinogenic insulin load (g/100g) calories/100g MCA
lamb liver 19 48% 20 168 1.47
lamb kidney 19 52% 15 112 1.45
turkey liver 16 47% 21 189 1.25
beef brains 8 22% 8 151 1.24
veal liver 17 55% 26 192 1.20
beef liver 17 59% 25 175 1.14
chicken liver 14 50% 20 172 1.13
beef kidney 14 52% 20 157 1.10
lamb brains 6 27% 10 154 1.05
chicken liver pate 7 34% 17 201 0.91
lamb heart 10 48% 19 161 0.90
ham 12 59% 17 113 0.88
ground turkey 6 30% 19 258 0.88
turkey heart 9 47% 20 174 0.85
rib eye steak 8 41% 21 210 0.84
roast pork 7 41% 20 199 0.83
roast beef 7 38% 21 219 0.83
beef tongue 1 16% 11 284 0.81
lamb sweetbread 6 43% 15 144 0.79
lamb chop 8 42% 25 234 0.79
lean beef 11 61% 23 149 0.78
beef heart 9 52% 23 179 0.78
park sausage 2 25% 13 217 0.78
pork liver 11 59% 23 165 0.77
turkey meat 8 52% 21 158 0.74
turkey drumstick 8 52% 21 158 0.74
chicken 10 60% 22 148 0.73

dairy and egg

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food ND % insulinogenic insulin load (g/100g) calories/100g MCA
whole egg 9 30% 10 143 1.20
egg yolk 8 18% 12 275 1.15
sour cream 2 13% 6 198 1.02
cream 2 6% 5 340 0.93
cream cheese 2 11% 10 350 0.84
Swiss cheese 5 22% 22 393 0.80
cheddar cheese 5 20% 20 410 0.78
Greek yogurt 3 37% 9 97 0.74

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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