Category Archives: ketogains

“high protein” vs “low protein”

In a recent Facebook thread Richard Morris of 2 Keto Dudes fame said:

The lipophobics and the aminophobics are both talking past each other at strawmen.  

The hysteria is not just humorous, it’s confusing and turning away novices.  

This phony controversy causes people to recommend insane amounts of protein at BOTH ends of the spectrum.

Protein tends to be a passionate topic of discussion n the online macronutrient wars.  So I thought it would be useful to set out arguments at both extremes of the ‘protein controversy’ and detail some responses to bring some balance.  My hope is that this article will bring some clarity to the civil war in the low carb/keto community.

The TL:DR summary is:

  • appetite is a reliable driver to make sure you get enough protein to suit your needs,
  • our appetite decreases when we get enough protein,
  • it’s hard to overeat protein because it’s hard to convert to energy, so the body doesn’t want more than it can use,
  • most people get adequate protein without worrying about it too much,
  • people who require a therapeutic ketogenic approach should pay attention to their diet to ensure that they don’t miss out on essential micronutrients while maintaining a low insulin load, and
  • if you prioritise nutritious whole foods, you’re likely getting enough protein but not too much.

If you want more detail, read on! The arguments and responses of the two sides are outlined below.  The article then concludes with some learnings and observations from the Nutrient Optimiser about how we can optimise protein intake to suit our goals and situation.

High protein bros

This section outlines the arguments and responses from the “high protein bro” extreme end of the debate.

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“There is no such thing as too much protein.”

Refined protein supplements do not contain the same quantity of much vitamins, minerals or essential fatty acids as whole foods.

As shown in the plot of percentage protein vs nutrient score, a focus on obtaining adequate vitamins, minerals and essential fatty acids from whole foods typically leads to obtaining plenty of amino acids.  Meanwhile, actively avoiding protein tends to dilute overall nutrient density in terms of vitamins and minerals.

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The body typically down-regulates appetite before it consumes ‘too much protein’.  It is physically difficult to eat ‘too much protein’ from whole foods (although hyperpalatable whey protein shakes may be another matter).

While protein is beneficial, we also need a balanced diet that provides the other vitamins and minerals (e.g. electrolytes that will enable the kidneys to maintain acid/base balance which is critical to insulin sensitivity which is hard to obtain from protein supplements).

In summary, it is possible to focus too much on protein to the point that you are missing out on other important micronutrients.  Conversely though, if you chase micronutrients from whole foods you will get adequate amounts of protein.

“Fasting will cause you to lose muscle due to a lack of protein intake.”

A high-fat diet reduces the need for glucose and therefore the requirements for protein from gluconeogenesis decrease.  Someone who is ‘fat adapted’ with lower insulin and blood glucose levels will also be more readily able to access their stored body fat for fuel.

The body defends lean muscle loss by upregulating appetite.[1]  People with more body fat and/or lower insulin levels will likely find fasting easier than people who are lean and/or have high insulin levels.

Fasting will drive autophagy, which is beneficial, to an extent.  Fasting and feasting is a cyclic process of building and cleaning out.  We need to balance both parts of the cycle.  Humans generally do this well in the absence of hyper-palatable processed foods.

One of the benefits of fasting is that when you re-feed, your body will be more insulin sensitive so you will build back new muscle more efficiently with less protein and insulin required.  People doing regular multi-day fasts should ensure their average protein intake is adequate over a number of days and not just on the days they eat.

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You should target more nutritious foods on your eating days to ensure you are getting adequate nutrients over the long term.  If your goal is to lose body fat, then re-feeding to satiety on very high-fat foods may be counterproductive in terms of fat loss and micronutrient sufficiency.[2]

“Everyone needs to lift heavy weights and be jacked.”

Not everyone wants to look good with their shirt off or is willing to invest the dedication that it takes to have a six-pack.  However, being active and having sufficient lean muscle mass is important to maintaining insulin sensitivity and delaying the diseases of ageing.  Doing something is better than nothing.  Having sufficient lean muscle mass is arguably better than manipulating macronutrients if your goal is glucose disposal and fat burning.

Low protein “ketonians”

This section outlines a number of arguments against ‘too much protein’ along with some responses.

“Too much protein will turn to glucose like chocolate cake in your bloodstream”

Protein can be converted to glucose via gluconeogenesis if there is no other fuel available.  However, gluconeogenesis does not come easily, and the body only resorts to increased levels of gluconeogenesis above baseline levels in emergency situations.  Gluconeogenesis yields only 2 ATP from 6 ATP.[3]

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“Too much protein is dangerous for your kidneys”

High levels of protein are only a concern if you have a pre-existing kidney issue,[4] and even then not everyone is in agreement.

“Protein is expensive and a waste to use for fuel”

The fact that using protein for fuel is metabolically expensive can be beneficial if our goal is fat loss as it increases overall energy expenditure.[5] [6]  By contrast, fat and carbs are more efficient fuel sources.  Higher levels of protein intake will drive satiety as well as being less efficient and cause more losses.

High protein foods are often financially expensive.  Processed high fat and high carb foods are cheaper to produce and hence can have a higher markup applied to them.  Thus, food companies tend to promote cheaper foods with a higher carb and/or fat content.

“Too much protein is dangerous for people with diabetes.”

People with diabetes convert more protein to glucose through uncontrolled gluconeogenesis (i.e. due to insulin resistance in Type 2 and a lack of insulin in Type 1).[7]  They also find it harder to build muscle due to a lack of insulin.  Hence, people with diabetes may benefit from consuming more protein to maintain or gain muscle.

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Conversely, people who are insulin sensitive may require less protein because they can use it more efficiently to build and repair muscle.

Older people tend to require more protein to prevent sarcopenia.[8]  A loss of lean muscle mass is a significant risk factor for older people.[9]

As shown in the chart below, people with diabetes (yellow lines) produce more insulin in response to protein than metabolically healthy people (white lines).[10]  Forcing more protein beyond satiety may make diabetes management more difficult.  However, most people get the results they require from reducing carbohydrates.  The fact that protein turns to glucose can be a useful hack for people with brittle diabetes who want to get their glucose without the aggressive swings that refined carbohydrates can provide.

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“Too much protein will make it hard maintain healthy blood sugar levels because protein stimulates insulin and glucagon.”

Protein requires insulin to metabolise.  Insulin also works to keep glycogen stored in the liver.

As shown in the charts below,[11] an increase in protein in the diet typically forces out processed and refined carbohydrate and so decreases your insulin and glucose response to food.[12] [13] [14] [You can check out the interactive Tableau version of these charts here.]

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People with Type 1 diabetes don’t have enough insulin to metabolise protein and maintain healthy blood sugars at the same time and hence require exogenous insulin.

People with Type 2 diabetes often have plenty of insulin but need to ‘invest’ their insulin wisely on metabolising protein to build muscles and repair their vital organs rather than ‘squandering it’ on refined carbohydrates.

People with hyperinsulinemia will often see their blood sugars decrease after a high protein meal as the insulin released to metabolise the protein also works to reduce their blood sugars.[15]

If you see your blood sugars rise after a high protein meal you may have inadequate insulin.  IF you have an insulin insufficiency, you may need to learn to accurately dose with insulin for protein rather than avoiding protein.[16]

“High protein will shorten life due to excess mTOR stimulation.”

Humans need to balance growth (i.e. increased IGF-1, insulin and mTOR) with repair (i.e. autophagy, fasting and ketosis).  Driving excess growth through unnatural means may not be beneficial for long-term health.

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However, the research into protein restriction and longevity is either theoretical or in worms in a petri dish where they grew more slowly when protein and/or energy was restricted.  Free-living humans typically don’t manage to voluntarily restrict energy intake.  We seem to have an inbuilt drive to protect ourselves from a loss of muscle mass, depression (note: good nutrition, especially amino acids is crucial to brain function) and loss of sex drive, and generally feeling cold and miserable.

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Longevity research in monkeys suggests that energy restriction or at least a reduction in modern processed foods is beneficial.  However, there is no research in mammals that demonstrates that protein restriction extends lifespan or health span.

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The low target protein values proposed by some for longevity (i.e. 0.6g/kg lean body mass or LBM) are practically impossible to achieve from whole foods without the addition of a significant amount of oils and refined fats and/or substantial calorie restriction to the point of rapid weight loss (e.g. check out the Nutrient Optimiser analysis of Dr Rosedale’s diet here).

There is a difference between lifespan and healthspan. Humans in the wild who are frail risk fractures and other complications related to muscle wasting and lethargy.

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As shown in the chart below, there is an optimal balance between growth and wasting.[17]  Too much insulin and you grow to the point that you get complications of metabolic disease.  Too little growth and you become frail, lose your muscle and bone strength then you may fall, break your hip and never get up again.

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“Just eating protein won’t give you gainz!”

Yes indeed!  You need to force an adaptive stress to cause muscle gains, not just eating protein.  If you work out, you will likely crave more protein.  This is natural and healthy and ensures that we can recover, adapt and get stronger.

“Overeating protein will make you fat.”

Excess consumption of any macronutrient will make you fat.  However, eating more protein and fewer carbs and fat tends to increase satiety.[18]

Research in resistance-trained athletes shows that overeating protein does not cause an increase in fat mass.[19] [20]  Research in sedentary adults shows that overeating protein causes a more favourable change in body composition than overeating the same amount of calories from fat and/or carbohydrate.

“Too much protein will lead to rabbit starvation.”

Healthy people can metabolise up to 3.5g/kg protein per day and digest up to 4.3g/kg per day.[21]  This makes sense in an evolutionary context (or even in more recent times before we had refrigerators) when there wouldn’t have been a regular supply of food but we would have needed to be able to use the food when we came across a big hunt after a long famine.

Theoretical research suggests there is no upper limit to protein intake to the point it is dangerous.   However, the practical upper limit seems to be around 50% of energy intake.  If you force extreme levels of protein, you get thirsty and pee out the excess protein.

Growing children and active people tend to crave higher levels of protein to build and repair their muscles (i.e. 10-year-old Bailan Jones, shown on the right here with his brother, who is a growing young man with Type 1 who consumes 4.4g/kg LBM).

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If you’re obese and eat only lean protein, your body will be forced to use body fat for fuel.  If you are very lean and eat nothing but very thin protein satiety will kick in and you will not have enough body fat to burn.  This is dangerous and leads to death.  So if you are already very lean and going to live in the wilderness with only wild rabbits to eat, make sure you take some butter.  However, most people will have adequate body fat to use for fuel for a significant period of time before rabbit starvation would be an issue.

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“If you’re not losing weight, you should cut your protein and your carbs and eat fat to satiety.”

Reducing processed carbs helps to lower insulin and stabilise blood sugars and helps a lot of people reduce their appetite and lose body fat.[22] [23]  However, not everyone reaches their optimal weight with this method.

LCHF / keto works until it doesn’t.

Many people find that they need to reduce dietary fat in addition to carbohydrates to ensure they burn body fat.

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Restricting protein and carbs while eating ‘fat to satiety’ may lead to an inadequate intake of vitamins and minerals which can lead to cravings and a lack of satiety.[24] [25]

While reducing the insulin load of your diet to the point that we achieve healthy blood glucose levels often helps improve satiety, effective weight loss diets typically involve some permutation of reduced fat and/or carbs to achieve a reduction in energy intake.

Medical weight loss clinics typically use a version of a protein sparing modified fast which provides adequate protein to prevent loss of lean muscle mass while restricting carbohydrates and fat.[26] [27] [28]

People on a low carb or keto diet may have an increased requirement for protein due to the body’s increased reliance on protein for glucose compared to someone who is getting their glucose from carbohydrate.[29]  Protein is the most satiating macronutrient and eating more fat when your appetite is actually craving protein, or other nutrients may lead to excess energy intake.[30]

“Too much protein will kick you out of ketosis and halt fat burning.”

Contrary to popular belief (which is often propagated by people marketing ketogenic products), ketosis is only one of a number of pathways that we burn fat.

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Ketones (i.e. AcetoAcetate or AcAc) are produced when there we don’t have enough Oxaloacetate (OAA) to produce citrate in the Krebs cycle.[31]

If you are consuming enough protein and/or carbs to provide OAA you will still burn fat but through the Krebs cycle rather than via ketogenesis.  Thus, you may be “kicked out of ketosis” if you eat more protein but you’re still burning plenty of fat.[32]

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fat burning via Krebs cycle or ketosis (via Amy Berger)

If you have high levels of NADH (which is associated with ageing and diabetes),[33] [34] [35] more of your AcAc will be converted to BHB in the liver.

Most people will see ketones in their blood increase when fasting or restricting energy intake due to the lack of OAA as they burn body fat.  As shown in the chart below, blood glucose levels decrease while BHB increases.

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There are a number of beneficial processes (e.g. autophagy, increased NAD+, increase in sirtuins) that current during fasting/energy restriction that is associated with increased BHB.  It is possible that many of the benefits related to BHB may actually be due to these other beneficial processes that occur in endogenous ketosis (i.e. it’s probably not the ketones).

We can force higher levels of BHB in the blood by eating more dietary fat and less protein and carbohydrates.  In this case, high BHB may be an indication that you are eating more fat than can be burned in the Krebs cycle and it is building up in the blood.   High levels of BHB in the blood do not mean you are achieving the same benefits via exogenous ketosis as we do in endogenous ketosis.

If your AcAc is not converted to BHB due to a low NAD+:NADH ratio you will tend to see more breath acetone (BrAce).  If you do not have metabolic syndrome, you may see higher levels of BrAce (i.e. measured with the Ketonix) and lower levels of BHB in the blood.   You should also be aware that exercise and an adequate intake of B vitamins in the diet will also increase your NAD+ levels and ‘kick you out of ketosis’.

Before you get caught up chasing ketones by whatever means possible, you should keep in mind that someone who is metabolically healthy and easily able to access their body fat stores for fuel (i.e. low insulin levels) will have lower overall levels of energy floating around in their blood (i.e. from blood glucose, ketones or free fatty acids).  Higher levels of energy in the bloodstream is a sign of poor metabolic health and reduced ability to access and burn fat.

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High levels of glucose lead to glycation.  High levels of free fatty acids lead to oxidised LDL.  High levels of glucose and free fatty acids tends to lead to glycated LDL.  High levels of ketones can similarly lead to metabolic acidosis if not balanced with an adequate mineral intake which may also ‘kick you out of ketosis’.[36]

Learnings from the Nutrient Optimiser

What is everyone else doing?

The Nutrient Optimiser Leaderboard demonstrates that low carbers have a wide range of protein intakes.

  • The average fat intake of these people is 60%, with half the people between 54% and 68% calories. The average carb intake is 11% with half the people between 6 and 15%.   So, we can see that this is generally a CLHF population.
  • Half of the people lie between about 1.4 and 2.5g/kg LBM with an average of 2.1g/kg LBM. In terms of percentage, half of the people sit somewhere between 18 and 29% of energy from protein with an average of 24% energy from protein.
  • Dr Rhonda Patrick, who is sitting at the top of the leaderboard, seems to be eating about 2.5g/kg LBM protein even though she says she is not particularly active and eats heaps of veggies.
  • People who are active tend to eat more protein (e.g. Brianna, Andy Mant and Alex Leaf).
  • “High” protein advocates Luis Villasenor of Ketogains and Dr Ted Naiman both seem to be consuming around 2.4g/kg LBM to support recovery from their higher activity exercise levels.
  • People following a zero carb approach tend to be eating more protein (e.g. Shawn Baker at 6.1g/kg LBM and Amy on 3.3g/kg LBM) as more of their energy comes from animal food. Perhaps many of the satiety effects of a Zero Carb dietary approach are actually due to the high satiety effects of protein.
  • The people with less than 1.0g/kg LBM tend to be relying on a significant amount of added fats and do not tend to achieve the highest overall nutrient score (see examples here, here and here).

What are the recommendations?

The very wide range of protein intake levels can be confusing.  Some are outlined below for reference.

  • In long-term fasting, we use about 0.4g/kg LBM protein from our body via gluconeogenesis.
  • The Estimated Average Requirement is 0.68g/kg body weight for men to prevent protein related deficiencies and 0.6g/kg body weight for women.  For a woman with 35% body fat, this equates to 0.92g/kg LBM as a minimum protein intake.[37]  (Note: These standard values are in the context of someone eating a conventional diet where they would typically be getting plenty of glucose from carbohydrates and are not particularly active, and protein requirements may be higher where someone is active and using some protein for glucose via gluconeogenesis.)
  • The Recommended Daily Intake is 0.84g/kg body weight for men to prevent protein related deficiencies and 0.75g/kg body weight for women (Note: For a woman with 35% body fat this equates to 1.15g/kg LBM as a minimum for someone who is sedentary).[38]
  • Steve Phinney recommends 1.5 to 2.0g/kg reference body weight (see slide below from his recent presentation in Brisbane) which equates to around 1.7 to 2.2g/kg LBM for someone wanting to lose 10% of their body weight to achieve their ideal ‘reference weight’. This increased level allows for some glucose to come from protein via gluconeogenesis and allows adequate protein for people who are not eating carbs and active.

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  • Ketogains suggest 0.8 to 1.0g/lb LBM or 1.8 to 2.2g/kg LBM for people who are looking to maintain or build higher levels of muscle mass.
  • Mainstream bodybuilding recommends 1.7 to 2.5g/lb body weight or 3.7 to 5.5g/kg body weight.[39] For someone with 15% body fat, this equates to 4.3 to 6.4g/kg LBM!!!

What happens to micronutrients when we chase protein?

When I first started tinkering with nutrient density, I assumed that we would want to boost all the essential nutrients (i.e. similar to Dr Mat Lalonde’s approach[40]).  The chart below shows the nutrients provided when we prioritise foods that have higher amounts of all the essential micronutrients.  The amino acids are shown in maroon.

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The ‘problem’ with this array of foods is that, because protein is easy to obtain, this group of foods ends up being very high in protein!  Even the “high protein bros” won’t be able to consume seventy percent of their energy from protein.

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As you can see from the figure below, we typically can’t eat more than 50% of our energy from protein.  However, satiety levels tend to be highest, and hence energy intake is the lowest at around 50% protein (dark blue area).[41]

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There is generally no need to prioritise amino acids because it is easy to meet the Recommended Daily Intake for amino acids if we eat whole foods.

Emphasise only harder to find nutrients

Rather than prioritising all the micronutrients, the chart below shows the micronutrient profile that we get if we prioritise the harder to obtain micronutrients (shown in yellow) without prioritising any of the amino acids (shown in maroon).   (Note:  Vitamin E and Pantothenic Acid haven’t been prioritised as the target levels are based on population averages rather than deficiency studies).

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As you can see, we still get heaps of protein. However, we get a much better micronutrient profile in the vitamins and minerals because we are only prioritising the harder to find micronutrients.

Maximising nutrient intake while minimising energy intake appears to be central to reducing natural energy intake and minimising nutrient related cravings and bingeing.  It’s not hard to see how we could reduce our energy intake eating these foods while still getting plenty of the essential micronutrients.

Highest protein foods

For comparison, the chart below shows the nutrient profile of the highest protein foods.   It seems when we prioritise foods based on their protein content we end up missing out on a number of the vitamins and minerals.  Thus, there appears to be a danger that we will miss out on micronutrients when we focus only on protein.

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Do plant-based diets provide enough protein?

The one situation I have seen people not meeting the recommended daily intake levels for protein is people following a purely plant-based diet.  In the nutrient profile shown below, Sidonie is only getting 11% of her calories from protein and you can see that leucine is not meeting the DRI levels while methionine and lysine are just meeting the minimum levels.  This may be a legitimate concern for someone on a plant-based diet as amino acids tend to be less bioavailable from plans in comparison to animals.

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The image below shows the foods that will help to fill in the gaps in her current nutritional profile which is focused on high protein vegetables and legumes.

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This food list shows the foods that would fill in Sidonie’s nutritional gaps if she was open to adding animal foods.  This is an interesting contast to the typical food list for someone on a low carb diet which has a much longer list of vegetables to rebalance the vitamins and minerals.

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Most ketogenic foods

The chart below shows the nutrient profile of the most ketogenic foods (i.e. the ones that require the lowest insulin by limiting carbs and moderating protein).  It seems that, if you actually require therapeutic ketosis (i.e. to manage epilepsy, cancer, dementia or Alzheimer’s), you will need to pay particular attention to getting adequate micronutrients (i.e. notably, choline, folate, potassium, calcium and magnesium).

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Lowest protein foods

And finally, the chart below shows the micronutrient profile if we actively avoid protein.

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It seems that actively avoiding protein has a diabolical impact on the micronutrient profile of our food.  However, when we focus on balancing our diet at a micronutrient level, everything else seems to work out pretty well.

So what should I eat?

With all the conflicting opinions it can be confusing to know what to eat.

In the end, it comes down to eat good food when hungry. 

If we remove hyperpalatable processed foods, I think we’ll have a much better chance of being able to trust our appetite to guide us to the foods that will be good for us.

The food lists below have been prepared to provide the most nutrients while aligning with different goals (e.g. therapeutic ketosis, blood sugar control weight loss, maintenance or athletic performance).  There are a whole lot of other lists in the Optimal Foods for YOU article that are tweaked to suit different goals.

I think if you limit yourself to these shortlists of healthy foods you will be able to listen to your appetite to guide you towards the protein rich foods, the mineral rich foods or the vitamin rich foods depending on your need right now.

approach average glucose (mg/dL) average glucose (mmol/L) PDF foods nutrients
well formulated ketogenic diet > 140 > 7.8 PDF foods nutrients
diabetes and nutritional ketosis 108 to 140 6.0 to 7.8 PDF foods nutrients
weight loss (insulin resistant) 100 to 108 5.4 to 6.0 PDF foods nutrients
weight loss (insulin sensitive) < 97 < 5.4 PDF foods nutrients
most nutrient dense < 97 < 5.4 PDF foods nutrients
nutrient dense maintenance < 97 < 5.4 PDF foods nutrients
bodybuilder < 97 < 5.4 PDF foods nutrients
endurance athlete < 97 < 5.4 PDF foods nutrients

Once you’re eating well and want to further refine your diet you want to check out the Nutrient Optimiser.

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references

[1] http://www.nature.com/ejcn/journal/v71/n3/full/ejcn2016256a.html?foxtrotcallback=true

[2] https://optimisingnutrition.com/2016/10/29/the-complete-guide-to-fasting-book-review/

[3] https://www.youtube.com/watch?v=Og8PTdjVAWE

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4031217/

[5] http://www.tandfonline.com/doi/abs/10.1080/07315724.2004.10719381

[6] http://ajcn.nutrition.org/content/87/5/1558S.long

[7] https://www.ncbi.nlm.nih.gov/pubmed/15836464

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4555150/

[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4066461/

[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC524031/

[11] https://public.tableau.com/profile/marty.kendall7139#!/vizhome/foodinsulinindexanalysis/insulinloadvsFII

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

[13] https://public.tableau.com/profile/marty.kendall7139#!/vizhome/foodinsulinindexanalysis/fatandFII

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

[15] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC524031/

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

[17] http://press.endocrine.org/doi/full/10.1210/jc.2011-1377

[18] http://ajcn.nutrition.org/content/97/1/86.full

[19] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4617900/

[20] https://jissn.biomedcentral.com/articles/10.1186/1550-2783-11-19

[21] http://www.sciencedirect.com/science/article/pii/S0261561417302030

[22] http://annals.org/aim/article/717451/low-carbohydrate-ketogenic-diet-versus-low-fat-diet-treat-obesity

[23] https://jamanetwork.com/journals/jama/fullarticle/205916?rel=1

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

[25] https://optimisingnutrition.com/2017/03/11/which-nutrients-is-your-diet-missing/

[26] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

[27] https://www.dropbox.com/s/rjfyvfsovbg9fri/The%20protein-sparing%20modified%20fast%20for%20obese%20patients%20with%20type%202%20diabetes%20What%20to%20expect.pdf?dl=0

[28] https://optimisingnutrition.com/2017/06/17/psmf/

[29] https://www.ncbi.nlm.nih.gov/pubmed/15836464

[30] 2http://ajcn.nutrition.org/content/87/5/1558S.long

[31] http://www.tuitnutrition.com/2017/09/measuring-ketones.html

[32] https://itunes.apple.com/us/podcast/mastering-nutrition/id1107033358?mt=2#Really

[33] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869616/

[34] https://www.hindawi.com/journals/jdr/2015/512618/

[35] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683958/

[36] https://optimisingnutrition.com/2016/11/19/the-alkaline-diet-vs-acidic-ketones/

[37] https://www.nrv.gov.au/nutrients/protein

[38] https://www.nrv.gov.au/nutrients/protein

[39] https://www.youtube.com/watch?v=3PhVURDZi1c

[40] https://www.youtube.com/watch?v=HwbY12qZcF4

[41] https://www.ncbi.nlm.nih.gov/pubmed/24588967

optimal protein sparing modified fast (PSMF) foods & meals

The Protein Sparing Modified Fast (PSMF) is regarded by many to be the most effective way to lose body fat while preventing loss of lean muscle and rebound binge eating due to nutrient deficiencies.

First developed in the 1970s, the PSMF has seen various permutations in weight loss clinics and the bodybuilding community.

While the details vary depending on context, a PSMF generally defined as an energy-restricted diet with adequate protein while simultaneously limiting carbohydrates and fat.

Technically, the PSMF will be ketogenic because a significant amount of body fat will be burned due to a restricted energy intake.

Adequate protein is provided to prevent loss of lean muscle mass.  Supplements are often used to prevent nutrient deficiencies.

This article outlines the key principles of the PSMF that can be applied to weight loss or maintenance over the long-term.

Optimal nutrient-dense foods are identified for someone looking for an aggressive weight cut (e.g. a bodybuilder leading up to a competition) as well as a hybrid low carb – PSMF approach for someone who is insulin resistant wanting to lose a significant amount of weight over a longer period.

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Medical applications of the PSMF

In the medical application of the PSMF patients obtain the majority of their energy from protein while keeping energy from carbohydrates and fat low.[1]

  • Protein levels are set at 1.2 to 1.5 g/kg of ideal body weight per day.  (For someone with 30% body fat wanting to get to 10% body fat this would be equivalent to 1.5 to 1.9g protein per kilogram of lean body mass or LBM.)
  • Carbohydrate intake is typically restricted to less than 20 to 50 g/day.
  • Additional dietary fat beyond what comes from lean protein sources is minimised.
  • Patients in the weight loss clinic setting are restricted to less than 800 kcal/day.

The Cleveland Clinic has done extensive research into the use of adequate protein low-calorie diets for aggressive weight loss with the following encouraging findings:[2] [3] [4]

  • patients are encouraged by the initial period of rapid weight loss which leads to a lower dropout rate;[5]
  • meal replacements in the form of commercial shakes or bars can be used, however learning to make meals from whole foods critical to developing habits that lay the foundation for long-term success;
  • the PSMF is effective for people with normal glycemic control as well as pre-diabetes or type 2 diabetes;[6]
  • people on a whole food-based PSMF are significantly less hungry and preoccupied with eating compared to those on a liquid-formula based version of the PSMF; and
  • most of the weight lost during a PSMF is from fat tissue rather than muscle.[7]

Adherence to a very-low-calorie, ketogenic PSMF program results in major short-term health benefits for obese patients with type 2 diabetes. These benefits include significant weight loss, often more than 18kg, within 6 months. 

In addition, significant improvements in fasting glucose and haemoglobin A1c levels are linked to the caloric and carbohydrate restriction of the PSMF.

Insulin resistance was also attenuated, with possible partial restoration of pancreatic beta-cell capacity.[8] [9]

Bodybuilding applications

Lyle McDonald reinvented the PSMF in bodybuilding  community with his 2005 Rapid Fat Loss Handbook.

McDonald details how someone can individualise the PSMF based on their goals and context.

  • Someone who is already very lean and undertaking heavy weight training will need higher levels of protein.
  • Someone who isn’t yet lean may do better with a less aggressive approach over a longer period.
  • McDonald’s recommended protein intake ranges from 2.2g/kg LBM to 4.4g/kg LBM!
  • Unlimited green leafy fibrous veggies are strongly encouraged as they are filling and provide the vitamins and minerals with minimal calories.
  • McDonald also recommends supplementing with a good multivitamin, sodium potassium, magnesium, taurine, calcium and fish oil.
  • A PSMF is typically not a long-term proposition due to nutrient deficiencies.

KetoGains’ Luis Villasenor added:

McDonald’s recommendations seem “massive” to most people due to the book being geared toward strength athletes who DO require more protein as they are effectively breaking it down when strength training. 

Bodybuilders who diet down to 4 – 5% bodyfat need an increased protein intake when preparing for a contest as their aim is to maintain as much as lean mass as possible; and for that, one needs protein and resistance exercise. 

With my clients, to avoid nutrient deficiencies, we use a “Ketogains PSMF” which adds 3-4 whole eggs a day, at least 150g spinach, plus other green veggies, and some avocado. The rest is lean sources of protein and more veggies, plus electrolytes.  This effectively puts the person in between 35 to 50g fats and 20g net carbs.  The rest of their energy comes from lean protein.

Protein drives satiety

The body actively defends loss of muscle mass by increasing appetite after periods of fasting or low protein consumption to ensure that muscle mass is retained.[10]

Conversely, the Protein Leverage Hypothesis (Simpson, 2005) suggests that we continue to eat food until we get enough protein for critical bodily functions.[11] [12]

“Protein generally increases satiety to a greater extent than carbohydrate or fat and may facilitate a reduction in energy consumption under ad libitum dietary conditions.”[13] [14]

If we eat lower protein foods, we may end up consuming more energy to obtain our adequate protein.   Conversely, we can ‘hack’ our appetite by prioritising adequate protein while minimising energy from carbohydrate and fat.

  • Minimum carbohydrate requirement: While there is a need for the vitamins and minerals that are often packaged with carbohydrate containing foods (i.e. vegetables), there is indeed no such thing as an essential carbohydrate.
  • Minimum fat requirement: Most people have plenty of body fat stores that they can draw on and hence do not have an immediate need for dietary fat other than the essential Omega 3 fatty acids.

So, theoretically, if we get adequate protein as well as vitamins, minerals, the essential fatty acids can go a long way to providing everything that we need for long-term survival with less energy which is really the holy grail of weight loss and long-term maintenance.

Thermic effect of food

The other advantage of consuming a higher protein diet is increased thermogenesis (i.e. the energy lost in the process of converting food into energy).  The thermic effect (or specific dynamic action) is 5 to 15% for carbohydrates and fat and 20 to 35% for protein.[15]

The thermic effect of food is illustrated nicely by these images from Physioqonomics.[16]  We lose a lot more calories metabolising protein compared to fat or carbohydrates.

While we can convert protein to glucose (i.e. gluconeogenesis), it is really hard, and our body doesn’t like to do unless it has to.[17]

Satiety typically kicks in quickly once we have had adequate protein and we go in search of fat or carbs which are easier to convert to energy.  Just think, you can only eat so much steak, but you always have a ‘dessert stomach’, even after a big meal.

While there is much debate over the “metabolic advantage” of fat vs. carbohydrates with claims that we can eat more calories of fat than carbs, there is actually an advantage’ when it comes to how many calories of protein we eat versus how much we can convert to energy.

Should you just eat the highest protein foods?

So, the obvious question is:

What should I eat on a PSMF?

The table below lists the foods with the highest protein content as a percentage of energy.  These foods may be useful if you are looking to boost your protein intake.

food % protein
cod 92%
haddock 92%
white fish 92%
orange roughy (fish) 92%
crab 91%
lobster 91%
egg white 91%
mozzarella cheese (non-fat) 90%
pollock 90%
protein powder (whey) 89%
turkey breast (fat-free) 88%
halibut 86%
crayfish 86%
whiting 86%
rockfish 86%
molluscs 86%
veal 84%
perch 81%
shrimp 81%
trout 81%
chicken breast 79%
lean beef 79%
whey protein concentrate (WPC) 78%
octopus 77%
ground beef 76%
pork chop 75%
flounder 74%
beef tripe 74%
pork shoulder 74%
scallop 74%
leg ham 74%
sirloin steak 73%
ham (lean only) 73%
beef heart 73%
turkey (skinless) 72%
clam 72%
turkey gizzard 72%
top round steak (fat trimmed) 72%
lamb kidney 71%
beef heart 70%
beef kidney 70%

I have summarised these in this image for easy reference.

The problem with a very high protein diet

But wait!

While you may be getting plenty of essential amino acids if you focus purely on high protein foods, there is a good chance that you may not be getting all the vitamins and minerals you need.

As shown in the chart below, there is a strong relationship between protein and nutrient density.  However, if we just focus on high protein foods, we may still end up missing out on the harder to find vitamins and minerals.[18]

The chart below shows the micronutrients provided by the top 10% of the foods in the USDA database when sorted for maximum protein content.

Now imagine, that rather than getting 2000 calories, we are getting only 800 or 400 calories during long-term fasting or extreme dieting.  We have a higher chance of becoming deficient in many key nutrients which may in turn increase appetite and drive us to eat more than we would like to.

Ensuring you are getting adequate micronutrients is a key component to long-term success in weight loss and maintenance.  

In the Rapid Fat Loss Handbook McDonald mentions ‘The Last Chance Diet’ which was popular in the 1970s and 80s.  It was essentially a PSMF centred around liquid nutrition which led to the death of a number of devotees due to some fatal flaws.[19] [20]

First, they picked the cheapest protein source available, collagen; a protein that provides essentially zero nutrition to the body.  Second, they provided zero supplemental vitamins and minerals (some of which would have been obtained if the dieters had been eating whole foods in the first place). This caused a couple of problems including cardiac heart loss (from the total lack of protein) and arrhythmias from the lack of minerals.

Basically, the problem wasn’t with the approach so much as with the food choices.

PSMF’s based around whole foods (which provide high quality proteins as well as vitamins and minerals) and with adequate mineral supplementation have shown no such problems.[21]

Bruce Ames’ Triage Theory

Nutrient density becomes even more important when we consciously try to limit our energy intake.

Attaining adequate micronutrients can help to mitigate metabolic/mitochondrial slow down and adaption to the severe calorie deficit.  If we are getting the range of micronutrients we need, the body is more likely to keep on feasting on our own excess fat stores without reacting like there is a famine and holding onto our excess fat stores.

Similar to the protein leverage hypothesis, it seems if we provide the body with low nutrient density food it is driven to consume more energy to ensure that it gets the nutrients it needs.

I get some comments in response to the Nutrient Optimiser analysis suggesting that the Daily Recommended Intakes (DRI) for various micronutrients are excessive because an individual person has done fine on a diet per for a period of time with a less than optimal nutrient profile.

While we can argue that the some of the DRIs for various nutrients are overly conservative, you also don’t have to look too far to find people that argue that we need multiple times the DRI for another particular nutrient to optimise our health and longevity.

I don’t think we need to worry about precisely meeting the daily recommended intake for every single micronutrient every single day.  There is no diet that meets the daily recommended intake for every nutrient without overdoing others.  I think a healthy well-balanced diet will achieve the DRI for the majority of the essential micronutrients most of the time.

More research is required to understand whether our requirements for different nutrients change depending on our diet (e.g. how much less vitamin C do we need if we are not consuming as much glucose) and how much more bioavailable nutrients are from plants versus animals.

However, if you are an order of magnitude under the DRI for a handful of nutrients, perhaps you should consider focussing on foods that contain that contain higher levels of that cluster of nutrients.  If you are an order of magnitude over the DRI for a particular group of nutrients you don’t need to prioritise foods that contain those nutrients.

Bruce Ames’ sobering Triage Theory suggests that if we are low in critical nutrients, the body will prioritise those nutrients for functions essential to short term survival rather than longevity and preventing the diseases of ageing (e.g. cancer, heart disease, Parkinson’s, Alzheimer’s, etc.).

“The triage theory posits that some functions of micronutrients (the approximately 40 essential vitamins, minerals, fatty acids, and amino acids) are restricted during shortage and that functions required for short-term survival take precedence over those that are less essential.  Insidious changes accumulate as a consequence of restriction, which increases the risk of diseases of ageing.”[22] [23]

So, while we might do OK with poor nutrition for a period of time, we will probably do better if we obtain a solid amount of all the essential nutrients.  Ideally, we would get these nutrients from whole foods which are more likely to contain all the non-essential but also beneficial vitamins and minerals that we don’t track.

Low energy density

Another way to maximise nutrient density and prioritise protein at the same time is to reduce the energy density of the food we eat.

As shown in the chart below there is a relationship between the harder to find nutrients and energy density.[24]  While fat is a great fuel source and should not be feared or avoided, refined high-fat foods do not typically contain high levels of the harder to find vitamins and minerals that we need to thrive.  Foods with more fibre and water are also more filling and are more difficult to overeat and will lead to increased short term satiety.

If we prioritise adequate protein while minimising fat and carbohydrates we make up the deficit from our own body fat stores. Hence there is no need to prioritise dietary fat.

The nutrient dense adequate protein diet

So, to recap:

  1. getting adequate protein is important, especially if we are fasting or restricting energy intake, and
  2. not getting adequate nutrients is potentially dangerous and possibly the fatal flaw of the PSMF.

We can use the Nutrient Optimiser to prioritise foods with the nutrients we want to obtain more of.   Listed below are the 20 nutrients that have been prioritised in the following list of prioritised foods.

  1. Alpha-linolenic acid
  2. EPA + DHA
  3. Vitamin E
  4. Vitamin D
  5. Choline
  6. Calcium
  7. Magnesium
  8. Potassium
  9. Thiamine
  10. Phosphorus
  11. Pantothenic acid
  12. Manganese
  13. Folate
  14. Zinc
  15. Niacin
  16. Riboflavin
  17. Valine
  18. Selenium
  19. Leucine
  20. Tyrosine

Prioritising amino acids is usually unnecessary because maximising vitamins and minerals generally leads to more than adequate protein.   However, in a PSMF where we are severely limiting energy we want to increase protein as well (hence valine, leucine and tyrosine have been included).  As well as nutrient density, we have also prioritised low energy density foods in the multicriteria analysis.

The chart below shows the resultant micro nutrient profile achieved if we ate 2000 calories per day of these foods.  In the chart above we saw that if we just focus on protein, we will not be meeting the DRI for eleven nutrients.  However, when we focus on nutrient density, we get adequate quantities of all nutrients other than the Omega 3 fatty acid alpha-linolenic acid.

The chart below shows the same foods if we only ate 600 calories per day rather than 2000.  Even with these highly nutrient dense foods, we miss the DRI for eight of the essential nutrients.  Hence, we may still benefit from supplementing with Omega 3, vitamin D, calcium, magnesium and potassium.   The nutrients provided by an energy restricted diet without also prioritising nutrient density would be much worse.

It’s not hard to imagine that our ability to maintain a low energy intake and achieve sustained weight loss is likely related to getting adequate levels of the various essential micronutrients without having to over consume energy.  Conversely, a nutrient poor diet will likely drive us to consume excess energy which will lead to obesity.

Best foods for a PSMF

The tables below summarise highest ranking 10% of foods in the USDA database when we prioritise for high nutrient density and low energy density.

Also included in the tables are:

  • the nutrient density score (based on the 20 nutrients listed above),
  • energy density, and
  • the MCA which is the overall ranking from the multi criteria analysis.

Compared to the highest protein food listed above which are 80% protein, these foods work out to be 59% protein, 20% fat, 13% net carbs and 8% fibre.  While this may seem high, as we will see in the ‘calorie math’ section below, it becomes more reasonable once we account for the energy from body fat.

Vegetables

It would be hard to imagine getting fat by overeating the vegetables listed below.

Maximising your intake of these vegetables will ensure you are getting adequate vitamins and minerals and hence maximise your chance of long-term success.

While these vegetables have a very high nutrient density score (ND) in terms of nutrients per calorie, they also have a low energy density which means you need to eat a lot of them to get the nutrients you need.

The downside of vegetables is that they can be expensive and take time to prepare fresh.

food % protein ND calories/100g MCA
watercress 60%  25  11  3.1
spinach 41%  23  23  2.9
seaweed (laver) 50%  22  35  2.7
asparagus 34%  21  22  2.7
basil 44%  20  23  2.5
endive 25%  19  17  2.5
white mushroom 43%  19  22  2.4
brown mushrooms 36%  18  22  2.4
portabella mushrooms 36%  18  29  2.4
Chinese cabbage 42%  17  12  2.3
lettuce 30%  16  15  2.2
coriander 31%  16  23  2.1
chicory greens 24%  16  23  2.1
alfalfa 52%  16  23  2.1
spirulina 64%  16  26  2.1
chard 30%  15  19  2.1
zucchini 24%  15  17  2.1
seaweed (wakame) 22%  15  45  2.0
parsley 27%  15  36  2.0
escarole 25%  15  19  2.0
okra 27%  15  22  2.0
beet greens 32%  14  22  2.0
shiitake mushroom 29%  15  39  2.0
turnip greens 36%  14  29  1.9
chives 35%  14  30  1.9
broccoli 23%  14  35  1.8
mung beans 35%  13  19  1.8
arugula 33%  12  25  1.7
dill 27%  12  43  1.7
cauliflower 26%  12  25  1.7
celery 16%  11  18  1.6
summer squash 18%  10  19  1.5
seaweed (kelp) 13%  11  43  1.5
yeast extract spread 52%  12  185  1.5
radicchio 22%  9  23  1.4
pickles 14%  9  12  1.4
cucumber 14%  9  12  1.4
mustard greens 34%  9  27  1.4
peas 26%  9  42  1.4
snap beans 18%  9  15  1.4
collards 27%  9  33  1.3
cabbage 18%  8  23  1.3
soybeans (sprouted) 34%  8  81  1.2
onions 19%  7  32  1.2
pumpkin 12%  7  20  1.2
kale 23%  7  28  1.2
radishes 16%  7  16  1.2
banana pepper 21%  7  27  1.2
bamboo shoots 43%  7  11  1.2
Brussel sprouts 28%  7  42  1.1
edamame 37%  8  121  1.1
artichokes 23%  6  47  1.1
sauerkraut 17%  5  19  1.0
red peppers 13%  6  31  1.0
eggplant 13%  5  25  1.0
chayote 9%  5  24  1.0

Animal products

These animal products are both nutrient dense and have a low energy density compared to fattier cuts of meat.  While the nutrient density scores are not as high as for the vegetables, the energy density is higher so you will be able to get more nutrients in using these foods.

food % protein ND calories/100g MCA
lamb kidney 71%  19  112  2.2
chicken liver 62%  19  172  2.2
beef liver 63%  18  175  2.1
veal liver 61%  18  192  2.0
lamb liver 61%  17  168  2.0
turkey liver 59%  17  189  2.0
ham (lean only) 73%  16  113  1.9
pork liver 66%  16  165  1.9
beef kidney 70%  15  157  1.7
chicken breast 79%  13  148  1.6
pork chop 75%  13  172  1.5
veal 84%  12  151  1.5
pork shoulder 74%  12  162  1.4
lean beef 79%  11  149  1.4
leg ham 74%  11  165  1.4
ground pork 69%  11  185  1.4
turkey heart 60%  11  174  1.3
lamb heart 65%  11  161  1.3
beef tripe 74%  9  103  1.3
ground beef 76%  10  144  1.2
sirloin steak 73%  10  177  1.2
beef heart 70%  10  179  1.2
turkey meat 66%  10  158  1.2
turkey drumstick 66%  10  158  1.2
bison 69%  9  171  1.1
chicken liver pate 27%  9  201  1.1
turkey gizzard 72%  8  155  1.1
lamb sweetbread 59%  8  144  1.0
chicken drumstick 62%  8  149  1.0
veal loin 63%  8  175  1.0
roast pork 53%  8  199  1.0

Seafood

Omega 3 fats (EPA, DHA and ALA) are essential and harder to get so you should prioritise fish in your nutrient dense PSMF.

food % protein ND calories/100g MCA
crab 91%  20  83  2.4
fish roe 58%  19  143  2.2
crayfish 86%  18  82  2.2
lobster 91%  18  89  2.2
halibut 86%  17  111  2.1
pollock 90%  16  111  1.9
salmon 68%  16  156  1.9
rockfish 86%  15  109  1.9
flounder 74%  14  86  1.8
oyster 46%  14  102  1.8
shrimp 81%  14  119  1.8
haddock 92%  14  116  1.8
perch 81%  14  96  1.7
cod 92%  16  290  1.7
sturgeon 64%  14  135  1.7
whiting 86%  13  116  1.6
trout 59%  13  168  1.6
octopus 77%  13  164  1.5
white fish 92%  12  108  1.5
anchovy 57%  13  210  1.5
clam 72%  12  142  1.5
tuna 68%  11  184  1.3
scallop 74%  9  111  1.3
caviar 36%  11  264  1.2
orange roughy 92%  8  105  1.2
sardine 49%  10  208  1.2
molluscs 86%  8  130  1.1

Egg and dairy

Eggs are nutritious.  Only a couple of low fat dairy products make the list.  Higher fat foods such as butter and cream need to be minimised on a PSMF to allow your body to use the fat from your butt and your belly.

food % protein ND calories/100g MCA
cream cheese (low fat) 61%  11  105  1.5
whole egg 36%  9  143  1.2
egg white 91%  7  52  1.1
cottage cheese (low fat) 51%  7  81  1.1

These nutrient dense PSMF foods are summarised in this image for easy reference.

Calorie math

To make this a little more practical let’s look at some calorie math using a hypothetical scenario.

Let’s say Super Ted is looking to get shredded for the Ketogains conference in two weeks where he wants to pose for shirtless but also wants to stay strong and to win the arm wrestle and beat the reigning champion, Mighty Mouse.

Super Ted currently weighs 160 lbs or 73kg and has 10% body fat.  His maintenance energy intake is 2336 cal/per day.

While getting the majority of your energy intake from protein might seem excessive…

… it’s not so dramatic when you also take into account the body fat being burned.

Between the 8% dietary fat (8%) his body fat stores (60%) Super Ted will be getting a ketogenic level of 68% of his energy from fat while also adequate protein to maintain his muscles and enough carb containing vegetables to get the vitamins and minerals that are also critical to his long-term success.

The details of the calorie math are shown below.  Once you take the energy deficit into account Super Ted is consuming 2.2g/kg LBM.

body weight (kg) 73
body weight (lbs) 160
body fat (%) 10%
lean body mass (kg) 62
maintenance (cal) 2336
deficit 60%
diet (calories) 934
protein (% diet) 59%
fat (% diet) 20%
net carbs (% diet) 13%
diet protein (g) 138
dietary fat (g) 21
body fat (g) 156
body fat (kg/week) 1.1
net carbs (g) 30
fibre (g) 19
protein (% energy burned) 24%
dietary fat (% energy burned) 8%
carbohydrate (% energy burned) 5%
protein (g/kg LBM) 2.2

These calculations assume that Super Ted’s insulin levels are going to be low enough to allow him to yield a significant amount of energy from his body fat stores.   Similar to fasting, it may take a few days before glycogen stores to be depleted enough for his insulin levels to drop which will allow his fat stores to more easily flow out of storage.  

These calculations also do not account for the metabolic slowdown that you will get during long term energy restriction.  This is the same with any way of eating that consciously restricts energy intake.  However, I think if we can minimise nutrient deficiencies we will have a better chance of avoiding an increase in which could drive our body to seek out the missing nutrients that it is not getting enough of.  

When you look at his Nutrient Optimiser analysis, you see that Ted Naiman (aka Super Ted) is actually consuming 2.4g/kg LBM.

Meanwhile, Luis Villasenor (aka Mighty Mouse) is also consuming protein at 2.4g/kg LBM during his PSMF.  Luis says his regular protein intake is around 140g increases this up to 180g during a strict PSMF.

Insulin resistant long-term fat loss scenario

For most of us, such an aggressive fat loss approach might be hard to maintain long-term.  So, let’s consider another scenario with another hypothetical character.

Introducing…  Big Ted.

As you can see, Big Ted doesn’t post shirtless for photos on the internet.

At 110kg and 30% body fat Big Ted is far from shredded.

Big Ted is also pre diabetic.

His doctor has warned him that if he doesn’t lose a significant amount of weight he will need to take Metformin and then insulin before too long.

Big Ted is motivated to drop a large amount of weight with perhaps a calorie deficit of 30% which will take him about 30 weeks to get to his goal weight of 90kg.

We can refine Big Ted’s PSMF approach given that his circumstances and goals are different from Super Ted’s.

Nutrients to prioritise

Given Big Ted is not looking to be as dramatically calorie restricted we only need to prioritise the following nutrients.

  1. Alpha-linolenic acid
  2. EPA + DHA
  3. Choline
  4. Vitamin D
  5. Vitamin E
  6. Calcium
  7. Magnesium
  8. Potassium
  9. Phosphorus
  10. Zinc

Although amino acids are not prioritised the resultant list of foods is still 36% protein, 30% fat and 20% net carbs.

Rather than just prioritising nutrient density and energy density, this scenario also prioritises a lower insulin load given Big Ted’s looming pre diabetes situation.

This is basically a hybrid between a PSMF and a low carb diet.

The chart below shows the nutrient profile of these foods once we take a 30% energy deficit into account.  Big Ted will be meeting the DRI for all his nutrient other than Omega 3s which he may need to supplement.

Calorie math

The charts below show the energy consumed and energy burned.

There is a significant amount of fibre which will not be metabolised for energy but rather feed his gut bacteria.  There is still a solid amount of net carbs from veggies. However, there is no sugars or processed grains to be seen, so they’re not about to boost his insulin or send him on a blood sugar roller coaster.

Once his body fat loss is accounted for, half of Big Ted’s energy expenditure is still coming from fat.

Although we didn’t prioritise amino acids we still get a solid 2.2g protein per kilogram LBM.

body weight (kg) 110
body weight (lbs) 242
body fat (%) 30%
lean body mass (kg) 77
maintenance (cal) 3000
deficit 30%
diet (cals) 1875
protein (% diet) 36%
fat (% diet) 30%
net carbs (% diet) 20%
fibre (%) 14%
diet protein (g) 169
dietary fat (g) 63
body fat (g) 100
body fat (kg/week) 0.7
net carbs (g) 94
fibre (g) 66
protein 23%
dietary fat 19%
carbohydrate 13%
protein (g/kg LBM) 2.2

Optimal foods for Big Ted are listed below.

Vegetables

food % protein ND calories/100g MCA
endive 25% 11 17 2.5
chicory greens 24% 11 23 2.4
coriander 31% 10 23 2.2
escarole 25% 9 19 2.1
spinach 41% 12 23 2.1
basil 44% 11 23 2.0
alfalfa 52% 7 23 2.0
zucchini 24% 9 17 1.9
chard 30% 11 19 1.9
arugula 33% 10 25 1.9
beet greens 32% 8 22 1.9
mustard greens 34% 8 27 1.8
watercress 60% 12 11 1.7
asparagus 34% 9 22 1.7
parsley 27% 9 36 1.7
Chinese cabbage 42% 9 12 1.6
curry powder 14% 6 325 1.6
collards 27% 7 33 1.6
summer squash 18% 8 19 1.6
lettuce 30% 8 15 1.6
paprika 15% 7 282 1.6
turnip greens 36% 7 29 1.5
broccoli 23% 8 35 1.5
cloves 6% 7 274 1.4
sauerkraut 17% 6 19 1.4
banana pepper 21% 5 27 1.4
okra 27% 7 22 1.4
pickles 14% 5 12 1.4
cucumber 14% 5 12 1.4
chives 35% 7 30 1.3
celery 16% 7 18 1.3
brown mushrooms 36% 10 22 1.3
sage 11% 5 315 1.3
artichokes 23% 6 47 1.3
marjoram 14% 5 271 1.3
thyme 10% 6 276 1.3
cauliflower 26% 6 25 1.3
edamame 37% 5 121 1.2
portabella mushrooms 36% 7 29 1.2
radishes 16% 5 16 1.2
eggplant 13% 4 25 1.2
cabbage 18% 6 23 1.2
blackberries 11% 3 43 1.2
shiitake mushroom 29% 6 39 1.1
radicchio 22% 8 23 1.1
jalapeno peppers 12% 3 27 1.1
caraway seed 19% 4 333 1.1
chayote 9% 4 24 1.1
rhubarb 15% 5 21 1.0
avocado 5% -0 160 1.0
snap beans 18% 6 15 1.0
red peppers 13% 3 31 1.0
olives 3% -1 145 1.0
turnips 26% 5 21 1.0
white mushroom 43% 7 22 1.0
dill 27% 6 43 1.0
poppy seeds 13% 3 525 1.0
kale 23% 5 28 0.9
seaweed (kelp) 13% 8 43 0.9
raspberries 8% 1 52 0.9
seaweed (laver) 50% 8 35 0.9
soybeans (sprouted) 34% 4 81 0.9
seaweed (wakame) 22% 8 45 0.9
Brussel sprouts 28% 4 42 0.9
celery flakes 14% 6 319 0.9
cumin 16% 4 375 0.8
bamboo shoots 43% 3 11 0.8
carrots 6% 3 37 0.8
onions 19% 5 32 0.8
carrots 9% 5 23 0.8
dill seed 15% 3 305 0.7
mustard seed 19% 2 508 0.7

Animal products

food % protein ND calories/100g MCA
beef brains 32% 5 151 1.5
turkey ham 63% 4 124 1.0
lamb brains 36% 2 154 1.0
lamb sweetbread 59% 4 144 0.9
turkey (skinless) 72% 3 170 0.8
turkey liver 59% 4 189 0.8
ground turkey 39% 2 258 0.8
lamb liver 61% 4 168 0.8
turkey drumstick (with skin) 50% 1 221 0.8
turkey bacon 29% 0 226 0.8
headcheese 36% –       0 157 0.8
lamb kidney 71% 4 112 0.8
turkey heart 60% 3 174 0.8
sweetbread 16% –       1 318 0.7

Seafood

food % protein ND calories/100g MCA
fish roe 58% 9 143 1.6
oyster 46% 10 102 1.5
mackerel 25% 4 305 1.4
caviar 36% 6 264 1.4
molluscs 86% 8 130 1.4
crab 91% 10 83 1.3
sardine 49% 6 208 1.2
flounder 74% 7 86 1.2
trout 59% 6 168 1.2
cisco 38% 4 177 1.2
sturgeon 64% 6 135 1.2
crayfish 86% 8 82 1.2
salmon 68% 7 156 1.2
lobster 91% 9 89 1.1
halibut 86% 8 111 1.1
anchovy 57% 5 210 1.0
perch 81% 7 96 1.0
herring 47% 4 217 1.0
rockfish 86% 7 109 1.0
pollock 90% 7 111 1.0
cod 92% 8 290 0.9
shrimp 81% 7 119 0.9
whiting 86% 6 116 0.8
white fish 92% 6 108 0.8
haddock 92% 6 116 0.7

Egg

food % protein ND calories/100g MCA
egg yolk 21% 4 275 1.4
whole egg 36% 4 143 1.3

Nut sand seeds

food % protein ND calories/100g MCA
tofu 43% 3 83 1.0
sunflower seeds 13% 2 546 0.9
pumpkin seeds 20% 3 559 0.8
flax seed 13% 1 534 0.8
almonds 13% 2 607 0.7

This image below summarises these foods for easy reference.

The nutrient profile of these foods is also excellent.  These foods will help Big Ted to minimise his chance of developing nutrient deficiencies which may lead to rebound binge eating and derail his long term weight loss efforts.

How often should I eat on a PSMF?

Big Ted is fond of intermittent fasting.  He finds it easier to not eat for a day or two and then eat to satiety rather than trying to count calories or restrict energy.

Meanwhile, Super Ted likes to eat two meals per day which save him time and helps him not overeat.

Personally, I don’t think it matters exactly when you eat as long as you stick to the foods that align best with your goals.  Recent research suggests that in the fasted state we can use up to 3.5 g/kg/day and digest up to 4.3 g/kg/day.[25]  This makes sense in an evolutionary context when there wouldn’t have been a regular supply of food but we would have needed to be able to use the food when we came across a big hunt after a long famine.

Either Super Ted or Big Ted could still utilise their required protein intake if they followed an alternate day fasting or 5:2 plan or indeed any other permutation of fasting.  What is important though is that they ensure that they stick to their nutrient dense diet when they break their fast rather than reaching for the more energy dense foods when they eat again.

How low can you go?

Hopefully, this article has given you some actionable principles:

  • During weight loss, you should ensure that you get adequate protein while fat and carbs can be limited to achieve the energy deficit required to suit your target rate of loss.
  • As well as protein intake, we should aim to maximise all micro nutrients (vitamins, minerals, essential fatty acids and amino acids) ideally using whole foods.
  • You will find it hard to obtain adequate vitamins, minerals and essential fatty acids at one extreme or the other of protein intake.

As discussed in the ‘How Much Protein is Too Much’ article I noted that the minimum intake of protein and minimum essential fats tally up to around 314 calories as shown in the table below.

If we could stick to this approach, we would have a massive and highly ketogenic 85% of our energy coming from our body fat.  However, you would be at an increased risk of inadequate vitamins, mineral and fatty acids with such a low energy intake.

macro DRI (g) DRI (calories) % energy
minimum protein 56 224 71%
essential fats 10 90 29%
total 66 314 100%

If you’re starving to death and only have lean protein available you might call it “rabbit starvation”.  However, if you still have plenty of body fat to burn it’s a PSMF.

#context matters


PSMFs for aggressive weight loss in a medical context generally aim for around 800 calories per day.

Lyle McDonald suggests that people following a PSMF for aggressive weight loss over a short period (e.g. cutting in the lead up to a bodybuilding show) might be eating between 400 and 800 calories per day.

Each person needs to find the ideal approach that they can live with for the long-term.

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How to do a nutrient dense PSMF

  • Eat mostly foods from the lists below.  
    • The nutrient dense PSMF diet foods are ideal for aggressive short term weight loss (i.e. leading up to a bodybuilding comp).
    • The nutrient dense weight loss foods for insulin resistance may be more appropriate if you have more weight to lose over a longer period.
    • Minimum protein intake in a weight loss clinic setting is 1.2g/kg total body weight.
    • Appetite will likely drive you to eat more protein if you are working out.   2.4g/kg lean body mass is typical for someone lifting heavy.
    • The highest protein foodcan be used to increase protein intake if required.
    • Focusing on these foods will ensure you still get adequate protein as well as vitamins and minerals while minimising energy consumption.
    • Limit carbs to what comes with non-starch veggies (i.e. no processed grains or sugars).
    • Limit fat to what comes with the lean protein foods.
  • Don’t eat too much
    • It will be hard to overeat these high nutrient density low energy density foods.
    • You may not have to consciously limit your food intake if you can focus only eat these foods.
    • It may be beneficial to track or plan your energy intake to achieve your goals.
    • Ratchet down your energy intake until you achieve your desired rate of weight loss.
  • Lift heavy / exercise (optional)
    • Working out will help you to use the protein to build lean muscle and keep your metabolic rate up.
  • Repeat 

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Summary

  • The protein sparing modified fast (PSMF) provides adequate levels of protein to support lean muscle mass while restricting energy from carbohydrates and fat.
  • Protein intakes vary widely depending on the goals and the level of energy restriction between.
  • Providing adequate nutrients, ideally from whole foods, is critical to long term weight loss and maintenance.
  • Just maximising protein may not provide optimal levels of vitamins and minerals. Therefore, it’s important to prioritise nutrient dense foods to improve your chances of long-term success.
  • While the PSMF is commonly used in weight loss clinics and in the bodybuilding community, the principle can also be applied in other situations.

 

References

[1] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

[2] https://www.ncbi.nlm.nih.gov/pubmed/9149474

[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4784653/ama

[4] https://www.ncbi.nlm.nih.gov/pubmed/4037162

[5] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

[6] https://www.ncbi.nlm.nih.gov/pubmed/24513578

[7] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

[8] https://www.dropbox.com/s/rjfyvfsovbg9fri/The%20protein-sparing%20modified%20fast%20for%20obese%20patients%20with%20type%202%20diabetes%20What%20to%20expect.pdf?dl=0

[9] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

[10] http://www.nature.com/ejcn/journal/v71/n3/full/ejcn2016256a.html

[11] http://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2005.00178.x/abstract

[12] https://www.dropbox.com/s/zej4razn4dn993y/protein%20leverage%20hypothesis%20-%20simpson2005.pdf?dl=0

[13] http://ajcn.nutrition.org/content/87/5/1558S.long

[14] https://www.ncbi.nlm.nih.gov/pubmed/15466943

[15] https://en.wikipedia.org/wiki/Specific_dynamic_action

[16] http://physiqonomics.com/calories-child-friendly-version/

[17] http://www.biologydiscussion.com/biochemistry/energy-production/specific-dynamic-action-factors-and-example-energy-production/43998

[18] https://optimisingnutrition.com/2017/05/27/is-there-a-relationship-between-macronutrients-and-diet-quality/

[19] http://www.dietsinreview.com/diets/last-chance-diet/

[20] https://www.amazon.com/Last-Chance-Diet-When-Everything-Failed/dp/0818402393

[21] http://www.bodyrecomposition.com/the-rapid-fat-loss-handbook/

[22] https://www.ncbi.nlm.nih.gov/pubmed/19692494

[23] http://ajcn.nutrition.org/content/90/4/889.full.pdf+html

[24] https://optimisingnutrition.com/2017/05/27/is-there-a-relationship-between-macronutrients-and-diet-quality/

[25] http://www.sciencedirect.com/science/article/pii/S0261561417302030

 

post updated August 2017

why do my blood sugars rise after a high protein meal?

Complex issues often require more detail than you can pack into a Facebook post.

One such area of confusion and controversy is gluconeogenesis and the impact of protein on blood sugar and ketosis.

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Some common questions that I see floating around the interwebs include:

  • If you are managing diabetes, should you avoid protein because it can convert to glucose and “kick you out of ketosis”?

Imageresultforketonesglucose

  • If you’ve dropped the carbs and protein to manage your blood sugars, should you eat “fat to satiety” or continue to add more fats until you achieve “optimal ketosis” (i.e. blood ketone levels between 1.5 and 3.0mmol/L)?

  • Then, if adding fat doesn’t get you into the “optimal ketosis zone”, do you need exogenous ketones to get your ketones up so you can start to lose weight?

  • And what exactly is a “well formulated ketogenic diet” anyway?

This article explores:

  • the reason that some people may see an increase in their blood sugars and a decrease in their ketones after a high protein meal,
  • what it means for their health, and
  • what they can do to optimise the metabolic health.

Protein is insulinogenic and can convert to glucose

You’re probably aware that protein can be converted to glucose via a process in the body called gluconeogenesis.

Gluconeogenesis is the process of converting another substrate (e.g. protein or fat[1]) to glucose.

  1. Gluco = glucose
  2. Neo = new
  3. Genesis = creation
  4. Gluconeogenesis = new glucose creation

As shown in the table below, all but two of the amino acids (i.e. the building blocks of protein) can be converted to glucose.  Five others can be converted to either glucose or ketones depending on the body’s requirements at the time.

Once your body has used up the protein, it needs to build and repair muscle and make neurotransmitters, etc. any “excess protein” can be used to refill the small protein stores in the blood stream and replenish glycogen stores in the liver via gluconeogenesis.

The fact that protein can be converted to glucose is of interest to people with diabetes who go to great lengths to keep their blood sugar under control (e.g. taking medications, changing their diet, exercising, trying to lose weight, etc.).[2]

Someone on a very low carbohydrate diet may end up relying more on protein for glucose via gluconeogenesis.[3]  The benefit of getting more glucose from protein via gluconeogenesis rather than carbs is that it is a slow process and easier to control with measured doses of insulin compared to simple carbs which will cause more abrupt blood sugar rollercoaster.

How much insulin does protein require?

The food insulin index data[4] [5] [6] is an untapped treasure trove of data that can help us understand the impact of foods on our metabolism.   I have discussed how we can use the insulin index at length in the articles here, but have summarised some relevant observations below.

Our glucose response to carbohydrate

The food insulin index testing measured the glucose and insulin response to various foods in healthy people (i.e. non-diabetic young university students).

To calculate the glucose score or the insulin index pure glucose gets a score of 100% while everything else gets a score between zero and 100% based on the comparative glucose or insulin area under the curve response.  So we are comparing the glucose and insulin response to various foods to eating pure glucose.

As shown in the chart below, the blood glucose response of healthy people is proportional to their carbohydrate intake.  High protein meat and fish and high-fat foods (butter, cream, oil) tend to have a negligible impact on glucose.

Our insulin response to carbohydrates

The story is not so simple when it comes to our insulin response to food.

As shown in the chart below, the carbohydrate content of our food only partially predicts our insulin response to food.  Low fat, low carb, high protein foods elicit a significant insulin response.

As you can see in the chart below, once we account for protein we get a better prediction of our insulin response to food.  It seems we require about half as much insulin for protein as we do for carbohydrate on a gram for gram basis to metabolise protein and use it to repair our muscles and organs.

image10

But does this mean we should avoid or minimise protein for optimal diabetes management or weight loss?

Does protein actually turn to chocolate cake?

Read on to find the answer.

What happens to insulin and blood sugar when we increase protein?

While protein does generate an insulin response, increasing the protein content of our food typically decreases our insulin response to food.

Increasing protein generally forces out processed carbs from our diet and improves the amount of vitamins and minerals contained in our food.[7]

Similarly, increasing the protein content of your food will also decrease your glucose response to food.

But what about a huge protein meal?

It’s worth noting that the food insulin index testing was done using 1000 kJ or 240 calories of each food (i.e. a substantial snack, not really a full meal).  But what about if we ate a LOT of protein?  Wouldn’t we get a blood sugar response then?

The figure below shows the glucose response to 80g of glucose vs. 180g of protein (i.e. a MASSIVE amount of protein).  While we get a roller coaster-like blood sugar rise in response to the ingestion of glucose, blood sugar remains relatively stable in response to the large protein meal.[8] [9] [10]

So, if protein can turn to glucose, why don’t we see massive glucose spike?

What is going on?

The role of insulin and glucagon in glucose control

To properly understand how we process protein, it’s critical to understand the role of the hormones insulin and glucagon in controlling the release of glycogen release from our liver.

These terms can be confusing.  So let me spell it out.

  • The liver stores glucose in the form of glycogen in the liver.
  • Glucagon is the hormone that pushes glycogen out into the bloodstream as blood glucose.
  • Insulin is the opposing hormone that keeps glycogen stored in our liver.

When it comes to getting glucose out of the liver, glucagon is like the accelerator pedal while insulin is the brake.

When our blood glucose is elevated, or we have external sources of glucose, the pancreas secretes insulin to shut off the release of glycogen from the liver until we have used up or stored the excess energy.

Insulin helps to turn off the flow of glucose from our liver and store some of the excess glucose in the blood as glycogen and, to a much lesser extent, fat (via de novo lipogenesis).  It also tells the body to start using glucose as its primary energy source to decrease it to normal levels.

We can push the glucagon pedal to extract the glycogen stores in our liver by eating less carbohydrate (i.e. low carb or keto diets), even better yet, not eating at all (aka fasting)!

High insulin levels effectively mean that we have enough fuel in our blood stream and we need to put down the fork.

While fat typically doesn’t require significant amounts of insulin to metabolise, an excess of energy from any source will cause the body to ramp up insulin to shut off the release of stored energy from the liver and the fat stores.

Glucose, insulin and glucagon response to a high carbohydrate meal

At the risk of getting a little technical, let’s look at how our hormones respond to different types of meals.

As shown in the chart above, when we eat a high carbohydrate meal insulin rises to stop the release of glycogen.  Meanwhile, glucagon drops to stop stimulating the release of glycogen from the liver.  When we have enough incoming glucose via our mouth, we don’t need any more glucose from the liver.[11]

Glucose, insulin and glucagon response to a high protein meal

When we eat a high protein meal, both glucagon and insulin rise to maintain steady blood glucose levels while promoting the storage and use of protein to repair our muscles and organs and make neurotransmitters, etc. (i.e. important stuff!).

In someone with a healthy metabolism, we get a balance between the brake (insulin) and the accelerator (glucagon).  Hence, we don’t get any glycogen released from the liver into the bloodstream to raise our blood sugar because the insulin from the protein is turning off the glucose from the liver.

This is why metabolically healthy people see a flat line blood sugar response to protein.

(You may need to read that a few times to understand it.  It’s taken a couple of years for it to sink in for me.) 

Insulin response to protein for people with diabetes

Things are different if you have diabetes.

Insulin resistance means that between our fatty liver and insulin resistant adipose tissue, things don’t work as smoothly.

While your blood sugar may rise or fall in response to protein your insulin will need to rise a lot more to metabolise the protein to build muscle and repair your organs.

Unfortunately, people who are insulin resistant may struggle to build muscle because of the insulin resistance.  Then the higher levels of insulin may drive them to store more fat in the process.[12]  Becoming insulin sensitive is important!

The chart below shows the difference in the blood glucose and insulin response to protein in a group of people who are metabolically healthy (white lines) versus people who have type 2 diabetes (yellow lines).[13]

People with diabetes may see their glucose levels drop from a high level after a large protein meal and will have a much greater insulin response due to their insulin resistance.  People with more advanced diabetes (i.e. beta cell burn out or Type 1 diabetes) may even see their blood sugar rise.  This is because their ability to produce insulin to metabolise the protein and keep glycogen in storage cannot keep up with the demand.

Drawing on the brake/accelerator analogy, it’s not necessarily protein turning into glucose in the blood stream via gluconeogenesis, but rather the glucagon kicking in and a sluggish insulin response that isn’t able to balance out the glucagon response to keep the glycogen locked away in the liver.

Healthy people will be able to balance the opposing hormonal forces of the insulin (brake) and the glucagon (accelerator), but if we are insulin resistant and/or don’t have a properly functioning pancreas (brake), we won’t be able to produce as much insulin to balance the glucagon response.

Someone who is insulin resistant has normally functioning accelerator pedal (glucagon stimulating glucose release in the blood) but a faulty brake (insulin).

Real life example

To unpack this further, let’s look at an example close to home.

The picture below is of a family meal (i.e. steak, sauerkraut, beans and broccoli) that we had when my wife Monica (who has Type 1 Diabetes) was wearing a continuous glucose meter.

The photo of the continuous glucose monitor below shows Monica’s blood sugar response after the meal which we had at about 5:30 pm.  Her blood sugar rises in response to the veggies and then comes back down as the insulin kicks in.

image31.jpg

The process to bring her blood sugars back under control from a few carbs in the veggies takes about two hours.

But over the next twelve hours, Monica’s blood sugar level drifts up as the insulin dose goes to work as she metabolises the protein.  For all intents and purposes though it looks like the protein is turning to glucose in her blood!

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This is not a one off.  We’ve seen this blood glucose response regularly.

Many people with type 1 diabetes know they need to dose with adequate insulin for protein.  Once you work out how to reduce simple carbs, working out how to dose for protein is the next frontier of proper insulin management. It’s complicated and sometimes confusing.

More insulin or less protein?

So, what is the problem here?  Why are Monica’s blood sugars rising?

Is it too much protein?

Or not enough insulin (i.e. because she has type 1 diabetes)?

I think the best way to explain the rise in blood sugars is that there is not enough insulin to keep the glycogen locked away in her liver and metabolise the protein to build muscle and repair her organs at the same time.

Meanwhile, the glycogen pedal is pushed down as it normally would be in response to a protein which is driving the glucose up in her bloodstream.

There is just not enough insulin in the gas tank (pancreas) to do everything that needs to be done.

So, if Monica had a choice, should she:

  • A. Keep her blood sugars stable and stop metabolising protein to repair her muscles and organs,
  • B.  Metabolise protein to build her muscles and repair her organs while letting her blood sugars drift up, or
  • C. Both of the above.

Personally, I think the correct answer is C.

While it’s probably not wise to go hog-wild with protein supplements and powders if you have diabetes, as detailed in this article, swinging to the other extreme to target minimal protein levels is a sure way to end up with a poor nutritional outcome.

According to Simpson and Raubenheimer in Obesity: the protein leverage hypothesis (2005), people with diabetes may actually need to eat more protein to ensure that they have adequate amounts to build lean muscle mass given that higher levels of gluconeogenesis may cause more protein loss to glucose due to their insulin resistance.

One source of protein loss is hepatic gluconeogenesis, whereby amino acids are used to produce glucose. This is inhibited by insulin, as is the breakdown of muscle proteins to release amino acids, and therefore occurs mainly during periods of fasting (or low carb).

However, inhibition of gluconeogenesis and protein catabolism is impaired when insulin release is abnormal, insulin resistance occurs, or when circulating levels of free fatty acids in the blood are high. These are interdependent conditions that are associated with overweight and obesity, and are especially pronounced in type 2 diabetes (12,34).

It might be predicted that the result of higher rates of hepatic gluconeogenesis will be an INCREASED requirement for protein in the diet.

A lot of my early motivation in developing the Optimising Nutrition blog was to understand which foods provoked the least insulin response and how to more accurately calculate insulin dosing for people with diabetes to help Monica get off the blood glucose roller coaster.

Like Ted Naiman, I thought if we reduced the insulin load from our food (including minimising protein) we would have a pretty good chance of losing a lot of weight (just like someone with uncontrolled type 1 diabetes).

I no longer think we need to restrict protein to optimise insulin resistance.  However, there’s no need to go to the other extreme and binge on protein.   Worrying about getting too little or too much protein is largely irrelevant.  We will get enough protein when we eat a nutritious diet.  Left to its own devices, our appetite typically does a good job of seeking out adequate protein to suit our current needs.

Meanwhile actively aiming to minimise protein will make it harder to maintain lean muscle mass which is critical to glucose disposal and insulin sensitivity.

If you see your blood sugar levels rise due to protein, it is likely due to inability to produce enough insulin rather than too much protein.

Basal and bolus insulin

One option to minimise the adverse effects of excess insulin is to focus on reducing the insulin load of our diet and eat only high-fat foods that have a low proportion of insulinogenic calories (i.e. ones towards the bottom left of this chart).

If you are highly insulin resistant and obese, this will work like magic, at least for a little while.

People who suddenly stop eating processed junk carbs and eat more fat often find that their appetite plummets as the insulin demand of their food drops and they are more easily able to access their own body fat.[14] [15]

But this is only part of the story.  Again, we can learn a lot about insulin from people with Type 1 diabetes who have to manually manage their insulin dose.

In diabetes management there are two kinds of insulin doses:

  1. basal insulin, and
  2. bolus insulin.

The bolus insulin is the insulin for the food we eat.

The basal insulin is a steady flow of insulin that is required throughout the day and night.

Without the basal insulin, we would disintegrate into uncontrolled gluconeogenesis and ketoacidosis (e.g. uncontrolled type 1 diabetes).

In a person eating a typical western diet around half the insulin given in a day is for the food and half is basal insulin. The chart below shows the daily insulin dose of a person with type 1 diabetes eating a standard diet.  The white component is the basal, and the black is the bolus for their food.

In someone following a low carb diet only around 30% of the insulin is for the food and 70% is basal insulin as shown below in my wife Monica’s daily insulin dose shown below.

daily insulin.jpg

We can only reduce our insulin requirements marginally by changing our diet.   We always need basal insulin.  If we’re insulin resistant, we’ll need more.

Like caffeine or alcohol, we become more sensitive to insulin when we are exposed to less of it.  As we reduce the insulin load of our diet, our insulin sensitivity will improve.

But not everyone who follows a low carb diet instantly turns into a super athlete.  There has to be more to the story.

How to improve your basal insulin sensitivity

In addition to modifying our diet, we can also improve our blood glucose control by maximizing our body’s ability to dispose of glucose without relying on insulin (i.e. non-insulin mediated glucose uptake).  We enhance our insulin sensitivity and our ability to use glucose by building more lean muscle mass.

I used to think that if we just dropped the insulin load of our diet down far enough, we would be able to lose weight, a bit like someone with uncontrolled type 1 diabetes.  But now I understand that there will always be enough basal insulin in our system to store excess energy (regardless of the source) and stop our liver from releasing stored energy.

While a diabetic can reduce their insulin requirements for food by eating food with lots of fat, they can actually end up insulin resistant and need more basal insulin if they drive over abundance of energy, regardless of whether it’s from protein, fat or carbs.[16]

While ketones can rise to quite high levels when fasting (which is great), I fear that some people are chasing high ketone levels with lots of dietary fat and the excess energy may lead to insulin resistance in the long term.

Dr Bernstein’s approach

The method recommended by Dr Bernstein (who has type 1 diabetes himself) is typically lower in carbs, adequate protein (depending on whether you are a growing child) and moderate in fat.

Even at 83, Dr B feels it is important to maintain lean muscle mass through regular exercise to maximise his insulin sensitivity.

Will too much protein “kick me out of ketosis”?

While the ketogenic diet is becoming popular, I think most people who are interested in it do not necessarily require therapeutic ketosis, but rather are chasing weight loss or blood sugar control/diabetes management.

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If you are managing a condition that benefits from high levels of ketosis (e.g. epilepsy, dementia, cancer, traumatic brain injury, Alzheimer’s) then limiting protein may be necessary to ensure continuously elevated ketone levels and reduce insulin to avoid driving growth in tumour cells and cancer.  

Giving the burgeoning interest in the ketogenic dietary approach, I think it’s important to understand the difference between exogenous ketosis and endogenous ketosis.

  • Endogenous ketosis occurs when a person eats less than the body needs to maintain energy homeostasis and we are forced to up the glycogen in our liver and then our body fat to make up the difference.
  • Exogenous ketosis (or nutritional ketosis) occurs when we eat lots of dietary fat (or take exogenous ketones), and we see blood ketones (beta hydroxybutyrate) build up in the blood. We are burning dietary fat for fuel.

Higher levels of ketones in the blood are an indication that you are eating more fat than you are burning.  Having some level of blood ketones is an indication that your insulin is low, but whether your blood ketones are high or low should not be a major cause for concern as long as your blood glucose levels are also low.  Unless we are doing a long term fast, we will all be somewhere on the spectrum between exogenous and endogenous ketosis.

Keep in mind though that most of the beneficial things we attribute to “ketosis” and the “ketogenic diet” occurs when we are in endogenous ketosis (i.e.  when fat is coming from our body, not our plate or coffee cup).

As detailed in the popular article What are Optimal Ketone and Blood Sugar Levels in Ketosis? it seems that lower levels of total energy (i.e. towards the left of this the chart below) is a better place to be, particularly if we are chasing weight loss or diabetes management.

Our blood ketones may not be as high when we are in endogenous ketosis, but that’s OK because most of the good stuff happens in a low energy state.  

Endogenous ketosis Exogenous ketosis
Low total energy (i.e. blood glucose + blood ketones + free fatty acids) High total energy (i.e. blood glucose + blood ketones + free fatty acids)
Stored energy taken from body fat for fuel Ingested energy used preferentially as fuel
Stable ketone production all day Sharp rise of ketones for a short duration.  Need to keep adding fat or exogenous ketones to maintain elevated ketones.
Insulin levels are low which allows release of glycogen from our liver and fat stores Insulin levels increase to hold glycogen in liver and fat in adipose tissue
Mitochondrial biogenesis, autophagy, increase in NAD+, increase in SIRT1 Mitochondrial energy overload, autophagy turned off, decrease in NAD+
Body fat and liver glycogen used for fuel Liver glycogen refilled and excess energy in the bloodstream stored as fat.

Summary

  • Gluconeogenesis is the creation of new glucose (generally from protein).
  • Protein requires about half as much insulin as carbohydrate to metabolise.
  • Increasing protein intake will generally improve our blood glucose and insulin levels.  Protein forces out processed carbohydrates, increasing the nutritional quality of our diet and helps us to build muscle which in turn burns glucose more efficiently.
  • In a metabolically healthy person glucagon balances the insulin response to protein, so we see a flat line blood sugar response to even a large protein meal.
  • If you cannot produce enough insulin, you may see glucose rise as your body tries to metabolise the protein and keep the energy stored in the liver at the same time.
  • The insulin for the food we eat (bolus) represents less than half of our daily insulin demand. We can improve our basal insulin sensitivity by building lean muscle mass and improving mitochondrial function via a nutrient dense diet.
  • If we are aiming for weight loss and health, then low blood sugars and low ketones will be more desirable rather than chasing high ketone levels via exogenous ketosis.

references

[1] http://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1002116

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636610/

[3] https://optimisingnutrition.com/2015/06/04/the-goldilocks-glucose-zone/

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

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

[6] https://optimisingnutrition.com/2015/03/30/food_insulin_index/

[7] https://optimisingnutrition.com/2017/05/27/is-there-a-relationship-between-macronutrients-and-diet-quality/

[8] https://www.ncbi.nlm.nih.gov/pubmed/16694439

[9] http://caloriesproper.com/dietary-protein-does-not-negatively-impact-blood-glucose-control/beef-vs-glucose/

[10] http://www.ketotic.org/2013/01/protein-gluconeogenesis-and-blood-sugar.html#¹

[11] https://books.google.com.au/books?id=3FNYdShrCwIC&printsec=frontcover&dq=marks+basic+medical+biochemistry&hl=en&sa=X&ei=-ctaVcivOJfq8AXL84CAAw&redir_esc=y#v=onepage&q=glucagon&f=false

[12] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4997013/

[13] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC524031/

[14] https://docmuscles.com/

[15] https://optimisingnutrition.com/2017/01/15/how-optimize-your-diet-for-your-insulin-resistance/

[16] https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/1743-7075-11-23

 

post last updated August 2017

nutrient dense insulinogenic foods for bodybuilding

As well as identifying nutrient dense diabetic friendly foods, we can use the food insulin index to highlight more insulinogenic nutrient dense higher energy density foods for use by athletes or people wanting gain weight.

This article highlights more insulinogenic nutrient dense foods that could be used by metabolically healthy people to strategically “carb up” before events, to intentionally trigger insulin spikes (e.g. Carb Back-Loading, Alt Shift Diet or the targeted ketogenic diet) or to maximise growth for people who are underweight while still maintaining high levels of nutrition.

insulin load, a refresher

Many people with diabetes will try to reduce the insulin load of their diet to normalise blood glucose levels.  It’s the non-fibre carbohydrates, and to a lesser extent protein, that drive insulin and blood glucose, particularly for someone who is insulin resistant.

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Managing the insulin load of your diet is an effective way to get off the blood glucose roller coaster and stabilise blood glucose levels.  We can calculate the insulin load of our diet based on the carbohydrates, fibre and protein using the formula shown below.

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We can also calculate the percentage of insulinogenic calories to identify the foods that will affect our blood glucose levels the least, or the most.

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but why would you want to spike your glucose levels?

Much of the nutrition and diabetes world is focused on helping people who are struggling with insulin resistance and trying to normalise blood glucose.  However, there are others who are blessed to be metabolically healthy who may want to strategically refill their glycogen tanks or raise their insulin levels.

  • Some follow a targeted ketogenic diet and strategically replenish glucose around workouts by eating higher carbohydrate foods.
  • Some bodybuilders use a cyclical ketogenic diet where they deplete glucose and then replenish glucose periodically.
  • Some fat adapted endurance athletes will look to ‘carb up’ before an event so that they have both glucose and fat based fuel sources (a.k.a. train low, race high).

  • Others find success with dietary approaches such as the AltShift Diet, Carb Back-Loading which alternating periods of extreme high and low carb dietary approaches (not always with the most nutritious high carb foods).

the mission…

Dr Tommy Wood approached me to design a high insulin load and a low insulin load diet regimen that he could try for a month of each to see how his body responded. The constraint was that both the high and low insulin load foods would have to be nutrient dense whole foods so as to be a fair comparison of the effect of insulin load.

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The foods listed below represent the top 10% of the USDA food database prioritised for higher insulin load, higher nutrient density and higher energy density.  In terms of macronutrients they come out at 36% protein, 15% fat and 44% net carbohydrates.

While these foods might not be ideal for someone with diabetes they actually look like a pretty healthy list of foods compared to the “food like products” that you’d find in the isles of the supermarket.

This chart shows the nutrients provided by the top 10% of the foods using this ranking compared to the average of all foods in the USDA foods database.

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Also included in the tables below are the nutrient density score, percentage of insulinogenic calories, insulin load, energy density and the multicriteria analysis score score (MCA) that combines all these factors.

vegetables

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food ND insulin load (g/100g) calories/100g MCA
watercress 19 2 11 1.2
seaweed (wakame) 13 11 45 1.0
shiitake mushrooms 5 72 296 0.9
spinach 17 4 23 0.9
brown mushrooms 11 5 22 0.7
asparagus 15 3 22 0.7
chard 14 3 19 0.7
seaweed (kelp) 9 10 43 0.7
yeast extract spread 8 27 185 0.6
white mushroom 11 5 22 0.6
spirulina 10 6 26 0.6
mung beans 9 4 19 0.6
Chinese cabbage 12 2 12 0.5
celery flakes 4 42 319 0.5
portabella mushrooms 11 5 29 0.5
broccoli 11 5 35 0.4
parsley 12 5 36 0.4
lettuce 12 2 15 0.4
radicchio 8 4 23 0.4
shiitake mushroom 9 7 39 0.4
peas 7 7 42 0.4
dandelion greens 9 7 45 0.3
endive 15 1 17 0.3
okra 10 3 22 0.3
pumpkin 6 4 20 0.3
bamboo shoots 8 5 27 0.3
beet greens 12 2 22 0.3
snap beans 8 3 15 0.3
zucchini 11 2 17 0.3

animal products

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food ND insulin load (g/100g) calories/100g MCA
ham (lean only) 11 17 113 0.7
veal liver 9 26 192 0.7
beef liver 9 25 175 0.7
lamb liver 11 20 168 0.7
lamb kidney 11 15 112 0.6
chicken breast 8 22 148 0.5
pork liver 7 23 165 0.5
chicken liver 9 20 172 0.5
pork chop 7 23 172 0.5
veal 6 24 151 0.5
beef kidney 8 20 157 0.5
lean beef 7 23 149 0.5
leg ham 7 22 165 0.5
turkey liver 8 21 189 0.5
pork shoulder 6 22 162 0.4
ground beef 6 20 144 0.4
sirloin steak 6 24 177 0.4
ground pork 6 25 185 0.4

seafood

food ND insulin load (g/100g) calories/100g MCA
cod 14 48 290 1.5
crab 15 14 83 1.1
lobster 14 15 89 1.1
crayfish 12 13 82 0.9
shrimp 11 19 119 0.9
pollock 11 18 111 0.8
octopus 9 28 164 0.8
halibut 11 17 111 0.8
fish roe 13 18 143 0.8
haddock 10 19 116 0.8
white fish 10 18 108 0.8
clam 9 25 142 0.8
scallop 8 22 111 0.7
rockfish 10 17 109 0.7
salmon 11 20 156 0.7
whiting 9 18 116 0.7
perch 10 14 96 0.7
oyster 11 14 102 0.7
flounder 11 12 86 0.6
anchovy 9 22 210 0.6
trout 10 18 168 0.6
caviar 10 23 264 0.6
sturgeon 10 16 135 0.5
tuna 6 23 184 0.3
orange roughy 4 17 105 0.3
sardine 7 19 208 0.3

legumes

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food ND insulin load (g/100g) calories/100g MCA
cowpeas 2 68 336 0.8
black beans 2 63 341 0.6
soybeans 3 49 446 0.6
pinto beans 1 64 347 0.6
kidney beans 1 63 337 0.6
broad beans 2 54 341 0.5
peas 0 57 352 0.4

grains

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food ND insulin load (g/100g) calories/100g MCA
oat bran 6 65 246 0.7
baker’s yeast 10 16 105 0.5
baking powder 2 45 97 0.4
wheat bran 8 34 216 0.4
rye flour 0 58 325 0.4
quinoa 1 22 120 0.1

dairy

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food ND insulin load (g/100g) calories/100g MCA
whey powder 10 82 339 1.6
cream cheese (low fat) 12 19 105 1.0
cottage cheese (low fat) 6 14 72 0.5
parmesan cheese 3 35 420 0.4
cottage cheese (low fat) 7 13 81 0.4
cheddar (non-fat) 6 20 173 0.3
mozzarella 4 26 304 0.3
kefir 6 7 41 0.3
gruyere cheese 3 23 413 0.3
low fat milk 6 8 56 0.2
Greek yogurt (low fat) 5 11 73 0.2
Swiss cheese 3 22 393 0.2
gouda cheese 3 21 356 0.2
cheddar cheese 3 20 410 0.2
egg yolk 6 12 275 0.2
edam cheese 3 21 357 0.1

other dietary 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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