Category Archives: weight loss

nutritious protein sparing modified fast diet foods

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

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

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

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

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

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

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

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Medical applications of the PSMF

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

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

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

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

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

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

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

Body building applications

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

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

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

KetoGains’ Luis Villasenor added:

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

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

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

Protein drives satiety

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

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

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

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

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

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

Thermic effect of food

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

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

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

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

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

Should you just eat the highest protein foods?

So, the obvious question is:

What should I eat on a PSMF?

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

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

I have summarised these in this image for easy reference.

The problem with a very high protein diet

But wait!

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

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

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

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

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

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

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

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

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

Bruce Ames’ Triage Theory

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

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

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

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

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

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

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

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

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

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

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

Low energy density

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

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

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

The nutrient dense adequate protein diet

So, to recap:

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

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

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

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

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

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

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

Best foods for a PSMF

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

Also included in the tables are:

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

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

Vegetables

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

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

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

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

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

Animal products

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

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

Seafood

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

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

Egg and dairy

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

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

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

Calorie math

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

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

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

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

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

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

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

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

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

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

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

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

Insulin resistant long-term fat loss scenario

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

Introducing…  Big Ted.

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

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

Big Ted is also prediabetic.

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

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

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

Nutrients to prioritise

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

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

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

Rather than simply prioritising nutrient density and energy density, this scenario also prioritise a lower insulin load in view of Big Ted’s looming prediabetes situation.

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

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

Calorie math

The charts below show the energy consumed and energy burned.

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

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

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

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

Optimal foods for Big Ted are listed below.

Vegetables

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

Animal products

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

Seafood

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

Egg

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

Nut sand seeds

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

This image below summarises these foods for easy reference.

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

How often should I eat on a PSMF?

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

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

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

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

How low can you go?

Hopefully this article has given you some actionable principles:

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

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

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

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

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

#context matters


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

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

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

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How to do a nutrient dense PSMF

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

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Summary

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

 

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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which nutrients is YOUR diet missing?  

I recently took a look at which nutrients might be missing from various popular dietary approaches in preparation for a recent on nutrient density.  At a population level, the chart below shows the proportion of the US population that are deficient in various micronutrients.  Many people are not getting enough vitamin D, vitamin E, magnesium, calcium, etc.

While your body hasn’t read the World Health Organisation’s reports on the Daily Recommended Intake of the various essential nutrients,[1] it’s likely that your appetite will drive you to seek out the nutrients that are lacking.  If we are deficient in something that is required the body kicks in “nutrient hunger” and cravings that will make sure it gets what it needs.[2] [3] [4]

If you work hard to restrict your food intake to a certain dietary approach, but the body doesn’t receive the nutrients it needs, it may slow down and not function at full capacity.   By contrast, adequate nutrition, without too much energy, slows many of the modern diseases of aging such as diabetes, Alzheimer’s and cancer and improves your chance of living healthfully to a ripe old age.[5]

USDA foods database

The chart below shows the nutrients that are both easiest and hardest to obtain from the eight thousand foods in the USDA foods database.  At the bottom of this plot we have iron, various amino acids, and vitamin C, all of which are easy to obtain in adequate quantities.

However, at the top of the chart, we can see that it is much harder to obtain adequate quantities of six essential nutrients (omega 3 fatty acids, vitamin D, choline, vitamin E, and potassium).  We would obtain sufficient quantities of all the other essential nutrients if we ate just a little of each of the foods in the USDA food database.

If we want to maximise nutrient density, it makes sense to prioritise foods that contain more of the harder-to-obtain nutrients.  The chart below shows the nutrients for the top 10% of the 8000 foods in the USDA database (blue bars) when we prioritise for those.  Not only do we get an increase in the more difficult to obtain nutrients, we also get a massive boost in all nutrients.  Rather than being inadequate in six nutrients, we are now lacking only one (alpha-Linolenic acid, an Omega 3 fatty acid).

Limiting our food selection to the most nutrient dense foods makes it easier for us to consume the required nutrients without excessive energy, which is ideal if we are trying to lose fat or reduce calorie intake to slow the diseases of ageing.[6] [7]  Nutrient density becomes even more important if you’re fasting or restricting calories to achieve long term weight loss.

Optimising nutrient density

If you’re reading this, then you’re likely aware that there is a wide variety of dietary approaches that people follow to optimise their health depending on their preferences and beliefs.

I’ve tried to turn many of these beliefs about nutrition into a quantitative algorithm that we can use to evaluate and compare these approaches, and make sure we’re getting the outcome we want (e.g. low insulin, blood glucose control, nutrient density, or low/high energy density).

After testing a number of options, the three quantitative parameters that I have found the three parameters that are most useful are:

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

My aim in this post is to show how considering nutrient density can improve various dietary approaches, from therapeutic ketogenic, vegan, paleo, and low fat.   This post highlights which nutrients you will most likely be lacking with each of the different nutritional approaches, which foods you can use to fill these nutritional gaps, and perhaps which supplements you may need if you are still looking for some added nutritional insurance.

There’s been a lot of talk lately by Taubes[8] and Lustig[9] about how bad sugar and fructose are, but I think these nutritive sweeteners are just extreme examples of nutrient poor foods that are highly insulinogenic and energy dense.  At the other end of the spectrum, we have foods like liver, broccoli, and spinach.  Everything else is somewhere in the middle and will support or work against your goals, whatever they may be, to different degrees.

My aim here is to help you see where each of these foods sits on that continuum and use this information to help you refine your food choices to reach your personal goals.

Therapeutic ketogenic diet

Let’s start with the therapeutic ketogenic dietary approach.   I have previously noted that a number of the issues and concerns with the ketogenic diet seem to relate to being able to obtain essential nutrients rather than consuming excessive levels of fat.[10] [11] [12]  On one hand, I’m excited that the concepts of insulin load and percentage of insulinogenic calories have been helpful for people with chronic conditions such as epilepsy, cancer, dementia, Alzheimer’s etc.  However, I think there is a risk their ultra-high fat diet will not contain the nutrients which are critically important for mitochondrial function and energy production.

The chart below shows the vitamins and minerals provided by a therapeutic ketogenic dietary approach if we simply prioritise for low insulin load (red bars)[13] in comparison to the average of all foods in the USDA database (orange bars).  If you don’t pay attention to nutrient density a therapeutic ketogenic diet can provide lower levels of nutrition.

As shown in the chart below if we ate a little of all the foods in the USDA database, we would be deficient in six essential nutrients, whereas if we follow a therapeutic ketogenic diet, we will likely be lacking in ten essential nutrients.

The chart below shows the effect of how thinking in terms of nutrient density can improve the therapeutic ketogenic dietary approach (blue bars) compared to prioritising for insulin load only (red bars).  All nutrients are boosted, particularly the harder to obtain ones.

While lots of people find that higher fat whole foods are hard to overeat, there are still some hyper palatable high fat foods that go down easily.  We talk about eating “fat to satiety”, but what happens when nutrient hunger kicks in and your body is craving more potassium, magnesium, calcium, or one of the other nutrients that are harder to obtain in a very high fat dietary approach?  If you keep on consuming large amounts of processed fats that don’t contain the nutrients you require, your appetite may not automatically turn off before you’ve consumed a lot of excess energy!

Low carb

The chart below shows the boost in nutrients when we consider nutrient density combined with a low carbohydrate approach.  It appears that, based on this analysis, that without a focus on nutrient density, a low carbohydrate diet is likely to be deficient in folate, vitamin D, choline, potassium, magnesium, pantothenic acid, calcium, vitamin E and manganese.  With a focus on nutrient dense foods, a low carb diet provides adequate amounts of the majority of nutrients.

Weight loss (insulin sensitive)

The weight loss approach is intended for people who are insulin sensitive but still have excess body fat to lose.  Foods with a lower energy density (e.g. spinach, broccoli cucumber, celery, lettuce etc) typically are harder to overeat because they are bulky.

This approach doesn’t pay any attention to insulin load because it is assumed that people using this approach are not insulin resistant and are able to maintain good blood glucose levels.  Practically, it’s also difficult to achieve a really high insulin load with these foods because they do not contain a large amount of processed carbs and are hard to overeat.

Without consideration of nutrient density, the essential fatty acids tend to be low along with vitamin B-12, choline, and tyrosine.  However, once we factor in nutrient density all these nutrients dramatically improve.

This approach may not be viable for long term maintenance due to the extremely low energy density which would make it hard to get in enough energy.  However, in the short term, it may be appropriate for a period of substantial energy restriction, and will provide maximum nutrition with a minimum amount of energy.

Zero carb

Getting adequate protein on a zero-carb approach is not a problem.  However, unless there is a major focus on organ meats, there are a large number of vitamins and minerals, such as   vitamin K, manganese, vitamin C, vitamin E, vitamin D, potassium, magnesium and calcium that may be worth supplementing.

Vegan

At the other extreme, the chart shows the nutritional analysis of the vegan diet.  The main deficiencies in a vegan approach are omega 3s and vitamin B-12, which are hard to obtain without animal products.  It may be prudent for vegans to consider fish oil supplementation and B-12 injections, or alternatively adding some seafood occasionally.

While it appears possible to obtain the recommended levels of protein, it’s hard to get very high levels of it.    If you are insulin resistant, the fat levels can be increased using added coconut products and nuts.

Higher insulin load foods for bulking

The bulking approach is designed for people who are looking to gain strength and size by combining nutrient density with more calories and insulin load.  Without consideration of nutrient density, a high insulin load means very low nutrient density foods.  However, once we factor in nutrient density, we get a range of highly nutritious foods that may be helpful if you want to gain size and strength, while still maximising health and nutrition.

Paleo

The chart below shows the nutrients provided by the Paleo approach (i.e. no processed foods, dairy or grains) both with and without consideration of nutrient density.  While ‘going Paleo’ eliminates many of the nutrient-poor processed food, it appears to be beneficial to also consider nutrient density as well in addition.

What does this all mean?

So, how do we decide which approach is best?  Unfortunately, it’s not straightforward so I’ll look at this a number of ways.

What we ideally want is to identify the foods that will provide us with high amounts of all of the nutrients.   The blue bars in the chart below represents the average of the % daily recommended intake of all the nutrients in the various approaches evaluated above, without considering nutrient density.  The orange bars represent the average minus 0.5 x the standard deviation which is a measure of reliability.  The higher the reliability the more consistent and high are the nutrients over all.

This chart shows that, in comparison to the other approaches, Paleo foods have a high and consistent level of nutrients; while the vegan and low energy density weight loss foods have high levels of some individual nutrients, but low levels of some others.  Without consideration of nutrient density, the high insulin, low carb and zero carb approaches are a bit lacking in nutrients.

Things become a little more interesting once we factor in nutrient density.  The vegan, therapeutic keto, low carb and zero carb approaches do poorly against the paleo, higher insulin load, most nutrient dense of all foods, and the lower energy density weight loss foods.

Many people will benefit on a high fat therapeutic ketogenic dietary approach, at least until their blood glucose and insulin levels normalise.  However, in time, it may be beneficial to transition to more nutrient dense foods to continue their journey towards optimal health.

As detailed in the ‘how to optimise your diet for insulin resistance’ article, I think you should eat the most nutrient dense foods your pancreas can keep up with while maintaining good blood glucose levels.  In time, someone who is highly insulin resistant may be able to progress to a more nutrient dense and more moderate fat approach if your ultimate goal is to normalise blood glucose levels and lose weight.

Food lists

If you identify with any of these goals, you may be interested in following these food lists.   If blood glucose levels are sky high or you are managing a chronic condition such as epilepsy, cancer, Alzheimer’s or dementia, you may benefit from a higher fat therapeutic keto dietary approach, for a period.  As your glucose levels come under control, you can transition to more nutrient dense foods that will also help you to achieve your weight goals.

approach average glucose waist : height

(mg/dL)

(mmol/L)
therapeutic ketosis

> 140

> 7.8
diabetes and nutritional ketosis

108 to 140

6.0 to 7.8
weight loss (insulin resistant)

100 to 108

5.4 to 6.0

> 0.5

weight loss (insulin sensitive)

< 97

< 5.4

> 0.5

bulking

< 97

< 5.4

< 0.5

nutrient dense maintenance

< 97

< 5.4

< 0.5

Getting even more personal

As you can see, nutrients are provided at different levels depending on the approach.  However, most people don’t follow any dietary approach strictly, so the nutrients in your diet will be different depending on your personal habits and preferences.

Rather than trying to pick up someone else’s nutrition plan, or live by a strict list, I think it’s better to refine your current habits, emphasising the good foods, minimising the bad, and progressively trying new foods that may be beneficial.

To this end, I’ve been developing a Nutrient Optimizer algorithm that can help you refine your food choices to suit your goals.  By identifying the foods you are currently eating that align most with your current goals, which ones don’t, and which new foods perhaps you should consider.

Most current nutritional advice is driven by the avoidance of fat, particularly saturated fat, and therefore ends up being next to useless.  Calorie counting apps like MyFitnessPal does nothing but count calories, which is also of limited use.  Cron-o-meter tracks your micronutrients and can recommend foods to boost a single nutrient.  However, there doesn’t seem to be anything available that will tell you which foods will help you actually correct multiple deficiencies and  achieve a diet that is truly balanced in micronutrients.

The Nutrient Optimiser also allows you to tailor the approach to your goals, such as:  therapeutic ketosis, diabetes management, weight loss or just nutrient dense maintenance.  Food preferences like vegan, pescetarian, autoimmune, or paleo can be factored in to the recommended food lists.

At the moment, the process involves manually exporting food intake data from Cron-o-meter, then analysing it in a spreadsheet to manually generate a personalised report.  I am eager to do this as a proof-of-concept for a range of people with various goals (particularly therapeutic ketosis, vegetarian, zero carb, fruitarian) to demonstrate how it works.  So, if you’re happy to have your report shared publicly, and have a couple of weeks of Cron-o-meter data, feel free to send it to me and  have your data analysed.

In time, the plan is to automate the process via an online interface and then ideally an independent mobile app.    To keep up-to-date with progress, watch this space and check out the various analysed examples on the Marty Kendall’s Nutrient Optimiser Facebook page.

Epilogue…  limitations

For completeness, I thought it would be worth mentioning a few limitations relating to calculating nutrient density…

  1. Measuring foods in terms of calories has its own limitations as different macronutrients provide different amounts of energy (ATP) in different people. Some smart friends of mine are working on calculating ATP yield for different foods based on their macronutrient content.  I’ll happily update this analysis in terms of nutrients per ATP as soon as that data is available.  Initial indications are that people who are fat-adapted are able to use fat more efficiently (i.e. less entropy/losses in metabolism) and hence require less calories to yield the same amount of energy in the body (i.e. ATP).  Hence, it appears that it is even more important for someone following a low carb or ketogenic approach to maximise nutrient density in terms of nutrients per calorie.
  2. The official dietary reference values are based on limited research.[14] Typically, they relate to the minimum amount of a nutrient to avoid disease rather than the amount required for optimal function.  They may also vary by person (e.g. someone who is more active may need more protein) and by their diet type (e.g. someone who is on a low carb diet may need less vitamin C to process the limited amount of glucose).  Hence, I think the DRI values should be seen as a minimum.  Ideally, we want to get more than the minimum while not having to ingest too much energy.  I also don’t think nutrients are meant to come as individual vitamins and minerals in a bottle.  The nutrients required to metabolise a certain food typically come packaged in whole foods, and often work synergistically.  Taking supplements or fortifying foods will always be inferior to obtaining nutrients from whole foods.
  3. Species-specific bioavailability and anti-nutrients are contentious topics. Zero carbers will tell you that nutrients in animal based foods are more bioavailable than plant based foods, while the vegans will tell you the opposite.  To date, I haven’t been able to find useful data that would enable me to quantitatively refine the nutrient data in the USDA database regarding bioavailability.  All we currently have is a measure of the nutrients contained in the food– rather than the nutrients that make it into your body after digestion.  Again, if this data ever comes to hand, I’ll eagerly update the analysis.

Overall, I don’t think these limitations make a difference in the outcomes of the analysis.  This is not an exact science and the body doesn’t operation like a rigid machine.  Calculation of nutrient density is just a way to identify the foods that contain the most raw materials with the least amount of calories that your body can work with.

referecnes

[1] http://www.who.int/nutrition/publications/nutrient/en/

[2] https://books.google.com.au/books?id=gtQyAgAAQBAJ&pg=PA185&lpg=PA185&dq=%22nutrient+hunger%22&source=bl&ots=VMRQ8EbvHx&sig=l_xJEksBS538UX3QwQNxVJBXTLw&hl=en&sa=X&ved=0ahUKEwjRj6mSs5DSAhWKyLwKHXBQAjEQ6AEIKDAC#v=onepage&q=%22nutrient%20hunger%22&f=false

[3] https://www.amazon.com/Perfect-Health-Diet-Regain-Weight/dp/1451699158

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

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

[6] http://ajcn.nutrition.org/content/78/3/361.full

[7] http://www.nature.com/articles/ncomms14063

[8] https://www.amazon.com/Case-Against-Sugar-Gary-Taubes/dp/0307701646

[9] https://www.youtube.com/watch?v=dBnniua6-oM

[10] https://www.thepaleomom.com/adverse-reactions-to-ketogenic-diets-caution-advised/

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

[12] http://www.thelivinlowcarbshow.com/shownotes/10888/868-dr-sarah-ballantyne-challenges-the-wisdom-of-low-carb-diets-for-women-2/

[13] In terms of macronutrients this high fat dietary approach comes out at 80% fat, 15% protein, 2% fibre and 3% net carbs.

[14] http://www.who.int/nutrition/publications/nutrient/en/

analysis of what a nutritionist eats and hospital food

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

references

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

sardines, spinach, eggs and avocado

My dad has been working hard to craft nutrient dense moderate protein meals.  For a while he was pursuing ketosis with a higher amount of dietary fat and his Bulletproof teas with extra butter after I introduced him to Dave Asprey’s version of “intermittent fasting” .

After an initial period of success  he found he was putting on weight, becoming inflamed and his blood glucose levels were starting to drift back up.

He then started to go for a slightly higher amount of protein in line with the concepts described in Volek and Phinney’s four phases of a ketogenic diet chart.  That is, during weight loss some of the fat being burned each day should come from body fat.  Hence his meals needed to focus on getting adequate protein to support muscle maintenance and obtain other necessary nutrients, while significantly reducing dietary fat.

Once he did this he started losing weight and his ketones actually increased due to the body fat being burned.  With adequate protein in place he then dialed down the dietary fat to the place that still comfortably satisfied hunger.  From there he had some great results in terms of weight loss.

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This meal of sardines, eggs, spinach, garlic, broccoli sprouts, avocado, goat cheese and a few walnuts is an example of one of those meals.  The details are shown in the analysis below.  As you can see it does well in terms of both the vitamins and minerals and the protein score.  While there is not a lot of added fat in this meal (butter used for cooking) there is still 65% fat from whole foods.

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

net carbs Insulin load carb insulin fat protein fibre
4g 23g 16% 65% 35g 5g

stir fry veggies with sardines

This is a simple  breakfast we’ve been doing at our place lately.

For an speedy pre-work breakfast we buy the veggies pre-chopped from Coles (in a bag) and throw them in the fry pan with some butter.

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For some extra protein and nutrients open a can of sardines when the veggies are done.

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As you can see below, the vitamin and mineral score very well and the protein score is great too!

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The veggies contain some carbs, but not a lot of net carbs once you account for the fibre.  This meal has a nice gentle response on Moni’s (my wife who has Type 1 diabetes) blood glucose levels too.

If you were looking for a more ketogenic approach you could add some more butter in the cooking.  If you were looking to lose weight you could add a bit less.

This recipe comes in at:

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

net carbs insulin load carb insulin fat protein fibre
8g 29g 26% 54% 39g 11g

Some other variations on the theme include, veggies with canned salmon and cottage cheese.

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Or just straight with the almonds, no fish.

 

Moni enjoys this if she’s sick of diary and eggs.

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

net carbs insulin load carb insulin fat protein fibre
12g 22g 55% 65% 18g 14g

how optimize your diet for your insulin resistance

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

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

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

the importance of monitoring blood glucose levels

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

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

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

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

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

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optimal ketone levels

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

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

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

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

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

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

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

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

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

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

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“The ratio of β-OHB to AcAc depends on the NADH/NAD+ ratio inside mitochondria; if NADH concentration is high, the liver releases a higher proportion of β-OHB.”[14]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

the relationship between ketones and glucose

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

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

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

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

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

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

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

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

it works until it doesn’t

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

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

What gives?

What do you do now?

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

It can be confusing on the interwebs!

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

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

what is insulin resistance anyway?

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

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

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

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

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

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

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

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

be a nutrient chaser

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

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

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

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

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

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

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

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

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

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

ask the experts

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

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

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

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

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

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

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

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are you really insulin resistant?

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

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

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

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

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

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

oral glucose tolerance test

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

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

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

kraft test

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

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oral protein tolerance test

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

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

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

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

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

optimal dietary approach survey

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

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

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

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

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

can I take my insulin levels to zero?

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

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

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

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

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

so just tell me what to eat!

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

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

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

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

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

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

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

post last updated May 2017

references

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[21] http://perfecthealthdiet.com/

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

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

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

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

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

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

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

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

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

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

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

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

how to use your bathroom scale as a fuel gauge

“Complete abstinence is easier than perfect moderation.”

St Augustine

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This article is a follow up to the “How to use your glucose metre as a fuel gauge” article, which has been quite popular, with lots of people reporting success in lowering their blood glucose and recalibrating their hunger signals by using the numbers they see on their glucose metre.

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To recap, the process revolves around the idea that, perhaps even better than calorie counting or carbohydrate counting, the numbers you see on your blood glucose metre are a good indication of whether you are running low on fuel and need to eat or whether you are just eating out of habit, routine, social boredom or for entertainment.

While eating for pleasure occasionally or as part of a celebration is fine and part of enjoying life, in the long run most of us need to find a way to obtain the nutrients we need with less energy if we want to avoid obesity, diabetes and all the associated negative consequences.

If we eat highly insulinogenic low nutrient density foods regularly our insulin levels stay high and our fat stays locked in storage and hunger drives us to eat more frequently.  However, if we reverse this cycle to lower our glucose and insulin to normal levels we start to eat less frequently and we allow our stored energy to flow out of our fat cells, our appetite decrease and there is a good chance we will lose weight and gain health.

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The table below shows the simple process whereby someone could decide if they really need to eat.  Using this process would ensure that their blood glucose levels continue to trend down as their excess energy in their bloodstream and vital organs (pancreas, liver etc) flows out of storage.

blood glucose action
>  7 day average, well slept and low stress delay eating and / or exercise and wait for blood glucose to come down
< 7 day average if hungry, enjoy nutrient dense foods that align with your insulin sensitivity
< 73mg/dL or 4.0 mmol/L if hungry, eat higher insulin load foods and delay exercise

Using numerical outputs to guide our decision making

There is no end of debate as to whether a calorie is a calorie or whether calories matter.   Rather than tracking estimates of inputs like calories eaten or calories burned in exercise, there is nothing like tracking outputs such as your blood glucose levels, waist or weight to understand what your body is doing with the food you are eating and whether you are eating too much or too little.

If your glucose levels, insulin, waist or weight are increasing then chances are you’re eating too much, too often or the wrong type of food.

The plot below is a stark reminder that our chances of living longer improve if we have lower body fat levels or a waist to height ratio close to 0.5.

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The problem with tracking glucose levels

The ‘problem’ with tracking blood glucose levels is that, in time, with regular fasting, our glucose levels will normalise to healthy levels but we may still be left with excess weight.  So where do we turn once our blood glucose levels are optimal but our body fat levels are still above optimal?

This brings us to the star of this article, Rebecca Latham, who is a great example of how you can use your body measurements to guide your feast / fast cycle to achieve your long-term goals.

Rebecca has been following a low carb diet since the start of February 2009.  She was featured in the 2010 New Atkins for a New You[1]  as well as on the Atkins site as an example success story.[2]  She was a guest on Episode 404 of Jimmy Moore’s Livin’ La Vida Low Carb podcast.

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After a stressful time towards the end of 2015 Rebecca Latham decided she needed to make a focused effort to her lose some extra weight that had crept on.  Rebecca is also particularly motivated by her family history of ALS, Parkinson’s Disease, dementia and cancer and her own ongoing battle with Type 2 Diabetes.

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Rebecca’s Protocol

On 1 January 2016 Rebecca set an initial goal to lose 0.2 pounds per day over three months.      Rebecca was also eager to reduce her fasting blood glucose levels from the 100mg/dL back to the 70mg/dL that they had been at before she regained her weight.

Part of Rebecca’s inspiration comes from her uncle, Buell Carlton Cole.

He was general surgeon to the President of the United States, who would control his weight by simply not eating until he returned to his goal weight.  I initially thought this was an unhealthy approach until I read up a more about intermittent fasting.

Rather than simply not eating until she achieved her goal weight, Rebecca’s system involved not eating on days when her weight in the morning was above her target weight.  Her only exception was to be special occasions and celebrations.

Here are Rebecca’s weight loss results during her initial 90-day challenge.  Initial weight loss can be quite quick as the insulin levels drop and the body releases water.  However, it gets a bit harder to continue with straight line weight loss as time goes on as you can see towards the end.

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After the reached her initial goal, Rebecca had some issues that she needed to look after and ended up regaining some of the weight as you can see in the plot below of her weight over the past year.  However, once these challenges were behind her she got back on her program.  For the final part leading up to the end of the year she has dropped her goal weight loss back to 0.06lbs per day to hit her goal on 31 December 2016.   See if you can spot the few ‘blips’ around Thanksgiving and Christmas.

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This chart shows that she needed to fast for about one day in three through the year to lose nearly a quarter of her body weight over the year!

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Reflecting on her journey, Rebecca says:

I reached my highest lifetime weight in February 2009, when I weighed in at 158 pounds, with a body fat percentage of 43.7%. This is my scale weight chart for this past almost eight years, since I started eating low carb high fat (LCHF) and nutritional ketosis.

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Each time I lost weight and stopped tracking and weighing myself, I gradually put most of the weight back on again. As you can see by the chart, this happened several times, and the last few times it happened, my weight was going up a little higher each time.

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On January 1, 2016, I developed and started using my Protocol. Since starting the Protocol, I took two breaks, once in May 2016 when my husband had a heart attack and I was too concerned with his health to care about my own, but I got back on the Protocol within a couple of weeks and started seeing success again.

The next time I took a break was in July 2016, when I had to eat high carb and not fast for a week in preparation for some metabolic testing. As soon as the testing was over, I was back on the Protocol and started losing again. I have been going strong ever since, with small gains here and there brought on by restaurant meals and Thanksgiving.

I have now I reached my ultimate goal for scale weight, weighing in at 122.4 pounds with a body fat percentage of 25.7%, which means that I have lost approximately 37.5 pounds of body fat. The Protocol is the only thing that has brought me sustained weight loss, and I plan to follow it for the rest of my life!

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Many people have a love / hate or even just a hate / hate relationship with their bathroom scale.  It would be nice if low carb or nutrient dense achieved optimal health outcomes without any restriction for everyone.  However, unfortunately, sustaining weight loss in the long term often takes discipline, some form of accountability and some level of restriction for most of us.

While weighing yourself every day isn’t much fun, the national weight control registry data indicates that people who have successfully lost weight and kept it off weigh themselves regularly.[3] [4]  [5] Rebecca’s intended long term maintenance plan will likely be to weigh herself regularly and fast again once her weight goes outside her target range.

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Better than calorie counting?

Some people who first try low carb or keto find that they initially lose a lot of weight eating to satiety as their blood glucose and insulin levels drop to healthier levels.  However, in the long term many people find that they need to be more disciplined and mindful of how much and / or how often they are eating to reach their optimal level of body composition.

The great thing about combining fasting with working to a goal like this is that it makes sure you don’t overdo the feasting days.  I’ve found personally that it can be hard to know how much to eat after a fast.  A quantitative system like this helps to manage and calibrate your appetite when you’re feasting.

If you eat to satiety, and not beyond, then you won’t have to fast again as soon as compared to if you binge after your fast.  Eating to satiety on a regular basis means that your body’s metabolism doesn’t slow and adjust in the same way that it would if you maintained a constant caloric restriction.[6]

Life extension benefits

There are a number of benefits to fasting:

  • You can reduce your insulin levels more than if eating small but regular meals which keeps your insulin levels consistently elevated.
  • Fasting gives your body a chance to repair through a process called autophagy which is where the old cells are cleaned up which allow space for the fresh new cells to grow.
  • Fasting trains your body to become ‘metabolically flexible’ so you can use your body fat stores for and your food for fuel.
  • There is less need to focus on the quantity of food eaten at every single meal.
  • It’s not ideal to always be in growth mode with mTOR switched on. Alternating periods of growth and repair appear to be more beneficial in the long term.[7]
  • Fasting makes sense from an ancestral point of view when we wouldn’t have had constant access to plentiful food the way we do now. Periods of intentional restriction mimic what we have become adapted to and follow the seasons of the past.

Fasting also seems to have some special anti-aging effects.  When food is scarce your body senses an emergency, and sends out sirtuin proteins to maximise the health of our mitochondria to increase the chance that you will survive the famine and have the best chance of living to a time when food is more plentiful and you can reproduce and pass on your genes.  Unfortunately, this emergency repair function doesn’t happen when food is plentiful.

Fasting and blood glucose levels

During the first three months following her Protocol Rebecca added a blood glucose target to also bring her blood sugar down by 0.25 mg/dL per day.  As you can see in the chart below her blood glucose levels have dropped pretty much in parallel with her weight loss during this time.

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More recently, she tested her blood glucose levels and found that they were consistently great so she ended up discontinuing the testing because it was becoming monotonous and not helping her make useful decisions.

While it’s useful to track a few things, it can be overwhelming and time consuming to keep track of too many things at once and lead to analysis paralysis.  It’s good to find a handful of things to track that will help you make useful decisions.

Do we lose fat or muscle during fasting?

One hot topic of discussion is the amount of lean mass (i.e. or muscle) that one may lose in long term fasting.

The reality is that any weight loss is going to consist of a combination of water, fat and muscle (or lean muscle mass).  The chart below from Kevin Hall’s model shows that we initially lose a lot of carbohydrate (glycogen) and with it a lot of water.

Protein / muscle loss is the smallest component of loss from the body and this decreases as we adapt more to using fat and ketones rather than relying on glucose.  It takes a few days to adapt to using fat and ketones, but in the long run they are by far the greatest proportion of energy used during fasting.

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Rebecca’s experience aligns with this.  She didn’t get a DEXA scan, but she does take regular body measurements which she uses to calculate her body fat percentage (see US Navy Circumference Method).  Based on these measurements she lost 28.6 lbs of fat and 3.0 lbs of lean mass.   So, more than 90% of her weight loss over the past year was fat.

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“Problems” with fasting

Jason Fung has recently popularised the concept of fasting in the low carb community via his blog and videos and published The Complete Guide to Fasting.  There is a ton of convincing evidence on the benefits of fasting which is an age old practice for a variety of reasons.

However, Dr Steve Phinney has come out highlighting his concerns with long term fasting with respect to loss of lean tissues as well as vitamins and minerals.    A number of others have expressed concerns that fasting without due care and attention to refeeding will not be beneficial in the long term.

One way to reconcile the differences is to see these concerns as two ends of the spectrum.  Jason’s focus is very sick people who come to him with major kidney issues due to their advanced Type 2 Diabetes, while Steve’s focus is more around maximising athletic performance for those whom maintaining muscle mass is critical to performance.

As you can see in the chart below from Differences in fat, carbohydrate, and protein metabolism between lean and obese subjects undergoing total starvation the proportion of energy from lean body mass increases as our level of available level of body fat decreases.

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Also, if you are more fat adapted your body will be able to more easily draw energy from stored body fat rather than requiring glucose which can be drawn from the protein in your body via gluconeogenesis.

Most people don’t fit neatly into either of the extremes, so how do you refine the approach to suit your current situation?   That is where optimising your food choices to suit your current situation comes in.

How much to eat after your fast?

Personally, one challenge I find with fasting is that it’s easy to overdo it when you get to eat again.  I think some people experience this more than others.  Dr Phinney made the analogy that telling someone not to binge at the end of a fast is like telling someone to hold their breath but then not to take too big a breath when they come up for air.

While some people can eat normally the next day after a fast, personally I find that it’s easy to reach for the energy dense lower nutrient dense foods or to give yourself liberty to eat foods that you may not normally eat if you were being disciplined all the time.   By doing this, I’ve found it’s still possible to maintain or gain weight when fasting more days that you eat if you’re not disciplined with what you eat on your feasting days.

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If you find yourself reaching for energy dense low nutrient density foods like processed carbs, a block of chocolate or litre of cream after your fast then you could take that as a sign that you need to revert to shorter fasting periods until you’re more fat adapted.

Another challenge with fasting is that it will deplete your system of vital nutrients in the long term meaning that you may be more inclined to binge when you do eat unless you’ve focusing on maximising nutrient density in your feasting periods.[8]

What to eat after you fast

One of the unique things about fasting is that it forces your body into the cleansing process of autophagy and primes the body to rebuild.  Hence, it’s especially important to feed the parts of the body you want to grow (lean muscle mass is critical for long term health[9]) and maximise the nutrient density during the initial refeed.

In some ways, a fast is only as good as the feast afterwards that your body is highly primed to absorb.  For me that means trying to plan some nutrient dense greens and a solid amount of protein for my first meal so I don’t end up reaching for the energy dense cream, butter or peanut butter or indulge in some junk carbage because I feel like I’ve earned it.

If your goal is to lose fat during the fast then it’s important to build back the essential vitamins, minerals and amino acids during the feeding period.   The body will fight to get what it needs in the long run and I think you’ll have a better chance of avoiding cravings and involuntary binging if you maximise the essential nutrients of your food when you do this.  And if you are using fasting to achieve long term weight loss I think it makes sense to try to get the maximum number of nutrients with the least amount of energy (a.k.a.  avoiding empty calories and maximising nutrient density).

People looking to use fasting for long term weight loss may benefit from starting out with a higher fat dietary approach if they are very insulin resistant.  However, as blood glucose levels progressively improve you should be able to transition to a more nutrient dense nutritional approach which will allow you to get your required nutrients with less energy.

I see a lot of arguments online regarding whether high fat keto or high protein is optimal. I think these arguments come down to context.  The table below gives some guidance as to which approach might be right for you initially based on:

  1. your blood glucose levels (if your glucose levels are high you will likely benefit from a higher fat keto approach, at least initially until your glucose levels start to normalise),
  2. ketones (some is better than none, but there’s no need to chase high ketones with heaps of extra dietary fat, especially if you are trying to lose body fat), and
  3. waist to height ratio (this is going to be more useful than the BMI chart to tell you if you still need to lose a bit of weight).
approach average glucose ketones (mmol/L) waist : height
(mg/dL) (mmol/L)
therapeutic ketosis > 140 > 7.8 < 0.3
diabetes and nutritional ketosis 108 to 140 6.0 to 7.8 < 0.3
weight loss (insulin resistant) 97 to 108 5.4 to 6.0 < 0.3 > 0.5
weight loss (insulin sensitive) < 97 < 5.4 > 0.2 > 0.5
nutrient dense maintenance < 97 < 5.4 > 0.2 < 0.5

This graphic from Dr Ted Naiman demonstrates how foods are all somewhere on the sliding scale between maximum energy density and maximum nutrient density.  If we are aiming for long term weight loss, we want to maximise nutrient density as much as we can while keeping blood glucose levels and insulin levels low. Then as we improve blood glucose levels and insulin sensitivity we will be able continue to move towards the right to more nutrient dense approaches which will help to provide satiety and adequate nutrition with less energy.[10]

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If / when we reach our ideal weight or level of body fat, we can afford to add back in some more energy dense foods because we are no longer trying to use the glucose in our liver (glycogen) and body fat from our belly.[11] [12]

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Rebecca says:

I originally started eating ketogenically a few years ago by eating very high fat, lower protein, and very low (sometimes zero) carbs. That worked for a while, and I lost weight, but as time went on, I found that I was eating so much fat and so little protein that I was getting hungry all the time.

I now get plenty of protein on my eating days. I am 5’3″ and eat 125g on the days that I feast.  I find with this approach I am less hungry and my Protocol requires me to fast less often.[13] [14]

Losing lean muscle mass is bad news whether you’re a bodybuilder, a diabetic or an older person battling sarcopenia.[15]   Not only will losing muscle decrease your metabolic health, glucose disposal and metabolic rate, your body will also increase appetite to regain the muscle, making it harder to keep on losing the fat.[16]

It’s not just about looking buff and building muscles, amino acids are critical to fueling mitochondrial function and creating neurotransmitters that assist in staying happy and sleeping well.  For example, the amino acid tryptophan produces serotonin which makes us happy and melatonin which helps us sleep.[17]

For reference, Rebecca’s 125g of protein per day ends up being 3g/kg LMB.  This equates to 2g/kg LBM per day on average if you factor in the fact that she fasts every third day.   This aligns with Volek and Phinney’s recommendations in the Art and Science of Low Carb Living (i.e. 1.5 – 2g/kg reference body weight) which equates to 1.7 to 2.2g/kg LBM .  In Lyle McDondald’s Rapid Fat Loss Handbook he recommends between 1.8 to 4.4g/kg LBM protein, with higher level of protein if you are lean and more active, and less if you are obese and inactive, to prevent muscle loss during a protein sparing modified fast.

The optimal food lists have been designed to help maximise nutrient density (including ensuring adequate amino acids) ideally without needing to rely on tracking calories.  Rebecca does track what she eats, but mainly to make sure she is getting adequate protein on her feasting days.

The Protocol does not *require* tracking food intake, but I strongly recommend it. I found, for myself, that if I did not track on feast days, I ate too much fat and not enough protein, and I was having to fast a lot more to make my daily goals. Starting in April, I did start using the OKL macros and recommending the same to others.[18]

Rebecca also practices early time restricted feeding (eTRF) which means she eats earlier in the day due to better insulin sensitivity which seems to be producing good results for a lot of people.  I have heard a lot of reports from people that have found that eating earlier rather than later helps with sleep, appetite and blood sugar.

Variations

I encourage you to check out Rebecca’s Facebook group where she has documented her daily progress and learnings and supports others using the Protocol.  You can download a spreadsheet and start tracking and sharing your own progress.  Public accountability and a supportive community are always going to be helpful in achieving such a long-term goal.

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Rebecca has ‘stacked’ several different techniques from her learnings to ensure her long term success this time around to fight her genetics and tendency to regain her weight.

Before launching in, there are several considerations to tailor Rebecca’s approach to suit your situation and goals such as:

  • Target rate of weight loss. Rebecca recommends that people aim for a maximum weight loss of 0.2lbs or 0.1kg per day.  Anything more is typically hard to sustain in the long term.  You might be feeling ambitious and this level might be easy to achieve when things are going well but it may be hard to sustain in the longer term, especially if you have a few social gatherings or parties that leave you with some catching up to do.  As you approach your goal weight you may be glad you chose a less aggressive goal as the weight loss becomes a little harder to achieve.

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  • Social context. This type of approach can be hard to work around family or social commitments.  I like to enjoy good food with my family on the weekends and save my fasting for work days when it’s easier to skip food.  When I’ve followed this protocol, it leaves me fasting Monday and Tuesday and eating dinner Tuesday night with the family or ideally a hearty breakfast Wednesday morning.  Based on my scale weight I may end up fasting another day or two on Thursday and / or Friday.
  • What’s your maximum fasting tolerance? Fasting gets easier with practice.  You might want to start with just skipping a couple of meals, then going for 36 hours, then a couple of days.  If you find your cravings are leading you to binge or sacrifice food quality, then you may want to stick with shorter fasting periods or aim for a less aggressive target rate of weight loss.
  • What else do you want to measure? The good thing about measuring weight is that it’s easy.  It can however be problematic in that there are a ton of things that influence your weight other than fat gain or loss (e.g. muscle, water, how full is your gut, when did you go to the toilet etc); it’s an easy way to measure your progress day to day.  In the long term, you want to see a trend in the right direction.  If you have diabetes, then you may also want to track your glucose and even your ketone levels.  It will also be useful to track your waist measurement periodically to see whether you’re getting closer to your optimum waist to height ratio of 0.5, particularly if you are building muscle and hence the BMI chart categories won’t mean much for you.  For reference, during 2016 Rebecca’s waist to height ratio went from 0.54 to 0.44.

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How full is your stress bucket?

A word of warning, again from personal experience, is that this approach is simple, but it’s not necessarily easy.  Wondering what number you will see on the scale each day can be exciting but a bit stressful.  It can be frustrating when you see the number going in the wrong direction or not keeping up with your target rate of weight loss.

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Chris Masterjohn recently did an excellent podcast How I Lost 30 Pounds in Four Months and How I Knew It Was Time which I highly recommend if you’re hoping to lose some serious weight.

A regular fasting routine is another thing that you will add to your “stress bucket” and if you don’t already have your sleep, nutrition, relationships, stress, circadian rhythm and regular activity in check then the cortisol and related insulin spikes may make achieving long term success with this approach harder than it would otherwise be.

If you do have these things ticked off and you’re feeling relaxed after a Christmas holidays but may have overdone the celebratory food then you can download a copy of the spreadsheet from My Low Carb Road – Fasting Support and give it a go.

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references

[1] http://www.why-low-carb-diets-work.com/atkins-forum.html

[2] https://www.carbsmart.com/low-carb-success-story-rebecca-latham.html

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

[4] https://www.ncbi.nlm.nih.gov/pubmed/18198319

[5] https://www.ncbi.nlm.nih.gov/pubmed/14668267

[6] https://www.ncbi.nlm.nih.gov/pubmed/20921964

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

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

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

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

[11] http://livinlavidalowcarb.com/blog/the-llvlc-show-episode-1161-qa-medical-panel-2016-low-carb-cruise/26797

[12] https://www.youtube.com/watch?v=2KYYnEAYCGk

[13] http://www.artandscienceoflowcarb.com/

[14] http://www.ketoisland.com/blog/is-keto-high-fat-or-low-fat/

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

[16] http://www.nature.com/ejcn/journal/vaop/ncurrent/full/ejcn2016256a.html?platform=hootsuite

[17]  https://optimisingnutrition.com/2016/12/03/finding-your-optimal-insulin-load/

[18] https://www.facebook.com/groups/MyLowCarbRoadFastingSupport/permalink/147072942381538/

eggs florentine with chicken livers and bacon

This recipe for eggs florentine with chicken livers and bacon is from Rebecca Latham who runs the My Low Carb Road – Fasting Support Facebook group.

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By using her regular fasting routine and nutrient dense feasting she has been able to lose 37.5 lb (17kg) of body fat during 2016 (which is significant given she is only 5′ 3″).

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This was one of her favourite go to recipes during her weight loss.     Rebecca says:

I originally started eating ketogenically a few years ago by eating very high fat, lower protein, and very low (sometimes zero) carbs.

That worked for a while, and I lost weight, but as time went on, I found that I was eating so much fat and so little protein that I was getting hungry all the time.

I now get plenty of protein on my eating days. I am 5’3″ and eat 125g on the days that I feast

It seems that as you approach your goal weight your body works increases appetite to maintain lean muscle mass.  I think this style of higher protein meal will maximise your chance of managing appetite during weight loss as well as maximising nutrient density to prevent rebound binges due to cravings for nutrients.

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Rebecca’s recipe is:

114g (4 oz.) raw chicken livers, cut into small pieces
1/4 tsp. chopped, dried rosemary
1/4 tsp. ground, dried thyme
1/4 tsp. garlic powder
1/4 tsp. sea salt
114g (4 oz.) frozen, chopped spinach, cooked, drained, warm
1 Tbs. butter, divided
57g (2 oz.) raw onion, chopped
114g (4 oz.) raw white mushrooms, chopped
2 thick slices bacon, cooked and cut into small pieces
1 Tbs. whiskey
2 raw eggs
Additional sea salt, as desired

In a small bowl, combine chicken livers, spices, and salt, stirring to combine. Set aside.

Preheat a small cast iron skillet on medium-low heat, then add 1/2 Tbs. butter. Add onions, cover and cook for 1 minute. Add mushrooms, cover and cook for an additional 2 minutes, or until veggies start to brown. Add chicken livers to the skillet, and continue to cook, stirring, until liver is cooked medium well. Add bacon and whiskey and stir again.

Cut the remaining 1/2 Tbs. butter into a several pieces and add to the skillet, allowing it to melt down into the bottom of the pan. Do not stir it in.

Carefully break the eggs into the skillet, letting them rest on top of the mixture. Cover the skillet and cook just long enough for the eggs to cook to however you like them. For the whites to be firm and the yolks to be runny, it may take 2-3 minutes.

Arrange the warm spinach on a plate, and with a spatula, carefully lift out the food from the skillet and set on top of the spinach. If there is any butter left in the skillet, pour it over the eggs. Add additional sea salt if desired, and enjoy!

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The nutritional analysis for this recipe is shown below.  This recipe comes in at #52 of 400 in the nutrient dense meals ranking and #67 in the diabetes and nutritional ketosis meal ranking.

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However if we sub out some of the onion and add some spinach it comes up to #23 of 400 in the nutrient nutrient dense meals ranking and #27 in the diabetes and nutritional ketosis.  Not bad.

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Look out for the article detailing Rebecca’s fasting / feasting Protocol which will be published on 1 January 2017 just in time for your New Years resolutions.

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

net carbs insulin load carb insulin fat protein fibre
6g 30g 19% 56% 44g 6g

 

curried egg with cows brain

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

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

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

Clean water.  More sunshine.  Closer to the equator.

These guys are the real deal.

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

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

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

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

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

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

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

 

nutrient dense foods for weight loss and insulin resistance

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

optimal foods for diabetes and nutritional ketosis

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

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

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

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

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

optimal foods for weight loss

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

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

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

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

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

finding the optimal balance between the extremes

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

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

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

weight-loss-insulin-resistant

vegetables

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

seafood

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

animal products

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

dairy and egg

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

other dietary approaches

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

dietary approach printable .pdf
weight loss (insulin sensitive) download
autoimmune (nutrient dense) download
alkaline foods download
nutrient dense bulking download
nutrient dense (maintenance) download
weight loss (insulin resistant) download
autoimmune (diabetes friendly) download
zero carb download
diabetes and nutritional ketosis download
vegan (nutrient dense) download
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If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help identify the optimal dietary approach for you.

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