basil pesto

Pesto can be a yummy way to get your get your micronutrients as well as high levels of fat at the same time.

This rustic version comes from Jessica Haggard’s Primal Edge Ketogenic Cookbook.

2016-11-19-3

Simple to make, it contains basil, pine nuts and olive oil with garlic for extra taste and minerals.

The basil and nuts end up being a carrier for the olive oil.

2016-11-19-4

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

net carbs Insulin load carb insulin fat protein fibre
3g 6g 53% 92% 5g 2g

 

how to use your bathroom scale as a fuel gauge

“Complete abstinence is easier than perfect moderation.”

St Augustine

image13

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.

image00

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.

image22

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.

image12

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.

image01

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.

image16

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.

image11

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.

15823034_10209877052875396_3419408148461382419_n

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!

15823300_10209877058475536_8030290499401844136_n

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.

image03

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.

15817831_10209874190763845_1533331424_o

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!

image10

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.

image21

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.

image06

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.

image23

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.

15726291_10209877054995449_1454532664093740434_n

“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.

image20

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.

image02

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 BMI 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]

image05

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]

image14

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.

image28

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.

image17

  • 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, whne 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 categories won’t mean much for you.  For reference, during 2016 Rebecca’s waist to height ratio went from 0.54 to 0.44.

image09

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.

image24

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.

image18

 

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.

2016-12-27

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″).

15727057_10209821240200114_1785777679376495249_n

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.

15241956_10209573518287221_140411797991623404_n

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!

15288609_10209573504406874_9115949053764426960_o

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.

2016-11-29

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.

2016-11-30

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

 

micronutrient flax crackers

Who would have thought crackers could be so ketogenic and nutrient dense at the same time.

This another recipe from the Ketogenic Edge Cookbook by Jessica Haggard.

2016-11-18-1

There are a ton of seeds and spices that soak up a liberal amount of butter or coconut oil which is what makes them so ketogenic.

2016-11-19

While the recipe comes out to be 20% total carbs, once you account for the massive amount of fibre the net carbs are negligible.  And the nutrient density from the herb and spices is awesome!

2016-11-19-1

If you like this sort of thing make sure you check out Jessica’s cookbook where she has created a whole range of real food ketogenic and diabetic friendly meals that won’t boost your blood sugars!

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

net carbs

Insulin load

carb insulin

fat

protein

fibre

4g

11g

34%

70%

13g

21

optimising protein and insulin load

  • “Low carb”, “ketogenic” or “nutrient dense” mean different things to different people. Defining these terms numerically can help us to choose the right tool for the right application.
  • Decreasing the insulin load of your diet can help normalise blood glucose levels and enable your pancreas to keep up. However, at the same time a high fat therapeutic ketogenic approach is not necessarily the most nutrient dense option, and may not be optimal in the long term, particularly if your goal is weight loss.
  • Balancing insulin load and nutrient density will enable you to identify the right approach for you at any given point in time.
  • This article suggests ideal macro nutrient, protein and insulin load, and carbohydrate levels for different people with different goals to use as a starting point as they work to optimise their weight and / or blood glucose levels.

context matters

Since I started blogging about the concepts of insulin load and proportion of insulinogenic calories many people have asked:

“What insulin load should I be aiming for?” 

Unfortunately, it’s hard to give a simple answer without some context.

The answer to this question depends on a person’s current metabolic health, age, activity level, weight, height and goals etc.

This post is my attempt to provide an answer with some context.

image16

disclaimers

Full disclosure…  I don’t like to measure the food I eat.  I have developed the optimal foods lists to highlight what I think are the best foods to suit different goals and levels of metabolic health.

I think food should be nutritious and satiating.  If you goal is to lose weight it will be hard to overeat if you limit your food choices to things like broccoli, celery, salmon and tuna.

At the same time, some people like to track their food.  Tracking food with apps like MyFitnessPal or Cron-O-Meter can be useful for a time to reflect and use as a tool to help you refine your food choices.  If you’re preparing for a bodybuilding competition you’re probably going to need to track your food to temporarily override your body’s survival to force it to shed additional weight.

Ideal macronutrient balance is a contentious issue and a lot has already been said on the topic.  I’ll try to focus on what I think I have to add to the discussion around the topics of insulin load and nutrient density.

If you want to and skip the detail in the rest of this article, this graphic from Dr Ted Naiman does a good job of summarising optimal foods and ideal macronutrient ranges.   If you’re interested in more detail on the topic, then read on.

image17

insulin is not the bad guy

The insulin load formula was designed to help us more accurately understand the insulin response to the food we eat, including protein and fibre.

insulin load = total carbohydrates – fibre + 0.56 * protein

The first thing to understand is that insulin per se is not bad.  Insulin is required for energy metabolism and growth.  People who can’t produce enough insulin are called Type 1 Diabetics and typically don’t last long without insulin injections after they catabolise their muscle and body fat.

Insulin only really becomes problematic when we have too much of it (i.e. hyperinsulinemia[1]) due to excess processed carbohydrates (i.e. processed grains, added sugar and soft drinks) and/or a lack of activity which leads to insulin resistance.

The concepts of insulin load and proportion of insulinogenic calories can provide us with a better understanding of how different foods trigger an insulin response and how to quantitatively optimise the insulin load of our diet to suit our unique situation and goals.

image20

different degrees of the ketogenic diet

Words like “ketogenic”, “low carb” or “nutrient dense” mean different things to different people.   This is where using numbers can be useful to better define what we’re talking about and tailor a dietary approach.  For clarity, I have numerically defined a number of terms that you might hear.

image18

ketogenic ratio

The therapeutic ketosis community talk about a “ketogenic ratio” such as 3:1 or 4:1 which means that there are three or four parts fat (by weight) for every part protein plus carbohydrate.[2]

For example, a 3:1 ketogenic diet may contain 300g of fat plus 95g of protein with 5g of carbs.  This ends up being 87% fat.  A 4:1 ketogenic ratio is an even more aggressive ketogenic approach that is used in the treatment of epilepsy,[3] cancer or dementia and ends up being 90% fat.

These levels of ketosis is hard to achieve with real food and is hard to sustain in the long term.  Hence, it is typically used as a short term therapeutic treatment.

ratio of fat to protein

People in the ketogenic bodybuilding scene (e.g. Keto Gains) or weight loss might talk about a 1:1 ratio of fat to protein (by weight) for weight loss.    A diet with a 1:1 ratio of fat to protein could be 120g of fat plus 120g of protein.  If we threw in 20g of carbs this would come out at 66% fat (which is still pretty high by mainstream standards).   A 1:2 protein:fat ratio would end up being around 80% fat.

protein grams per kilogram of lean body weight

Some people prefer to talk in terms of terms of percentages or grams of protein per kilo of lean body mass.  For example:

  • The generally accepted minimum level of protein is 0.8g/kg/day of lean body mass to prevent malnutrition.[4] This is based on a minimum requirement of 0.6kg to maintain nitrogen balance and prevent diseases of malnutrition plus a 25% or two standard deviations safety factor.[5]
  • In the Art and Science of Low Carb Performance Volek and Phinney talk recommend consuming between 1.5 and 2.0g/kg of reference body weight (i.e. RW). Reference weight is basically your ideal body weight say at a BMI of 25kg/m2.  So, 1.5 to 2.0kg RW equates to around 1.7 to 2.2g/kg lean body mass (LBM).
  • There is also a practical maximum level where people just can’t eat more lean protein (i.e. rabbit starvation[6]) which kicks in at around 35% of energy from protein.

The table below shows a list of rule of thumb protein quantities for different goals in terms of grams per kilogram of lean body mass and as a percentage of calories assuming weight maintenance.[7]

scenario % calories g/kg LBM
minimum (starvation) 6% 0.4
RDI/sedentary 11% 0.8
typical 16% 1.2
strength athlete 24% 1.8
maximum 35% 2.7

gluconeogenesis

You may have heard that body will convert ‘excess protein’ to glucose via gluconeogenesis, particularly if there is minimal carbohydrates in the diet and/or we can’t yet use fat for fuel.

For some people this is a concern due to elevated blood glucose levels, but it may also mean that more protein is required because so much is being converted to glucose that you need more to maintain muscles growing your muscles.  As we become more insulin sensitive we may be able to get away with less protein because we are using it better (i.e. we are growing muscles rather than making glucose).

Most people eat more than the minimum level of protein to prevent malnutrition.  People looking to gain muscle mass will require higher levels.  Although keep in mind you do need to be exercising to gain muscle, not just eating protein.

Ensuring adequate protein and exercise is especially important as people age.  Sarcopenia is the process of age related muscle decline which is exacerbated in people with diabetes.

Sadly, many old people fall and break their bones and never get up again.   When it comes to longevity there is a balance between being too big (high IGF-1) and too frail (too little IGF-1).

image03

carbohydrate counting

Then there is carb counting.

  • People on a ketogenic approach tend to limit themselves to around 20g (net?) carbohydrates.
  • Low carbers might limit themselves to 50g carbs per day.
  • A metabolically healthy low carb athlete might try to stay under 100g of carbs per day.

Limiting non-fibre carbohydrates typically eradicates most processed foods (e.g. sugar, processed grains, sodas etc).   Nutrient density increases as we decrease the amount of non-fibre carbohydrates in our diet.

image01

protein, insulin load and nutrient density

In the milieu of discussion about protein I think it’s important to keep in mind that minimum protein levels to prevent the diseases of malnutrition may not necessarily optimal for health and vitality.

Protein is the one macronutrient that correlates well with nutrient density.  Foods with a higher percentage of protein are typically more nutrient dense overall.

image22

Considering minimum protein levels may be useful if you are looking to drop your energy intake to the bare minimum and while still providing enough protein to prevent loss of lean muscle mass (e.g. a protein sparing modified fast).   However, if you are looking to fill up the rest of your energy intake with fat for weight maintenance then you should be aware that simply eating foods with a higher proportion of fat will not help you maximise nutrient density.

Practically though very high levels of protein will be difficult to achieve because they are very filling, thus it is practically difficult to eat more than around 35% of your energy from protein.  Protein is also an inefficient fuel source meaning that you will lose around 25% of the calories just digesting and converting it to glucose via digestion and gluconeogenesis.

If you are incorporating fasting then I think you will need to make sure you are getting at least the minimum as an average across the week, not just on feasting days to maintain nitrogen balance.  That is,  you might need to try to eat more protein on days you are eating.

what is ketosis?

“Ketogenic” simply means “generates ketones”.

An increase in ketosis occurs when there is a lack of glucogenic substrates (i.e. non-fibre carbohydrates and glucogenic protein).  It’s not primarily about eating an abundance of dietary fat

I think reducing insulin load (i.e. the amount of food that we eat that requires insulin to metabolise), rather than adding dietary fat, is really where it’s at if you’re trying to ‘get into ketosis’.   We can simply wind down the insulin load of our diet to the point that out blood glucose and insulin levels decrease and we can more easily access our stored body fat.

insulin load = total carbohydrates – fibre + 0.56 * protein

Whether a particular approach is ketogenic (i.e. generates ketones) will depend on your metabolic health, activity levels and insulin resistance etc.

Whether you want to be generating ketones from the fat on your excess belly fat rather than your plate (or coffee cup) is also an important consideration if weight loss is one of your goals.

While people aiming for therapeutic ketosis might want to achieve elevated ketone levels by consuming more dietary fat, most people out there are just looking to lose weight for heath and aesthetic reasons.  For most people, I think the first step is to reduce dietary insulin load until they achieve normalised blood glucose levels (i.e.  average BG less than 5.6mmol/L or 100mg/dL, blood ketones greater than 0.2 mmol/L).   People with diabetes often call this “eating to your meter”.

Once you’ve achieved normal blood glucose levels and some ketones the next step towards weight loss is to increase nutrient density while still maintaining ketosis.  Deeper levels of ketosis do not necessarily mean more fat loss, particularly if if you have to eat gobs of eating processed fat to get there.

Ray Cronise and David Sinclair recently published an article “Oxidative Priority, Meal Frequency, and the Energy Economy of Food and ACtivity:  Implications for Longevity, Obesity and Cardiometabolic Disease”  which does an interesting job of looking at the ‘oxidative priority’ of various nutrient and demonstrate that the body will burn through nutrients in the following order:

  1. alcohol,
  2. protein (not used for muscle protein synthesis),
  3. non fibre carbohydrate, and then
  4. fat.

What this suggests to me is that if you want to burn your own body fat you need to minimise the alcohol, protein and carbohydrate which will burn first.  To me this is another angle on the idea that insulin levels are the signal that stops our body from using our own body fat in times of plenty.   And if we want to access our own body fat we need to reduce the insulin load of our diet to the point we can release our own body fat.

insulin load versus nutrient density

The risk however with the insulin load concept is that people can take things to extremes.  If our only objective is to minimise insulin load we’ll end up just eating bacon, lard, MCT, olive oil… and not much else.

image05

In his “Perfect Health Diet” book Paul Jaminet talks about “nutrient hunger”, meaning that we are more likely to have an increased appetite if we are missing out on a particular nutrients.  He says

“A nourishing, balanced diet that provides all the nutrients in the right proportions is the key to eliminating hunger and minimising appetite.“

In the chart below shows nutrient density versus proportion of insulinogenic calories.  The first thing to note is that there is a lot of scatter!  However, on the right-hand side of the chart there are high carb soft drinks, breakfast cereals and processed grains that are nutrient poor.  But if we plot a trendline we see that nutrient density peaks somewhere around 40% insulinogenic calories.

image14

If you are metabolically challenged, you will want to reduce the insulin load of your diet to normalise blood glucose levels.  But if you reduce your insulin load too much you end up living on purified fats that aren’t necessarily nutrient dense.

If we are trying to avoid both carbohydrates and protein we end up limiting our food choices to macadamia nuts, pine nuts and a bunch of isolated fats that aren’t found in nature in that form.  Rather than living on copious amounts of refined oils I think we’re in much safer territory if we maximise nutrient density with whole foods while still maintaining optimal blood glucose levels.

The chart below shows the proportion of insulinogenic calories for the highest-ranking basket of foods (i.e. top 10% of the foods in the USDA foods database) for a range of approaches, from the low insulin therapeutic ketosis, through to the weight loss foods for someone who is insulin sensitive and a lot of fat is coming from their body.  At one end of the scale a therapeutic ketogenic may only contain 14% insulinogenic calories while a more nutrient dense approach might have more than half of the food requires insulin to metabolise.

image11

macronutrient splits

It’s one thing to set theoretical macronutrient targets, but real foods don’t come in neat little packages of protein, fat and carbohydrates.  The chart below shows the macronutrient split of the most nutrient dense 10% of foods for each of the four nutritional approaches.  The protein level for the weight loss approach might seem high but then once we factor in an energy deficit from our body fat it comes back down.

image06

In reality you’re probably not going to be able to achieve weight maintenance if you just stick to the nutrient dense weight loss foods.  You’ll either become full and will end up using your stored body fat to meet the energy deficit or you will reach for some more energy dense foods to make up the calorie deficit.  If you look at the macronutrient split of the most nutrient dense meals for the different approach you find they are lower in protein and higher in fat as shown in the chart below.

2016-12-03-3

nutrient density

The chart below shows the percentage of the daily recommended intake of essential vitamins, minerals, amino acids and fatty acids you can get from 2000 calories for each of the approaches.

image04

You can meet most of your nutritional requirements with a therapeutic ketogenic diet, however you’ll have to eat enough calories to maintain your weight to prevent nutritional deficiencies.

As you progress to the more nutrient dense approaches you can meet your nutrient requirements with less energy intake.   The beauty of limiting yourself to nutrient dense whole foods is that you can obtain the required nutrition with less energy and you’ll likely be too full to overeat.

As far as I can see the holy grail of nutrition,  health and longevity is adequate energy without malnutrition.

If we look in more detail we can see that the weight loss (blue) and nutrient dense approaches (green) provide more of the essential micronutrients across the board, not just amino acids.

image02

While the protein levels in the “weight loss” and “most nutrient dense” approaches are quite high, keep in mind that the food ranking system only prioritises the nutrients that are harder to obtain.

The table below shows the various nutrients that are switched on in the food ranking system for each approach.

image07

This table shows the number of vitamins, minerals, amino acids and fatty acids counted for each approach.

image00

In the weight loss and nutrient dense approach, of the twelve essential amino acids, only Tyrosine and Phenylalanine has been counted in the density ranking system.

It just so happens that protein levels are high in whole foods that contain essential vitamins, minerals and fatty acids. 

It appears that if you set out to actively avoid protein it may be harder to get other essential nutrients.  The risk here is that you may be setting yourself up for nutrient hunger, and rebound/stall inducing cravings in the long term as your body becomes depleted of the harder to obtain nutrients.

choosing the right approach for you

I believe one of the key factors in determining which nutritional approach is right for you is your blood glucose levels which gives you an insight into your insulin levels and insulin sensitivity.

As shown in the chart below, if your blood glucose levels are high then it’s likely your insulin levels are also high which means you will not be able to easily to access your fat stores.  I have also created this survey which may help you identify whether you are insulin resistant and which foods might be ideal for you right now.

image19

While you may need to start out with a higher fat approach, as your glucose levels decrease and ketone levels rise a little you will be able to transition to more nutrient dense foods.

The table below shows the relationship between HbA1c, glucose, ketones and GKI.   Once you are getting good blood glucose levels you can start to focus more on nutrient density and weight loss.

 Risk level HbA1c average blood glucose ketones GKI
 (%)  (mmol/L)  (mg/dL)  (mmol/L)
low normal 4.1 4.0 70 5.5 0.7
optimal 4.5 4.6 83 2.5 1.8
excellent < 5.0 < 5.3 < 95 > 0.2 < 30
good < 5.4 < 6.0 < 108 < 0.2
danger > 6.5 7.8 > 140 < 0.2

more numbers

The table below shows what the different nutritional approaches look like in terms of:

  • ketogenic ratio
  • ratio of fat to protein
  • protein (g)/kg LBM
  • insulin load (g/kg LBM)
approach keto ratio fat : protein protein g/LBM insulin load (g/LBM)
therapeutic ketosis 1.8 2.2 1.0 0.9
diabetes 0.9 1.0 1.8 1.5
weight loss (incl. body fat) 0.5 0.6 2.5 2.4
nutrient dense 0.3 0.3 3.0 2.8

The 1.0g/kg LBM for therapeutic ketosis is greater than the RDA minimum of 0.8g/kg LBM so will still provide the minimum amount while still being ketogenic.  It’s hard to find a lot of foods that have less than 1.0g/kg LBM protein in weight maintenance without focussing on processed fats.

At the other extreme most nutrient dense foods are very high in protein but this might also be self-limiting meaning that people won’t be able to eat that much food.  As mentioned earlier, it will be hard to eat enough of the nutrient dense foods to maintain your current weight.  Either you will end up losing weight because you can’t fit as much of these foods in or reaching more energy dense lower nutrient density foods.  Also, if you found you were not achieving great blood glucose levels and some low-level ketones with mean and non-starchy veggies you might want to retreat to a higher fat approach.

The table below lists optimal foods for different goals from most nutrient dense to most ketogenic.    Hopefully over time you should be able to work towards the more nutrient dense foods as your metabolism heals.

dietary approach printable .pdf
weight loss (insulin sensitive) download
nutrient dense (maintenance) download
weight loss (insulin resistant) download
diabetes and nutritional ketosis download
therapeutic ketosis download

what about mTOR?

Many people are concerned about excess protein causing cancer or inhibiting mTOR (Mammalian Target of Rapamycin).[8]  [9]

From what I can see though, the story with mTOR is similar to insulin.  That is, constantly elevated insulin or constantly stimulated mTOR are problematic and cause excess growth without being interspersed with periods of breakdown and repair.

Our ancestors would have had times when insulin and mTOR were low during winter or between successful hunts.  But during summer (when fruits were plentiful) or after a successful hunt, insulin would be elevated and mTOR suppressed as they gorged on the nutrient dense bounty.

These days we’re more like the futuristic humans from Wall-E than our hunter gather ancestors.   We live in a temperature controlled environment with artificial lighting and tend to put food in our mouths from the moment we wake up to the time we fall asleep.[10]

image15

Rather than chronic monotony (e.g. eating five or six small meals per day every day), it seems that periods of growth (anabolism) and breakdown and cleaning (catabolism) are optimal to thrive in the long term.  We need periods of both.  One or the other chronically are bad news.

image00

As my wise friend Raymund Edwards from Optimal Ketogenic Living says

“FAST WELL, FEED WELL.” 

image21

how much protein?

Optimal protein levels are a contentious topic.  There is research out there that says that excess protein can be problematic from a longevity perspective.  Protein promotes growth, IGF-1, insulin and cell turnover which can theoretically compromise longevity.  At the same time, there are plenty of studies that indicate that we need much more protein than the minimum RDI levels.[11]

image09

In the end, you need to eat enough protein to prevent loss of lean muscle and maintain strength.  If you’re trying to build lean muscle and working out, then higher levels of protein may be helpful to support muscle growth.  If you are trying to lose weight, then higher levels of protein can be useful to increase satiety and prevent loss of lean muscle mass.  Maintaining muscle mass is critical to keeping your metabolic rate high and avoiding the reduction that can come with chronic restriction.[12] [13]

In addition to building our muscles, protein is critical for building our bones, heart, organs and providing many of the neurotransmitters required for mental health.  So protein from real whole foods is generally nothing to be afraid of.  It’s typically the processed high carb foods that make the detrimental impact on  insulin and blood glucose levels.

The table below shows a starting point for protein in grams depending on your height.  This assumes that someone with a lean body mass (LBM) of 80 kg is burning 2000 calories per day and your lean body mass equates to a BMI of 20 kg/m2.  LBM is current weight minus fat mass minus skeletal mass which again is hard to estimate without a DEXA.

There are a lot of assumptions here so you will need to take as a rule of thumb starting point and track your weight and blood glucose levels and refine accordingly.  It’s unlikely that you will get to the high protein levels of the most nutrient dense approach because either you would feel too full or your glucose levels may rise and ketones disappear, so most people, unless your name is Duane Johnson, will need to moderate back from that level.

image10

Example:  Let’s say for example you were 180cm and were managing diabetes and elevated blood glucose levels.  You would start with around 117g of protein per day as an initial target and test how that worked with your blood glucose levels.  If your blood glucose levels on average were less than say 5.6mmol/L or 100mg/dL and your ketones were above 0.2mmol/L you could consider increasing transitioning to more nutrient dense foods. 

If you want to see what this looks like in terms of real foods and real meal meals check out the optimal food list and the optimal meals for the different approaches.

insulin load

Using a similar approach, we can calculate the daily insulin load (in grams) depending on your height and goals.  The values in this table can be used as a rule of thumb for the insulin load of your diet.

If you are not achieving your blood glucose or weight loss goals, then you can consider winding the insulin load back down.  If you are achieving great blood glucose levels, then you might consider choosing more nutrient dense food which might involve more whole protein and more nutrient dense green leafy veggies.

image08

Example:  Let’s say for example you are a 180cm person with good glucose control but still wanting to lose weight, your initial target insulin load would be 156g from the superfoods from fat lost list.  If you were not losing weight at this level, you could look to wind it back a little until you started losing weight.  If you are consistently achieving blood glucose levels less than 5.6mmol/L or 100mg/dL and ketones greater than 0.2mmol/L you could consider transitioning to more nutrient dense foods. 

summary

In summary, reducing the insulin load of your diet is an important initial step.  However, as your blood glucose and insulin levels normalise there are a number of other steps that you can take towards optimising nutrient density on your journey towards optimal health and body fat.

  1. Reduce the insulin load of your diet (i.e. eliminate processed carbage and maybe consider moderating protein if still necessary) to normalise blood glucose levels and reduce insulin levels to facilitate access to stored body fat.
  2. If your blood glucose levels are less than say 5.6 mmol/L or 100mg/dL and your ketone levels are greater than say 0.2 mmol/L then you could consider transitioning to more nutrient dense foods.
  3. If further weight loss is required, maximise nutrient density and reduce added fats to continue weight loss.
  4. Consider also adding an intermittent fasting routine with periods of nutrient dense feasting. Modify the feasting/fasting cycles to make sure you are getting the results you are after over the long term.
  5. Once optimal/goal weight is achieved, enjoy nutrient dense fattier foods as long as optimal weight and blood glucose levels are maintained.
  6. If blood glucose levels are greater than optimal blood glucose levels, return to step 1.
  7. If current weight is greater goal weight return to step 3.

references

[1] http://diabesity.ejournals.ca/index.php/diabesity/article/view/19

[2] http://www.epilepsy.com/learn/treating-seizures-and-epilepsy/dietary-therapies/ketogenic-diet

[3] http://www.epilepsy.com/learn/treating-seizures-and-epilepsy/dietary-therapies/ketogenic-diet

[4] http://www.health.harvard.edu/blog/how-much-protein-do-you-need-every-day-201506188096

[5] https://intensivedietarymanagement.com/how-much-protein-is-excessive/

[6] https://en.wikipedia.org/wiki/Protein_poisoning

[7] https://optimisingnutrition.com/2015/08/31/optimal-protein-intake/

[8] https://www.youtube.com/watch?v=Yv-M-5-s9B0

[9] http://nutritionfacts.org/video/prevent-cancer-from-going-on-tor/

[10] https://www.youtube.com/watch?v=qPpAvvPG0nc

[11] https://www.ncbi.nlm.nih.gov/pubmed/27109436

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

[13] https://en.wikipedia.org/wiki/Protein-sparing_modified_fast

spinach and egg

I’m a pretty simple cook, but sometimes the simple things in life are the best.   You don’t have to achieve great feats of molecular gastronomy to get a hearty nutrient dense start to the day.

This recipe is a simply egg and spinach fried up with some dill, some cream with the egg and coconut oil with the spinach for cooking.

img_6295-copy

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

2016-11-19-5

Even with four eggs and 300g of spinach the end result is still very much ketogenic as well as being nutrient dense!

For some extra taste and you could throw in some mozzarella with the egg.

For all it’s simplicity, this recipe ends up ranking at #9 in the diabetes and nutritional ketosis ranking and #17 in the therapeutic ketogenic meals ranking.

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

net carbs insulin load carb insulin fat protein fibre
5g 18g 28% 72% 24g 6g

 

 

the alkaline diet vs acidic ketones

  • Whether you think eating alkaline foods is useful or woo woo junk it appears that metabolic acidosis is a thing.
  • Metabolic acidosis seems to be interrelated with insulin resistance, Type 2 Diabetes and retention of muscle mass.
  • To prevent metabolic acidosis it appears prudent to ensure that your body has adequate minerals to enable your kidneys to balance pH over the long term. This can be achieved by eating plenty of veggies and / or supplementing with alkaline minerals (e.g. magnesium, sodium, potassium, zinc etc).
  • If you eat plenty of veggies you’re probably getting enough alkalising minerals, however you can easily test your urine to see if your dietary acid load is high.
  • If you are targeting a high fat therapeutic ketogenic diet, following a zero-carb dietary approach and / or taking exogenous ketones it seems then it may be even more important to be mindful of your acid load and consider mineral supplementation.

some unique ketone and blood glucose results

Recently I had a very interesting, surprising and exciting experience during a fast.  The chart below shows my ketones, glucose and ‘total energy’ (i.e. glucose plus ketones) over the seven days.

image03

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

image14

I really did feel sky high on ketones!

It was the full keto brochure experience.  It was like my body fat was effortlessly feeding my brain with delicious, succulent ketones!  I felt great.

This chart shows my glucose : ketone index (GKI) dropping to below 0.5 after a few days.

image07

The orange dots in this chart shows the relationship between glucose and ketones about 18 months ago when I first started trying this keto thing (after I read ‘Jimmy’s Moore’s Keto Clarity’).  The blue dots show the relationship between my glucose and ketones during the recent fast.  As you can see from the much flatter line, my blood glucose levels were lower and I could more easily access my body fat for fuel to manage my appetite.

image21

The frustrating thing is that, thinking I was now a bonafide keto super hero, I’ve tried to repeat this feat of super ketones and perfect blood glucose levels without any luck!   My ketones just didn’t go as high again!

So, what’s the go?  What changed?  What gives?  What was it that let me trip with the magic ketone fairies in Keto Land for such a short period!

image53

context

So let’s rewind the story a little and give some context…

In July 2016, I got some blood tests.  I’d been good with my diet, eating nutrient dense foods, with some fasting and intense exercise.

My HbA1c was great at 4.9% and the cholesterol markers were all good.

I went to see Elizma Lambert (pictured below), my family doctor / naturopath / friend / mentor / hero, with the simple request that I wanted to feel superhuman.  I felt like I had been doing all the right things (e.g. good food, exercise etc) but not quite getting results that I was after (e.g. weight loss, energy levels, higher ketone levels).

image00

Elizma said everything looked good but my blood tests indicated that I was acidic.  But what does this mean?

  • You can see in the test results shown below that my uric acid levels are at the top of the normal range. High uric acid levels can be affected by fasting and exercise (i.e. lactic acid)[1] which may have influenced my test results.
  • My “other anions” test was at the top of the normal range.
  • I had also been using exogenous ketones occasionally around workouts leading up to these tests. I wondered whether they might contribute to the acidity.
  • My bicarbonate levels were on the low end which I’ve now learned suggests that I was running low on alkalising minerals (i.e. magnesium, calcium and potassium) for my kidneys to balance the acid load I was serving up with my exercise, diet and fasting.
  • My calcium and potassium were also on the lower end of the normal range.

image01

So Elizma sent me away with a mineral mix of magnesium, potassium, N-acetyl Cysteine and Calcium-D-Glucarate to help with the acidity issue that she had observed in my tests and to help improve my fat metabolism.

image25

I wasn’t sure what to expect, if anything.  But after a couple of weeks of taking this stuff my brain felt really clear and sharp and I felt full of energy.  I actually felt the superhuman energy and crispness that I’d been hoping for!

image38

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

image51

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

Seven days later I had some spectacular ketone readings.

image03

As well as the alkalizing mineral mix, I was also taking some Celtic sea salt, Carnitine, Creatine and some alkalising green powder to keep my micronutrients up during the seven days.  I was aware of keto experts like Steve Phinney advocating adequate electrolytes during keto or fasting and I wanted to give myself the best chance of surviving and keeping up with my day job as well as riding to work.  I also started taking Nicotinamide Riboside which arrived on day four of the fast.

image36

So unfortunately, it wasn’t a really well controlled experiment to understand which supplement during my ‘fasting’ had the biggest effect.

Towards the end, I ran out of the alkalising mineral mix and I spent the day in the sun at a birthday party with my daughter (pictured below on the last day…  she knows how to pose for better for photos than me).

image42

I started to feel a bit shabby, so I decided to eat.

I figured seven days was a good ‘achievement’.

Since then I’ve tried a number of four-day fasts with various supplements (i.e. the alkalising minerals, Nicotinamide Riboside, exogenous ketones, a ‘fat fast’ and Robert Miller’s MitoFuel) to understand what the magic ingredient was, but I haven’t been able to repeat the phenomenal ketone excursions.

15204045_10154380499344807_1281857376_o.jpg

I quizzed Elizma about what she thought might have happened.  Could it simply be the alkalising mineral mix that causes the magic ketone fairies to visit me?  She said:

Whether you call it resistance or stuck, the alkalizing minerals can open up a lot of enzyme pathways that work at more neutral pH levels, which means it’s like opening the door with a massive crowd outside.

Once the door is open everyone just rushes through (giving you those big readings), but the crowd eventually thins out and becomes a regular stream of customers walking through the door again.

Very interesting though.  Every single person on ketogenic diet that I have tested have high acidity levels, which is natural considering that ketones are highly acidic, but it does mean it’s something to really look out for when ketogenic.

Hmmm…  intriguing.

Then I came across a Ben Greenfield podcast with Yuri Elkaim where he talked about alkaline diets.  It got interesting when Yuri started talking about the Potential Renal Acid Load which is based around the balance between the foods that leave an acidic residue (i.e. sulphur from protein and phosphorus) versus the foods that leave an alkaline residue once metabolised (i.e. magnesium, calcium and potassium).

image35

Previously when I’d heard talk of alkaline foods I’d written it off as woo woo.  But maybe this might explain the symptoms what I’d experienced (e.g. loss of appetite, high ketones, perfect blood glucose etc)?   Given the fact that taking the magnesium, potassium and calcium supplements had worked wonders for me I was interested and thought I’d dig into the topic a little further.

Here’s a video from Yuri on the pros of the alkaline dietary approach.  I’m not saying I’m advocating 100% of this, but it’ll give you an overview of some of the theory on alkaline diets from one of the less fringe advocates of the concept of alkalising.

let’s start with the basics

As I am prone to do, I went down a bit of a ‘rabbit hole’ looking at the research on this topic looking for answers trying to understand and explain my experience.   In this article I have tried to explain my journey and learnings along the way.

So let’s start with the less controversial stuff.  Basic biochem.

pH (or “potential hydrogen”) is a measure of the number of negatively charged hydrogen ions (H+).[2]

More formally, “pH is the negative of the logarithm to base 10 of the molar concentration, measured in units of moles per liter, of hydrogen ions.”

But why should we care about pH?

Well, when it comes down to it, your entire metabolism exists to pass around hydrogen ions.

You call it energy.  It’s important.

image30

maintaining pH homeostasis

The body goes to great lengths via a range of different systems to keep different parts of your body at a specific pH to enable the chemical reactions that fuel metabolism to continue function.

A pH of 7.0 is “neutral”, however the blood is slightly alkaline at somewhere between a pH of 7.35 and 7.45.  It’s virtually impossible to change the pH of your blood outside this range.

If your pH drops to 6.9, you’re in a coma.  At 6.8 you’re dead.[3]

image46

At this point many people simply say “see, we can’t change the pH of our blood so worrying about alkalinity is bogus garbage” (or something to that effect) and walk away.  Conversation over.

image24

However, I think it’s interesting to think about how the body actually maintains this tight homeostasis and whether a pH of 7.35 is different (more acidic) to a pH of 7.45 (more alkaline).

The body has so many different buffers and so many different systems and ways of mitigating pH.   Intracellularly, it has phosphate; extracellularly, hydrogen types of proteins. The lungs get involved, the kidneys get involved.   Which just tells you is the more processes or mechanisms in the body, or systems, devoted to a certain subject or topic of process, the more important that process is.

Bryan Walsh, Keto Summit Interview[4]

Part of the body’s pH balance involves our kidneys which use the various minerals that it obtains from our food to keep a tight rein on the acid / base balance of our blood.

The minerals that can donate acid forming negative charge are:

  • Bromine (Br-)
  • Chlorine (Cl-)
  • Copper (Cu-)
  • Fluorine (Fl-)
  • Iodine (I-)
  • Phosphorus (P-)
  • Silicon (Si-)
  • Sulphur (Su-)

The minerals that can donate alkaline positive charge are:

  • Boron (B+)
  • Calcium (Ca+)
  • Iron (Fe+)
  • Magnesium (Mg+)
  • Manganese (Mn+)
  • Nickel (Ni+)
  • Potassium (P+)
  • Sodium (Na+)
  • Zinc (Zn+)

alkalinity, carbon dioxide and oxygen

In Australia, one of our premier tourist attractions, Great Barrier Reef, is dying as the ocean absorbs CO2 from the atmosphere and becomes more acidic.[5]  It’s not hard to see how an increasing environmental acid load could similarly be affecting our internal microbiome.[6]

image33

Every farmer knows the importance of getting the pH of the soil right before planting a crop.  A higher pH is achieved by adding extra potassium and lime which is taken up by the plant.   The pH of the soil in which plants are grown can have considerable influence on the mineral content of the food we eat.

When it comes to the pH and net acid load in the human diet, there has been considerable change from the hunter gather civilization to the present.[7]

As we continue to grow mono crops in the same field year after year with farmers relying on chemical fertiliser to provide nutrients for the plant, it’s understandable that our veggies are also decreasing in nutrient content, particularly the alkalising minerals.

With the agricultural revolution (last 10,000 years) and even more recently with industrialization (last 200 years), there has been a decrease in potassium (K) compared to sodium (Na) and an increase in chloride compared to bicarbonate found in the diet.

It is generally accepted that agricultural humans today have a diet poor in magnesium and potassium as well as fibre and rich in saturated fat, simple sugars, sodium, and chloride as compared to the pre-agricultural period. [8]

This results in a diet that may induce metabolic acidosis which is mismatched to the genetically determined nutritional requirements. With aging, there is a gradual loss of renal acid-base regulatory function and a resultant increase in diet-induced metabolic acidosis while on the modern diet.[9]

Even if you don’t like veggies, it’s not hard to see how the meat from animals fed with grains (which contain less alkalising minerals than grass) grown with chemical fertilisers could be leading to a higher acid load compared to animals that are able to eat grass and other natural stuff.

image47

When the pH of something is higher (more alkaline) it can hold more dissolved oxygen.  If it is more acidic (lower pH) it can hold less oxygen.  Blood with a pH of 7.3 (more acidic) and can carry 65% less oxygen than blood at a pH of 7.45 (more alkaline).[10]

Good things happen when there is more oxygen available.  For example, when there is more oxygen the body is able to utilise the fat burning Krebs Cycle based / aerobic metabolism (with oxygen) and less on the sugar based Cori cycle / anaerobic metabolism (without oxygen).

Conversely, more acidic = not so good.

image05[11] [12]

While still controversial, in the 1930s Otto Warburg (pictured below, with poodle) suggested that “cancer cells live in hypoxic, very low oxygen, and acidic conditions and derive energy from sugars by fermenting them the way yeast does.” [13] From this, he theorized that these low-oxygen and more acidic conditions caused cancer.

image18

So low oxygen = bad.  Lots of oxygen = good.

Wim Hof, Iceman Extraordinaire, achieves superhuman feats essentially by hyperventilating to increase the oxygen in his blood.

image41

the effect of food and alkalinity

There is some indication that this ability to absorb more oxygen is also affected by the food we eat.

The chart below shows how athletes on a lower acid load dietary approach appear to be burning more fat (as indicated by a lower respiratory exchange ratio or RER[14]) and have a longer lead time to exhaustion.[15]

image45

The study Effects of Dietary Acid Load on Exercise Metabolism and Anaerobic Exercise Performance (Caciano et al, 2015) noted that:

An alkaline promoting (low-PRAL) diet increases anaerobic exercise performance, as evidenced by greater time-to-exhaustion during high-intensity treadmill running.

Preliminary evidence suggests that an alkaline promoting (low-PRAL) diet increases lipid oxidation and may have a carbohydrate-sparing effect during submaximal endurance exercise, although further studies are needed.[16]

More fat burning = winning!

image26

This aligns with my personal experience.  During a good workout it feels like my cells can “breath better”.  My stamina and performance in my cycling or kettlebell workouts is not so much limited by my strength but more by my ability to recover my breath quickly.  When everything is working just right I seem to be able to maintain a high heart rate easily for a longer time without running out of breath.

image02

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

image10

It seems that a lower insulin load (i.e. low carb / ketogenic) diet with lower levels of insulin enables us to tap into our fat stores more easily.  However, in addition, it seems that a more alkaline pH also helps us burn more fat by enabling us to access more oxygen as well.

potential renal acid load

So how does all this this relate to nutrition and optimising our food choices?

Well, back in the late 1870s a scientist named Marcellin Berthelot used the Bomb Calorimeter to study the amount of heat produced or absorbed during chemical reactions.[17]  This machine consisted of a cylinder-shaped chamber, pressurized oxygen, and a small amount of water.

image04

Berthelot would take various food substances and incinerate them within this device which turned the item into an ash-type substance. When this ash was mixed with water, Berthelot could check the pH of each item to determine whether a food was acidic or alkaline after it had been burned.

The Potential Renal Acid Load (PRAL) revolves around the idea that there is a residual ash remaining after a food is metabolised in our body that is either acidic or basic.  This residual ash, which has a net acidic or alkaline property, then needs to be cleared from the body to maintain optimal pH.[18] [19] [20]

A simplified PRAL value can be calculated based on the most dominant nutrients affecting pH.  That is, protein (which forms sulphur) and phosphorus (acidic) minus the magnesium, calcium and potassium (alkaline).

Potential renal acid load (PRAL) = [0.49 x grams of protein + 0.037 x mg of phosphorus]  – [0.026 x mg magnesium + 0.013 x mg calcium + 0.021 x mg potassium] 

If the PRAL value is negative, then you are left with an alkaline residue.

If the PRAL number is positive, then you are left with a net acidic residue that needs to be cleared by the kidneys.

urine ph

While significantly changing the pH of the blood is controversial, the food we eat does seem to have an impact on the pH of our urine as the kidneys clear the excess acid load that is not used up in balancing our pH.[21] [22]  The theory is that pH of our urine changes based on whether the residual ash from our food after it is metabolised is either acidic or alkaline.

The chart below shows the urine pH of the test subjects in the Effects of Dietary Acid Load on Exercise Metabolism and Anaerobic Exercise Performance study mentioned above.  In the cross over trial participants performed the best when they had a more alkaline urine pH greater than 7.0 (alkaline) in comparison to when they had a pH less than 6.0 (acidic).

image19

balancing electrolytes

If you’re a die hard low carber / ketonian congratulations in getting this far into the article before switching off and writing me off as a vegan tree hugging hippie.

You’ll also likely be aware that in The Art and Science of Low Carbohydrate Performance Volek and Phinney talk a lot about how important it is to manage minerals and electrolytes when following a low carb / ketogenic dietary approach.  Chapter 9 of The Art and Science of Low Carbohydrate Performance is all about how important it is to make sure you keep up your electrolytes in the form of sodium, potassium, magnesium and zinc.

[Steve was recently in Brisbane and we had the privilege of having him stay at our place.  Not only did he make us his famous blue cheese dressing (see action shot below) I also got to pick his brains for a day!]

2016-11-15-10-58-17

You get bonus points if you realised that these critical electrolytes that Volek and Phinney talk about are the same as the alkalising minerals in the PRAL formula (i.e. magnesium, calcium and potassium)!  Maybe erring on the side of being alkaline and ensuring good mineral / electrolyte management in a keto diet are two sides of the same coin?

image34

We can get this critical electrolytes from supplements or more ideally from real food.

As you dig further you quickly find that the discussions around PRAL can go sideways really quickly and turn into a keto / carnivore vs vegan / plant based argument.

I have tried to wade through the science versus woo woo, which I’ll try to summarise later in this article.  But for now let’s jump into what the analysis of PRAL could mean for our choices around what we should eat.

the most alkaline foods

The table below shows the most alkaline foods with their nutrient density (ND), and PRAL value per 100g and PRAL / 2000 calories.[23]

Most lists I’ve seen use PRAL per 100 calories.  However, I think it’s more useful to think of it in terms of the amount as a proportion of your daily energy intake (i.e. per 2000 calories).

To make the lists more concise I’ve filtered for the most nutrient dense foods for each category.

vegetables and spices

image15

The PRAL values of the most nutrient dense vegetables are listed below.  Overall vegetables are quite alkaline (i.e. negative PRAL values).  Only alfalfa has a positive PRAL value due to high levels of phosphorus.

The other observation here is that nutrient density and alkalinity don’t necessarily go hand in hand.  It’s not as simple as saying ‘eat your veggies’ because there is a wide range of nutrient density and PRAL values within the vegetables.

If you are striving for optimal in terms of ND and PRAL then some veggies are better than others.

 

food ND PRAL / 2000 cal PRAL / 100g
beet greens 19 -1,523 -17
Chinese cabbage 20 -1,241 -7
watercress 24 -1,034 -6
spinach 25 -895 -10
chard 19 -857 -8
coriander 23 -841 -10
chicory greens 18 -724 -8
dill 16 -721 -15
endive 19 -707 -6
arugula 16 -629 -8
parsley 19 -618 -11
celery 12 -610 -5
basil 22 -569 -7
mustard greens 16 -507 -7
escarole 15 -495 -5
zucchini 20 -489 -4
pickles 11 -424 -3
lettuce 19 -419 -3
summer squash 13 -397 -4
brown mushrooms 16 -383 -4
yeast extract spread 12 -369 -34
dandelion greens 16 -353 -8
cauliflower 15 -351 -4
sauerkraut 11 -328 -3
chives 16 -317 -5
turnip greens 13 -307 -4
banana pepper 10 -296 -4
sage 13 -295 -46
cabbage 10 -286 -3
paprika 11 -262 -37
okra 15 -243 -3
seaweed (kelp) 12 -224 -5
cloves 13 -216 -30
snap beans 11 -215 -2
white mushroom 13 -205 -2
portabella mushrooms 13 -204 -3
asparagus 20 -199 -2
broccoli 27 -167 -2
collards 11 -141 -2
shiitake mushroom 11 -80 -2
mung beans 13 -64 -1
seaweed (wakame) 17 -59 -1
spirulina 11 -1 -0
alfalfa 12 154 2

dairy

image08

Dairy is widely regarded to be some of the most acidic of foods.   As you can see below there are a wide range of PRAL values, from slightly alkaline high fat cream and butter to the low fat cheeses which are quite acidic.

Even though dairy can be nutrient dense, many people seem to do better with their weight or allergies when they limit dairy.

Personally, I know I lost some weight when I reduced dairy for a period.  I thought it might be related to the energy density.  Maybe the minerals and pH balance plays a role too and living on a low carb diet primarily comprised of cheese could be a problem for some people in the long term.


https://s0.wp.com/wp-content/themes/pub/twentyfourteen/js/html5.js

food ND PRAL/2000 cal PRAL/100g
sour cream 4 -2 0
low fat milk 4 -1 0
milk (full fat) 2 0 0
butter 3 0 0
cream 4 3 1
milk 5 5 0
kefir 10 14 0
cream cheese 4 15 3
brie 1 66 11
blue cheese 2 68 12
Colby 0 83 16
cheddar cheese 7 85 17
feta cheese 5 85 11
muenster cheese 1 87 16
camembert 2 87 13
Monterey cheese 1 88 16
limburger cheese 2 90 15
edam cheese 2 100 18
Greek yogurt 6 100 5
parmesan cheese 6 102 21
gruyere cheese 2 103 21
Swiss cheese 7 104 21
gouda cheese 3 113 20
goat cheese 2 119 16
mozzarella 8 123 19
egg yolk 8 133 18
whole egg 7 133 10
Greek yogurt (low fat) 6 143 5
cottage cheese (low fat) 6 157 6
cheddar (non-fat) 2 262 23
cream cheese (low fat) 8 306 16

 

baked products, cereals and grains

image04

Baked products, cereals and grains, in addition to generally having quite poor nutrient density values are also typically highly insulinogenic.

Baking soda or bicarbonate is a powerful alkaline supplement that can be used to aggressively shift pH.

Other than wheat bran and baker’s yeast (think vegemite, marmite or brewer’s yeast), processed grains have a poor nutritional value while also being quite alkaline AND insulinogenic.

According to Bill Davis the phytates in grains also make it harder to absorb alkalising minerals.[24]

No wonder processed grains are problematic for so many people.

the alkaline diet vs acidic ketones | optimising nutrition
https://s0.wp.com/wp-content/themes/pub/twentyfourteen/js/html5.js

food ND PRAL/2000 cal PRAL/100g
baking soda 0 -309 -15
oat bran muffins -4 13 2
crackers -3 18 4
croissant -2 22 5
blueberry muffins -4 23 4
bagels -4 23 3
wheat bran bread -4 27 3
rice bran bread -3 28 3
egg bread -4 31 4
wheat bran 12 32 3
bread roll -4 32 4
quinoa -2 38 2
rye flour -3 40 7
English muffins -3 50 5
baker’s yeast 15 50 3
wild rice -4 53 9
pancakes -4 128 22
oat bran 3 137 17

 

seafood

image21

Seafood is typically acidic due to the protein though also nutrient dense.  However, as we’ll see later, it’s not as simple as avoiding protein, as protein seems to help with calcium absorption.[25]
https://s0.wp.com/wp-content/themes/pub/twentyfourteen/js/html5.js

food ND PRAL/2000 cal PRAL/100g
mackerel 7 34 5
anchovy 13 69 7
cisco 7 75 7
caviar 14 76 10
octopus 9 107 9
herring 7 114 12
white fish 8 123 7
trout 14 131 11
sardines 8 136 13
oyster 18 146 7
sardine 8 153 16
sturgeon 11 165 11
pollock 11 168 9
rockfish 11 168 9
halibut 12 175 10
salmon 17 180 14
haddock 9 188 11
whiting 8 197 11
tuna 9 197 18
lobster 12 201 9
cod 11 205 30
crab 15 238 10
crayfish 11 253 10
shrimp 12 282 17
fish roe 16 285 20
perch 8 297 14
flounder 11 322 14

animal foods

image09

Animal products have a high PRAL values due to their protein content.     Grain fed animals are likely to be even worse than animals able to eat their natural diet.

food ND PRAL/2000 cal PRAL/100g
chicken liver pate 7 105 11
rib eye steak 5 130 14
lamb chop 5 139 16
bison 5 166 14
beef brains 8 166 13
ground pork 6 168 16
ground beef 6 171 12
leg ham 6 175 14
pork shoulder 6 178 14
turkey heart 8 182 16
turkey meat 6 188 15
turkey drumstick 6 188 15
chicken 7 189 14
pork chop 6 195 17
beef tripe 6 208 11
lamb heart 8 212 17
lean beef 9 216 16
turkey liver 14 218 21
pork liver 10 218 18
beef heart 5 220 18
beef heart 8 229 21
turkey 6 230 16
chicken liver 15 233 14
ham 11 239 13
veal 8 239 18
veal liver 16 244 23
chicken liver 14 250 22
beef liver 16 262 23
lamb kidney 19 267 15
lamb liver 18 274 23
beef kidney 13 283 22

 

fruits

fruits-and-vegetables

Fruits are typically quite alkaline, however the nutrient density value is typically less than ideal.  Fruits are also typically quite insulinogenic.  So I don’t think it’s a matter of simply  saying that we should eat a ton of “fruits and vegetables” if nutrient density or insulin load are also an issue.
https://s0.wp.com/wp-content/themes/pub/twentyfourteen/js/html5.js

food ND PRAL/2000 cal PRAL/100g
rhubarb 3 -621 -7
cantaloupe -2 -298 -5
honeydew melon -4 -247 -4
jackfruit -3 -186 -9
kiwifruit -2 -184 -6
apricots -4 -180 -4
grapefruit -4 -174 -3
peaches -4 -160 -3
strawberries -1 -159 -3
oranges -4 -156 -4
carambola -2 -138 -2
blueberries -0 -137 -3
blackberries -1 -130 -3
limes -3 -115 -2
avocado -1 -102 -8
raspberries -2 -93 -2
boysenberries -2 -86 -2
blackberries -4 -69 -2

 

legumes

image11

Legumes have a range of PRAL values, though again the nutrient density values are not that great compared to the veggies, seafood or animal products.

 

food ND PRAL/2000 cal PRAL/100g
navy beans 0 -32 -5
soybeans 2 -21 -5
cowpeas 1 -14 -2
peanut butter 2 -5 -1
broad beans -1 -2 -0
lentils 0 37 2
tofu 4 41 2
soy protein isolate 0 400 67

 

nuts and seeds

nuts_seeds

There are a range of PRAL values when it comes to nuts and seeds depending on the mineral content.

Anything based on coconut seems to do well in terms of nutrient density and alkalinity.  There’s nothing quite like fresh coconut water.  The photo below shows how we finished our recent holiday in Fiji!

image44

the alkaline diet vs acidic ketones | optimising nutrition
https://s0.wp.com/wp-content/themes/pub/twentyfourteen/js/html5.js

food ND PRAL/2000 cal PRAL/100g
coconut water 4 -539 -5
gingko nuts -6 -20 -1
coconut milk 0 -16 -2
coconut meat -1 -15 -3
coconut -1 -13 -3
coconut cream -1 -9 -1
hazelnuts -3 -6 -2
macadamia nuts -2 -4 -1
sesame butter -1 -3 -1
almond butter -2 5 2
pecans -6 6 2
almonds -2 7 2
flax seed -2 8 2
pistachio nuts -3 8 2
cashews -2 24 7
brazil nuts -3 25 8
pine nuts -4 26 9
butternuts -6 43 13
walnuts -3 44 14
sesame seeds -3 54 17
pumpkin seeds 1 98 27
sunflower seeds 2 110 30

 

balancing alkalinity and nutrient density

So my big takeaway from the analysis above is that alkalinity and nutrient density are not necessarily related.  You can’t just say ‘eat your fruits and vegetables and avoid protein’ to manage your alkalinity and maximise nutrients at the same time.  Particularly given that protein is the one macronutrient that seems to be correlated with nutrient density.

Recent clinical studies and a meta-analysis have indicated either no effect or a modest benefit associated with higher protein intakes. These contradictory considerations may be explained by the existence of a two-faced relationship between protein and bone, with simultaneous positive and negative pathways. In opposition to the negative effects of dietary acid load, protein may exert positive effects related to improving calcium absorption, increasing insulin-like growth factor 1, or improving lean body mass, which, in turn, improves bone strength.[26]

The chart below shows  a comparison of the nutrient density of the top 10% of the USDA food database for a range of dietary approaches.  If we prioritise our food choices based on low PRAL values alone we end up with a lower nutrient density.

image52

Most things in nutrition are not binary.  We can’t just take one parameter and use it to guide ALL our decisions about nutrition.  That includes protein, carbs, fat, energy density, nutrient density or alkalinity.

Where it gets gets is when we mix and match a number of factors to prioritise our food choices to suit our goals.

image20

Nutrient dense low alkaline foods typically have quite a low energy density so we don’t have to worry too much about that.  To develop the list of more alkaline nutrient dense in the following section I have factored in:

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

The chart below shows a comparison of the nutrients provided by the top 10% of foods for the following approaches:

  • low PRAL,
  • nutrient dense alkaline, and
  • nutrient dense maintenance.

image31

If we just prioritise low PRAL (grey bars) then the amino acids drop.  However, if we prioritise low PRAL and nutrient density we get a better balance of alkalinity and nutrient density across the board.

  • The chart below shows a comparison of macronutrients.
  • The nutrient dense approach is quite high in protein while the more alkaline approach has less protein and more carbs from more veggies.
  • If we only look at minimising PRAL we get a lot of fibre and less protein.
  • The nutrient dense alkaline approach provides a reasonable balance in terms of macronutrients.

image50

From an insulin load perspective, the low PRAL approach is relatively insulinogenic.  Considering insulin load in the multi criteria analysis gives us a little bit of additional dietary fat which is useful for blood glucose regulation or satiety, particularly if we’re not trying to lose weight.  Moderate amounts of dietary fat help with the absorption of the fat-soluble vitamins A, D, E and K).

image11

The chart below shows a comparison of some of the key minerals provided by a number of dietary approaches (note: phosphorus is acidic while the magnesium, calcium, potassium and sodium are alkaline).

  • The therapeutic ketosis and the average of all foods do not have a lot of alkalising magnesium, calcium, potassium and sodium to balance the acid forming phosphorus.
  • By comparison, the nutrient dense alkaline and low PRAL foods have a lot more alkalising minerals to balance the acidic phosphorus.

image16

Rather than worrying about actively balancing our pH I think we focus on maximising nutrient density our body will have what it needs to do what is necessary to balance pH.  Maximising nutrient density will also minimise nutrient hunger so our bodies will be satisfied with less and our kidneys won’t have to process as much.

The chart below shows that after Vitamin D and Vitamin E, many people are getting less than the recommended intake of magnesium, calcium and zinc (i.e. alkalising minerals).

image13

PRAL value of different nutritional approaches

The chart shows the PRAL value for thirteen different nutritional approaches outlined on this blog.

  • The nutrient dense vegan approach the is the most alkaline while the zero-carb approach is the most acidic.
  • The nutrient dense alkaline foods (listed below) end up being nearly as alkaline as the vegan.
  • On average, the 8000 foods in the USDA database have a net acid load.
  • The zero carb, high insulin load and therapeutic ketogenic approaches have net acid load.
  • Most of the other approaches that focus on nutrient density have adequate vegetables to ensure that they are alkaline overall.

image12

If the alkalinity of our diet does actually have a bearing on insulin resistance, oxygen availability / hypoxia, insulin sensitivity I wonder if people pursuing a therapeutic ketogenic approach should actually be considering prioritising their veggies and / or or mineral supplements that will balance their alkalinity to balance out their diet.

Results of recent observational studies confirm an association between insulin resistance and metabolic acidosis markers, including low serum bicarbonate, high serum anion gap, hypocitraturia, and low urine pH.[27]

image28

nutrient dense alkaline foods

The list of foods is prioritised for nutrient density, alkalinity and a lower insulin load.

vegetables, spices and fruit

image19

The list of vegetables and fruit below are both nutrient dense and highly alkaline.  Whether you buy into this alkaline food theory it will be hard to go wrong if you eat more of these foods which are nutrient dense and have a low insulin load.

If you are concerned that your body is lacking alkalising minerals, focusing on the green leafies at the top of this list will be a good first step.   Real food is always going to be a better option than supplements.

food ND insulin load (g/100g) PRAL/2000cal MCA
watercress 13 2 -1,034 2.8
spinach 11 4 -895 2.7
endive 9 1 -707 2.7
chicory greens 8 2 -724 2.5
basil 9 3 -569 2.3
coriander 7 2 -841 2.3
chard 9 3 -857 2.3
beet greens 7 2 -1,523 2.2
escarole 6 1 -495 2.2
zucchini 7 2 -489 2.2
Chinese cabbage 8 2 -1,241 2.1
lettuce 8 2 -419 2.0
mustard greens 6 3 -507 2.0
parsley 7 5 -618 2.0
arugula 7 3 -629 2.0
dandelion greens 8 7 -353 1.9
sage 6 26 -295 1.9
asparagus 9 3 -199 1.9
turnip greens 7 4 -307 1.8
summer squash 6 2 -397 1.8
okra 7 3 -243 1.7
alfalfa 8 1 154 1.6
thyme 5 31 -257 1.6
cloves 6 35 -216 1.6
curry powder 5 14 -107 1.6
collards 6 4 -141 1.6
paprika 4 26 -262 1.6
cucumber 4 1 -424 1.5
pickles 4 1 -424 1.5
celery 4 3 -610 1.5
chives 5 4 -317 1.5
brown mushrooms 7 5 -383 1.5
broccoli 6 5 -204 1.4
marjoram 3 27 -364 1.4
cauliflower 4 4 -351 1.4
bamboo shoots 4 5 -591 1.3
banana pepper 3 3 -296 1.2
celery flakes 3 42 -530 1.2
sauerkraut 3 2 -328 1.2
seaweed (wakame) 8 11 -59 1.2
cabbage 4 4 -286 1.2
dill 3 8 -721 1.2
radicchio 4 4 -413 1.2
radishes 2 2 -551 1.2
rhubarb 3 3 -621 1.2
seaweed (kelp) 6 10 -224 1.2
portabella mushrooms 5 5 -204 1.2
edamame 5 13 7 1.1
artichokes 4 7 -211 1.1
kale 4 5 -302 1.1
poppy seeds 3 23 -7 1.1
white mushroom 5 5 -205 1.1
snap beans 4 3 -215 1.0
eggplant 1 3 -314 1.0
caraway seed 3 28 -80 1.0
yeast extract spread 3 27 -369 1.0
dill seed 2 43 -218 0.9
cumin 2 44 -171 0.9
turnips 2 3 -275 0.9
shiitake mushroom 5 7 -80 0.9
onions 3 6 -312 0.9
jalapeno peppers 1 3 -269 0.9
soybeans (sprouted) 4 12 -16 0.9
tarragon 2 56 -437 0.9
pumpkin 3 4 -380 0.9
spirulina 6 6 -1 0.9
red peppers 2 3 -219 0.8
chayote 1 3 -228 0.8

nuts and seeds

image15

Coconuts do pretty well.  Some of the other nuts are not so nutrient dense or alkaline, so this list isn’t too long.  Keep in mind that drinking a lot of coconut water might not be ideal for someone with diabetes due to the carbohydrate content.

food ND insulin load (g/100g) PRAL/2000cal MCA
coconut water 2 3 -539 1.0
coconut milk 1 5 -16 0.9
flax seed 1 16 8 0.9
coconut meat 1 9 -15 0.9
coconut cream 1 7 -9 0.8
almond butter 1 26 5 0.8
pumpkin seeds 2 29 98 0.8
almonds 1 25 7 0.8
sunflower seeds 1 22 110 0.7

seafood

image21

If you are eating plenty of veggies I think you can so afford to also eat plenty of nutrient dense seafood as the acid / alkaline will balance each other out in the long run.   While there have been some concerns that a high protein diet will cause acidity that will, in turn, cause osteoporosis due to calcium being used to buffer the acid, more recent research indicates that protein has a net positive effect on bone health.[28] [29]

food ND insulin load (g/100g) PRAL/2000cal MCA
fish roe 11 18 285 1.6
caviar 7 23 76 1.5
trout 8 18 131 1.3
salmon 8 20 180 1.3
sturgeon 8 16 165 1.2
sardine 6 19 153 1.2
oyster 8 14 146 1.1
halibut 9 17 175 1.1
mackerel 3 10 34 1.1
anchovy 6 22 69 1.1
cisco 5 13 75 1.1
cod 9 48 205 1.1
flounder 9 12 322 1.1
crab 9 14 238 1.1
crayfish 9 13 253 1.1
pollock 8 18 168 1.1
rockfish 8 17 168 1.0
lobster 8 15 201 1.0
perch 8 14 297 0.9
herring 4 19 114 0.9
white fish 7 18 123 0.9
whiting 7 18 197 0.9
shrimp 8 19 282 0.9
haddock 7 19 188 0.8
clam 7 25 128 0.8

dairy and egg

image08

A number of cheeses make it onto the list due to their nutrient density along with egg, butter and cream.  Cheese are typically acidic however, in moderation, they can potentially form part of a well-rounded diet.

The problem, I think, is a that a lot of people looking for a low carb / keto dietary approach (me included) end up eating large quantities of dairy (e.g. cream, cheese and butter) and end up struggling to keep the weight off or find that they are “allergic to dairy”.   Perhaps excess acid load without adequate minerals to balance it from green leafy veggies may be playing a role here?

 

food ND insulin load (g/100g) PRAL/2000cal MCA
egg yolk 4 12 133 1.1
feta cheese 4 15 85 1.1
whole egg 5 10 133 1.0
milk 5 7 5 1.0
Swiss cheese 4 22 104 1.0
cheddar cheese 3 20 85 1.0
gruyere cheese 3 23 103 1.0
gouda cheese 4 21 113 0.9
Eggnog 5 11 14 0.9
kefir 6 7 14 0.9
edam cheese 3 21 100 0.9
mozzarella 4 26 123 0.9
cream 1 5 3 0.9
Monterey cheese 3 19 88 0.8
limburger cheese 2 15 90 0.8
butter 0 3 -0 0.8
muenster cheese 3 19 87 0.8
goat cheese 3 14 119 0.8
sour cream 1 6 -2 0.8
cream cheese 1 10 15 0.8
Colby 2 20 83 0.8
camembert 2 16 87 0.8
low fat milk 5 8 -1 0.8
blue cheese 2 19 68 0.8
cream cheese (low fat) 8 19 306 0.7
parmesan cheese 3 35 102 0.7
ricotta 2 12 71 0.7

animal products

image09

Several animal products make the list even though they carry an acid load.  I don’t think “animal protein” is really a concern if you are also eating your alkalising veggies.  Seafood and animal products are also nutrient dense and have beneficial properties, including lean body mass[30] and bone health.    If you can, it’s going to be ideal to consume seafood and animals that aren’t fed more acidic grains.

food ND insulin load (g/100g) PRAL/2000cal MCA
lamb liver 7 20 274 0.9
beef brains 3 8 166 0.9
ham (lean only) 7 17 239 0.8
lamb kidney 6 15 267 0.8
turkey liver 5 21 218 0.7
ground turkey 3 19 115 0.7
turkey heart 4 20 182 0.6
pork 3 22 128 0.6
roast ham 3 18 137 0.6
lamb brains 2 10 197 0.6
beef kidney 5 20 283 0.6
roast pork 3 20 130 0.6
chicken liver 5 20 250 0.6
lamb sweetbread 4 15 313 0.5
turkey drumstick 4 21 188 0.5
turkey meat 4 21 188 0.5
pork chop 5 23 195 0.5
leg ham 4 22 175 0.5

 

 

other dietary approaches

I’ve added this list to the various dietary in the table below.  If you’re already getting plenty of veggies then acidity probably won’t be a problem with your acid balance.  But if you already have metabolic acidosis, gout or kidney concerns they you may want to focus on getting more of the alkaline foods.

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

If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help you identify your optimal dietary approach.

image43

am I getting enough veggies?

If you have blood tests handy you can see if they show any of the following signs that may suggest that your diet is more acidic and / or you are struggling to balance your acid load:

  • high uric acid levels,
  • low bicarbonate levels / CO2 levels,
  • a high anion gap,[31]
  • high potassium, or
  • low sodium / potassium ratio,

These values will give you an indication whether your kidneys are keeping up and you might need to review your diet.

If you don’t have the blood tests available, you can test your urine pH which gives you an indication of how much acid versus alkaline ash your kidneys are clearing after digestion.  This will not necessarily tell you how alkaline your blood is, but rather whether your body is having to excrete alkaline or acidic waste products after digestion which appears to still be a relevant guide.

The chart below shows the urine pH of people in the Caciano et al study noted above when they changed their diet to a low PRAL (alkaline) or high PRAL (acidic) dietary approach.   Most participants could achieve the high PRAL acidic target of greater than a pH of 6.0 within four days.  However, it took some participants up to nine days of changing their diet to achieve an alkaline pH of greater than 7.0.

image19

If you’re interested, you can grab some pH test tape and see where you are currently at.  If you find your urine is more acidic (i.e.  pH lower than 6.0) you could consider manipulating your diet and / or use mineral supplements until you are achieving a pH of greater than 6.8 or so.

image15

supplementation

Obviously eating real food such as the ones listed above is preferable.  However, if simply adding more non-starchy veggies listed above doesn’t work for you there are a number of other more aggressive options that you can turn to.

One popular approach is to use a greens powder.  On the positive side, a few spoonful’s of this will quickly give you lots of micronutrients and alkalising minerals.  However, real veggies are always going to be better and it will give you about one gram of carbohydrates per serving.

image40

Another option is to use baking soda which is highly alkaline and has been shown to improve athletic performance in a range of studies (check out the plethora of study reviews on Adel’s SuppVersity site if you are interested in seeing how the alkalinity provided by Bicarbonate can affect exercise performance).[32] [33] [34]

image39

In situations that result in acute acidosis, supplementing younger patients with sodium bicarbonate prior to exhaustive exercise resulted in significantly less acidosis in the blood than those that were not supplemented with sodium bicarbonate.[35]

The pros of baking soda is that it is cheap and effective and will turn your urine pee sticks blue very quickly (see picture below).  It may also cause gut distress if you have a sensitive gut (as many people with diabetes do).  And you’ll also be missing out on all the other benefits of eating whole veggies.

image08

Elizma says:

I prefer citrate minerals since taking bicarb soda can dilute stomach acid when taken with meals whereas citrate minerals can be taken at any time.  Using citrate minerals has a ‘bicarbonate sparing’ effect without necessarily taking bicarbonate.

By reducing the workload on the pancreas more ATP is available to produce insulin.   The lungs can only deal with volatile acids that can be excreted via CO2, but the kidneys have to do the rest via ammonia.

I think people try and simplify it for themselves by talking about acid / alkaline diets when it’s more to do with minerals imbalances and other factors that shift metabolic acid production.

But does it really matter what we call it if people eat better?

In our house what we’re trying to do is maximise the green leafy veggies, not overdo the dairy, perhaps increase the coconut intake as well as taking the a little and then take the potassium, calcium and magnesium citrate mineral supplement mix until the urine pH consistently is above 6.8.

are ketones acidic ketones?

If you are taking exogenous ketone supplements, then making sure you get your green leafies or taking a mineral supplement may be even more important.

Your body will likely secrete some insulin to bring down the total energy in your bloodstream if you have really high ketones, particularly in a fed state.  A recent study indicated that the pancreas does not secrete insulin in response to ketones alone, but rather when glucose is greater than 5.0 mmol/L or 90 mg/dL and you add in additional ketones.

So, I wondered if adding exogenous ketones to a diet that is not already ketogenic (i.e. high blood glucose levels) is a recipe for accelerated hyperinsulinemia and acidity?

image22

I had some exogenous ketones lying around the house so I thought it would be interesting to test at what point they become acidic.

Seems the answer is yes for the ketone salts…

image06

2016-11-19 11.03.08.jpg

… and so is the ketone ester.

image37

So maybe some of the acidity that I saw on my blood tests could also have been contributed to by me dabbling with exogenous ketones?

image49 [36]

So are exogenous ketones also acidic inside the body?  In the name of science I downed two packets of Keto//OS.  My ketone value went from 0.6 to 0.8mmol/L and the increased insulin released to clear the exogenous ketones also brought the blood glucose levels down over a period of about five hours.

2016-11-19 10.49.07.jpg

But the pH of my urine also went from alkaline to acidic as my kidneys worked to clear the acid load from the exogenous ketones.  I sure hope all those people with the recurring order of Keto//OS are also taking mineral supplements and ideally eating lots of green leafy veggies.

2016-11-19 12.57.53.jpg

I also wonder what the long term effects of high levels of exogenous ketones will be on people who are taking them for cancer and other conditions which appear to be exacerbated by insulin and acidity.  I suppose time will tell.

Interestingly there are some people who feel that increased ketones are more a downstream symptom of increased NAD+.  It’s actually the increased NAD+ that occurs in fasting and carb restriction and the upregulated Sitruins that is causing the positive outcomes and not actually the ketones themselves.

2016-11-20 03.04.20.png

endogenous ketones

Endogenous ketones are acidic too,[37] [38] though this is not really a problem in someone who has a functioning pancreas and is producing adequate insulin to keep ketone levels under control.  When the pancreas fails to produce adequate insulin in (i.e. Type 1 Diabetes) it is called ketoacidosis and it can be very dangerous.

In a metabolically healthy person, alkalising minerals play a role in balancing out the acid load of the ketones and actually neutralising them.  Perhaps this is part of the reason that many metabolically fit athletes do not tend to see really high blood ketones even if they have been following a ketogenic diet for a long time?  If their kidneys and pancreas are functioning well they have adequate minerals to balance their acidity they will be able to happily operate most of the time with very low glucose and ketone values (i.e. low total energy).

Perhaps the reverse could be an interesting “hack” if you really wanted to achieve higher blood ketone values without fasting?

In his Keto Summit interview Bryan Walsh (pictured below) raised some interesting questions about pH balance on a long term ketogenic diet.

Can we deplete our buffering capacity by being in this chronically acidic state all the time, a self-induced acidic state, meaning a ketogenic diet?  Long term can we deplete our body’s ability to mitigate this pH shift? 

The body will still maintain an incredibly tight pH.  But at what expense? What are we using up that we may have used for something else to try to maintain this golden egg of pH in the body?

I don’t think over time you’d see somebody’s pH shift.  But what I do think is that other things would suffer as a consequence.

image32

metabolic acidosis and insulin resistance

When you dig into the literature there seem to be a lot of parallels between Type 2 Diabetes and metabolic acidosis.[39] [40] [41]  Type 2 Diabetes and kidney disease often occur together.

“[The] dietary acid load is directly associated with an increased risk of type 2 diabetes. From a public health perspective, dietary recommendations should not only incriminate specific food groups but also include recommendations on the overall quality of the diet, notably the need to maintain an adequate acid/base balance.”[42]

image09

The pancreas’ job is to maintain normal blood glucose levels within a tight range.  The adipose tissue continues to store the excess energy from processed carbs through de novo lipogenesis until it can’t take anymore and we become insulin resistant in order to slow the storage of fat in the adipose tissue.  Then, in the long run the pancreas burns out and we require exogenous insulin.

Similar to the pancreas’ role with glucose, it seems the kidneys maintain our pH within a tight range.  But then over time if it is subjected to excessive acid load, just like excessive glucose in our pancreas, our tight grip on pH may slip, even a little.  Then the kidneys start to burn out.  They no longer maintain optimal acid levels, but rather slightly more acidic levels and then lose their grip on optimal oxygenation of the blood which leads to a plethora of metabolic issues.

Similar to maintaining tight blood glucose control, part of the solution to slow the decline in our kidney function may be to eat some more leafy greens while minimizing the acidic load from nutrient poor foods such as sugar and processed grains.

muscle loss

Another parallel between Type 2 Diabetes and metabolic acidosis is muscle loss.  Our ability to optimise lean muscle mass is critical to maintaining good glucose disposal and insulin sensitivity.

Recent insights indicate that several consequences of metabolic acidosis including the development of insulin resistance can stimulate muscle protein degradation.[43]

So if we don’t eat our veggies maybe we risk losing our gainz?!?!?

In Type 2 Diabetes we often see excess gluconeogenesis when the body can’t burn fat due to high insulin / insulin resistance and instead to protein in our diet and body for energy.

Evidence increasingly suggests that acidosis promotes muscle protein wasting by both increasing protein degradation and inhibiting protein synthesis.

Correction of acidosis may therefore help to preserve muscle mass and improve the health of patients with pathological conditions associated with acidosis.[44]

The chart below shows that people with the highest amount of potassium excretion in the urine (i.e. most alkaline) had a greater percentage of lean body mass.  Perhaps the quickest way to get buff is to get adequate protein AND eat your veggies to enhance fat burning and reduce your reliance on glucose and protein for energy.

image27

It has been demonstrated that even the slightest degree of metabolic acidosis produces insulin resistance in healthy humans. Many recent epidemiological studies link metabolic acidosis indicators with insulin resistance and systemic hypertension.

The strongly acidogenic diet consumed in developed countries produces a lifetime acidotic state, exacerbated by excess body weight and aging, which may result in insulin resistance, metabolic syndrome, and Type 2 diabetes, contributing to cardiovascular risk, along with genetic causes, lack of physical exercise, and other factors… 

Even very slight levels of chronic kidney insufficiency are associated with increased cardiovascular risk, which may be explained at least in part by deficient acid excretory capacity of the kidney and consequent metabolic acidosis-induced insulin resistance.[45]

image23 [46]

As we age, there is a loss of muscle mass, which may predispose us to falls and fractures. A three-year study looking at a diet rich in potassium, such as fruits and vegetables, as well
as a reduced acid load, resulted in preservation of muscle mass in older men and women. Conditions such as chronic renal failure that result in chronic metabolic acidosis result in accelerated breakdown in skeletal muscle. 

Correction of acidosis may preserve muscle mass in conditions where muscle wasting is common such as diabetic ketosis, trauma, sepsis, chronic obstructive lung disease, and renal failure.[47]

summary

  • Whether you think eating alkaline foods is useful or woo woo junk it appears that metabolic acidosis is a thing.
  • Metabolic acidosis seems to be interrelated with insulin resistance, Type 2 Diabetes and retention of muscle mass.
  • To prevent metabolic acidosis it appears prudent to ensure that your body has adequate minerals to enable your kidneys to balance pH over the long term. This can be achieved by eating plenty of veggies and / or supplementing with alkaline minerals (e.g. magnesium, sodium, potassium, zinc etc).
  • If you eat plenty of veggies you’re probably getting enough alkalising minerals, however you can easily test your urine to see if your dietary acid load is high.
  • If you are targeting a high fat therapeutic ketogenic diet, following a zero carb dietary approach and / or taking exogenous ketones it seems then it may be even more important to be mindful of your acid load and consider mineral supplementation.

epilogue

So, you may be wondering how my ketones are going these days with the alkalising minerals on board.  They seem to be a little lower now with the mineral supplementation.   When I fast for a few days they kick in and might get to around 2.0mmol/L and hunger is not a big deal.  I think the ketones are doing what they’re meant to do.

I’m still not exactly sure why my ketone spiked off the chart that brief period.  I think Elizma’s explanation makes sense.  That is, my insulin sensitivity improved and the flood gate of free fatty acids was released for a time and then settled down.  In time though I think the alkalising minerals balance out the ketones and keep them from getting too high.

I have also been taking the Niacel on an ongoing basis to increase NAD+ which in appears to increase the breath acetone (fat burning) and decreases the ketones in the blood (BHB).  But more on that in future posts.  This one is already too long.

The ratio of β-OHB to AcAc depends on the NADH/NAD+ ratio inside mitochondria; if NADH concentration is high, the liver releases a higher proportion of β-OHB.[48]

I think being able to run with a lower total energy (i.e. glucose plus ketones) in the blood most of the time might be a good thing.  When high levels of glucose or ketone are required (e.g. fasting or explosive exercise) they can be easily accessed if we have good insulin sensitivity.

P.P.S.

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

references

[1] https://www.ncbi.nlm.nih.gov/pubmed/8396707

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

[3] http://www.forbes.com/sites/quora/2016/03/11/how-our-bodies-go-to-extraordinary-lengths-to-maintain-safe-ph-levels/#4dd8545c208a http://www.forbes.com/sites/quora/2016/03/11/how-our-bodies-go-to-extraordinary-lengths-to-maintain-safe-ph-levels/#667262df208a

[4] http://ketosummit.com/

[5] http://www.gbrmpa.gov.au/managing-the-reef/threats-to-the-reef/climate-change/how-climate-change-can-affect-the-reef/ocean-acidification

[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195546/

[7] http://thepaleodiet.com/acidbase-balance/

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195546/

[9] http://downloads.hindawi.com/journals/jeph/2012/727630.pdf

[10] http://christinecronau.com/wp-content/uploads/2014/01/pH.pdf

[11] https://www.facebook.com/drjackkruse/posts/1537554709642211

[12] http://www.nature.com/articles/srep35907

[13] https://en.wikipedia.org/wiki/Warburg_hypothesis

[14] https://en.wikipedia.org/wiki/Respiratory_exchange_ratio

[15] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4424466/

[16] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4424466/

[17] http://www.madehow.com/inventorbios/32/Pierre-Eug-ne-Marcellin-Berthelot.html

[18] https://www.ncbi.nlm.nih.gov/pubmed/7797810

[19] http://www.precisionnutrition.com/acid-base

[20] http://thepaleodiet.com/acidbase-balance/

[21] https://www.ncbi.nlm.nih.gov/pubmed/7797810

[22] https://www.ncbi.nlm.nih.gov/m/pubmed/23439373/

[23] https://www.ncbi.nlm.nih.gov/pubmed/7797810

[24] http://www.wheatbellyblog.com/2015/02/mind-minerals/

[25] https://www.ncbi.nlm.nih.gov/pubmed/21248199

[26] https://www.ncbi.nlm.nih.gov/m/pubmed/21457266/

[27] https://www.ncbi.nlm.nih.gov/m/pubmed/21481501/

[28] http://nutritionfacts.org/video/alkaline-diets-animal-protein-and-calcium-loss/

[29] https://www.ncbi.nlm.nih.gov/pubmed/15546911

[30] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2597402/

[31] https://en.wikipedia.org/wiki/High_anion_gap_metabolic_acidosis

[32] http://firstendurance.com/the-ph-of-foods-and-their-effect-on-performance/

[33] https://www.facebook.com/groups/optimisingnutrition/permalink/1607541596213549/?comment_id=1608380926129616&comment_tracking=%7B%22tn%22%3A%22R%22%7D

[34] https://www.facebook.com/groups/optimisingnutrition/permalink/1607541596213549/?comment_id=1608380926129616&comment_tracking=%7B%22tn%22%3A%22R%22%7D

[35] http://downloads.hindawi.com/journals/jeph/2012/727630.pdf

[36] https://www.facebook.com/livinlowcarbman/photos/a.145604576319.138059.91566951319/10154770616481320/?type=3&comment_id=10154788120686320&comment_tracking=%7B%22tn%22%3A%22R%22%7D

[37] http://chemistry.stackexchange.com/questions/54459/why-are-ketones-acidic

[38] http://answers.wikia.com/wiki/Is_a_ketone_an_acid_or_a_base

[39] http://l.facebook.com/l.php?u=http%3A%2F%2Fsuppversity.blogspot.com.au%2F2013%2F04%2Fscience-round-up-seconds-macro-mineral.html&h=sAQHCVlPJ

[40] https://www.cambridge.org/core/journals/british-journal-of-nutrition/article/diet-induced-acidosis-is-it-real-and-clinically-relevant/D7F03DFEF497996E90BB6DA487C777B8/core-reader

[41] https://www.ncbi.nlm.nih.gov/pubmed/21481501

[42] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4935236/

[43] https://www.ncbi.nlm.nih.gov/pubmed/16736444

[44] https://www.ncbi.nlm.nih.gov/pubmed/15586003

[45] https://www.ncbi.nlm.nih.gov/pubmed/21352078

[46] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3155690/

[47] http://downloads.hindawi.com/journals/jeph/2012/727630.pdf

[48] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709699/

curried egg with cows brain

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

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

2016-11-18-1

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.

2016-11-18

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.

2016-11-18-3

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

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

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

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

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

 

zero carb

For most people, the optimal dietary approach seems to include a balance of plant and animal based foods.  Some people prefer more (or all) plants due to ethical or religious reasons, while others prefer to avoid vegetables and grains.

Some people just don’t like veggies, while others struggle to digest plant fibres and find relief from debilitating digestive, mental health[1] or other symptoms when they avoid plant based foods and even dairy.[2] [3] [4]

Others feel that the nutrients in plant based foods are less bioavailable and that the nutrients in animal based foods will be more easily absorbed.[5]

image04

The chart below shows a comparison of the nutrients provided by:

  • the most nutrient dense zero carb foods,
  • the most nutrient dense plant based foods, and
  • the most nutrient dense foods available.

As you might expect, the zero carb foods (red bars) do well in the proteins and fatty acids while the plant based foods (blue bars) generally contain more vitamins and minerals.

image07

 

Going zero carb will reduce the insulin load compared to most dietary approaches, although the higher levels of protein may mean that you won’t necessarily be ‘ketogenic’ or showing high levels of blood ketones.

2016-11-07-1

While the recommended daily intake values for various nutrients is debatable, it appears that it is more difficult to obtain the recommended quantity of calcium, magnesium, potassium, vitamin E and vitamin C on a zero carb approach compared to others that contain plant based foods and hence it may be useful to supplement these nutrients.

2017-02-26 (19).png

You’ll notice the most nutrient dense zero carb foods listed below contain a solid amount of organ meats which are very nutrient dense.  The chart below shows the nutrient density of the highest ranking zero carb foods with and without organ meats (cutting out all carbohydrate containing foods narrows the list of available foods from 8000 to 2887 and removing offal narrows the list to 2784 available foods).  Organ meats makes a significant difference to the levels of copper, manganese, selenium, vitamin A and vitamin B-12.  So if you are going to go with a zero carb approach it makes sense to maximise your organ meats.

image03

The zero carb foods below are sorted using both nutrient density and insulin load (to make sure you’re not just eating lean protein).  Also included in the table are the nutrient density scores, percentage of insulinogenic calories, insulin load, energy density and the multicriteria analysis score (MCA) that combines all these factors (see the building a better nutrient density index article for more details on the MCA process).

offal

food ND insulin load (g/100g) calories/100g MCA
turkey liver 9 21 189 1.6
lamb liver 9 20 168 1.4
chicken liver 9 20 172 1.4
beef brains 5 8 151 1.4
lamb kidney 8 15 112 1.3
veal liver 8 26 192 1.2
beef liver 9 25 175 1.2
chicken liver pate 4 17 201 1.1
lamb brains 3 10 154 1.0
beef kidney 5 20 157 0.8
pork liver 5 23 165 0.7
beef heart 3 16 165 0.7
lamb sweetbread 3 15 144 0.7
liver sausage -2 10 331 0.7
turkey heart 3 20 174 0.7
lamb heart 3 19 161 0.6
sweetbread -2 9 318 0.6
beef tripe 3 14 103 0.6
beef heart 2 23 179 0.5

animal products

food ND insulin load (g/100g) calories/100g MCA
ham (lean only) 8 17 113 1.1
ground turkey 2 19 258 0.8
chicken breast 6 22 148 0.8
pork chop 5 23 172 0.8
roast ham 3 18 178 0.7
roast pork 3 20 199 0.7
turkey ham 3 14 124 0.7
ham 1 11 149 0.7
turkey drumstick 4 21 158 0.7
turkey meat 4 21 158 0.7
turkey (skinless) 2 16 170 0.6
turkey bacon -1 11 226 0.6
turkey drumstick (with skin) 0 15 221 0.6
chicken (leg with skin) 2 18 184 0.6
pork ribs 2 21 216 0.6
pork loin 2 19 193 0.6
pork shoulder 4 22 162 0.6
pork sausage -0 13 217 0.6
turkey -1 21 414 0.6
leg ham 4 22 165 0.6
pork 2 22 209 0.6
meatballs -1 14 286 0.6
veal loin 3 20 175 0.6
ground pork 3 25 185 0.6
salami -2 17 378 0.6
turkey 3 23 189 0.6
bratwurst -2 13 333 0.5
kielbasa -2 12 325 0.5
bologna -1 11 172 0.5
pork sausage -2 16 325 0.5
bacon -3 11 417 0.5
pork ribs -2 16 361 0.5
lean beef 3 23 149 0.5
veal 4 24 151 0.5

seafood

food ND insulin load (g/100g) calories/100g MCA
fish roe 10 18 143 1.6
caviar 7 23 264 1.5
salmon 9 20 156 1.5
trout 8 18 168 1.4
sturgeon 8 16 135 1.4
mackerel 3 10 305 1.2
crab 10 14 83 1.2
anchovy 6 22 210 1.2
halibut 9 17 111 1.2
crayfish 9 13 82 1.2
sardine 5 19 208 1.2
oyster 7 14 102 1.0
cisco 3 13 177 1.0
cod 8 48 290 1.0
lobster 8 15 89 1.0
flounder 7 12 86 1.0
herring 3 19 217 0.9
pollock 8 18 111 0.9
rockfish 7 17 109 0.8
perch 6 14 96 0.8
shrimp 6 19 119 0.7
haddock 6 19 116 0.7
tuna 4 23 184 0.7
whiting 5 18 116 0.6
white fish 5 18 108 0.5
octopus 5 28 164 0.5
clam 4 25 142 0.4
scallop 5 22 111 0.3

 

dairy and egg

food ND insulin load (g/100g) calories/100g MCA
egg yolk 4 12 275 1.4
whole egg 4 10 143 1.2
kefir 5 7 41 0.7
whey powder 9 82 339 0.6
cream -4 5 340 0.5
sour cream -3 6 198 0.5
feta cheese -2 15 264 0.4
butter -5 3 718 0.4
cheddar cheese -2 20 410 0.4
limburger cheese -2 15 327 0.4
camembert -2 16 300 0.4
blue cheese -2 19 353 0.4
Swiss cheese -2 22 393 0.4
cream cheese -4 10 350 0.4
gruyere cheese -2 23 413 0.4
cream cheese (low fat) 5 19 105 0.4
edam cheese -3 21 357 0.3
muenster cheese -3 19 368 0.3
Monterey cheese -3 19 373 0.3
gouda cheese -3 21 356 0.3

 

other dietary approaches

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

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

If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help identify the optimal dietary approach for you.

image02

 

notes

[1] https://zerocarbzen.com/2016/10/04/zero-carb-interview-amber-ohearn/

[2] https://www.gutsense.org/fiber-menace/about-fiber-menace-book.html

[3] https://optimisingnutrition.com/2015/10/05/ketogenic-fibre/

[4] https://zerocarbzen.com/

[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3153292/

[6] However, keep in mind that this analysis is based on the USDA database that includes all the nutrients in the food rather than what will be absorbed.  Species specific nutrient bioavailability is still an emerging area.  While we can measure the nutrient in a food, it is hard to quantify how much of those nutrients are digested and absorbed into the body.

the complete guide to fasting (review)

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

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

image08

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

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

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

Essentially, Jason’s key points are that:

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

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

my experience with fasting

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

Complete abstinence is easier than perfect moderation.

St Augustine

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

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

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

My key fasting takeaways are:

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

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

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

image25

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

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

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

context

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

2016-10-29-6

Desperate times call for desperate measures!

image11

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

image07

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

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

image06

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

the Complete Guide to Fasting

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

image01

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

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

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

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

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

The book covers:

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

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

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

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

my additional 2c…

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

target glucose levels

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

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

image12

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

image31

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

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

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

image24

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

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

image00

fasting to optimise blood glucose levels

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

image10

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

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

image04

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

image26

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

image09

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

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

fasting frequency

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

image02

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

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

14633142_10209291396354349_7869008000126784615_o

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

image28

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

image15

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

image16

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

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

FAST WELL, FEED WELL

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

image29

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

image32

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

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

“Fasting without proper refeeding is called anorexia.” 

Mike Julian

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

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

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

optimising insulin levels AND nutrient density

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

image30

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

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

image22

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

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

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

image03

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

image33

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

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

protein

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

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

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

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

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

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

image14

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

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

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

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

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

image18

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

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

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

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

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

are you really insulin resistant?

Insulin resistance and obesity is a continuum.

Not everyone who is obese is necessarily insulin resistant.

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

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

image05

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

image19

optimal ketone levels

Measuring ketones is really fascinating but confusing as well.

“Don’t be a purple peetone chaser.”

Carrie Brown, The Ketovangelist Podcast Ep 78

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

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

image27

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

image20

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

the root cause of insulin resistance is…

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

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

But what is the root cause of insulin resistance?

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

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

image13

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

image23

summary

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

references

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

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

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

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

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

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

nutrient density optimised for diabetes, ketosis, weight loss, longevity and performance

%d bloggers like this: