Category Archives: ketosis

Is the acetone:glucose ratio the Holy Grail of tracking optimal ketosis?

Key points

  • The real magic of ketosis seems to occur in a lower energy state.
  • High levels of beta-hydroxybutyrate ketones (BHB) can be a good sign, particularly with lower blood glucose levels.
  • Unfortunately, forcing in extra energy in the pursuit of higher BHB levels (e.g. exogenous ketones or refined fat) has the potential to drive higher insulin and insulin resistance.
  • As we lose weight, improve our metabolic health and stop over fueling, many people start to see lower levels of BHB.
  • While it can be used as an alternative to glucose in the brain, BHB needs to be converted to acetoacetate to be used by the body.
  • If you are making and using ketones without consuming excessive energy you will likely see lower blood glucose, higher breath acetone and lower BHB levels.
  • The ratio between breath acetone and glucose can be a useful indicator of genuine nutritional ketosis and a healthy metabolism.

Introduction

In previous articles we’ve looked at why chasing higher blood ketones with more dietary fat or exogenous ketones might not be smart.[1] [2]

We also looked briefly at the glucose:ketone ratio as a useful parameter to track therapeutic ketosis.[3] [4]

This article looks at the ratio between acetone (a form of ketones that can be measured on your breath) and your blood glucose.

It appears that this ratio may be helpful if you require therapeutic ketosis (e.g. to manage cancer, epilepsy, Parkinson, Alzheimers, dementia etc) or to optimise your metabolic health for weight loss, general health or longevity.

We crunch the numbers to see how you can use breath acetone to help you optimise your metabolic health.

[TL;DR…  Higher breath acetone with lower blood glucose seems to be a good place to be.  Breath acetone is potentially more useful than monitoring BHB in the blood.]

What is ketosis?

Ketosis is trending hard at the moment.

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But what is it?

And do you really need more of it?

Some people think that we need to be “in ketosis” to burn fat.  Hence, many people think that more ketosis is better, especially if you have body fat you want to burn.

While this message helps sell keto-related products, it’s technically not correct.

Ketosis is an alternative metabolic pathway that our body uses when there is not enough oxaloacetate in our diet (from carbs or protein) to burn fat via the Krebs cycle.  When this occurs, fat that can’t be oxidised in the Krebs cycle is oxidised via ketosis.

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This is a “sliding scale” sort of thing.  People following a typical western diet will have lower levels of blood ketones (e.g. 0.1 or 0.2 mmol/L),[5] while people eating more fat and less carbs may have higher levels.

The fact that we can use this backup metabolic pathway has helped us survive many a famine to procreate another day.

Ketosis is a critical component of our metabolism and our survival as a species.

Are ketones magical?

Our understanding ketones and ketosis is evolving fast.

Some people believe that ketones have unique and special signalling properties.[6] [7]  While others feel that these beneficial properties of ketosis are limited to endogenous ketosis (i.e. when we predominantly burn stored body fat).[8]

When our energy levels are low, we also see an upregulation of mitochondrial biogenesis, sirtuins, autophagy and NAD+ which are also highly beneficial.

But perhaps it’s actually all of these things working together that causes the benefits that many people associate with “being in ketosis”, not just the ketones themselves.

When energy levels are low, our body goes into repair mode to ensure survival and we switch over to burn body fat.  Our blood ketones rise significantly after a few days without food.

The chart below shows about three thousand data points from people following a low carbohydrate or ketogenic diet measuring blood ketones and blood glucose at the same time.  Blood ketones (shown in blue) are not necessarily high for most people while they are eating normally, even if blood sugar levels are low (shown as orange).

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We can drive high blood ketones by taking exogenous ketones and/or lots of refined fat (the right-hand end of this chart).  But, unless you’re about to do some explosive exercise to burn off all this energy, this over fueling may not be optimal.

Oxidative priority

Our appetite does an excellent job of making sure we get the fuel if it’s available.  Our metabolism is pretty good at balancing the different fuel sources based on inputs and demand.

While our bodies are adapted to deal with a range of fuel sources, it struggles to deal with too much energy for a long time.

The chart below (from a paper by Ray Cronise, David Sinclair and Andrew Bremer, with the addition of exogenous ketones courtesy of Craig Emmerich) shows the order that we generally prioritise the use of different fuel sources.

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  1. Alcohol will be burned off first because it’s effectively a poison that the body can’t store.  (Alcoholics can have really low HbA1c levels because insulin rises to shut off the release of glucose into the bloodstream while the alcohol is burned off.[9])
  2. Similar to alcohol, ketones are used up as a priority because we can’t channel them back into storage in the body.  Ketones are acidic and high levels of ketones in the blood lead to diabetic ketoacidosis.  (note: As discussed below, Beta-hydroxybutyrate (BHB) can be thought of as the storage form of ketones.  While BHB can be used directly by the brain, it needs to be converted back to acetoacetate to be used by the rest of the body.)
  3. Protein is not a great fuel, so we can’t store much of it in the blood.  It’s hard for the body to convert protein to energy so it’s hard to overeat.[10]
  4. Carbohydrates can be a useful source of fuel for explosive efforts.   But glucose can be toxic in large quantities (it leads to glycation) so the body tries to limit the amount in the bloodstream.
  5. If glucose levels are high, the body won’t burn off the fat from our diet.  Fat is last in line to be burned because it’s such an effective way of storing energy.
  6. Similarly, if the level of fat in our diet is high we won’t burn off the fat on our body effectively.  (High levels of fat in the bloodstream can lead to oxidised LDL, so the body wants to keep it moving rather than building up high levels.)

Your body increases insulin to hold back the release of stored energy until the energy in the blood decreases.  As you burn through all these fuel sources the body decreases your insulin levels to eventually allow the release of your stored fuel for use to make up the difference.

You can think of a lower energy state as one where you don’t have a lot of fuel lined up in front of our body fat, while a high energy state occurs where your body has to ramp up insulin levels to hold your stored energy back from being used while the energy from your mouth is being used.  

When you look at it from this perspective you see that nutrition is essentially a process of optimising our food choices to ensure we get the nutrients and fuel we need without stacking up too much energy in front of our body fat stores.[11] [12]

Low carb and weight loss

More stable blood glucose levels help people normalise appetite.  People often eat less when they are no longer on the blood glucose roller coaster.  For people with diabetes, weight loss is often a spontaneous response to reducing carbohydrates as demonstrated by the recently released Virta one year trial results.[13]

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However, while high blood ketones (BHB) is often targeted as evidence of being “in ketosis”, BHB levels often typically taper off over time, especially if you are lean, active, metabolically healthy and weight stable.

It seems that as our fat stores become ‘less full’ we don’t store as much energy in the bloodstream.   And, as we will see later, once our NAD+: NADH ratio increases, less acetoacetate is pushed off to into storage as BHB.

One of the most fascinating outcomes of the one-year Virta study was that over the period of a year, participants’ BHB levels went from 0.17 mmol/L to an average of 0.54 mmol/L after 10 weeks and then settled back to 0.3 mmol/L after a year.[14]

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I found it ironic that in this study of treating diabetes with a ‘ketogenic diet’ that, on average, these people only temporarily dipped into “nutritional ketosis” (defined as having BHB > 0.5 mmol/L).  Then in the long term, they settled back to much lower levels of BHB.

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Even under the supervision of the doctors and dietitians who are the world experts in ketosis and literally wrote the book on the topic, at no time did they go near “optimal ketosis” (as defined as having BHB between 1.0 mmol/L and 3.0 mmol/L[15]).

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Blood sugar and HbA1c

While the science around ketosis is still controversial, we do know that a lower HbA1c and lower blood sugar levels can be beneficial in terms of long-term health and avoiding many common killers (e.g. diabetes, heart disease, cancer, stroke etc).

The chart below shows that a HbA1c of 4.5% (i.e. a proxy for your average blood sugar level) gives the lowest hazard ratio (i.e. lowest risk of mortality from all causes).[16] [17]

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As shown below, a lower HbA1c is beneficial in terms of reducing your risk of stroke, heart disease, cardiovascular disease and many of the modern diseases.

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The risk  of focusing on beta-hydroxybutyrate as your measure of ketosis

However, if at first, you don’t succeed in achieving “optimal ketone levels” many people resort to the following to raise their blood ketone levels:

  • load up on high levels of refined fat such as Bulletproof Coffee with butter and MCT oil,

[warning: These foods are typically more energy dense and less satiating, so many people find them easy to overeat.  While most people don’t need to avoid dietary fat, simply eating ‘fat to satiety’ doesn’t lead to long-term weight loss for many people.]

  • eat less protein to reduce oxaloacetate and force more fat to be burned via ketosis rather than the Krebs Cycle,

[warning: Replacing energy from protein and carbohydrates with fat can lead to a less nutrient dense selection of foods as evidenced by many of the lower ranking people in the Nutrient Optimiser Leaderboard.  In this recent article Volek and Phinney suggested that protein intake is between 1.5 and 2.0 g/kg reference weight and that while reducing protein will help to increase ketosis you should not drop below 1.2 g/kg BW.[18]],

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  • eat a more acidic diet with less electrolytes to ensure that the keto acids are not able to be balanced with alkaline minerals such as magnesium, potassium and calcium), or

[warning: This approach may lead to the keto flu in the short term and insulin resistance[19] and metabolic acidosis in the longer term.[20]]

  • eat a diet that contains less B vitamins to decrease your NAD+:NADH ratio to force more acetoacetate to be stored and converted to BHB.

[warning: B vitamins are important for efficient and effective energy production].

The glucose:BHB index

So we do know that lower glucose levels are a good thing and high blood ketones are not necessarily bad.  They can actually nourish the brain if we are insulin resistant and aren’t using glucose well and this is helpful where therapeutic ketosis is required (i.e. Alzheimer’s, epilepsy, Parkinson’s, cancer etc).

But high ketones are not great if they are also accompanied by high blood glucose levels and/or free fatty acids.

So, the way to make sure we are not overloading our system in our pursuit of ketosis is to ensure that our higher ketone levels are also accompanied by lower glucose levels.

Enter the glucose: ketone index which was developed by Professor Thomas Seyfried of Boston College[21] [22] to help optimise the metabolism of cancer patients.

Seyfried subscribes to the Warburg hypothesis of cancer which says that cancer cells ferment glucose and, hence, reducing the glucose supply to cancer cells can help them slow proliferation.

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To help understand what this looks like in practice I have plotted more than 1200 blood glucose versus ketone values in the chart below and divided them up into five groups based on their GKI value.  The average GKI values of these groups of data points are shown on the charts (i.e. GKI = 1.5, 2.8, 4.5, 7.5 and 20).

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The worst metabolic health is the GKI = 20 population (green dots at the bottom of the chart) with high blood glucose levels and low ketones.  This means that glucose values are twenty times that of the ketone values.

Meanwhile, the people with the lower glucose and the higher ketone are likely to be in a better place metabolically.  They will be more likely to experience the positive therapeutic benefits associated with “being in ketosis”.

Before you go chasing a super low GKI value, be aware that most people are not going to get GKI values under than 2.0 until they fast for a few days, even if they are following a ketogenic diet.  The chart below shows what you could expect if you fasted for seven days.

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The glucose : acetone index

Both Michel Lundell from Ketonix and Dave Korsunsky from Heads of Health recently told me that, building on the GKI concept, a number of people are tracking the ratio between their breath acetone readings and their glucose levels.

In order to better understand the relationship between breath acetone and ketones, I have plotted about two and a half thousand glucose and breath ketone readings taken at the same time in the chart below.

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You can see from this chart that there is a similar relationship between glucose and breath ketones as with blood ketones.  However, there is less scatter compared to the previous chart.  It seems that blood glucose and breath acetone are more closely correlated than blood ketones.

It’s hard to have high breath acetone with high blood glucose levels.   You can’t ‘game the system’ in the same way you can with BHB by forcing in exogenous fat or ketones.

As your energy and insulin levels start to rise, more of your acetoacetate will be shunted off to storage as BHB.  So, while some refer to BHB as ‘the gold standard”, it’s hard to know whether high blood ketone values are due to a low energy state or if your bloodstream is full of energy so you need to store more as BHB.

I think the optimal situation to be in is to have lower blood glucose levels with a solid amount of breath acetone in your system which suggests you are producing ketones without driving excess energy.

If you have good metabolic health, you’ll probably be in the purple or green area on this chart.  If you are achieving a therapeutic level of ketosis or fasting for longer periods, you will ideally be in the upper left corner of this chart (green or light blue) with low glucose and high breath ketones.

The chart above shows breath acetone (BrAce on the Ketonix scale of 0 to 100) and the blood glucose in mmol/L.  To calculate your BrAce:BG ratio you can divide your Ketonix reading by your blood glucose level.  If you’re going to measure it’s probably better to measure your glucose and ketones in the morning when you first wake up.  They key is to measure these values all at the same time.  While it’s interesting to see how you compare with others it’s most important to make sure your values moving in the right direction over time.

The chart below shows glucose vs breath acetone with glucose in mg/dL (American units).  If you have Ketonix and blood glucose meter you can test and see how you compare.

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Are breath ketones a better measure of health than BHB?

If you’re really interested in this topic, I recommend you watch this video from Chris Masterjohn that explains in detail how ketones are made and used.

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In summary:

  • Acetoacetate is the first ketone body made in the liver (unfortunately, it’s hard to measure).
  • If your NAD+:NADH ratio is low, more acetoacetate will be converted to BHB, which can be measured in the blood.
  • While the brain can use BHB directly, BHB needs to be converted back to acetoacetate to be used in the rest of the body.
  • When the level of energy in your bloodstream decreases, your NAD+:NADH ratio increases and insulin levels decrease. You will then be able to shuttle the ketones stored as BHB back to acetoacetate to be used for energy in the rest of the body.

Acetone is like a vapour that is released from acetoacetate, similar to nail polish fumes.  If you are releasing a high level of breath acetone, then people might say you have a ‘fruity’ smell on your breath or you will experience a different, metallic taste in your mouth.

It’s not easy to measure acetate in the blood, but devices like the Ketonix are becoming more popular to measure acetone in your breath.  Acetone on your breath is not a direct measure of the quantity of acetoacetate in your system but it’s a useful proxy.  Imagine the difference in smell if you have a small thimble versus a massive drum of nail polish.  You’re going to get more fumes coming off a large amount of acetone.

The take-home point here is that if our NAD+:NADH ratio is high, and our overall energy levels are low then not as much acetoacetate will be converted to BHB, and hence more acetoacetate will be available in the blood and more acetone will be measured on the breath.

Meanwhile, if you have excess energy in your system, you will have high levels of ketones in their “storage form” available for use only by the brain.  Conversely, if you have a lower energy state that is more conducive to burning body fat, you may have less BHB and more acetoacetate.

So, breath acetone is more of a measure of ketones ready to be used by your body while BHB is more of a measure of ketones being stored for later use.

Why does the balance of acetone vs BHB vs BrAce matter?

NAD+ is a metabolite that declines with age.[23]  A lot of the anti-aging research at the moment is focusing on how we can boost NAD+ levels.[24] [25] [26] [27] [28]   IV NAD+ treatments are being used for drug addiction, anti-ageing and quick recovery from a really big night.[29] [30] [31]

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The secret here is that, while you can take supplements and injections to boost NAD+, most people can get plenty from B vitamins (particularly vitamin B3 (niacin) which is dirt cheap).[32]

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NAD is also made from tryptophan in the diet.

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NADH builds up when we become over-fueled and is typically higher in conditions such as diabetes.[33]  When we eat and get energy from food, a hydrogen ion (H+) and two electrons (2e-) attaches to NAD+ and we get NADH.  When we use the energy and go without foods the reverse reaction occurs.  NADH decreases and NAD+ builds up.

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Too much energy in our system drives high NADH levels.  Just like in a car engine, we can drown our mitochondria in fuel and they choke.

When we have lots of fuel in our system NADH rises but then if we don’t have enough NAD+ we can’t use it.  So we’re drowning in fuel but we can’t use it!

Bringing this back to measuring ketones… if we have a higher NAD+:NADH ratio we will see higher breath acetone, lower blood glucose and lower levels of BHB (which is a good thing).

Tell me what to do!!!

So ideally we want to see:

  • higher breath acetone,
  • lower blood glucose levels, and
  • blood ketone values of maybe greater than 0.2 mmol/L (they’re not really a big deal unless you specifically require high levels of blood ketones to feed your brain in conditions such as epilepsy, Alzheimer’s or Parkinson’s).

How to get higher NAD+ levels and higher acetoacetate

Boosting your NAD+ levels can be achieved by:

  1. Eating nutrient dense foods with plenty of B vitamins (which are a precursor to NAD+),
  2. Not avoiding protein (particularly tryptophan), and
  3. Supplementing with niacin.

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If you find your breath acetone is on the lower end you can try supplementing with Niacin.  When I supplement with Niacel or Niacin my BHB levels drop and my breath acetone rises substantially.

Be warned, you can get a flushing reaction so make sure you start slowly.  There is no need to take super high levels, particularly if you’re already keto-adapted.

You can supplement to the point that you start to see higher Ketonix readings.  Or, if you don’t have a Ketonix, to the point that you get a funky metallic taste in your mouth.

You might want to start with 25 mg or 50 mg of Nicotinic Acid and build up to 100 mg or even 200 mg if you don’t see any flushing or a rise in your breath acetone.

  • If you’re wanting to start gently, the Carson Lab niacin is the only one I’ve been able to find in 50 mg in Australia via iHerb.
  • The 100 mg Nicotinic Acid is actually a lot cheaper (only 5 c per tab).
  • Nicotinamide Riboside can be useful for people who can’t as easily convert niacin to NAD+, but it’s more expensive.

However, rather than supplementing, nutrient dense minimally processed whole foods are ideal, at least as a starting point before you start adding supplements.  The Nutrient Optimiser has been designed to help you find the most nutritious whole foods to balance your macro and micronutrients.

If you require therapeutic ketosis the Nutrient Optimiser free report will give you a suggested macro range that will also help you avoid excessive energy.  It will also give you a short list of nutrient dense meals and foods that will help boost your mitochondrial function.

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If you’re interested, the Nutrient Optimiser full report will give you a longer list of foods and meals.  You also have the option to upload your Cronometer data to progressively fine-tune your diet to achieve your goals.

How to get lower blood glucose levels

The key to achieving lower blood glucose levels is:

  1. Avoid processed, and nutrient-poor high carbohydrate foods (e.g. processed grains, cereals and sugars),
  2. Eat less often / fast / avoid snacking,
  3. Eat less overall.

If you do these things, you will see your blood glucose levels decrease, your NAD+ levels increase, and your breath acetone levels increase.

You can stabilise your blood glucose levels by eating a diet with more fat and less carbohydrates, but to really shift your NAD+:NADH ratio in a favourable direction, you may need to reduce your body fat to more optimal levels.

The article How to use your blood glucose meter as a fuel gauge can guide you through how to use a glucose meter to re-calibrate your eating routine based on when you really need to eat.

The Nutrient Optimiser will suggest macronutrient ranges and nutritious foods that will help you stabilise your blood sugars.

 

 

Thanks

Special thanks to:

  • Robert Miller for sharing his unique insights into biochemistry.
  • Michel Lundell from Ketonix for supplying all the data!
  • Weikko Jaross and Alessandro Ferretti for help with the initial database analysis.
  • Craig Emmerich. Mike Julian, Ben McDonald, Robin Reyes, Alex Leaf and Helen Kendall for their review and editing.

 

References

[1] https://optimisingnutrition.com/2016/08/08/how-to-make-endogenous-ketones-at-home/

[2] https://optimisingnutrition.com/2017/04/30/are-ketones-insulinogenic-and-does-it-matter/

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

[4] https://optimisingnutrition.com/2018/02/03/is-too-much-protein-on-keto-a-thing/

[5] https://link.springer.com/article/10.1007%2Fs13300-018-0373-9

[6] https://www.ncbi.nlm.nih.gov/pubmed/25686106?dopt=Abstract

[7] https://www.ncbi.nlm.nih.gov/pubmed/23223453?dopt=Abstract

[8] https://optimisingnutrition.com/2016/08/08/how-to-make-endogenous-ketones-at-home/

[9] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5125693/

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

[11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5326984/

[12] https://www.amazon.com/Keto-Complete-Ketogenic-including-Simplified/dp/1628602821

[13] http://doi.org/10.1007/s13300-018-0373-9

[14] http://doi.org/10.1007/s13300-018-0373-9

[15] https://www.amazon.com.au/Art-Science-Low-Carbohydrate-Living/dp/0983490708

[16] http://circoutcomes.ahajournals.org/content/3/6/661

[17] This chart is interesting because it shows that very low blood glucose levels can be association with issues such as autoimmune issues or alcoholism which can cause blood sugars to go very low while the body burns through the alcohol.

[18] https://blog.virtahealth.com/how-much-protein-on-keto/

[19] https://optimisingnutrition.com/2017/10/21/redesigning-nutrition-from-first-principles/

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

[21] https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/s12986-015-0009-2

[22] https://www.bc.edu/bc-web/schools/mcas/departments/biology/people/faculty-directory/thomas-seyfried.html

[23] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852209/

[24] http://www.lifeextension.com/Magazine/2018/2/Anti-Aging-Effects-Of-NAD/Page-01

[25] https://www.sciencedaily.com/releases/2017/03/170323141340.htm

[26] http://www.iflscience.com/health-and-medicine/preliminary-results-early-human-trials-anti-aging-formulas-reveal-no-adverse/

[27] https://bengreenfieldfitness.com/podcast/anti-aging-podcasts/what-is-nad/

[28] http://longevityfacts.com/nmn-nad-nicotinamide-mononucleotide-david-sinclair-interview-anti-aging-drug-trials-nicotinamide-adenine-dinucleotide-sirtuins/

[29] https://www.nadtreatmentcenter.com/6-major-benefits-of-nad-iv-therapy

[30] https://www.vice.com/en_us/article/bn3vmq/nad-plus-brain-reboot-infusion-injection

[31] https://bengreenfieldfitness.com/podcast/anti-aging-podcasts/what-is-nad/

[32] https://openi.nlm.nih.gov/detailedresult.php?img=PMC4588049_cells-04-00520-g001&query=&req=4&npos=-1

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

keto… do you want some more?

key points

  • “Keto” is booming!   But there is still a lot of confusion about what exactly constitutes “optimal ketosis”.
  • Most of the magic of ketosis occurs when you burn your own body fat rather than eat more dietary fat or consume exogenous ketones.
  • If your goal is weight loss or diabetes management, chase lower blood glucose levels, not higher ketone levels.
  • Our bodies switch to burning more fat via ketogenesis when we eat less digestible carbohydrates and protein available.
  • While many people get caught up chasing ‘optimal ketosis’, anything above 0.2 mmol/L with lower blood sugar levels is a sign that your insulin sensitivity and metabolic health is improving.
  • Eating ‘fat to satiety’ on a low carb or ketogenic diet can help you achieve ‘non-diabetic’ blood sugar levels.   However, some degree of self-discipline may still be required to achieve optimal health and desirable body fat levels.

Keto is so hot right now!

Every woman and her cat seem to be getting on the keto bandwagon.

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Whether it be cookbooks, Facebook groups or forums, keto is booming!

If everyone else is getting on the keto train then surely you need some?

And more must be better?

Right?

If you’re not doing it yet then maybe you’re missing out?

Or like every exponential trend, is there a crash just over the horizon?

Like tulip bulbs in the 1630s?

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Or perhaps Bitcoin right now?

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My keto journey

Personally, I’ve had a keen interest in ketosis for a while.

I was into keto before it was cool.

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I followed Dave Asprey’s Bulletproof coffcoffeeze.  I even bought a bunch of his expensive mycotoxin free beans.

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I eagerly followed Jimmy Moore’s updates during his n=1 ketosis experiment during 2012.

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I was so eager to follow in his footsteps as soon as I could!

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I got hold of Keto Clarity as soon as it was released.  I started adding butter and MCT oil to my coffee and eating liberal amounts of cheese, cream and coconut products in an effort to get my ketone values into what I understood to be the “optimal ketone zone”.[1]

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I spent a good chunk of money on strips to test my blood ketones regularly to see if I was achieving ‘optimal ketosis’.

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Calories and energy balance didn’t matter.

I had faith.

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But unfortunately, I wasn’t one of the blessed that could ‘eat fat to satiety’ and be as lean and healthy as I’d hoped.

The picture below is my work profile shot a year or so after chasing higher ketones with more refined dietary fat.

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I was as heavy as I’d ever been, had early signs of fatty liver and prediabetes.

I realise now that I had been trying to drive exogenous ketosis with lots of extra dietary fat.

What I really needed was to learn how to achieve endogenous ketosis to burn off my unwanted body fat.

My quest to understand what went wrong has taken me on a fascinating journey in an effort to manage my own health as well as to understand how to assist my wife Monica better manage her type 1 diabetes.

In this post, I hope to share some of my learnings and insights to help people get what they really need from their keto journey and avoid the common pitfalls.

Virta Facebook Live Q&A

I recently had the opportunity to pose some of my most pressing questions about optimal ketone levels and protein intake to the Godfather of Keto, Dr Stephen Phinney in a recent Facebook live Q&A.

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Dr Phinney addressed one of my questions in the live broadcast as well as responding in writing in writing on the Virta blog.

I have included my question on optimal ketone levels and Dr Phinney’s response below along with my own additional thoughts.

But first, I think it’s important to understand what ketosis actually is.

What is ketosis?

Ketosis occurs when there is a lack of Oxaloacetate from non-fibre digestible carbohydrates and protein to enable fat to be oxidised in the Krebs cycle.    When Oxaloacetate availability reduces, the body produces Acetoacetyl CoA and Acetoacetate (AcAc) via ketosis.

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You can also think of this in terms of insulin load.  That is, when the net carbs and protein in the diet are reduced we switch to burn more of our fat via ketogenesis rather than in the Krebs cycle.

I used to think that we were only burning fat when via ketosis, but I now understand that’s not correct.  Ketosis is just how we burn fat when the Kreb cycle can’t operate normally.  Ketosis is an important biochemical process that allowed us to survive through times when food was scarce.

As described by Dr David Sinclair in this video, lots of good things happen during periods of low energy availability (e.g. increased autophagy, AND+ and SIRT1).  Our bodies go into emergency repair mode to increase our chances of being around to procreate in future times of plenty.

Energy restriction is the only thing that has conclusively been proved to promote longevity in humans.  But it’s hard, so it’s not very popular.  When food is available, left to our own devices, our bodies tend to store up a little extra fat for the winter.  Unfortunately, in our modern environment, winter never comes.

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If your NAD+ levels are lower, more Acetoacetate (AcAc) will be converted to Beta-hydroxybutyrate (BHB) in the blood.  If your NADH+:NADH ratio is high there will be more Acetoacetate in circulation.  Acetone can be thought of as the vapour that is released from Acetoacetate.   So, if less Acetoacetate is being converted to BHB, you will register higher breath ketones.  Chris Masterjohn explains this in more detail in this video.

Reduced NAD+ levels are associated with ageing, and increased NADH levels are associated with over fueling and diabetes.  Thus, high levels of BHB and low levels of breath acetone are not a good sign.

You may be interested to know that fat loss from the body is better correlated with higher breath acetone levels rather than ketones in the blood.[2]

Personally, I find when I take Niacin supplements (vitamin B3 increases NAD+) my BHB plummets and my breath acetone skyrockets.

In summary, the amount of beta-hydroxybutyrate in your bloodstream at any point in time is influenced by the amount of fat ingested, your NAD+:NADH ratio as well as the rate at which they are using BHB.

What are normal ketone levels?

We all like to compare others to others to understand if we are normal.

I thought it would be interesting to crowdsource some data to understand what normal ketone levels are in people following a low carb or ketogenic diet.  I wanted to understand if everyone was struggling to reach the ‘optimal ketone zone’ like I was.

The chart below shows the compilation of more than three thousand blood ketone and glucose data points crowdsourced from people following a low carb or ketogenic diet (with particular thanks to Michel from Ketonix for the anonymous data).  Ketone values are shown in blue on the bottom and glucose is in orange on top.

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Diabetic ketoacidosis

Someone with uncontrolled type 1 diabetes will have a very low NAD+:NADH ratio and hence very high levels of BHB (i.e. greater than 8 mmol/L).  This is termed “ketoacidosis” and is accompanied by very high blood glucose levels.  Someone with uncontrolled type 1 diabetes would be off the chart to the right.

High levels of BHB are dangerous because they are acidic.  However, people who do not have Type 1 diabetes typically have blood ketone values less than 4.0mmol/L.  People with a functioning pancreas do not need to fear acidic ketones, particularly if they are sitting to the left of this chart with lower levels of energy floating around in their blood.

The bloodstream, our metabolic highway

You can think of our bloodstream as our metabolic highway that helps get the energy to the cells that need it.  We want enough energy in the blood to fuel the body, but not so much that a traffic jam occurs.

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Really high levels of glucose in the bloodstream lead to glycation.  Similarly, high levels of free fatty acids lead to oxidised LDL which increases your risk of heart disease.

If your bloodstream is full like syrup with excess glucose, ketones and fatty acids then the energy and nutrients can’t get where they need to go.  Your kidneys will be working overtime clearing out the nutrients from the blood that your body does not require.

Your body raises insulin in an effort to stop energy flowing out of storage while you are still using up the energy in your blood.

When your bloodstream is clogged with energy there will be no opportunity for the body to cleanse and undertake autophagy.  Detoxification won’t be able to occur as effectively, and your fat stores will continue to build up toxins.

Exogenous vs endogenous ketosis

I now realise where I went wrong in my early keto journey was that I didn’t understand the difference between exogenous and endogenous ketosis.

I now realise that I was trying to address my pre-diabetes and obesity with a classical or therapeutic ketogenic diet which is intended to be used for epilepsy, cancer, Alzheimer’s, Parkinson’s and dementia.

All this excess energy was just exacerbating the situation I was trying to solve.

Exogenous ketosis

The chart below shows the blood glucose and ketone levels during exogenous ketosis.  While glucose may not be high, but we have high levels of ketones and likely higher levels of triglycerides in the bloodstream largely from external sources.

image23.png

This may be helpful in a situation such as epilepsy, Alzheimer’s, Parkinson’s or dementia where glucose is not being processed efficiently by the brain.  Excess glucose is thought to fuel the growth of some cancers, so reducing glucose and increasing ketones enables us to fuel the brain while not feeding the cancer cells.

Endogenous ketosis

The chart below shows what happens in endogenous ketosis.  In fasting or energy restriction your blood sugar will decrease.

image19.png

As you can see from this chart, your blood ketones may not be as high due to your high NAD+:NADH ratio and the fact that you are not pushing in large amounts of external fat.  Ketones will also be used for energy rather than building up in the bloodstream.

In this lower energy state, your body will be pulling fat from your belly and bum to offset the deficit of energy from glucose and ketones in the bloodstream.

Your blood will no longer be a congested and the toxins will be able to flow out of your fat stores.  Your kidneys will cleanse your bloodstream, and you will excrete the waste that was stored in your fat.

You will increase autophagy as you old proteins, and pre-cancerous cells are cleansed and eaten up by your body.  Your insulin levels will also decrease, and your fat stores will become insulin sensitive again.

Without constant incoming energy, the fat in your pancreas, liver, heart, brain, eyes etc will then be used for energy.  You will feel younger and lighter and start to think more clearly!   You will effectively be slowing the aging process!

Ketosis vs diabetes and obesity

Someone managing diabetes and/or seeking weight loss should ideally target a lower overall level of energy in their bloodstream.  Having less energy in the blood, whether in the form of glucose, ketones or free fatty acids, forces the body to supply more energy from body fat.

The chart below shows the levels of blood ketones that relate to higher and lower levels of glucose and ‘total energy’ from glucose and ketones.

The three thousand blood ketone and glucose levels have been divided into five ‘bins’ based on their total energy content.  The smallest is shown on the left with the largest total energy shown on the right.

image43.png

This data suggests that good metabolic health is characterised by not having excessive levels of energy floating around in the bloodstream.  Lower glucose levels tend to correlate with lower blood ketones.  The lowest blood glucose levels are associated with a blood ketone level of about 0.3 to 0.7mmol/L.

Virta ketone data

When I recently re-read the paper detailing the results of the first ten weeks of the Virta trial I was intrigued to see that, even though they were targeting ‘nutritional ketosis’  the average BHB level achieved was only just above the cut off for nutritional ketosis.  The average BHB was 0.6mmol/L with a standard deviation of 0.6 mmol/L.

To better understand what this means, the chart below, many people had ketone levels below the cut off for nutritional ketosis of 0.5 mmol/L.  The largest ‘bin’ of ketone values as 0.1 to 0.3 mmol/L.[3]  The second largest grouping was 0.3 to 0.5 mmol/L.

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It struck me that these blood ketone levels aligned reasonably closely with the values shown in my crowdsourced data.  My question to Virta and Dr Phinney’s response is shown below:

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Dr Phinney’s comment that it was the people with the higher ketone levels that experienced better results in the long term made me think of the relationship between ketones and blood glucose which is also based on the crowdsourced data.

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In fasting, people who are more insulin sensitive can more easily produce ketones when there is no food, while people with high levels of insulin have high blood sugar levels and tend to have lower levels of ketones as shown in the chart below.

So perhaps the people who did the best were the ones that were already more insulin sensitive and thus were able to go longer periods between food, especially once the insulin load of their diet was reduced and their blood sugar and insulin levels came down closer normal levels?

What does all this mean in practice?

At this point, you’re probably confused.  Is it even worth testing ketones?  And if I do, what values should I be targeting?

My conclusion, after doing a lot of self-testing as well as analysis of a lot of other people’s data is that, unless you require ketosis for therapeutic purposes your blood ketone levels probably don’t matter that much.

Some level of blood ketones is good to have (say 0.2 mmol/L or more), but more is not necessarily better.

And for goodness sake, don’t go chasing higher blood ketones with more dietary fat if your goal is fat loss from your body!

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For people trying to manage obesity and/or diabetes, ketosis is a fascinating side effect of a lower energy state when you have less carbohydrate and protein to burn.  But it is not the end goal.  Ketosis is part of the process that occurs as we burn out own body fat.

So how do I optimise my blood sugars?

A diet with a lower insulin load (i.e. less non-fibre carbohydrates and less insulinogenic protein) will enable someone with diabetes to stabilise their blood glucose levels.  They will require less insulin so their pancreas can more easily keep up to maintain healthy blood glucose levels.

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Stable blood sugars and removal of processed carbohydrates often helps to normalise appetite and spontaneous weight loss.

As body fat stores become less full your adipose tissue will become more insulin sensitive and can then absorb the day to day energy flux without needing to spill excess energy into the bloodstream.  Because your body fat is doing the job properly, you won’t see high levels of blood sugar in your blood.

Your body is always rebalancing your fuel system (i.e. glucose, ketones and free fatty acids) depending on your needs and dietary energy sources.

We can store a little bit of glucose in our bloodstream and liver, but the major fuel tank is our fat stores.  When our adipose tissue is full and can’t take anymore everything else backs up and overflows.

How to stay below your “Personal Fat Threshold”

Fascinating recent work by Professor Roy Taylor at Newcastle University in the UK has shown that reducing fat from the vital organs like the pancreas can actually reverse diabetes.[4]

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Professor Taylor coined the term ‘Personal Fat Threshold’ which is the point at which your adipose tissue can no longer easily absorb the extra energy from the food we eat and starts to send more of it to other places in our body.  It’s like our fat storage balloon is full.[5]

Once we exceed our personal fat threshold any extra is energy shuttled off to the bloodstream in the form of high glucose, high free fatty acids and higher ketones) as well as the other parts of the body that are more insulin sensitive than our adipose tissue such as our liver, pancreas, heart, eyes, kidney, brain and heart).

The problem however with Professor Taylor’s approach was that it was an 800 calorie per day short-term intervention based on Optifast meal replacement shakes. The ideal approach would be to design a nutritious set of foods that would provide the nutrients you need without excessive energy. 

Many people find that a low carb diet will help stabilise blood sugar levels.  However, many, if not most, people find that they need to restrict energy intake and/or increase the nutrient:energy ratio of their diet in order to achieve the blood glucose control and body fat levels that are associated with optimal longevity.  This can be achieved through intermittent fasting, time restricted feeding, meal skipping,  ‘clean eating’, calorie counting or whatever works for you.

Regardless of how you feel about any of these concepts, you need to do whatever it takes to reduce the inputs to the point that you see the energy in your bloodstream decrease.  How much discipline and deprivation you want to enforce on yourself depends on how close you want to get to optimal.

While it’s good to see your body fat levels reducing, measuring your blood sugar is probably the most effective way to get a cost-effective and immediate understanding of whether you actually need to eat (see How to use your glucose meter as a fuel gauge for more details on this concept).

The figures below show the relationship between HbA1c to various symptoms of metabolic disease such as diabetes, heart disease and stroke.[6]

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All-cause mortality is lowest with an HbA1c of somewhere between 4.5 and 5.0%.[7]image13.jpg

Can we achieve optimal in our modern environment?

This Australian Aboriginal hunter from more than 100 years ago is my favourite example of optimal metabolic health.

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Everything he could find to eat would have been filled with nutrients.  He wouldn’t have overeaten because he had to hunt or gather everything, and that took a lot of effort.

Every year or so he would have had a period of externally enforced fasting when food wasn’t so plentiful.  And if he was the fattest and slowest in his tribe he might have been prey to wild animals.

Today we like to reminisce about paleo and ancestral times.  However, I don’t think we can ever go back to mimic how this guy lived, even if we wanted to.

While we can get unprocessed organic fairly nutrient dense foods, we will probably never achieve the food scarcity context that he had.

Today food is fairly cheap and easy to get hold of.  And whenever when we eat ‘to satiety’ we are programmed by evolution to prepare for a famine on a long boat ride where only the people who could store energy survived.

Food is pleasure.

Food is entertainment.

Food is social connection.

Food is emotional.

People like to rail against the idea that we might need to limit our energy intake.  However, in today’s context, I think we need to work out how to recreate the useful elements of ‘the good old days’ in a modern context.

Unless we’re prepared to live in the desert and leave our credit cards behind, perhaps things like periods of fasting to reduce our blood glucose levels, gyms to build strength, energy tracking apps like Cronometer to ensure we are eating nutritious food (and not too much of it) all play a role in our modern context?

It’s not going to be a popular concept, but some level of deprivation or self-control may be necessary if you want to achieve optimal health and delay the diseases of aging.

It’s OK if you don’t want to go all in and invest everything it takes to achieve optimal health, but it’s still useful to understand how to get even part of the way there.

Introducing, our new toy!   The Nutrient Optimiser

It can be confusing to know how much of each macronutrient you should be eating.  Everyone has different goals and circumstances.

Over the last few months, I’ve been working with a very talented programmer, Alex Zotov, to develop some handy software called the Nutrient Optimiser to help people navigate all this information and help people put it into practice.

The table below shows how we how we segregate people based on their different goals based on your blood sugar levels, HbA1c, waist:height ratio and trigliceride:HDL ratio.  From there we can target the most nutrient dense foods and meals while also keeping your blood sugars stable, fueling your activity or help you to lose body fat.

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If you do have diabetes, then a low carb/keto diet will help stabilise your blood sugars and will often help to stabilise your appetite.  But then, as you improve your health you can continue to refine your food choices to and increase the nutrient density of your diet even more.

Meanwhile, if you’ve got great blood sugars but want to lose body fat there’s no reason to be eating a super high fat therapeutic ketogenic diet designed to control epileptic seizures.

The first instalment of the Nutrient Optmiser is a free calculator that will help you identify the ideal macronutrient ranges, energy intake and as well as a shortlist of optimal foods and meals to suit your goals.  We’d love you to check it and let us know what you think.   We hope it will help a lot of people avoid the confusion of keto and move forward towards optimal.

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references

[1]https://www.amazon.com.au/Keto-Clarity-Definitive-Benefits-Low-Carb/dp/1628600071

[2]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737348/

[3]http://assets.virtahealth.com/docs/Virta_Clinic_10-week_outcomes.pdf

[4]http://www.ncl.ac.uk/press/articles/archive/2017/09/type2diabetesisreversible/

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

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

[7]http://circoutcomes.ahajournals.org/content/3/6/661

[8]https://www.perfectketo.com/how-too-much-protein-is-bad-for-ketosis/

[9]https://nutritionfacts.org/video/the-great-protein-fiasco/

[10]https://digitalcommons.wku.edu/ijes/vol10/iss8/16/

[11]https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

[12]https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/s12986-015-0009-2

the Ketogains method

Ever wondered what foods and meals are optimal for fat loss and muscle building?

Ketogains’ Luis Villasenor recently put a call out for recipes for their upcoming Ketogains Boot Camp, so I thought it would be interesting to see what the Nutrient Optimiser had to say about optimal foods and meals that align with the Ketogains approach.

luis villasenor

The essence of the Ketogains approach is to:

  1. consume adequate protein,
  2. limit carbohydrates, and
  3. use ‘fat as a lever’.[1]

This article unpacks each aspect of the Ketogains system.

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Protein as a goal

The Ketogains macro calculator recommends a minimum protein intake of 0.8g per pound of lean body mass (LBM) (i.e. 1.8g/kg LBM), increasing to 1.0g/lb LBM (or 2.2g/kg LBM) on lifting days.

This protein intake level is more than would be recommended in a therapeutic ketogenic approach or even the average protein intake for the general population.[2] [3] It does, however, align with Steve Phinney’s recommended protein intake level for athletes and performance and represents a more optimal protein intake for active people.[4] [5] [6]

From a sports nutrition standpoint, more than 2.2 gram per kilogram of total body weight is regarded as “high protein”.[7]  This could be as high as 3.0g/kg LBM when fat mass is taken into account.  So, while the Ketogains protein recommendations might be considered high in therapeutic keto and vegan circles, the Ketogains recommendations would be ‘moderate’ in a sports nutrition and bodybuilding circles.[8]

This chart above (from Lemon, 1998[9]) shows that, for a strength athlete, muscle protein synthesis is maximised when they consume at least 1.8g/kg BW of protein.

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Protein intake even more important when you are trying to lose weight.  The higher the energy deficit, the greater is our need for protein to prevent loss of lean muscle mass.  If we are active and/or doing resistance training, then our requirement for protein is even higher again.  As shown in the chart below from a recent review paper by Stuart Phillips, muscle mass is best preserved best when we have higher levels of protein, particularly if you are targeting an aggressive deficit.[10] [11]  If you are targetting a moderate energy deficit (e.g. 10%) then a protein intake of around 1.5g/kg BW is appropriate.  However, if we are targetting a very aggressive energy deficit then higher levels, up to 2.6g/kg BW will be beneficial to prevent loss of lean muscle mass.  If we are active then we will also need more (dashed line) while we need less if we are sedentary (dotted line).

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While it’s actually difficult to consume such high levels of protein due to the satiety effect, more protein won’t turn to chocolate cake.  [12]

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Protein contributes to your energy intake.  So if your goal is fat loss, then you want to target the minimum effective dose of macronutrients and micronutrients.

As a general rule, a higher protein intake tends to lead to a better nutritional profile[13] and increased satiety.[14] [15]  Very high protein diets (i.e. above than 80% energy from protein) will likely rely on supplements and may minimise other foods that provide more vitamins and minerals.  As you can see on the far left of this chart, actively targeting a low protein intake can lead to a poor nutritional outcome.[16]

protein (%) vs nutrient density score [click to enlarge]
[note: If your goal is therapeutic ketosis for the management of epilepsy, dementia, cancer, Parkinson’s or Alzheimer’s you will need to pay particular attention to ensure you get your share of micronutrients.]

Carbs as a limit

As you can see in the chart below,[17] you can get a reasonable level of nutrition if you consume anywhere between 0 and 60% of your energy from non-fibre carbs.[18]  However, with an exploding diabetes epidemic,[19] [20] [21] it’s probably fair to say that the majority of people would do better if they reduced their consumption of refined grains and sugars.

carbohydrates (%) vs nutrient density score [click to enlarge]
If you have already developed insulin resistance or diabetes, then reducing your carbohydrate intake to the point you achieve normal blood glucose levels is a good idea,[22] both in terms of overall health and controlling appetite that can be driven by excessive blood sugar swings.

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The fact that much of the population is already insulin resistant is likely part of the reason the Ketogains approach, with its limit on carbs, has been so successful.

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Low carbers are fond of saying “there is no such thing as an essential carbohydrate”.  However, unless you are focusing on getting lots of organ meat, shellfish, or fresh meat, you may benefit from consuming some non-starchy veggies to get your essential vitamins and minerals.

Twenty or thirty grams of non-fibre carbs doesn’t sound like much in the context of grains or sugars, but it can feel like a LOT of food to consume if it’s from non-starchy veggies.[23]

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Fat as a lever

So to recap before we get into discussing fat:

  1. Adequate protein is critical to support muscle growth and repair.
  2. Non-starchy veggies (which contain a small amount of non-fibre carbohydrates) provide vitamins and minerals (unless of course, you are eating heaps of shellfish, organ meat or drinking blood like the Maasai).

Recently, many people are swinging back from their fear of fat to embrace dietary fat again.  Carbohydrate is a more explosive fuel source for emergencies, while fat is a slower burning and more efficient fuel source.

While there are essential fats, we don’t require much to meet our minimum requirements of essential fats.[24]  Beyond this, where you get your energy doesn’t matter that much.

Many people do fine on a diet that obtains a lot of the energy from carbs while other do well on a diet that get the majority of energy from fat.  However, where things seem to go wrong is when people consume diet that is high in energy dense nutrient poor fat and carbs with minimal amounts of protein.

fat vs carbs.jpg

As you can see from the chart below, we can achieve a respectable nutritional outcome with a fat intake of between 10 and 65%.   More fat is not necessarily better, but very low-fat levels are not great either as they tend to have minimal amounts of protein and other essential nutrients.

fat (%) vs nutrient density score [click to enlarge]
If you are trying to reduce body fat, then maximising the nutrient density and reducing the energy density of your food is a worthy goal.  A protein sparing modified fast, an extreme version of this, provides adequate protein while limiting both fat and carbohydrates.

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If you are looking to gain weight, add muscle or perform extended feats of endurance exercise on a regular basis, it may be beneficial to load up on more energy dense foods.  However, conversely, if are not an endurance athlete but trying to use your body fat for fuel (like most of us these days living in a sedentary environment full of hyperpalatable food), you may want to wind your dietary fat intake back.

Micronutrients

Once you’ve worked out your macros using the Ketogains calculator and got the hang of using fat as a lever to manage energy intake, the next step is to ensure you are getting your share of micronutrients.

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Focusing purely on macros (e.g. Flexible Dieting, IIFYM, etc.) is short-sighted because it fails to consider micronutrients.  Chronic energy restriction without attention to micronutrients can lead to chronic nutrient deficiencies,[25] a lack of energy, increased hunger,[26] rebound bingeing due to cravings and even death.[27]

You’re likely aware that the branched-chain amino acids (BCAAs) trigger muscle protein synthesis and ensure you use the rest of the amino acids to build and repair your muscles.[28]  However, recent research has found that the amino acids arginine and lysine trigger satiety and hence we find foods that contain these amino acids more filling.[29] [30]

The chart below shows what your micronutrient profile would look like if you focused on branched chain amino acids (valine, isoleucine, and leucine) and the satiety-related amino acids (lysine and arginine) while also keeping carbohydrates low.

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While we get plenty of protein with this approach, we would not obtain the recommended minimum levels of a large number of the essential vitamins, minerals, and essential fatty acids.

As much as we like to focus on macronutrients (i.e. fat, protein, carbohydrates, fibre, ketones), micronutrients are arguably a more useful to assist us in our nutritional decision making.

Getting adequate minerals is especially important for:

  • avoiding the symptoms of the keto flu,[31]
  • reversing insulin resistance and minimising the amount of basal insulin circulating in your body,[32] [33] [34] and
  • maximising athletic performance.[35]

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The chart below shows what happens to our micronutrient profile when, in addition to BCAAs, we also prioritise foods that contain the harder to find micronutrients.  The purple bars represent the nutrients contained in the average of all foods in the USDA foods database while the blue bars represent the nutrients contained in the shortlist of foods.

nutrients - weight loss insulin resistant vs all foods.PNG

Optimal foods

In case you were wondering which foods will give you the most micronutrients while also having a lower energy density and fewer carbs, I have listed them below.

vegetables

  • endive
  • alfalfa
  • chicory greens
  • escarole
  • coriander
  • pumpkin leaves
  • asparagus
  • spinach
  • Chinese cabbage
  • lettuce
  • parsley
  • okra
  • zucchini
  • beet greens
  • watercress
  • arugula
  • portabella mushrooms
  • chives
  • chard
  • white mushroom
  • turnip greens
  • cauliflower
  • mustard greens
  • banana pepper
  • cucumber
  • pickles
  • sauerkraut
  • yeast extract spread
  • summer squash
  • radishes
  • broccoli
  • collards
  • shiitake mushroom
  • celery
  • artichokes
  • eggplant
  • cabbage
  • snap beans
  • turnips
  • red peppers

spices

  • basil
  • dill (fresh)
  • sage
  • marjoram
  • curry powder
  • thyme
  • caraway seed
  • mustard seed
  • dill seed
  • cloves

fruit

  • blackberries
  • avocado
  • raspberries
  • olives

seafood

  • salmon
  • sturgeon
  • halibut
  • fish roe
  • anchovy
  • crab
  • trout
  • caviar
  • crayfish
  • flounder
  • mackerel
  • sardine
  • oysters
  • mussel
  • rockfish
  • pollock
  • lobster
  • herring
  • haddock
  • perch
  • whiting
  • tuna
  • shrimp
  • white fish
  • cod
  • octopus

offal

  • liver
  • kidney
  • heart
  • brains
  • headcheese
  • brains

animal products

  • pork chops
  • pork shoulder
  • lamb
  • roast pork
  • pork loin
  • ground pork
  • pork ribs
  • roast ham
  • leg ham
  • sirloin steak
  • ground beef
  • chicken drumstick
  • chicken breast
  • veal
  • bratwurst
  • chuck steak
  • roast beef
  • ham
  • ground turkey
  • turkey
  • beef roast
  • lamb
  • ribeye fillet
  • bison
  • beef loin
  • ground beef

dairy & egg

  • whole egg
  • egg yolk
  • whey protein powder

You should ideally focus on the foods closer to the top of these lists.  But once you’ve eaten as much endive, alfalfa, liver and caviar as you can, feel free to move down the list to more energy dense foods or ones that you might enjoy eating more.

Supplements

If you can’t get enough nutrient-dense foods, it may be beneficial to use supplements.[36]  Keep in mind though, the nutrients from whole foods are likely to be better absorbed.

Too many minerals at once will ‘give you a dose of the salts’ and all your expensive supplements will end up in the toilet.  Whole foods are also more likely to contain other beneficial non-essential nutrients that come along with nutrient-dense foods.

What to track

“What gets measured gets managed”.[37]

But we can only manage a handful of things at a time.

“If everything is a priority, nothing is a priority.”

Rather than trying to track everything all at once you need to identify a few things to track to ensure you are moving towards your goals.

In the context of losing fat and gaining muscle the best things to track appear to be:

  1. weight/body fat,
  2. macros/calories, and
  3. performance (e.g. weight on the bar).

weight / body fat

Most people want to have more energy and look good naked.  While it’s much easier to track body weight, this ultiamte goal really about losing body fat.

There are a ton of different ways to measure body fat (e.g. DEXA, comparison photos, bioimpedance scales, Skulpt, the Navy Method, etc.).  They are all inaccurate to some degree.

You can do your head in focusing on the fluctuations on the scale or body fat from day to day.  But, you want to see your overall weight and body fat reducing toward your target levels.  People who successfully lose weight and keep it off manage their food intake, measure their weight regularly and are active![38] [39]

If you’re a fitness model you might want to measure yourself daily.  If you’re just starting to focus on eating well and lifting, then you might just want to weigh yourself weekly or monthly.[40]

If you are not moving towards your goals over the long term, something needs to change.

body fat chart.png

But first, you need to set some realistic goals.  Take the time to determine your current and target body weight, fat (in kg and %) and lean body mass (LBM).

  current target
body weight (kg)
body fat (%)
body fat (kg)
LBM (kg)

If you are disciplined, it is possible to lose 1% of your mass per week, but 0.5% is a more realistic and less aggressive target.  If you are already lean, then it will be harder to lose fat without losing muscle so you may need a less aggressive deficit.[41]

It’s not all about the weight on the scale.  You can be losing fat and gaining muscle, the weight on the scale probably is the most reliable indicator that you’ve got your inputs right.  If you’re getting enough protein and working out, incrased muscle mass should be looking after itself, and any loss should be mainly fat.[42]

Keep in mind that body weight is a lagging measurement that tells you whether you’re on the right track.  Tracking inputs (e.g. food intake and exercise) will be much more useful.

macros / calories

Personally, I don’t enjoy tracking my food, so I’ve designed a range of food lists and meals that will help most people improve from where they currently are.  It will be pretty hard to get/stay morbidly obese if you eat only the foods and meals listed above.

But eating to satiety won’t guarantee you will lose weight.  If you want to look like a fitness model, or you are not getting your desired results from ‘eating ad libitum’ you will likely need to track your food to overcome your inbuilt impulse to maintain a higher body weight and prepare for a possible famine ahead.

Tracking your food in an app like Cronometer can be a useful educational experience.

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The Ketogains calculator will give you a starting point in terms of calorie intake based on your current weight and activity levels.  If, after a few weeks, you are not seeing the progress you were hoping for you will need to adjust your inputs.

Performance/weight on the bar

Building muscle or achieving a performance goal is probably more important than weight loss, particularly if you are not trying to get down to a very low level of body fat.

The great thing about using a performance goal is that it is both a leading and lagging measure.  By going harder, faster and heavier you are providing a greater stimulus for growth.  And by measuring your performance outputs, you are ensuring that you are getting fitter/faster/healthier.

While being strong doesn’t guarantee weight loss, being stronger will improve your metabolic health, insulin sensitivity and ability to burn fat more effectively than nearly anything else.

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Having more lean muscle mass will ensure you burn both glucose and fat more efficiently.  Lean muscle mass is a key predictor of longevity.[43]

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The Ketogains boot camp uses a 5×5 strength progression.  The Stronglifts 5×5 or Starting Strength uses a similar progressive overload approach.  These programs involve compound lifts (squat, deadlift, bench press, overhead press, row etc.) and progressive overload meaning that you add weight to the bar each time and continue to get stronger.   By doing this, you train your body to produce energy more efficiently.

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Don’t be surprised if your appetite ramps up during the first few months of intensive lifting as your body goes into anabolic overdrive to recover and build new muscle.  This should settle down though after a while, and you can then focus on dialling your diet in if you want to gain strength as well as lose body fat.[44]  You have a unique window of ‘newb gains’ during initial whne you can get stronger at in a way that you may never achieve again.  You can focus on getting to single digit body fat later.

Other stuff that you could track

There are other things that you might like to track, but they will be less useful than the things mentioned above.  Most people have limited time and don’t really want to live a completely quantified life.  Unless this is your only hobby or you are a professional athlete or fitness model, you may quickly hit ‘analysis paralysis’ and give up.

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There is no guarantee that technology will help you reach your goals.  In fact, it seems that you are more likely to gain weight if you use wearables like a Fitbit.[45]  It’s hard to know whether this is due to the EMF or perhaps the wearer is always allowing themselves to consume the extra calories that their technology told them that they just burned with exercise.

So, coming from a biohacker nerd….  don’t try to track too many things at once!  OK?

Heart Rate Variability

Heart Rate Variability (HRV) is a measure of the variability between your heart beats.  If you are stressed and/or exhausted your heart will be more rhythmically as well as more rapidly.   If you are relaxed and well rested your heart will be more to stresses and quickly return to rest.

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Measuring your Heart Rate Variability (HRV) can tell you if you’re pushing too hard and need to rest recover or you’re not pushing hard enough and should be working harder to maximise your progress.  Training when you are burning out can be counterproductive and lead to injury or under recovery.

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HRV tells you whether your sympathetic and parasympathetic nervous system is balanced.

  • If you are “parasympathetic nervous system dominant” you might be overstressed from too much activity, not enough sleep, too much caffeine or work stress.
  • If you are “sympathetic nervous system dominant”, then it probably means your body wants to rest. You’ll probably do better if you listen to it and let it recover.
  • If your overall HRV is dropping, it means you are burning out and should consider slowing down.

After 1.5 years of measuring my HRV each morning, it’s uncanny how many times I will see my HRV fall a few days before you get the flu or hit the wall.  I don’t like to stay still long enough to meditate, so tracking each day with Elite HRV is part of my relaxation, breathing and focus at the start of each day.

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Blood sugar

Your blood sugar and glucose control is a powerful indicator of metabolic health.  But blood sugar readings can vary depending, not just due to the food you eat or your metabolic health, but also exercise and stress.

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If you have diabetes, then refining your food choices to normalise your blood sugars is critical. However, regular blood sugar tracking is likely a waste of time and money for most people who are following a Ketogains style approach (i.e. tracking their food to ensure they are moving towards an optimal weight, getting adequate protein and lifting regularly) is unnecessary.

Blood ketones

Unless you require therapeutic ketosis to help manage epilepsy, cancer, Alzheimer’s or Parkinson’s measuring your blood ketones is also largely an irrelevant distraction.

Lots of people get caught up chasing ‘optimal ketosis’ by eating more dietary fat and less protein.  However, this is exactly the opposite of what you need to gain strength and lose body fat.

Blood ketones do increase when we don’t eat. But high ketone levels don’t mean you are burning your own body fat.  It could just be the three Bulletproof coffees and exogenous ketones you just had to get that are driving your high ketone levels.

Some people, especially those who are physically fit and/or have been practising a low carb diet for a long time, seem to have lower blood ketone levels, even if they are eating a ‘ketogenic’ diet.  It’s hard to know whether this is due to the more efficient use of ketones or the fact they are burning more fat through non-ketogenic pathways.

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Ketones are just one of a number of ways that we burn fat (chart from Dave Feldman)

Someone who is not so metabolically healthy can load up on exogenous ketones, butter and MCT oil and get a high blood ketone reading on their meter.  But this may just mean that they have eaten a lot of fat that they are not burning (because of their lack of activity and/or poor metabolic health) and the fat is backing up in their bloodstream.

A healthy metabolism seems to keep the total energy circulating in the bloodstream fairly low (i.e. from glucose, ketones or free fatty acids).  If you are metabolically healthy, you can easily access your fat stores so you don’t need to build up high energy stores in the blood.  By contrast, someone with a less healthy metabolism seems to maintain higher energy stores in the blood (i.e. glucose, ketones, free fatty acids) as well as on their body.[46]

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This chart shows more than 3000 data points of blood glucose and ketones together from a range of people following a low carb and ketogenic diet.  Having high blood ketones and high blood sugar at the same time is not good!  Healthy people tend to have lower blood sugar and moderate level ketones.

Most people don’t need to worry about their blood glucose and ketone levels consciously.  If you focus on nutrient dense food to optimise your mitochondrial function and strength building to keep pushing your mitochondria to produce energy at peak efficiency, then your body will probably look after the rest.

[At the risk of getting too technical, it’s worth pointing out that blood ketones rise because there is a lack of Oxaloacetate (from protein and carbs) available to burn Acetyl CoA from fat in the Krebs cycle, so the body defaults to a starvation protocol to produce ketones (AcetoAcetate). 

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Figure from Amy Berger showing how fat can be burned in the Krebs cycle or via ketosis when there is not enough Oxaloacetate from protein and carbs turn the Krebs cycle.

If your NAD+ is low, AcetoAcetate will not be converted to Acetone so there will be lots of beta-hydroxybutyrate left in the blood to be measured on your meter.  So, other than fasting and/or exercising to deplete your liver glycogen levels, one ‘hack’ to achieve high blood ketone is to avoid protein and eat a nutrient-poor diet low in niacin and other B vitamins (which produce NAD+).  But don’t try this at home.  It’s not a recipe for optimal health, just high blood ketone levels.]  

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Ketogains’ Tyler Cartwright has lost nearly three hundred pounds without exceeding 0.4mmol/L blood ketones on his ketone metre (other than that time he ate nothing but lard for two weeks as an experiment and got to 0.5mmol/L).[47]

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Breath ketones

Breath ketones are an interesting indication of your metabolic health.  But again, they’re not necessary if you are already focusing on a nutrient-dense diet without too much energy and plenty of activity.

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Waist measurement

BMI is often used to assess whether or not someone is at a healthy weight.

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However, BMI is notoriously problematic for people with more muscle.

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Waist to height ratio is a much better predictor of the years of life that you will lose due to your poor health.[48]

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Micronutrients and nutrient score

Focusing on the nutrient-dense whole foods above and the meals below will get you most of the way to optimal nutrition.  However, you can also track your macronutrients in Cronometer to help you identify the nutrients you are not getting from your diet.

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But then, once you’ve tracked your food in Cronometer, you are left wondering what foods and meals you should eat.  and if need to supplement, how much of each supplement do you require and how much?

The Nutrient Score is a measure of the micronutrient quality of your diet.  If you were able to get two times the recommended daily intake of all the essential micronutrients, you would get a perfect score of 100%.

To demonstrate what this looks like in practice, Ted Naiman’s diet got a very respectable nutrient score of 70%.

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Luis’ got 72%.

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Nutrition nerd Alex Leaf (and regular reviewer of my blog posts… thanks so much Alex!!!!) scored an impressive 74%.

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Mike Berta also scored 74%.

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Brianna Theroux’s scored a very healthy 79%.

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And sitting at the top of the leaderboard is Dr Rhonda Patrick with a score of 82%.

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But the coolest competition is against yourself.  Andy Mant managed to seriously up his nutritional game…

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… by eating a LOT of nutrient-dense seafood…

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… in preparation for his Paris wedding.

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By following the recommendations of the Nutrient Optimiser analysis, Robin was able to improve her nutrient score to 32% (junk food diet) to 68% over a number of iterations (see report 1, report 2 and report 3).

In the process, she was able to significantly improve her blood glucose levels, dropping her HBA1c from 10.6% to 6.4%.  Robin was also able to progress from taking hundreds of units of insulin per day to only needing occasional correcting doses to fine tune her blood sugars.  She also managed to lose 2.6lbs per week!

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And after a couple of rounds of following the Nutrient Optimiser recommendations and a couple of Ketogains boot camps the Matt Standridge (aka The Ketodontist) has stepped up from a nutrient score of 48% to 73%.  He says he is feeling great and continues to gain muscle and lose fat.

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The Nutrient Optimiser

While there are common themes, each person’s micronutrient fingerprint is unique.  The optimal foods and meals that will balance your micronutrient profile are unique to you.  The Nutrient Optimiser is the only tool that will tell you what foods are ideal to balance your diet while also aligning with your goals.

Currently, the Nutrient Optimiser is a manual report that will help you optimise your nutrition from the micronutrients based on your food log in Cronometer.  We’re working hard to develop an automated system that will use your goals and whatever data you have to help you refine your nutrition to achieve your goals.

If you don’t want to track your food, the system will tell you what meals and foods will align with your goals.  But if you want to step up your game and provide other data we can work with that to further refine your nutritional prescription to fill in your micronutrient gaps.  The system will also adapt with you to improve your nutrition, ideally from diabetic to weight loss to achieving your performance goals.

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It might just be your secret weapon to help you blitz #transormationtuesday.

Summary

  • The Ketogains protocol involves getting adequate protein (to support muscle growth and recovery) and adequate carbs to get essential vitamins and minerals. Fat is used as a level to manipulate energy intake to suit your goals.
  • If you are limiting your energy intake, maximising your nutrient : energy ratio is critical!
  • The Nutrient Optimiser can help you identify foods and meals that align with your goals and fill in your micronutrient deficiencies.
  • Chose what you track wisely. Trying to manage too many things can lead to ‘analysis paralysis’.  If you manage the most important inputs, results should naturally follow.

 

 

Meals

I’ve been building a database of to help identify the meals that provide you with the nutrients you need more of and align with your goals.

If you are tracking in Cronometer, you can sign up for a Nutrient Optimiser analysis and report here to find out which foods and meals will help you move forward.  I’ve also been working with Alex from Nutrient Hero for the past few months building a massive database of recipes we can use to optimise your nutrition.

It feels like it’s been a long time coming, but it won’t be too long before it’s all automated and online.  If you want to be the first to trial the beta version then make sure you enter your email in the pop on this page or head over to NutrientOptimiser.com now to learn more.

The recipes below are some of the highest ranking when we prioritise some of the harder to find vitamins and minerals (potassium, magnesium, calcium, zinc, vitamin D, thiamine and choline) as well as higher protein and a lower energy density.

I have included the link to the Cronometer entry as well as the nutritional profile and a list of foods that will help you balance the nutritional profile of the recipe.

Bootcamp omelette

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Gayle Louise created this simple omelette recipe for her Ketogains boot camp workout days.   Nutritional yeast has a fantastic nutritional profile and adds a cheesy taste without the calories, minimising fat and maximising nutrient density.

ingredients

method

  • cook the spinach first with ghee or butter.
  • whisk 4 eggs with salt and pepper and add too cooked spinach
  • sprinkle with nutritional yeast, cover and cook until firm.

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Cronometer analysis

https://nutrienthero.com/recipe-analysis/boot-camp-omelette

 

Potassium salted caramel coffee

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Everyone loves coffee, and most people find potassium harder to get in their diet than sodium.  So why not potassium coffee?!?!  The milk and caramel syrup are not essential, but they give you that indulgent salted caramel taste.

Getting adequate minerals is critical to ensuring insulin sensitivity, nutrient partitioning, muscle building and recover and avoiding diabetes.

While most people don’t need to worry about getting too much salt, having a potassium : sodium ratio greater than two is hard to achieve for most people, even if they do eat a lot of greens.

My friend Raymund Edwards of Optimal Ketogenic Living has been doing a LOT of research into the wide-ranging benefits of alkalising electrolytes, in particular, potassium.  This recipe was inspired by Raymund after hearing that he was adding potassium to his coffee.

Raymund said, “A potassium enriched coffee in the morning really wakes the muscles.  It’s better than any warm up.  Loose and alive we can feel the difference as they soak up actively the potassium especially after the night fast (where muscles have been releasing potassium).  And  the coffee in my view tastes so much better too.”

It’s hard to get a significant amount of potassium from tablets as they are limited to 99 mg which is only a fraction of the 3,800 mg of potassium that we need each day (you would need to take forty tablets to get the DRI for potassium!).

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You can also add the potassium citrate powder to your drinking water, coffee or pre-workout mix.  You would need more than 10g of the citrate powder to get your recommended daily intake of potassium, but, like all things, start slowly. However, in time, it might just make you feel amazing!

ingredients

method

  • Pour coffee shot from fresh grounds
  • Add potassium citrate powder
  • Add caramel syrup (optional)
  • Add a dash of full cream milk to taste (optimal)
  • Add hot water to taste (depending on how you like your coffee)

Cronometer analysis

nutritional analysis

 

Greens + eggs + seafood

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Dom D’Agostino infamously told Tim Ferriss in his sound check that his breakfast was sardines, oysters, eggs and broccoli.  It might sound bizarre, but it packs a nutritional punch.

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Most days my breakfast is some variant on frozen greens (spinach, broccoli, kale) + eggs + seafood (sardines, mackerel, oysters, mussels, anchovies) + nutritional yeast.

If you’re not focusing on losing body fat you can add cheese or peanuts for some extra indulgent taste, but leaving these out will help you increase your protein : energy and nutrient : energy ratio which is ideal if you are trying to lose body fat (and will make Ted Naiman and Luis Villasenor proud).

You could take more time to fry these ingredients up and plate them up nicely, but most of the time breakfast only needs to be time efficient and doesn’t need to look good.  If you can start the day with a high protein nutrient dense breakfast, you’ll be less likely to succumb to other cravings later in the day.

ingredients:

  • 250g frozen veggies. Spinach is always best, but broccoli or kale work too.
  • Three eggs. Consider removing the yolks if you are focussed on lower fat higher protein fat loss phase, though this will decrease the overall nutrient profile.  The yolk is where all the vitamins and minerals are!
  • 1 can of seafood (e.g. mackerel, sardines, oysters, mussels or anchovies).
  • 1 teaspoon of nutritional yeast
  • Peanuts (optional, only if not looking to lean out)
  • 1 oz mozzarella cheese (optional, only if not looking to lean out)
  • Salt (No Salt, Celtic Sea or Redmond Real Salt) & pepper to taste.

method

  • Defrost greens in bowl for five minutes in the microwave.
  • Add eggs and cook for a further minute or until done. (I often find that the eggs need a bit more cooking but stir everything in at around three minutes and then cook for another two minutes).
  • Add other ingredients
  • Salt liberally to taste.

Nutritional analysis

Cronometer entry

Photos of other variants (hey, they ain’t pretty, but they work).

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Bacon, egg, spinach and mushroom

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This is a variant on the common bacon and eggs recipe. The spinach mushroom and tomato round out the nutritional profile of the stock standard bacon and eggs.

The spinach provides a wide range of vitamins and minerals, particularly vitamin K and vitamin A.  Most people think kale is the ultimate nutrient-dense green vegetable.  However, kale just has a lot of Vitamin K1 and not so as much of everything else.  Spinach has a much better nutritional profile across the board.

If you are focusing on reducing body fat and maximising nutrient density, consider eliminating the cream, draining the bacon fat and keeping the butter to a minimum for cooking.  If your goal is bulking and recover, then you can be more liberal with the cream and cheese to taste.  Remember, fat is a lever.

ingredients:

  • 3 large eggs
  • 200g fresh spinach
  • 2 mushrooms
  • 30g cream (optional)
  • 30g mozzarella cheese (optional)
  • butter
  • Salt (No Salt, Celtic Sea or Redmond Real Salt) & pepper to taste.

method

  • Fry bacon separately. If your priority is reducing body fat then you can let the bacon rest on a paper towel to drain the fat.  Alternatively, bacon grease can be used to fry the spinach, mushroom and eggs.
  • Fry eggs separately.
  • Add cream and cheese if not looking to lean out.
  • Salt to taste.

Nutritional analysis

Cronometer entry

 

Steak, egg, tomato, avo spinach and lettuce

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This is a fairly standard Sunday night family dinner at our place.  A solid piece of steak on the BBQ with salad.

ingredients:

method

  • Grill BBQ steak
  • Cook spinach with some butter or coconut on BBQ plate when grilling the steak.
  • Serve with boiled egg (or fried on the BBQ) along with salad (avocado, tomato and lettuce shown here).
  • Salt (No Salt, Celtic Sea or REdmond Real Salt) & pepper to taste.

Facebook

Nutritional profile

Cronometer

 

Be sure to check out the more than 300 meals on the Nutrient Optimiser Facebook Group.  You might even want to add some of your own.

 

 

 

references

[1] https://ketogains.com/2017/06/energy-balance-macros-nutrient-density/

[2] https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5304a3.htm

[3] http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32252-3/abstract

[4] http://www.artandscienceoflowcarb.com/the-art-and-science-of-low-carbohydrate-performance/

[5] https://www.amazon.com/Art-Science-Low-Carbohydrate-Performance/dp/0983490716

[6] https://www.youtube.com/watch?v=GkQYZ6FbsmI

[7] https://optimisingnutrition.com/2017/10/15/high-protein-vs-low-protein/

[8] https://jissn.biomedcentral.com/articles/10.1186/s12970-017-0201-z

[9] https://www.ncbi.nlm.nih.gov/pubmed/9841962

[10] https://www.ncbi.nlm.nih.gov/pubmed/29182451/

[11] https://l.facebook.com/l.php?u=https%3A%2F%2Fwww.dropbox.com%2Fs%2F1if7n957u66htiy%2F10.1123%2540ijsnem.2017-0273.pdf%3Fdl%3D0&h=ATNppfskJJ6fMuIVoJrC0rX_8H9KCT2SeryF0MeRrAnJz6X9p_3FPhPYUK3RGSOE-kDTeOLxKdw26vel3zBWDbOlaCQzxkxpDU8CjFs9Moo51fC9NByHYvs83uU7PvjFolOxvqx3Pw

[12] https://optimisingnutrition.com/2017/06/03/why-do-my-blood-sugars-rise-after-a-high-protein-meal/

[13] https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

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

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

[16] https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

[17] https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

[18] https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

[19] https://www.reuters.com/article/us-health-diabetes/cost-of-diabetes-epidemic-reaches-850-billion-a-year-idUSKBN1DD2SW

[20] http://www.diabetesincontrol.com/the-true-cost-of-diabetes-and-preventing-it/

[21] http://www.diabetes.co.uk/cost-of-diabetes.html

[22] https://optimisingnutrition.com/tag/insulin-load/

[23] https://www.dietdoctor.com/low-carb/20-50-how-much

[24] https://www.nrv.gov.au/nutrients/fats-total-fat-fatty-acids

[25] https://www.ncbi.nlm.nih.gov/pubmed/17593855

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

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

[28] https://metabolicnutrition.com/branched-chain-amino-acids-bcaas-benefits-for-muscle-growth/

[29] https://www.sciencedaily.com/releases/2017/09/170927093254.htm

[30] http://suppversity.blogspot.com.au/2013/09/the-satiating-secret-of-arginine-lysine.html

[31] https://ketogains.com/2017/06/keto-flu-electrolyte-imbalances/

[32] https://www.ncbi.nlm.nih.gov/m/pubmed/21036373/

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

[34] https://diabetesmealplans.com/6285/magnesium-and-diabetes-type-2/

[35] https://www.ncbi.nlm.nih.gov/pubmed/22150427

[36] https://ketogains.com/2016/08/ketogains-seven-must-supplements/

[37] https://athinkingperson.com/2012/12/02/who-said-what-gets-measured-gets-managed/

[38] https://www.ncbi.nlm.nih.gov/pubmed/24355667

[39] https://en.wikipedia.org/wiki/National_Weight_Control_Registry

[40] http://www.nourishbalancethrive.com/podcasts/nourish-balance-thrive/keto-masterclass-robb-wolf/

[41] https://www.ncbi.nlm.nih.gov/pubmed/15615615

[42] https://www.bodyrecomposition.com/muscle-gain/calorie-partitioning-part-1.html/

[43] https://optimisingnutrition.com/2016/03/21/wanna-live-forever/

[44] https://startingstrength.com/articles/clarification_rippetoe.pdf

[45] https://jamanetwork.com/journals/jama/fullarticle/2553448

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

[47] https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0ahUKEwjpo5y5qu_XAhWHFpQKHV8VAXgQFggvMAE&url=http%3A%2F%2Fketogeek.libsyn.com%2F14-tyler-cartright&usg=AOvVaw04xLzYxE3tS8oa8LWvLkZk

[48] http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0103483

“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.

NF-Sarcopenia[1].jpg

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

are ketones insulinogenic and does it matter?

There has been a lot of hype around the interwebs lately about exogenous ketones and whether they are health promoting, particularly for people with conditions that relate to excess insulin such as diabetes, traumatic brain injury, Alzheimer’s, cancer, epilepsy, obesity etc.

exogenous ketone are trendy
exogenous ketones, Pruvit and Keto//OS are becoming trendy.

Exogenous ketones are becoming trendy, particularly in the low carb scene!

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A couple of people recently asked me whether I thought exogenous ketones are insulinogenic.

Roger Unger’s 1964 paper the Hypoglycemic Action of Ketones.  Evidence for a Stimulatory Feedback of Ketones on the Pancreatic Beta Cells[1] indicates that ketone levels are controlled by insulin and that ketones suppress lipolysis:

Ketone bodies have effects on insulin and glucagon secretions that potentially contribute to the control of the rate of their own formation because of antilipolytic and lipolytic hormones, respectively.  Ketones also have a direct inhibitory effect on lipolysis in adipose tissue.[2]

It seems that exogenous ketones are indeed insulinogenic to some degree.

But how do we test this hypothesis to find out whether they are just slightly insulinogenic like fats or more insulinogenic like carbohydrates?

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how to test the insulin response to exogenous ketones in someone with Type 1 Diabetes

If someone with Type 1 Diabetes stops taking their insulin both their blood glucose levels and blood ketones spiral out of control as they slip into ketoacidosis[3] which can be dangerous and fatal before very long without exogenous insulin injection.[4]   In metabolically healthy people,  high levels of ketones suppress mobilisation of body fat (lipolysis).[5]

In someone with Type 1 Diabetes, taking exogenous insulin brings both ketones and blood glucose under control.  So, based on what we see in people with Type 1 Diabetes, it seems logical that exogenous ketones would provoke an insulin response to keep ketones and glucose under control.

One way to test whether exogenous ketones are insulinogenic would be to have a Type 1 Diabetic to take a significant amount of exogenous ketones and monitor how much additional insulin they need to keep the continuous blood glucose monitor stable with the same amount of calories in glucose.

I initially became interested in exogenous ketones after hearing a number of podcasts with Patrick Arnold and Dominic D’Agostino thinking that it may be a useful alternative source of energy that does not rely on insulin for my wife, who has Type 1 Diabetes.  However, the one time she tried it resulted in such bad gut distress she never touched it again.  So scratch that n = 1.

food insulin index testing with exogenous ketones

Another way to test whether exogenous ketones are insulinogenic would be to run a food insulin index test[6] [7] using ketones rather than food.  This would involve giving 1000kJ of exogenous BHB (e.g. 48g of KetoCaNa) and measuring the insulin response over two or three hours.

The chart below compares the results of previous food insulin index tests undertaken for different foods.[8]   Comparing the area under the curve insulin response for the exogenous ketones to the insulin area under the curve for glucose would give you the insulin index for exogenous beta hydroxybutyrate.

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I am surprised that the companies marketing exogenous ketones to people with metabolic issues, as part of their due diligence, haven’t already done this testing to understand to what degree exogenous ketones are insulinogenic.

but wait, the food insulin index testing with exogenous ketones has already been done!

Then I came across this figure in a paper, Nutritional Ketosis Alters Fuel Preference and Thereby Endurance Performance in Athletes (Cox et al, 2016)[9],  where they have effectively done the food insulin index testing with exogenous ketones.

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Thirty-nine athletes took an isocaloric dose of ketone esters, carbs and fat in three different sessions. In the chart on the right (G) we can see that the ketones provoked about half the insulin response compared to the carbohydrate drink.  This test is different to normal food insulin index testing in that the participants started to exercise ten minutes after taking the drinks (i.e. at T = 0) at which point insulin and glucose start to decline.

updated insulin load formula, including exogenous ketones

The chart below shows the relationship between the food we eat and our insulin response based on the previous food insulin index testing.

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In lieu of more thorough food insulin index testing, I think we can update the insulin load calculation formula to:

insulin load = carbohydrate – fibre + 0.56 * protein – 0.725 * fructose + 0.5 * exogenous ketones

It appears that exogenous ketones provide about half the insulinogenic impact of carbohydrates (i.e. about the same as protein).


So, if you’re avoiding protein because of its impact on insulin, should you also consider exogenous ketones for the same reason?

Exogenous ketones stimulate insulin, but BHB also inhibits lipolysis directly via the nicotinic acid receptor PUMA-G in adipose.[10]

While exogenous ketones may be equally as insulinogenic as protein, they’ll also be a counterproductive use of insulin.

Whereas the insulin response to protein is a positive use of insulin to build and repair muscle, with exogenous ketones, insulin simply reduces oxidation of other fuels to allow ketones to be burned.

Exogenous ketones displace the burning of other substrates.  You know what else displaces the burning of other substrates?  Glucose. Carbs reduce the amount of fat you burn. Similarly, exogenous ketones displace both fat and carbs/glucose.

That’s a double whammy in the wrong direction! Substrate competition is key.

Mike Julian

total energy = glucose + ketones

In a healthy metabolism, endogenous ketones are generated as fat stores are mobilised to compensate for a decreased energy availability from glucose.  When glucose is not available, ketones come to the rescue to ensure survival.

If you’re insulin resistant, you might have trouble releasing free fatty acids due to the high levels of insulin circulating in your bloodstream.  This inability to access your own fat stores will reduce your ability to create ketones and likely lead you to be more hungry and eat more than you otherwise would if you were insulin sensitive.  If you are insulin sensitive you can more easily access your own body fat stores.

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This chart demonstrates the concept of total energy (i.e. glucose + ketones) using more than a three thousand combined ketone and glucose readings from people following a low carb/keto lifestyle.  Other than in the extremes of extended fasts or major feasting, the body seems to use insulin to maintain a homoeostasis of around 5 to 6 mmol/L of total energy in the blood.

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On the left-hand side of the chart, when our blood glucose levels drop, we get a rise in ketones, but an increase in autophagy and all the good stuff that comes with fasting and ketosis.

On the right-hand side of the chart, when we drive our total energy high with excess energy (be it from processed carbs, Bulletproof Coffee, or exogenous ketones) the body releases insulin to stop stored body fat and glucose being released into our bloodstream.

People with the highest levels of metabolic health tend to walk around with a lower total energy in their bloodstream.  It seems you don’t need to buffer lots of energy in the blood if you can easily mobilise body fat and glycogen stores quickly when required.

Having high levels of energy sitting around in the blood stream is far from ideal and leads to glycation in the case of high blood glucose levels and oxidation in the case of free fatty acids.

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The total energy concept also seems to hold up with laboratory testing in rat pancreas islet cells, where exogenous ketone bodies promoted insulin secretion when there was greater than 5.0 mmol/L of glucose.[11]

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It appears that if your blood glucose levels are greater than 5.0 mmol/L (or 90 mg/dL), then exogenous ketones will be insulinogenic (at least if you’re a rat, but we have no reason to believe this wouldn’t occur in humans as well).

So if your blood glucose levels are greater than 5.0mmol/L (or 90 mg/dL),  then those expensive exogenous ketones will be working just like a quick burning insulinogenic fuel, just like a dose of carbs.

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do exogenous ketones “help” with fasting?

If exogenous ketones raise insulin and reduce blood glucose, then where does the glucose go?  It gets stuffed back into the liver. 

Think about all of these people who fast with the intent of depleting liver glycogen but drinking Keto/OS. They’re literally preserving glycogen stores! No wonder we were seeing whacky glucose and ketone response to fasting with exogenous ketones.

Instead of the normal trajectory of a fast that would result in depleted liver glycogen we see exogenous ketones keeps this from happening, so you would get purges of glucose out of the liver throughout the fast when people were fasting using exogenous ketones.”

Mike Julian

Let’s take a quick look at what Mike means by “the normal trajectory of glucose”.    In the chart below, we can see that blood glucose levels drop and ketone increase in four people.

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Where things get interesting is when you step look at the longer-term glucose and ketone trajectory of the fourth person who was taking exogenous ketones during the fast.

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What’s causing this anomaly in glucose and ketone response?   Is it a unique level of insulin resistance, or could this simply be explained by the use of exogenous ketones which are down regulating release of free fatty acids and endogenous ketone production?

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One theory is that exogenous ketones are switching off lipolysis, which drives the liver to release more glucose and ramp up gluconeogenesis to fuel the system during fasting?

The glucose : ketone index is the measure that Dr  Thomas Seyfried encouragescancer patients to use during a fast to measure its therapeutic effect.  The lower the better.  For most people the GKI continues to drop during extended fasting, but in this case the GKI dropped and then starts to rise over time when taking exogenous ketones.

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I would like to see some more thorough studies to understand if this is typical in people taking exogenous ketones during extended fasting.  It’s not conclusive, but n = 1s are useful to build a hypothesis that can be tested in a more controlled environment.

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oxidative priority

Ray Cronise and David Sinclair recently published an intriguing article, Oxidative Priority, Meal Frequency, and the Energy Economy of Food and Activity: Implications for Longevity, Obesity, and Cardiometabolic Disease (2016)[12] where they detailed the basis for the oxidative priority of different fuel substrates.

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  1. Alcohol will be burned first because the body has limited storage capacity for it. It sees it as a toxin that needs to be cleared.
  2. Protein will be burned second because you can only store a few hundred calories worth of amino acids in the bloodstream (though I think most people struggle to overeat protein when from whole food sources).
  3. Carbohydrate will then be burned before we can access our virtually unlimited stores of body fat.

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So, I think it would be logical that exogenous ketones would be first in line (before or just after alcohol) to be burned off because the body has no way of storing the exogenous ketones other than circulating in the blood stream.

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So, it seems that exogenous ketones neither lower insulin nor promote fat burning.  They’re just another fuel that will be burned before the fat on your bum and your belly.

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do exogenous ketones boost exercise performance?

Exogenous ketones in sports performance is an interesting area of research.  Rumour has it the Tour de France cyclists and British Olympic rowers are using ketone ester drinks (though it’s worth noting that the people spreading these rumours are selling the ketone esters).[13]

Some people use exogenous ketones as a preworkout, like caffeine, to give them a cognitive boost.  Research by Richard Veech and Kieren Clarke suggests that there may be a small athletic boost if you provide both exogenous ketones and exogenous glucose at the same time to provide a “dual fuel”.[14] [15]  This situation provides a fuel oversupply that would force the body to burn off the excess fuel quickly.

Dr Mike T Nelson suggest that driving a chronic energy surplus from high ketones and high glucose might be problematic in the long term as there is no precedent in nature for this condition.[16]

I have dabbled with exogenous ketones (i.e. KetoCaNa, Pruvit and the Ketone Aid ketone ester).  The chart below shows  how my blood ketones rose to 3.5mmol/L and then back down to normal levels after about 3 hours.  Note how my body tries to remove the excess energy from the blood stream and bring the total energy back down to around 5.0mmol/L.

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I didn’t find a massive boost in performance in my workouts with any of the ketone products.  My best performance is when I was fasted without supplementation and it seems I could easily access my fat stores and breath more effortlessly.

I’m far from a high level athlete, but when I perform at my best cycling or in my kettlebell workouts, my breathing seems effortless and my time to exhaustion increases.   When we are insulin sensitive and / or don’t have excess glucose in our system and burn more fat for fuel we use less oxygen than when we burn glucose for energy.[17]  That reduction in oxygen usage is critical to make sure you don’t get out of breath and fatigue.  It seems that too much exogenous ketones or glucose in the system will mean that we’re less reliant on burning our own body fat.

I think the future of exogenous ketones in athletic performance will revolve around finding the right dose to boost ketones enough to get a performance benefit, without switching off lipolysis, which is where the real performance powerhouse lies.   If you put in so much fuel in line in front of your virtually unlimited fat stores, then you may risk gassing out because you can’t access your fat stores as easily.

Perhaps someone who is a normal carb burner might benefit from having ketones raised to the 3 or 4 mmol/L range, while someone who is more fat adapted might benefit more with ketones in the 1 to 2 mmol/L range so as to get a dual fuel boost without switching off fat burning?

It’s still early days.  Time and more experimentation will tell.

does it matter?

If you’re metabolically healthy and you enjoy the brain buzz of exogenous ketones more than alcohol or caffeine and want to use exogenous ketones as a pre-workout, then I say go your hardest if you can afford it.

However, if you are looking for improvements in your metabolic health or magical weight, I think you should be cautious.

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Companies like Ketopia are marketing exogenous ketones as a “bridge” through the keto flu, which I think is a more ethical approach (although many people say you can eliminate the ‘keto flu’ with good mineral supplementation).

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But you probably haven’t heard of Ketopia, because selling seven days’ worth of exogenous ketones isn’t a great business model in comparison to getting people to sign up for an ongoing subscription as a distributor buying thousands of dollars of ‘inventory’ up front so they can take it… Every.  Single.  Day.

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Perhaps when exogenous ketones are no longer the realm of overhyped multi level marketing campaigns people will be able to experiment with exogenous ketones and find whether they live up to any of the claims and are indeed worth the money?  This is starting to happen now with Julian Baker’s InstaKetones coming in at about one sixth of the price of Pruvit’s products.

If you’re using exogenous ketones with the hope of reducing insulin levels or reversing metabolic disease (e.g. Type 2, cancer, Alzheimer’s, obesity), then maybe think again.  Exogenous ketones may alleviate your symptoms while they’re in your system (about 2 hours), but I fear they might worsen the conditions that people are using them for in the hope of improved metabolic health.

Mike Sheridan’s article in T-Nation makes a number of excellent points:

Ketones may be depressing dieters’ hunger and giving them a hit of energy and cognitive enhancement, but it’s INHIBITING their ability to burn fat, providing zero nourishment, and doing nothing for their metabolic health. There’s an assortment of evidence suggesting that it’s probably making things worse.

Think of exogenous ketones kind of like alcohol. When they’re consumed, everything is stored and nothing else is burned. So any lipolysis (fat burning) that would be taking place is halted; any glucose and fatty acids in your blood that were circulating are stored; and the ingested ketones are burned until there aren’t any left.

But suggesting individuals already fasting, restricting calories, or cutting carbs will get anything other than a brain buzz is misleading. And to serve up exogenous ketones to an obese, insulin-resistant general population with promises of fat-burning and disease prevention is potentially damaging.

Sure, it might suppress hunger and give a damaged brain a useable fuel source, but what happens when pre-diabetic Pete starts adding ketones to his glucose-rich blood? Or anaerobic Andy continues reloading with the same amount of carbs post-workout even though the liver glycogen he normally burns during his sessions is now suppressed?[18]

Sure, exogenous ketones might provide energy to the muscles or brain cells of someone with Type 2 or Alzheimer’s who can’t use glucose well because of decades of hyperinsulinemia.  But, if someone already has super high glucose and insulin levels, will they worsen the condition by chasing high ketone levels with large doses of insulinogenic exogenous ketones?

If someone is trying to shrink their brain tumour by reducing growth stimulating insulin, will ingesting large amounts of exogenous insulinogenic ketones accelerate growth in the brain tumors?  Recent studies suggest that this may in fact be the case.[19]

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At the current rate, it looks like we will be able to confirm the long term effects of exogenous ketones sooner rather than later.


But by then, the people running the MLMs will have driven off into the sunset and be on to another scheme.

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good news… endogenous ketones for free!

The good news is that all the benefits of endogenous ketosis is freely available risk free!  It’s not easy, but you can get the benefits of ketosis (e.g. autophagy, apoptosis, increased NAD+, mitogenesis etc) by keeping the insulin load of your normal diet down to the point that you can maintain normal blood glucose and insulin levels, then occasionally you can push the time between meals than usual in order to derive some extra benefits (i.e. intermittent fasting).

 

references

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

[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC441933/

[3] http://www.webmd.com/diabetes/type-1-diabetes-guide/ketoacidosis

[4] http://www.webmd.com/diabetes/tc/diabetic-ketoacidosis-dka-topic-overview#1

[5] https://www.dropbox.com/s/hnycwc6b5pw37hr/Inhibition%20of%20Ketogenesis%20by%20Ketone%20Bodies%20in%20Fasting%20Humans.pdf?dl=0

[6] http://ajcn.nutrition.org/content/66/5/1264.abstract

[7] http://ses.library.usyd.edu.au/handle/2123/11945

[8] http://ajcn.nutrition.org/content/90/4/986.short

[9] https://www.ncbi.nlm.nih.gov/pubmed/27475046

[10] https://www.dropbox.com/s/j66y3osyasvq3b3/KETONES%20and%20NICOTINIC%20ACID%20receptor.pdf?dl=0

[11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1152056/

[12] https://www.ncbi.nlm.nih.gov/pubmed/27869525

[13] http://www.nutraingredients.com/Markets-and-Trends/Ketones-get-rough-ride-at-Tour-de-France

[14] http://journals.lww.com/acsm-msse/Abstract/publishahead/A_Ketone_Ester_Drink_Increases_Postexercise_Muscle.97232.aspx

[15] http://www.nourishbalancethrive.com/blog/2016/10/10/instant-ketosis-04-62mm-30-minutes/

[16] http://www.nourishbalancethrive.com/podcasts/nourish-balance-thrive/high-ketones-and-carbs-same-time-great-performance/

[17] http://www.freemocean.com/2017/02/22/oxygen-and-your-dna/

[18] https://www.t-nation.com/diet-fat-loss/avoid-this-ketogenic-rip-off

[19] https://link.springer.com/article/10.1186/s40170-017-0166-z

 

post updated July 2017

are exogenous ketones right for you?

I’ve spent a lot of time lately analysing three thousand ketone vs. glucose data points trying to determine the optimal ketone and blood sugar levels for weight loss, diabetes management, athletic performance and longevity.

In this article, I share my insights and learnings on the benefits, side effects and risks of endogenous and endogenous ketosis.

Exogenous vs. endogenous ketosis

But first, I think it’s important to understand the difference between exogenous and endogenous ketosis:

  • Endogenous ketosis occurs when we go without food for a significant period. Our insulin levels drop, and we transition to burning body fat and ketones in our blood rise.
  • Exogenous ketosis occurs when we drink exogenous ketones or consume a ketogenic diet.

Ketones vs glucose

Ketones are important.  As blood glucose decreases, the ketones in your blood increase to keep our energy levels stable.

The chart below shows three thousand blood glucose vs ketone values measured at the same time from a range of people following a low carbohydrate or ketogenic diet.

BHB ketones vs blood glucose

While there is generally a linear relationship between glucose and ketones, each person has a unique relationship between their blood glucose and ketone values that provide a unique insight into a particular person’s metabolic health.

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Some people produce more ketones than others.  Some people have higher blood glucose levels.

What our ketone and glucose values tell us about our metabolic health

Hyperinsulinemia has been called as the “unifying theory of chronic disease” [1] [2] [3] [4] [5].  It’s beneficial to understand where you stand on the spectrum of metabolic health and insulin sensitivity.

The chart below shows the typical relationship between blood glucose and blood ketone for a range of different degrees of insulin resistance/sensitivity.

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If your blood glucose levels are consistently high it’s likely you are not metabolising carbohydrate well.   When you go without food, endogenous ketones are slow to kick in because your insulin levels are also high.  You feel tired and hungry, and you are likely to eat again sooner and not stop until you feel good.

By contrast, if you are insulin sensitive you may be able to go longer between meals naturally and you will not feel as compelled to eat as much or as often.  If someone is insulin resistant, a lower insulin load dietary approach will help with satiety and carb cravings while keeping blood glucose levels and insulin under control.

hyperinsulinemia and metabolic disorders

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

EXOGENOUS ketones may help to relieve the debilitating symptoms and side effects of acute hyperinsulinemia, Alzheimer’s, dementia, epilepsy or other conditions where glucose is not used well.

exogenous ketones and the low carb flu

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


However, once you have successfully transitioned to a lower carb eating style it may be wise to reduce or eliminate the exogenous ketones to enable your body to fully up-regulate lipolysis (fat burning), maximise ENDOGENOUS ketone production and access your body fat stores.

As discussed in the article Are ketones insulinogenic and does it matter? it exogenous ketones require about half as much insulin as carbohydrate to metabolise (or about the same amount as protein).  Hence the continual use of exogenous ketones will limit how much our insulin levels are able to decrease.

Someone with diabetes who follows with a nutrient dense low insulin load dietary approach may be able to successfully normalise their blood glucose and insulin levels. When this happens, your liver will be able to more easily produce ENDOGENOUS ketones which will help improve satiety between meals and decrease appetite which will, in turn, lead to weight loss.

Exercising to train your body to do more with less is also helpful.

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my experience with exogenous ketones

The light blue “mild insulin resistance” line is based on my ketone and glucose tests when I started trying to wrap my head around low carb/keto.

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I enthusiastically started adding generous amounts of fat from all the yummy stuff (cheese, butter, cream, peanut butter, BPC etc) in the hope of achieving higher ketone levels and therefore weight loss, but I just got fatter and more inflamed as you can see in the photo on the left.

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My blood tests suggested I was developing fatty liver in my mid-30s!  And I thought I was doing it right with lots of bacon and BPC?!?!?

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

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

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

Part of the reasons shelling out the money for the exogenous ketones was to see if it would provide a fuel source that didn’t need insulin for my wife Monica who has Type 1 Diabetes.

This metabolic jet fuel is definitely fascinating stuff!  My experience is that it gave me a buzz like a BPC but also has an acute diuretic effect.

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

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I did find it had an amazing impact on my appetite.  While it was in my system I didn’t care as much about food.  However, once the ketones were used up my appetite came flooding back.

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Unfortunately, my hunger and subsequent binge eating seemed to more than offset the short term appetite suppression that had occurred while the exogenous ketones were in my system.  And it was not going to be financially viable for me to maintain a constant level of artificially elevated ketone levels which return to normal levels after a couple of hours.

do exogenous ketones help with weight loss?

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

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

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

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According to Dominic D’Agostino in a Pruvit teleseminar, the EXOGENOUS ketone salts were not designed to be a weight loss product and hence have not been studied for weight loss after all!

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

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

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

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image16 [13]

Confused?

I don’t blame you.

Metabolically healthy

The “metabolically healthy” line in the chart above is based on RD Dikeman’s ketone and glucose data when he fasted for 21 days.

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Due to his hard-earned metabolic health and improved insulin resistance RD has developed the ability to fairly easily release ketones when he doesn’t eat for a while.  RD still doesn’t find going without food effortless, but it is easier than when his insulin levels were much higher which prevented his body from accessing his body fat stores.

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Through a disciplined diet and exercise habits RD has achieved a spectacular HbA1c of 4.4%.

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Perhaps a two or three day water only fast testing blood glucose and ketones with no exercise would be a useful test of your insulin status?  You could use RD’s glucose : ketone gradient as the gold standard.

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

I know Luis Villasenor from Ketogains finds the same thing.

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total energy = ketones + glucose

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

The average TOTAL ENERGY of the three thousand data points from these healthy people working hard to achieve nutritional ketosis is around 6.0mmol/L. It seems the body works to maintain homoeostasis around this level.

optimal fasting ketone and blood sugar levels in ketosis

When the TOTAL ENERGY in our bloodstream increases outside of the normal range it the body raises insulin to store the excess energy.  That is, unless you have untreated type 1 diabetes, in which case you end up in diabetic ketoacidosis with high blood glucose and high ketones due to the lack of insulin available to keep your energy in storage.

Regardless of whether your energy takes the form of glucose, ketones or free fatty acids, they all contribute to acetyl-coA which is oxidised to produce energy.  Forcing excess unused energy to build up in the bloodstream is typically desirable and can lead to long term issues (e.g. glycation, oxidised LDL etc).

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

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

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

image26[16] [17] [18]

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

Dealing with high ketones and high glucose is typically not a concern because it doesn’t happen in nature or when eating whole foods.  But now we have refined grains, HFCS, processed fats and exogenous ketones to ‘bio hack’ our metabolism and send it into overdrive.

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

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

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

My heart sank when I saw this video.

MORE investigation required?

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

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

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

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

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

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

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

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

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

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

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

The lower the better?

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

Metabolically healthy people are both metabolically flexible[25] and metabolically efficient.[26]   These people would have been able to both conserve energy during a famine and run away from a tiger and live to become our ancestors, while the ones who couldn’t didn’t.

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

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

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And he’s been able to lose 10kg (22lb) in one month!

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At 5.2mmol/L (i.e. glucose of 4.0mmol/L plus ketones of 1.2mmol/L) John’s TOTAL ENERGY is well below the average of the 26 people shown in the glucose + ketone chart above.  It seems excellent metabolic health is actually characterised by lower TOTAL ENERGY.

MORE is not necessarily BETTER when it comes to health.

Fast well, feed well

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

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

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

ketones (mmol/L)

blood glucose (mmol/L)

total energy (mmol/L)

average

0.7

4.8

5.5

30th percentile

0.4

4.6

5.2

70th percentile

0.9

5.1

5.8

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

ketones
(mmol/L)

blood
glucose (mg/dL)

total
energy (mg/dL)

average

0.7

86

99

30th percentile

0.4

83

94

70th percentile

0.9

92

104

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

the real magic of ketones

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

This is where autophagy, increased NAD+ and SIRT1 kicks in to trigger mitochondrial biogenesis and ENDOGENOUS ketone production (i.e. the free ones).[27]   The REAL magic of ketosis happens when all these things happen and ketones are released as a byproduct.

I do not believe that simply adding EXOGENOUS ketones will have nearly as much benefit to your mitochondria, metabolism and insulin resistance as training your body to produce ENDOGENOUS ketones in a low energy state.

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

image01

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

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

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

Perhaps as more exogenous products come to market without the marketing hype that that comes with multi level marketing (e.g. Julian Baker’s Insta Ketone which are a sixth of the price of the Pruvit products) people will get to see if they really do anything useful.

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

nutrient density

When we feed our body with quality nutrients we maximise ATP production which will make us feel energised and satisfied.  Nutrient dense foods will nourish our mitochondria and reduce our drive to keep on seeking out nutrients from more food.

Greater metabolic efficiency will lead to higher satiety, which leads to less food intake, which leads to a lower TOTAL ENERGY, increased mitochondrial biogenesis, improved insulin sensitivity and lower blood glucose levels.

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

the best exogenous ketone supplement

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

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

best exogenous ketone supplement

Check out the how to use your glucose meter as a fuel gauge article or how to use your bathroom scale as a fuel gauge for some more ideas on how to get started with fasting.

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

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

 

 

references

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

post last updated: July 2017

Jimmy Moore’s keto eggs

During his yearlong n=1 ketosis experiment Jimmy Moore in 2012 didn’t give too much away about exactly what he was eating.

What was he doing to keep his blood glucose consistently low and ketones high?  Could this help me lose some weight or perhaps my type 1 diabetic wife normalise her blood glucose levels

Jimmy did  publish a list of healthy high fat foods (i.e. avocados, butter, whole eggs, coconut oil, bacon, sour cream, 70% ground beef, full fat cheddar cheese and coconut) on the Carb Smart blog but he didn’t give away much more detail.

I suppose it’s part of what drove me to dig into the food insulin index to create a ranking of all foods.

One meal he did blog as one of his favourites was his “keto eggs” which he included in Keto Clarity and on his blog here.  He says it helps him “rock the ketones”.  This was often his meal for the day with intermittent fasting.  The recipe is shown below:

  • 4-5 pastured eggs
  • 2-3 oz grass-fed butter and/or coconut oil
  • sea salt
  • parsley (or your favorite spice)
  • 2 oz full-fat cheese (optional)
  • 2 Tbs Sweet Chili Sauce
  • 3 Tbs sour cream
  • 1 whole avocado

The nutritional analysis for the recipe below shows that it’s certainly ketogenic with 83% fat, 13% protein and 4% carbs.  This keto egg recipe provides a solid protein score though the vitamins and minerals aren’t as high as some of the other meals.  However if your primary aim is therapeutic ketosis then this meal will likely be great for you.

2016-07-18 (2)

The ranking for the keto eggs recipe, compared to the 241 other meals that have been analysed so far,  for each of the approaches is:

  • therapeutic ketosis – 18 / 242
  • diabetes – 54 / 242
  • weight loss – 175 / 242
  • nutrient dense (maintenance)  – 159 / 242

net carbs

insulin load carb insulin fat protein

fibre

6g 31g 21% 83% 13%

3g

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

¿Puede el ayuno intermitente optimizar los niveles de glucosa en la sangre y reducir la necesidad de medicamentos para la diabetes? Antonio Martínez estaba ansioso por descubrirlo, por lo que se propuso realizar un experimento con él mismo.

[for the English version of this post click here]

El Dr. Antonio C. Martinez II., es un Abogado reconocido de nivel distinguido por Martindale Hubbard, y de la Red Legal de los Mejores Abogados (Top Lawyers) en Nueva York y un hombre de negocios que trabajó para el ya fenecido Dr. Robert C. Atkins MD en relaciones gubernamentales y apareció en su programa de radio en los años 90. Fue uno de los principales cabilderos que logró la aprobación de la Ley de Educación y Salud de los Suplementos Dietéticos de 1994 (DSHEA). Ha participado activamente en cuestiones de salud en las leyes y políticas a lo largo de su carrera. En los años 90 Antonio adoptó un enfoque bajo en carbohidratos para bajar de peso durante un tiempo, pero luego retomó una dieta moderada en carbohidratos. No fue hasta que Antonio comenzó a tener sus propios problemas de salud, como la diabetes tipo 2 y un ataque cardíaco, que se dio cuenta que necesitaba intensificar sus esfuerzos para elevar la calidad de su nivel de vida con respecto a su salud.

image07

DIAGNOSTICO: DIABETES TIPO 2

Antonio tiene antecedentes familiares de diabetes tipo 2, ya que ambos padres sufren de la enfermedad, así que es diagnosticado con diabetes tipo 2 en 2002, por lo que los médicos le indicaron inicialmente empezar a tomar Metformina y a partir del 2008 utilizar Janumet. Con la ayuda de éstos Antonio mantenía un HbA1c (HbA1c se refiere a la hemoglobina glucosilada ( A1c ), que identifica la concentración promedio de glucosa en plasma)  en los 6s y fue elogiado por sus médicos por su gran control de la glucosa en sangre, sin embargo, a pesar de que los mantuvo por debajo de los recomendados por la Asociación Americana de Diabetes (un máximo de HbA1c del 7%) ,  Antonio en realidad estaba en el rango de alto riesgo para la enfermedad cardiovascular, como se muestra en la siguiente tabla. Durante este tiempo él siempre fue informado por sus médicos de que su A1c estaba entre 6 y 7 se encontraba dentro de las directrices médicas.

image05

Si bien los medicamentos antidiabéticos ayudan a disminuir los niveles de glucosa en la sangre (es decir, el de los síntomas) estos datos que se muestran a continuación muestran que los medicamentos no reducen necesariamente el riesgo de enfermedades o permiten que la grasa de sus órganos puedan ser lanzados para restaurar la sensibilidad a la insulina (es decir, la solución).

image09

Como se muestra en la tabla a continuación, la insulina es una hormona anabólica que permite que el cuerpo construya reservas de energía en el cuerpo. Sin embargo, si su problema es la hiperinsulina, la diabetes tipo 2 o hígado graso, entonces su objetivo debe ser reducir el nivel de glucosa en la sangre y los niveles de insulina para permitir que la grasa almacenada se metabolice a energía. Parece que simplemente tomando medicamentos para reducir el alto nivel de glucosa en la sangre sin cambios en la dieta va a conducir la energía de nuevo en el almacenamiento en forma de grasa, incluso dentro el corazón, el hígado y el páncreas.

El siguiente diagrama del Dr. Ted Naiman ayuda a explicar cómo la resistencia a la insulina, los niveles altos de insulina (hiperinsulina) y azúcar en la sangre (hiperglucemia) están interelacionados y ambas cosas son malas noticias.

image04

ATAQUE CARDIACO

image03

Lamentablemente el 28 de marzo de 2014 Antonio sufrió un ataque al corazón, razón por la cual le colocaron un stent en una arteria. A su ingreso en el hospital pesaba 158 libras y tenía una HbA1c del 7%. Después de su ataque cardíaco, Antonio se le indicó tomar aspirina, medicamentos para la presión arterial, una estatina, un anticoagulante y un bloqueador beta. En poco tiempo comenzó a sentir los efectos secundarios de las medicacione