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

June 3, 2017 Marty Kendall 10 Comments

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

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

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

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

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

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

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

This article explores:

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

Protein is insulinogenic and can convert to glucose

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

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

Gluco = glucose
Neo = new
Genesis = creation
Gluconeogenesis = new glucose creation

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

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

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

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

How much insulin does protein require?

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

Our glucose response to carbohydrate

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

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

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

Our insulin response to carbohydrates

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

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

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

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

Does protein actually turn to chocolate cake?

Read on to find the answer.

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

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

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

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

But what about a huge protein meal?

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

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

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

What is going on?

The role of insulin and glucagon in glucose control

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

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

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

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

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

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

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

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

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

Glucose, insulin and glucagon response to a high carbohydrate meal

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

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

Glucose, insulin and glucagon response to a high protein meal

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

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

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

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

Insulin response to protein for people with diabetes

Things are different if you have diabetes.

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

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

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

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

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

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

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

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

Real life example

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

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

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

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

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

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

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

More insulin or less protein?

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

Is it too much protein?

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

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

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

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

So, if Monica had a choice, should she:

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

Personally, I think the correct answer is C.

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

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

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

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

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

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

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

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

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

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

Basal and bolus insulin

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

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

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

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

In diabetes management there are two kinds of insulin doses:

basal insulin, and
bolus insulin.

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

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

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

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

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

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

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

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

How to improve your basal insulin sensitivity

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

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

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

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

Dr Bernstein’s approach

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

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

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

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

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

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

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

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

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

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

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

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

Summary

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

references

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

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

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

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

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

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

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

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

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

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

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

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

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

^[14] https://docmuscles.com/

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

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

post last updated August 2017

blood sugar, diabetes, fasting, fat, healthy foods, insulin index, insulin resistance, ketones

the complete guide to fasting (review)

October 29, 2016 Marty Kendall 14 Comments

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.

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

Michael 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 seem to be better when I’ve fasted for a few days.

My key fasting takeaways are:

Fasting is not that hard. Give it a try.
You can build up slowly.
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).

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.

Desperate times call for desperate measures!

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.

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.

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.

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, ffull-colourproduction 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.

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).

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.

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.

fasting to optimise blood glucose levels

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

summary

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.
Fasting can help optimise blood glucose and weight in the long term, with a disciplined regimen.
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.
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

athletes, nutrient density, recipes

Dom D’Agostino’s breakfast – sardines, oysters, eggs and broccoli

August 15, 2016 Marty Kendall 19 Comments

At first it sounds like a bizarre combination, but when the smartest guy in keto says that he has sardines, oysters, eggs and broccoli as his regular breakfast I wasn’t surprised to find this diet scored highly in the nutritional analysis.

Before he started saving the world by developing Warburg’s mitochondrial theory of cancer and oxygen toxicity seizures for DARPA Dominic D’Agostino studied nutrition and is rumoured to be able to do a 500-pound deadlift for 10 reps after a week of fasting.

Both physical and mental performance are undoubtedly critical to Dom, so it’s not surprising that he is very intentional about his diet and what he puts in his mouth to start each day.

As you can see in the plot from Nutrition Data below Dom’s breakfast scores a very high 93 in the vitamins and minerals score and a very solid 139 in the protein score.

You could say this meal was high protein (44%), low carb (10%) and moderate fat (46%), although his fatty coffee and high-fat desserts would boost the fat content to make it more “ketogenic”.

Dom’s breakfast scores well against the 250 meals analysed to date in the meal rankings for different goals coming in at:

therapeutic ketosis – 176
diabetes and nutritional ketosis – 87
nutrient density – 9
weight loss – 16

I’ve heard Dom say that he aims for a ‘modified Atkins’ approach with higher protein levels rather than a classical therapeutic ketogenic diet which is harder to stick to and might be used for people with epilepsy, cancer, dementia, etc. It was intriguing to see that Dom’s standard breakfast ranks the highest in nutrient density rather than therapeutic or nutritional ketosis.

Dom first mentioned his favourite breakfast concoction in his first interview with Tim Ferriss (check out the excellent three-hour podcast here). You can hear the shock and slight repulsion in Tim’s voice in the sound check as he responds with

“Do you blend that up in the Vitamix?”

But now Tim, rather than following his own slow carb approach, has made sardines and oysters a regular breakfast staple and mentions it as one of the top 25 great things he learned from podcasts guests in 2015.

The stats for a 500 calorie serve of Dom’s breakfast are shown in the table below.

net carbs	insulin load	carb insulin	fat	protein	fibre
6g	38g	18%	46%	44%	6g

I was aware that broccoli, eggs and sardines are nutritionally amazing, but then the oysters fill out the vitamin and mineral score to take it a little bit higher. Dom obviously understands the importance of Omega 3s which are hard to get in significant quantities from anything other than seafood.

I was surprised to see that oysters can be ‘carby’ (at 23% carbs) which is apparently due to their glucose pouch which varies in size depending on when they’re harvested.

If you wanted to skip the oysters due to taste or cost considerations, the combination of sardines, egg and broccoli still does pretty well. This option gives fewer carbs, a slight decrease in the vitamin and mineral score with a small increase in the amino acid score.

The ranking for the sans-oyster option is:

therapeutic ketosis – 159
diabetes and nutritional ketosis – 67
nutrient density – 11
weight loss – 20

The stats for a 500 calorie serving are:

net carbs	insulin load	carb insulin	fat	protein	fibre
3g	30g	10%	48%	44%	6g

The combination of nutrient dense seafood with nutrient dense vegetables is hard to beat. The chart below shows my comparison of the nutrients in the various food groups in terms the proportion of the Daily Recommended Intake (DRI) from 2000 calories (click to enlarge).

I couldn’t get any photos of Dom’s breakfast, but I did get a picture of my current go to lunch. Each weekend I get a bunch of quality celery and chop it up into tubs to take to work each day. I have cans of mackerel and sardines in my drawer at work.

Celery does really well in terms of nutrient density per calorie and sardines and mackerel are high on the nutrient density lists without being outrageously expensive (e.g. caviar, anchovy, swordfish, trout).

When I feel hungry, I might start munching on the celery which is pretty filling and hard to binge on. Then if I’m still hungry, I’ll have as many cans of mackerel or sardines as it takes to fill me up (which is usually 2 to 4).

At around 2 pm this is my first meal of the day (other than espresso shots with cream) at around 2 pm. If I start to feel hungry before then I might check my blood glucose to see if I really need to refuel or if I think I’m hungry because I’m bored. I’ll then go home and have an early dinner with the family around 6 pm.

I’ve been known to indulge in some peanut butter with, cream, Greek yoghurt or even butter if I’m still hungry (e.g. if I’ve ridden to work) but I try to not overdo it as I’m not as shredded as Dom yet.

The simple combination of celery and mackerel also does pretty well in the ranking of 250 meals and aligns well with my current goal of maximising nutrient density and ongoing weight loss now that I’ve been able to stabilise my blood glucose levels.

therapeutic ketosis – 137
diabetes and nutritional ketosis – 36
nutrient density – 16
weight loss – 8

net carbs	insulin load	carb insulin	fat	protein	fibre
8g	33g	25%	51%	35%	6g

articles, blood sugar, diabetes, exogenous ketones, insulin load, ketones, ketosis, nutrient density, protein, therapeutic ketosis

are exogenous ketones right for you?

August 8, 2016 Marty Kendall 56 Comments

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

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

Exogenous vs. endogenous ketosis

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

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

Ketones vs glucose

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

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

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

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

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

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

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

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

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

hyperinsulinemia and metabolic disorders

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

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

exogenous ketones and the low carb flu

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

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

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

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

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

my experience with exogenous ketones

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

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

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

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

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

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

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

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

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

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

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

do exogenous ketones help with weight loss?

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

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

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

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

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

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

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

^{^[13]}

Confused?

I don’t blame you.

Metabolically healthy

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

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

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

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

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

I know Luis Villasenor from Ketogains finds the same thing.

total energy = ketones + glucose

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

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

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

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

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

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

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

^[16]^[17]^[18]

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

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

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

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

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

My heart sank when I saw this video.

MORE investigation required?

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

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

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

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

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

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

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

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

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

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

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

The lower the better?

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

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

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

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

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

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

MORE is not necessarily BETTER when it comes to health.

Fast well, feed well

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

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

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

	ketones (mmol/L)	blood glucose (mmol/L)	total energy (mmol/L)
average	0.7	4.8	5.5
30th percentile	0.4	4.6	5.2
70th percentile	0.9	5.1	5.8

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

	ketones (mmol/L)	blood glucose (mg/dL)	total energy (mg/dL)
average	0.7	86	99
30th percentile	0.4	83	94
70th percentile	0.9	92	104

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

the real magic of ketones

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

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

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

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

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

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

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

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

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

nutrient density

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

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

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

the best exogenous ketone supplement

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

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

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

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

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

references

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

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

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

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

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

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

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

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

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

^{^[10]} http://docmuscles.shopketo.com/

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

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

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

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

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

^{^[16]} https://www.facebook.com/BurnFatNotSugar/

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

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

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

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

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

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

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

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

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

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

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

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

post last updated: July 2017

articles, diabetes, nutrient density, weight loss

choosing the right sized low carb band aid

May 30, 2016 Marty Kendall 34 Comments

This article identifies nutrient dense low insulin load foods that can help to stabilise your blood glucose levels and allow your own pancreas to keep up.
Once you normalise your blood glucose and lose some weight the progressive addition of nutrient dense low energy density foods may help continue your weight loss and improve your metabolic health.

how important is insulin sensitivity?

Managing your blood glucose levels through diet seems to be a major issue, if not THE most significant issue when it comes to health, longevity and reducing your risk of the leading causes of death (i.e. heart attack, stroke, cancer, Alzheimer’s and Parkinson’s Disease).^{^[1]}

As indicated by the charts below the lowest risk of the diseases associated with metabolic disease occurs when your HbA1c is less than 5% (i.e. an average blood glucose levels less than 100 mg/dL or 5.4 mmol/L).^{^[2]}

Insulin is an anabolic hormone that helps store nutrients and prevent their breakdown. High levels of insulin (hyperinsulinemia) can lead to excess fat storage. Excess insulin can also prevents us from accessing stored body fat.

is low carb the best approach for everyone?

There are people who will argue that you can eat as much fat as you want.

At the same time there are people who will argue that you can eat as much protein as you want.

And you guessed it, there are also people who argue that you can eat as much carbohydrate as you want.

So who is right?

It seems that Christopher Gardner’s recent study Weight loss on low-fat vs. low-carbohydrate diets by insulin resistance status among overweight adults and adults with obesity: A randomized pilot trial^{^[3]} might bring some clarity to the macro nutrient wars.^{^[4]}

As always, context matters.

It seems that there is no one single approach that is optimal for everyone all the time.

As well as encouraging participants to eat nutrient dense whole foods, Gardener’s study divided the participants up based on their insulin sensitivity and asked them to restrict carbohydrates or restrict fat as much as they could over a period of six months living in the real world without tracking calories.

As you can see from the chart below:

everyone did well when they increased their intake of nutrient dense whole foods;
participants who were insulin sensitive did better on the low energy density low fat foods; while
those where were insulin resistant did better on the low carbohydrate low insulin load foods.

This observation from Gardener’s study also aligns with the findings of the results of a 2005 study Insulin Sensitivity Determines the Effectiveness of Dietary Macronutrient Composition on Weight Loss in Obese Women (Cornier et al, 2005)^{^[5]} which also found that people who were insulin resistant did better with LCHF while those who were insulin sensitive did better on the HCLF approach.

Similarly, people who are insulin resistant improve their fatty liver on a low GI diet.^{^[6]}

Again, the results from Pitas (2005) show that people who are insulin sensitive lose more weight on a high glycemic diet while the people who were insulin resistant lose more on the low glycemic load diet.

In this video David Ludwig explains why someone who is insulin resistant might do better with a reduced carbohydrate approach.

am I insulin resistant?

So the obvious question then is whether or not you are insulin resistant and how do you tell?

Insulin resistance, and the compensatory hyperinsulinemia that follows, appear to be caused primarily by excess body fat, particularly around the abdomen and organs, which leads to inflammation, insulin resistance and elevated blood glucose levels.^{^[7]}

So if you have big belly there’s a pretty good chance you are also insulin resistant and have elevated blood glucose and / or high insulin levels. So having a waist circumference greater than half your height is a good indication you are insulin resistant.^{^[8]} ^{^[9]} ^{^[10]}

Unfortunately your size is not a perfect indicator of your metabolic health. Some people manage to store more fat before inflammation and insulin resistance sets in.^{^[11]} These people are called metabolically healthy obese.^{^[12]} Conversely some people can look thin on the outside but still have fat around their organs which causes insulin resistance. These people are called TOFIs (thin outside, fat inside).^{^[13]}

A more accurate way to ascertain if you are insulin resistant is to test your blood glucose levels. If your blood glucose levels are consistently above 5.0mmol/L or 90 mg/dL before meals then you might have a problem. If you wanted to get more serious you could get a fasting insulin test, a HOMA-IR test, test your glucose : ketone ratio or get an oral glucose tolerance test.

If you have elevated blood glucose and insulin levels you probably need to eat less processed carbohydrates. If you are obese but have great blood glucose levels then it’s probably time to incorporate some more lower energy density higher nutrient density foods to help you reduce your calorie intake.

nutrient dense low carb foods for blood glucose control

For most people, the nutrient dense foods shown in the ‘building a better nutrient density’ article would be a major improvement.

People who are insulin sensitive but still want to lose weight would do well with low calorie density high nutrient density foods.

However, for someone who is insulin resistant, the most nutrient dense foods, which have about 50% insulinogenic calories, may lead to unacceptable blood glucose swings. People who are unable to produce enough insulin or are insulin resistant need to manage their insulin budget and make sure that the insulinogenic foods that they do eat maximise nutrient density in order to provide adequate amino acids for muscle growth and repair and sufficient vitamins and minerals.

Where this gets more interesting is when we combine nutrient density with the proportion of insulinogenic calories to optimise both glucose levels and nutrient density. Listed below is a summary of the top 1000 foods of the 7000+ foods in the USDA database when we prioritise by both nutrient density and insulin load.

Included in the tables below are a number of parameters that may be useful:

The nutrient density score is based on the number of standard deviations above the average that a particular food is from the average.
The percentage of insulinogenic calories is the proportion of the energy in the food that can turn to glucose and require insulin.
The net carbs per 100g is the amount of digestible non-fibre carbohydrates in the food that can raise your blood glucose levels.
The insulin load is the weight of food per 100g that will require insulin to metabolise.
The energy density is the number of calories per 100g of the food. If you’re watching your weight as well as your blood glucose numbers than keeping the energy density down will also be of interest.

Vegetables

Listed below are the highest ranking vegetables.

While many of these vegetables have a high proportion of insulinogenic calories (i.e. digestible non-fibre carbohydrates that can raise blood glucose levels) they are also highly nutritious and have very low levels of non-carbohydrates and energy per 100g. Most people would have to eat a lot of these to have a significant impact on blood glucose levels.

Most of us would do well to focus on filling up on any of these vegetables to help keep overall calories down to assist with weight loss which is critical for improving insulin resistance. If you typically avoid vegetables due to blood glucose concerns then you could start out slowly and progressively increase your intake of these vegetables while keeping an eye on your blood glucose levels.

food	ND	% insulinogenic	net carbs/100g	insulin load (g/100g)	calories/100g
celery	2.63	49%	1	2	17
turnip greens	1.31	39%	1	4	37
rhubarb	1.46	57%	3	3	21
lettuce	1.34	52%	2	2	17
broccoli	1.21	57%	4	6	42
asparagus	1.12	46%	2	3	27
winter squash	1.22	80%	7	8	39
artichokes	0.83	33%	3	4	54
Chinese cabbage	1.02	60%	1	2	16
okra	0.94	57%	4	5	37
summer squash	1.00	65%	2	3	19
bamboo shoots	0.90	52%	3	4	28
seaweed (kelp)	0.74	43%	4	5	50
bell peppers	0.86	64%	6	7	43
cabbage	0.81	53%	3	4	30
snap green beans	0.74	47%	4	5	40
radishes	0.70	50%	2	2	19
peas	0.69	58%	5	7	51
kale	0.75	74%	8	10	56
dill	0.42	30%	2	4	52
thyme	0.27	21%	14	19	359
mushrooms	0.65	70%	2	5	30
jalapeno peppers	0.52	54%	4	5	35
collards	0.44	46%	2	5	40
paprika	0.19	17%	8	16	389
black pepper	0.24	36%	24	29	327
beets	0.34	44%	4	5	48
chives	0.27	34%	1	3	37
bay leaf	0.21	37%	34	38	406
mung beans	0.33	46%	1	3	26
onions	0.52	77%	7	8	41
mustard greens	0.27	45%	2	3	30

fruit

This list of diabetic friendly fruits is quite short compared to the veggies.

food	ND	% insulinogenic	net carbs/100g	insulin load (g/100g)	calories/100g
olives	0.02	15%	3	3	90
avocado	0.01	18%	5	6	131
raspberries	0.09	42%	6	6	58

nuts, seeds and legumes

The great thing about nuts and seeds is that they have a low percentage of insulinogenic calories and are often low in non-fibre carbohydrates. The drawback is that they have a much higher energy density due to their higher fat content and are not as high in nutrients as the non-starchy green veggies. Keep in mind that you can overdo the nuts if you are keeping an eye on your weight as well as your blood glucose levels.

food	ND	% insulinogenic	net carbs/100g	insulin load (g/100g)	calories/100g
pecans	0.15	5%	4	9	762
pine nuts	0.16	11%	9	18	647
tahini	0.17	16%	13	26	633
peanuts	0.17	18%	7	28	605
sunflower seeds	0.18	20%	11	24	491
macadamia nuts	0.12	5%	5	9	769
hummus	0.26	32%	8	14	175
pistachio nuts	0.16	23%	19	34	602
sesame seeds	0.12	18%	14	27	603
almonds	0.11	16%	15	27	652
brazil nuts	0.09	9%	4	15	704
chia seeds	0.10	16%	8	21	511
tofu	0.17	28%	2	8	112
walnuts	0.10	15%	7	25	683
coconut meat	0.09	11%	16	20	703
hazelnuts	0.10	16%	15	27	692
cashew nuts	0.11	22%	24	33	609
flaxseed	0.08	12%	2	16	568

dairy and eggs

Eggs and cheese are great in terms of proportion of insulinogenic calories. The nutrient density of these foods is above average but not as high as the non-starchy vegetables. As with the nuts, keep in mind that the energy density of these foods is high so it is possible to overdo them if you are keeping an eye on your weight as well as your blood glucose levels.

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g
butter	0.11	0%	1	734
cream cheese	0.15	10%	8	348
goat cheese	0.18	22%	25	451
egg yolk	0.18	19%	15	317
Gruyère cheese	0.18	21%	22	412
sour cream	0.12	9%	4	197
Limburger cheese	0.17	18%	15	327
cream	0.10	5%	5	431
Edam cheese	0.18	22%	20	356
blue cheese	0.17	20%	18	354
Gouda cheese	0.18	23%	20	356
cheddar cheese	0.16	20%	20	403
Muenster cheese	0.16	20%	18	368
Camembert cheese	0.17	20%	15	299
Monterey	0.16	20%	19	373
Colby	0.16	20%	20	394
feta cheese	0.17	22%	14	265
brie cheese	0.15	19%	16	334
provolone	0.17	24%	21	350
Swiss cheese	0.18	26%	25	379
parmesan cheese	0.19	30%	31	411
mozzarella	0.15	23%	18	318
whole egg	0.17	29%	10	138

seafood

Getting an adequate intake of omega 3 essential oils is important and it’s hard to do without eating fish. Higher protein lower fat fish such as cod will require more insulin to process though this is typically not an issue unless you have type 1 diabetes and need to calculate and time your insulin doses or have advanced type 2 where your insulin response is not well matched to your glucagon response from the protein.

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g
caviar	0.30	32%	22	276
anchovy	0.34	42%	21	203
herring	0.26	34%	18	210
sardine	0.24	36%	18	202
swordfish	0.28	41%	17	165
rainbow trout	0.28	43%	17	162
mackerel	0.28	45%	17	149
tuna	0.30	50%	17	137
sturgeon	0.26	47%	15	129
salmon	0.28	50%	15	122

animal products

Higher fat animal products will have a lower insulin response but but they also have a higher energy density. All these foods have more nutrients than average but not as many as the non-starchy vegetables.

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g
chicken liver	0.43	48%	20	165
beef liver	0.46	58%	24	169
bacon	0.18	23%	30	522
pepperoni	0.13	14%	17	487
chorizo	0.15	17%	19	448
foie gras	0.11	11%	13	459
pate	0.13	16%	13	315
beef ribs	0.11	13%	12	349
duck (with skin)	0.12	17%	14	331
salami	0.12	18%	12	258
lamb	0.14	24%	18	308
beef steak	0.16	28%	21	305
frankfurter	0.10	14%	11	322
ground turkey	0.19	37%	19	203
chicken drumstick	0.17	36%	22	238

is low carb a band aid or cure?

Some people say that a reduced carbohydrate approach only addresses the symptom (high blood glucose) rather than the cause (insulin resistance). However, the studies highlighted above suggest that the low carb “band aid” also helps with the healing process (e.g. fat loss).

If you are insulin resistant, then reducing the insulin load of your diet using the foods listed above to the point you achieve excellent blood glucose levels will most likely be helpful.

insulin load (g)=total carbohydrates (g)-fiber (g) + 0.56*protein (g)

As shown in the plots below, it’s the non-fibre carbohydrates, and to a lesser extent the protein, that drives our insulin and blood glucose response to food.

I’ve hit a plateau in my low carb diet, what now?

Let’s say you’re someone who has done well with a low carb diet. You’ve heard the message not to fear fat, reduced your carbs and seen a near miraculous improvement in your blood glucose and insulin levels. But, you haven’t quite reached your goal weight yet.

Listed below is a range of pieces of advice that you might hear given to people in this situation:

Just eat more fat.
Reduce total carbs.
Focus more on nutrient dense low calorie density more satiating foods.
Reduce net carbs.
Reduce the insulin load of your diet.
Eat more fibre.
Exercise more.
Lift heavy things to build lean muscle.
Develop a fasting routine.
Eat more plant based foods.
Get more sunshine.
Get less blue light at night.
Eat only during daylight hours.
Sleep more.
Do some high intensity exercise.
Cut out nuts and dairy.
Track your calories and reduce them until you start losing weight.
Stop stressing about your blood glucose levels so much, you’re just raising your cortisol!
Get another hobby and stop navel gazing so much!

In the list above I’ve crossed out (a) and (b) which I think could be counter productive.

As suggested by the studies noted above, there may be a point as you achieve normal blood glucose levels that someone would benefit from focussing on higher nutrient density and lower energy density rather than just low carbs.

The million-dollar question is, what is the cut over point where you can move on from the LCHF blood glucose rehabilitation approach and start focusing on weight loss in order to further improve your metabolic health?

I think the point at which you deem yourself to have become metabolically flexible is when your average blood glucose levels are less than 100mg/dL or 5.4mmol/L. At this point you will also be starting to show low level blood ketones.^{^[14]} It is at this point you can start adding some of the nutrient dense low energy density foods to see what effect they have on your blood glucose levels.

When to start focussing on high nutrient density low energy density foods

The chart below (click to enlarge) shows a comparison of the nutrient density for the following dietary approaches:

all foods,
high nutrient density foods,
nutrient dense low carbohydrate foods, and
nutrient dense low calorie density foods.

The low carbohydrate foods listed above will be more nutritious compared to the average of all of the foods available. However, if you have normal blood glucose levels it might be a good idea to try to incorporate more nutrient dense low energy density foods that may be more filling and nutritious to help you to continue to progress on your weight loss journey.

If your appetite is influenced by obtaining adequate nutrients from your diet and / or energy density then it may be wise to reduce the carbs in your diet only as much as you need to normalise your blood glucose levels, otherwise you may risk compromising the nutrient density of your diet.

The extent of the carbohydrate restriction (or the size of the band aid required) depends on the extent of the metabolic damage that you have sustained. It may not be sensible to sign up for a full body cast (e.g. very high fat therapeutic ketogenic diet) if you only have a broken toe (e.g. mild insulin resistance).

As you start to heal your insulin resistance you may be able to progress from the higher fat diabetic friendly list of foods above to incorporate more more nutrient dense, lower energy density foods.

Then maybe in the long run, once you optimise your weight loss, you might be able to focus on the most nutrient dense foods for optimal health.

references

^{^[1]} https://optimisingnutrition.com/2016/03/21/wanna-live-forever/

^{^[2]} http://www.diabetes.co.uk/hba1c-to-blood-sugar-level-converter.html

^{^[3]} http://onlinelibrary.wiley.com/doi/10.1002/oby.21331/full

^{^[4]} The results of Gardner’s full study should be available in late 2016.

^{^[5]} http://onlinelibrary.wiley.com/doi/10.1038/oby.2005.79/epdf

^{^[6]} http://ajcn.nutrition.org/content/84/1/136.full.pdf+html

^{^[7]} http://www.ncbi.nlm.nih.gov/pubmed/25515001

^{^[8]} https://en.wikipedia.org/wiki/Waist-to-height_ratio

^{^[9]} https://www.google.com.au/search?q=obesity+code&spell=1&sa=X&ved=0ahUKEwjpg8b94P7LAhUCE5QKHS63AP4QvwUIGSgA&biw=1218&bih=939

^{^[10]} http://bmcpediatr.biomedcentral.com/articles/10.1186/1471-2431-13-91

^{^[12]} https://en.wikipedia.org/wiki/Metabolically_healthy_obesity

^{^[13]} https://en.wikipedia.org/wiki/TOFI

^{^[14]} https://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

articles, athletes, blood sugar, calorie density, carbohydrates, foods, insulin index, nutrient density, protein

the most nutrient dense foods for different goals

September 14, 2015 Marty Kendall 6 Comments

While a lot of attention is often given to macronutrient balance, quantifying the vitamin and mineral sufficiency of our diet is typically done by guesswork. This article lists the foods that are highest in amino acids, vitamins, minerals or omega 3 refined to suit people with different goals (e.g. diabetes management, weight loss, therapeutic ketosis or a metabolically healthy athlete).

I’ve spent some time lately analysing people’s food diaries, noting nutritional deficiencies, and suggesting specific foods to fill nutritional gaps while still being mindful of the capacity of the individual to process glucose based on their individual insulin sensitivity and pancreatic function. The output from nutritiondata.self.com below shows an example of the nutrient balance and protein quality analysis.

In this instance the meal has plenty of protein but is lacking in vitamins and minerals, which is not uncommon for people who are trying to reduce their carbohydrates to minimise their blood glucose levels.

The pink spokes of the nutrient balance plot on the left shows the vitamins while the white shows the minerals. On the right hand side the individual spokes of the protein quality score represent individual amino acids.

A score of 100 means that you will meet the recommended daily intake (RDI) for all the nutrients with 1000 calories, so a score of 40 in the nutrient balance as shown is less than desirable if we are trying to maximise nutrition. [1]

I thought it would be useful to develop a ‘shortlist’ of foods to enable people to find foods with high levels of particular nutrients to fill in possible deficiencies while being mindful of their ability to deal with glucose.

essential nutrients

The list of essential nutrients below is the basis of the nutrient density scoring system used in the Your Personal Food Ranking System article, with equal weighting given to each of these essential nutrients. [2]

The only essential nutrients not included in this list are the omega-6 fatty acids which we typically get more than enough of in our western diet. [3]

essential fatty acids

alpha-Linolenic acid (omega-3) (18:3)
docosahexaenoic acid (omega-3) (22:6)

amino acids

cysteine
isoleucine
leucine
lysine
phenylalanine
threonine
tryptophan
tyrosine
valine
methionine
histidine

vitamins

choline
thiamine
riboflavin
niacin
pantothenic acid
vitamin A
vitamin B12
vitamin B6
vitamin C
vitamin D
vitamin E
vitamin K

minerals

calcium
copper
iron
magnesium
manganese
phosphorus
potassium
selenium
sodium
zinc

the lists

Previously I’ve developed short lists of nutrient dense foods also based on their insulin load or other parameters (see optimal foods lists).

But what if we want to get more specific and find the optimal foods for a diabetic who is getting adequate protein but needs more vitamins or minerals? What about someone whose goal is nutritional ketosis who is trying to maximise their omega-3 fats to nurture their brain?

To this end the next step is to develop more specific lists of nutrient dense foods in specific categories (i.e. omega-3, vitamins, minerals and amino acids) which can be tailored to individual carbohydrate tolerance levels.

I’ve exported the top foods using each of the ranking criteria from the 8000 foods in the database. You can click on the ‘download’ link to open the .pdf to see the full list. Each .pdf file shows the relative weighting of the various components of the multi criteria ranking system. The top five are highlighted in the following discussion below.

It’s worth noting that the ranking system is based on both nutrient density / calorie, and calorie density / weight. Considering nutrient density / calorie will preference low calorie density foods such as leafy veggies and herbs. Considering calorie density / weight tends to prioritise animal foods. Evenly balancing both parameters seems to be a logical approach.

You’re probably not going to get your daily energy requirements from basil and parsley so you’ll realistically need to move down the list to the more calorie dense foods once you’ve eaten as much of the green leafy veggies as you can. The same also applies if some foods listed are not available in your area.

weighting	all nutrients	omega-3	vitamins	minerals	aminos
no insulin index contribution	download	download	download	download	download
athlete	download	download	download	download	download
weight loss	download	download	download	download	download
diabetes and nutritional ketosis	download	download	download	download	download
therapeutic ketosis	download	download	download	download	download

all nutrients

This section looks at the most nutrient dense foods across all of the essential nutrients shown above. Consider including the weighting tables.

no insulin index contribution

If we do not consider insulin load then we get the following highly nutrient dense foods:

liver,
cod,
parsley,
white fish, and
spirulina / seaweed

Liver tops the list. This aligns with Matt Lalonde’s analysis of nutrient density as detailed in his AHS 2012 presentation.

It’s likely the nutrient density of cod, which is second on the list of the most nutrient dense foods, is the reason that Dwayne Johnson (a.k.a. The Rock) eats an inordinate amount of it. [4]

It certainly seems to be working for him.

athlete and metabolically healthy

If you have no issue with obesity or insulin resistance then you’ll likely want to simply select foods at the top of the nutrient dense foods list. However most people will also benefit from considering their insulin load along with fibre and calorie density. Most of us mere mortals aren’t as active or metabolically healthy as Dwayne.

When we consider insulin load we get the following foods at the top of the list:

basil,
parsley,
spearmint,
paprika, and
liver

We grow basil in a little herb garden and use it to make a pesto with pine nuts, parmesan and olive oil. It’s so delicious! (And when I say ‘we’ I mean my amazing wife Monica.)

You’ll note that spices and herbs typically rank highly in a lot of these lists. The good news is that they typically have a very low calorie density, high nutrient density and are high in fibre.

The challenge again is that it’s hard to get all your energy needs from herbs alone, so after you’ve included as many herbs and green leafy veggies as you can fit in, go further down the list to select other more calorie dense foods to meet your required intake.

weight loss

If we reduce calorie density, increase fibre and pay some attention to insulin load for the weight loss scenario we get the following foods:

wax gourd (winter melon),
basil,
endive,
chicory, and
dock

If you’re wondering what a winter melon looks like (like I was), here it is.

The winter melon does well in this ranking because it is very fibrous, has a very low calorie density and a very low 8% insulinogenic calories which means that it has very few digestible carbohydrates.

Again, basil does pretty well along with a range of nutrient dense herbs. Basil is more nutrient dense than the winter melon while still having a very low calorie density.

diabetes and nutritional ketosis

If we factor carbohydrate tolerance into the mix and want to keep the insulin load of our diet low we get the following foods:

wax gourd (winter melon),
chia seeds,
flax seeds,
avocado, and
olives

Wax gourd does well again due to its high fibre and low calorie density; however if you’re looking for excellent nutrient density as well, then chia seeds and flax seeds may be better choices. When it comes to flax seeds are best eaten ‘fresh ground’ (in a bullet grinder) for digestibility and also freshness and that over consumption may be problematic when it comes to increasing estrogens.

therapeutic ketosis

Then if we’re looking for the most nutrient dense foods that will support therapeutic ketosis we get the following list:

flax seeds,
fish oils,
wax gourd,
avocado, and
brazil nuts.

Good nutrition is about more than simply eating more fat. When you look at the top foods using this ranking you’ll see that you will need to use a little more discretion (e.g. avoiding vegetable oils, margarine and fortified products) due to the fact that nutrients and fibre have such a low ranking.

fatty acids

Omega-3 fats are important and most of us generally don’t get enough, but rather get too many omega-6 fats from grain based processed foods.

Along with high levels of processed carbohydrates, excess levels of processed omega-6 fats are now being blamed for the current obesity epidemic. [5]

The foods highlighted in the following section will help you get more omega-3 to correct the balance.

no insulin index contribution

If we’re looking for the foods that are the highest in omega 3 fatty acids without consideration of insulin load we get:

salmon,
whitefish,
shad,
fish oil, and
herring

I like salmon, but it’s not cheap. I find sardines are still pretty amazing but much more cost effective. [6] If you’re going to pay for salmon to get omega 3 fatty acids then you should make sure it’s wild caught to avoid the omega 6 oils and antibiotics in the grain fed farmed salmon.

Sardines have a very high nutrient density but still not as much omega 3 fatty (i.e. 1480mg per 100g for sardines versus 2586mg per 100g for salmon).

athlete and metabolically healthy

If we factor in some consideration of insulin load, fibre and calorie density we get:

salmon,
marjoram,
chia seeds,
shad, and
white fish

It’s interesting to see that there are also excellent vegetarian sources of omega-3 fatty acids such as marjoram (pictured below) and chia seeds (though some may argue that the bio-availability of the omega 3 in the salmon is better than the plant products).

weight loss

Some of the top ranking foods with omega-3 fatty acids for weight loss are:

brain,
chia seeds,
sablefish,
mackerel, and
herring

While seafood is expensive, brain is cheap, though a little higher on the gross factor.

Cancer survivor Andrew Scarborough tries to maximise omega 3 fatty acids to keep his brain tumour and epilepsy at bay and makes sure he eats as much brain as he can.

diabetes, nutritional ketosis and therapeutic ketosis

And if you wanted to know the oils with the highest omega-3 content, here they are:

Fish oil – menhaden,
Fish oil – sardine,
Fish oil – salmon,
Fish oil – cod liver, and
Oil – seal

amino acids

This section will be of interest to people trying to build muscle by highlighting the foods highest in amino acids.

no insulin index contribution

So what are the best sources of protein, regardless of insulin load?

cod,
egg white,
soy protein isolate,
whitefish, and
whole egg

Again, Dwayne Johnson’s cod does well, but so does the humble egg, either the whites or the whole thing.

We have been told to limit egg consumption over the last few decades, but now, in case you didn’t get the memo, saturated fat is no longer a nutrient of concern so they’re OK again.

And while egg whites do well if you’re only looking for amino acids, however if you are also chasing vitamins, minerals and good fats I’d prefer to eat the whole egg.

athlete and metabolically healthy

If you have some regard for the insulin load of your diet you end up with this list of higher fat foods:

parmesan cheese,
beef,
tofu,
whole egg, and
cod.

weight loss

If we aim for lower calorie density foods for weight loss we get this list:

bratwurst,
basil,
beef,
chia seeds, and
parmesan cheese

The bratwurst sausage does really well in the nutrition analysis because it is nutrient dense both in amino acids and high fat which keeps the insulin load down.

diabetes and nutritional ketosis

If you’re concerned about your blood glucose levels then this list of foods may be useful:

chia seeds,
flax seed,
pork sausage,
bratwurst, and
sesame seeds

Therapeutic ketosis

And those who are aiming for therapeutic ketosis who want to keep their insulin load from low protein may find these foods useful:

flax seed,
pork sausage,
sesame seeds,
chia seeds, and
pork

vitamins

People focusing on reducing their carbohydrate load will sometimes neglect vitamins and minerals, especially if they are counting total carbs rather than net carbs which can lead to neglecting veggies.

I think most people should be trying to increase the levels of indigestible fibre as it decreases the insulin load of their diet, [7] feeds good gut bacteria, leaves you feeling fuller for longer and generally comes packaged with heaps of good vitamins and minerals.

At the same time it is true that some high fibre foods also come with digestible carbohydrates which may not be desirable for someone who is trying to manage the insulin load of their diet.

The foods listed in this section will enable you to increase your vitamins while managing the insulin load of your diet to suit your goals.

no insulin index contribution

These foods will give you the biggest bang for your buck in the vitamin and mineral department if insulin resistance is not an issue for you:

red peppers,
liver,
chilli powder,
coriander, and
egg yolk

Peppers (or capsicums as they’re called in Australia) are great in omelettes.

Liver is also very high in vitamins if you just can’t tolerate veggies.

athlete and metabolically healthy

If we bring the insulin load of your diet into consideration then these foods come to the top of the list:

paprika,
chilli powder,
liver,
red peppers, and
sage

It’s interesting to see so many spices ranking so highly in these lists. Not only are they nutrient dense but they also make the foods taste better and are more satisfying.

Good food doesn’t have to taste bland!

weight loss

If weight loss is of interest to you then this list of lower calorie density foods might be useful:

chilli powder,
chicory greens,
paprika,
liver, and
spinach

It will be very challenging to eat too many calories with these foods. We find spinach to be pretty versatile whether it is in a salad or an omelette.

diabetes and nutritional ketosis

These foods will give you lots of vitamins if you are trying to manage your blood glucose levels:

chilli powder,
endive,
paprika
turnip greens, and
liver

Most green leafy veggies will be great for people with diabetes as well as providing excellent nutrient density and heaps of fibre.

therapeutic ketosis

If you really need to keep your blood sugars down then getting your vitamins from these foods may be helpful:

chilli powder,
liver,
liver sausage,
egg yolk, and
avocado

minerals

no insulin index contribution

Ever wondered which real whole foods would give you the most minerals per calorie without resorting to supplements?

Here’s your answer:

coriander,
celery seed,
basil,
parsley, and
spearmint

Even if you found a vitamin and mineral supplement that ticked off on all the essential nutrients there’s no guarantee that they will be absorbed by your body, or that you’re not missing a nutrient that is not currently deemed ‘essential’. Real foods will always trump supplements!

As you look down these lists you may notice that herbs and spices top the list of foods that have a lot of minerals. Once you have eaten as much coriander, basil, parsley and spearmint as you can and still feel hungry keep doing down the list and you will find more calorie dense foods such as spinach, eggs, sunflower seeds, and sesame seeds etc which are more common and easier to fill up on.

athlete and metabolically healthy

If we factor in some consideration of insulin load then we get this list:

basil,
spearmint,
wheat bran (crude),
parsley, and
marjoram

Wheat bran (crude) features in this list but it’s very rarely eaten in this natural state. Most of the value is lost when you remove the husk from the wheat.

As much as we’re told that we shouldn’t eliminate whole food groups, grain based products just don’t rate well when you prioritise foods in terms of nutrient density.

weight loss

If you’re looking for some lower calorie density options the list changes slightly:

basil,
caraway seed,
marjoram,
wheat bran (crude), and
chilli powder

diabetes and nutritional ketosis

If you’re trying to manage your blood sugars then this is your list of foods that are packed with minerals:

basil,
caraway seed,
flax seed,
chilli powder, and
rosemary.

therapeutic ketosis

If you’re aiming for therapeutic ketosis then the higher fat nuts come into the picture to get your minerals:

flaxseed,
sesame seed,
pine / pinon nuts,
sunflower seeds, and
hazel nuts.

application

So what does all this mean and how can we apply it?

I don’t think it’s necessary or ideal to track your food all the time, however it’s well worth taking a typical day of food and entering it into the recipe builder at nutritiondata.self.com to see where you might be lacking.

Are your vitamins or minerals low? Protein? What about fibre.

If you find these are lacking you can use these food lists to fill nutritional gaps while keeping in mind your ability to process carbohydrates and attaining your personal goals.

references

[1] http://nutritiondata.self.com/help/analysis-help

[2] http://ketopia.com/nutrient-density-sticking-to-the-essentials-mathieu-lalonde-ahs12/

[3] The omega 6 fatty acids are also classed as essential however it is generally recognised that we have more omega omega 6 than omega 3.

[4] http://www.muscleandfitness.com/nutrition/meal-plans/smell-what-rock-cooking

[5] http://ebm.sagepub.com/content/233/6/674.short

[6] http://nutritiondata.self.com/facts/finfish-and-shellfish-products/4114/2

[7] https://optimisingnutrition.wordpress.com/2015/03/30/what-about-fibre-net-carbs-or-total-carbs/

articles, blood sugar, diabetes

balancing diet and diabetes medications

August 17, 2015 Marty Kendall 16 Comments

High blood glucose levels (glucose toxicity) and high insulin levels (hyperinsulinemia) are both bad news for your health.
The highest priority in the treatment of diabetes should be to reduce foods that require large amounts of insulin.
Over reliance on medications can lead to ‘learned helplessness’, meaning that people do not use a dietary intervention to what is primary a dietary disease.
Periods of fasting and intense exercise also improve insulin sensitivity.
A lower insulin load diet and improved insulin sensitivity will enable you to reduce and possibly eliminate medications.

when do you need insulin?

Last year I was tracking my blood sugars. I was concerned with what I saw.

Based on my average sugars of about 6.2mmol/L my HbA1c would have been about 5.5%. I wasn’t happy because I knew it was still well away from ideal. [1] I knew that improving my blood sugars was likely the key to losing the weight that I had been struggling with.

In an odd sort of way I was jealous of my wife who has type 1 diabetes. She could manipulate her blood glucose levels manually with her insulin pump, but I wasn’t sure what to do to bring my blood glucose levels down to more healthy levels.

Given that doctors will typically not give insulin until your HbA1c is greater than 7.0% [2] there was no way a doctor was going to prescribe me with insulin. My doctor told me to lose some weight to combat the developing signs of fatty liver in my blood tests.

In January 2015 I found Jason’s Fung’s videos [3] and kicked myself in the butt. Intermittent fasting seemed to do the trick to break the insulin resistance even though I had been following a lower carb paleo approach for a while. I was able to get my blood sugars back down to an average of 5.4mmol/L to give me an estimated HbA1c of about 4.8% and in the process of actively trying to manage my blood glucose levels I lost ten kilograms.

Fasting and improving insulin sensitivity

Dr Jason Fung [4] has recently increased the focus on fasting and dietary intervention and discourages an over-reliance on insulin to manage diabetes.

Jason says that focussing on medicating the symptoms of diabetes rather than addressing the root cause of insulin resistance can lead to a ‘learned helplessness’ where people do not pursue a dietary solution to what is largely a dietary problem.

Addressing diabetes by giving insulin to address the symptom of high blood glucose levels is like giving an alcoholic alcohol to relieve the symptoms of their alcohol withdrawal.

Meanwhile, Dr Richard Bernstein says that most of his type 2 diabetics need to remain on small doses of insulin in addition to minimising carbohydrate in order to achieve ‘normal blood sugars’.[5]

In this video Dr Bernstein however notes a number of negative consequences of taking exogenous insulin including:

inconvenience,
it can make you fat if you eat a lot of carbohydrate, and
it can cause hypoglycaemia (i.e. low blood glucose levels).

the balance between diet and medication

So how do we find the optimal balance between an over-reliance on exogenous insulin and medication while still achieving normal blood sugars?

Dr Ted Naiman of BurnFatNotSugar.com says that when he sees a new diabetic patient he checks their fasting insulin and C-peptide levels to understand whether they are still producing insulin or if their pancreas is already burned out.

If you don’t have access to these tests another option is to test your ketones and blood glucose levels to establish the ratio of glucose to ketones, which can also help you estimate your insulin levels (see the glucose : ketone index).

High insulin and high blood glucose means that you are insulin resistant (i.e. hyperinsulinemia).

Low insulin and high blood glucose means that you are insulin deficient and your pancreas is not producing enough insulin (i.e. type 1.5 diabetes, LADA).

Dr Naiman (pictured below – he practices what he preaches!) says he “avoids insulin like the plague” if at all possible, preferring to focus on diet, fasting and exercise.

Ted says that if you are still producing insulin but have high blood glucose levels the urgent need is to reduce the insulin load of the diet, start an exercise routine to improve insulin sensitivity, and ideally commence intermittent fasting ASAP! If you continue to consume a diet with a high insulin load you risk burning out the beta cells of your pancreas at which point you will require insulin.

Ted has produced an excellent summary of intermittent fasting and the various ways to put it into practice that you can download here. For more detail you also can check out Brad Pilon’s Eat Stop Eat or Jason Fung’s series on the topic.

the dangers of glucose toxicity

As discussed in the Diabetes 102 article there are a range of well-established risk factors for high blood sugars including accelerated brain shrinkage, cancer, obesity, heart disease and stroke.

This article from Jenny Ruhl’s Blood Sugar 101 lists a number of other complications related to high blood sugars including nerve damage, beta cell destruction, heart disease, diabetic retinopathy, and kidney disease.

Just in case you weren’t already aware… elevated blood glucose levels are very bad news!

If you want to be healthy, feel good, look good and live a long life, then your number one priority should be to do whatever it takes to achieve excellent blood sugars.

the dangers of insulin toxicity

I was interested to hear Professor Tim Noakes tell Robb Wolf in episode 273 of the Paleo Solution Podcast

You really want to keep your control through diet and minimal medication and never use insulin.

What I take this to mean is not that insulin is forbidden for people who need it, but rather that you should do whatever you can to not get to the point that you need to be injecting insulin to control your blood glucose levels.

Dr Fung points to the ACCORD Study[6] along with the ADVANCE, VADT and ORIGIN studies which showed worse outcomes for people with type 1 diabetes who targeted a lower HbA1c of 6.0% rather than a more typical 7.5%.

The figure below from the ACCORD study shows the reduction in HbA1c with intensive therapy (i.e. more insulin) to “successfully” reduce blood sugar levels. What they found however was that the people in the intensive therapy group were 22% more likely to die (i.e. all-cause mortality) in spite of having ‘better’ blood glucose levels!

This may sound contradictory, because at the same time we know that reduced HbA1c levels actually lead to better health outcomes in the general population. So what’s the difference? Why are these studies suggesting that trying to normalise blood glucose levels are dangerous? Is there something about people with diabetes that makes it unhealthy for them to have lower blood sugars?

There is plenty of debate on what these studies really mean, [7] [8] [9] however Dr Fung says it is the use of medication in the absence of dietary intervention that is making the difference. Simply applying more insulin or other medications without addressing the diet is not only illogical it’s very dangerous!

This aligns with the data shown below[10] which shows that reducing HbA1c is highly beneficial when it comes to heart attack and stroke risk, however doing it through the use of antidiabetic medication does not help.

Ivor Cummings does a great job on his blog of highlighting a wide range of studies that demonstrate that insulin resistance is by far the dominant risk factor for heart disease. [11] [12] [13] [14] [15] All we do when we medicate a high carbohydrate diet with insulin is to exacerbate the insulin resistance.

So is insulin all bad? Not necessarily. Insulin is important for a range of bodily functions including growth. However, high levels of insulin to cover high levels of dietary carbohydrate is a recipe for metabolic disaster.

Rather than relying on insulin, Dr Fung recommends a low insulin load diet combined with periods of fasting to improve insulin sensitivity and reduce insulin and blood sugar levels. Dr Fung told me that people need to “reduce both blood glucose and insulin to reduce glucotoxicity and insulin toxicity.” He says a HbA1c of less than “6.0% is defined as normal, although the lower you get, the better. However, this only applies if you are using diet rather than medications.” [16]

two sides of the same coin?

Both Dr Fung and Dr Bernstein focus primarily on non-medical interventions which include:

A low carbohydrate / low glucose load / low insulinogenic diet. I suggest you focus on foods from this list and meals from here to bring your blood sugars under control.
Exercise will improve your insulin sensitivity and help to remove excess glucose from your system. High intensity short duration exercise is ideal along with regular movement through the day. Rather than forcing yourself to exercise out of guilt you may find once you balance your blood sugars with diet rather than medication you have more energy and want to move more.
Fasting is a great way to restore insulin sensitivity and reduce blood glucose levels naturally. It might be considered by some to be extreme, however it’s the most aggressive and effective approach to move the metabolic needle in the right direction. And it’s not that hard, particularly if you’ve got a lot of weight to lose and you’re looking down the barrel of major health complications.

Bob Briggs does a great job of putting this into simple terms that are easy to understand and apply.

refining insulin levels for type 1 diabetics

For someone with type 1 diabetes balancing dietary insulin load with exogenous insulin is an ongoing process of fine tuning.

Getting the basal insulin dose is important, particularly if you’re following a reduced carbohydrate approach, as it can represent up to 80% of the daily insulin dose. Unless you’re fasting you are unlikely to have a higher basal : bolus ratio than this. Covering too much of your food with basal insulin can be dangerous if you need to skip or delay a meal for any reason (e.g. sleeping in on the weekend).

The scatter plot of blood glucose readings below shows my wife Monica’s blood glucose readings. We use this data to review and refine her basal insulin rates (80% of her insulin dose) every couple of weeks.

While we are still on a journey, her blood glucose levels are the best they’ve been in her adult life and we’ve seen massive improvements since switching to a more nutrient dense low insulin load diet.

If her blood sugars drift up in a particular period of the day she will increase the basal rate on her pump in the two hours leading up to the point where the blood glucose levels are high. Conversely, if there are a cluster of hypos (lows) at a particular point in time she will drop back the basal insulin leading up to that time. Ideally we try to keep the high / low bars on the top chart on the red line, but not below it.

Her basal rates (shown below) are lower over night with a higher dose in the morning to cover the ‘dawn phenomenon’ which is the body’s way of supplying glucagon and adrenaline in preparation for the day ahead.

We’ve experimented with reducing basal insulin rates and running higher blood glucose levels to avoid lows and to reduce the overall insulin load. However this hasn’t really worked as Moni just doesn’t feel good with higher blood glucose levels.

It’s a delicate balancing act between blood glucose levels and insulin load. Your mileage may vary. You’ll need to refine things based on how you feel and with what you are comfortable with.

It’s also a good idea to look at the data over a longer period to make sure you’re not just reacting to recent events. Diet, hormones, stress, sickness and exhaustion all influence blood sugars and insulin requirements.

Knee jerk reactions to recent events can throw everything out of whack. We’ve found it better to make small refinements rather than large changes.

Some female diabetics also refine their basal rates around their monthly cycle as insulin resistance typically increases by around 15% in the four days leading up to their period. It’s worth tracking this and being ready to adjust insulin dosage.

the law of small numbers

The most important thing to know is that managing the insulin load of your diet is the most important thing you can do to improve blood glucose control. If you have a high degree of variability in your blood glucose from hour to hour due to a highly insulinogenic diet you’ll never be able to bring blood glucose levels down without risking going too low.

Most endocrinologists will recommend against targeting optimal blood glucose levels due to the risk of hypoglycaemia (low glucose levels). However reducing the insulin load of the diet will mean that the amplitude of the blood glucose swings are smaller, which will enable you to bring the overall average blood glucose level down using the basal insulin and smaller food bolus and correcting insulin doses.

Bernstein talks about the ‘law of small numbers’. If you are consuming a high carbohydrate diet then you will need ‘industrial doses’ of insulin and there is no way to calculate the insulin dose perfectly, so the errors compound and the resulting blood sugar swings are out of control. It’s the severe blood glucose swings that make you feel really bad, even more so than high or the low blood sugars alone.

adjusting insulin doses for type 2 diabetics

For the most part the observations from people with type 1 diabetes also apply to those with type 2 diabetes. A type 2 diabetic can balance their dietary insulin load with the insulin produced by their own pancreas supplemented with insulin sensitising drugs such as Metformin or injected insulin.

The first priority when transitioning to a low carbohydrate diet is to avoid driving your blood sugars low with too much medication. Rather than going low all the time it’s better to reduce your medications to a point where higher blood glucose levels will remind you that you need to manage blood glucose by controlling your diet.

If your medications are too high you will likely end up having to eat extra food to treat low blood glucose levels all the time. So not only do you have more insulin than you want (which will stop you using stored body fat for energy) you have to eat more than you need because of excess medication (which will also get stored as fat).

It’s hard to give an exact target blood sugar range, however the following guidelines may be useful:

Blood glucose levels less than 4.0mmol/L (73mg/dL) are typically considered low (unless you are young and / or have high ketone levels). If you are seeing these blood glucose levels you should decrease your diabetes medications.
Post meal blood sugars should be less than 6.7mmol/L (120mg/dL). If you’re seeing higher blood glucose levels than this after meals then you shouldn’t eat what you just ate again.
A fasting blood sugar of less than 5.0mmol/L (90mg/dL) and an average blood sugar of less than 5.4mmol/L (100mg/dL) is ideal.

Once you reduce your dietary insulin load (i.e. by reducing carbohydrates, moderating your protein and maximising high fibre foods) you will not require as much medication and may need to reduce your medications to prevent hypos (low blood sugars).

If your dietary insulin load reduces further you will be able to reduce, and possibly eliminate, your diabetes medications as your own pancreas is able to keep up with your decreased insulin requirements.

If you are able to further reduce your insulin load your blood sugars will come closer to normal levels. With reduced insulin you will be able to use your body fat stores for fuel and ideally lose weight.

Depending on your goals and level of dedication (or OCD), you might get to a point where injecting small amounts of insulin is no longer worth the hassle. This is something that you should work through with your doctor who prescribed the insulin and / or medications.

references

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

[2] http://www.diabetesselfmanagement.com/managing-diabetes/treatment-approaches/type-2-diabetes-and-insulin/

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

[4] https://intensivedietarymanagement.com/

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

[6] http://www.nejm.org/doi/full/10.1056/NEJMoa0802743#t=articleTop

[7] http://phlauntdiabetesupdates.blogspot.com/2012/10/new-page-why-lowering-a1c-below-60-is.html

[8] http://diatribe.org/issues/10/learning-curve

[9] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518370/

[10] http://www.cardiab.com/content/12/1/164

[11] http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2004.01371.x/epdf

[12] http://www.thefatemperor.com/blog/2015/5/5/hilarious-apob-now-being-used-as-predictor-of-insulin-resistance-cholesterol-lchf

[13] http://www.thefatemperor.com/blog/2015/4/30/insulin-resistance-the-primary-cause-of-coronary-artery-disease-bar-none-lchf

[14] http://jaha.ahajournals.org/content/4/4/e001524.full.pdf+html

[15] http://www.thefatemperor.com/blog/2015/5/3/cholesterol-lchf-whats-the-only-thing-that-matters-for-repeat-heart-attacks

[16] https://intensivedietarymanagement.com/lchf-for-type-1-diabetes/

carbohydrates, diabetes

do we really need carbs?

June 19, 2015 Marty Kendall 13 Comments

Current mainstream dietary guidelines recommend that we get 45 to 65% of calories from carbohydrates. [1]

In line with these recommendations carbohydrate intake has increased as people have endeavoured to avoid fat. During this period obesity increased from 14.5% to 30.9%.

It’s fair to say that macronutrient composition is only part of the story, but perhaps if we moved the carbohydrate intake back towards the ketogenic corner (along with a shift to more whole unprocessed foods) this trend would turn around again?

However more and more nutrition researchers are now saying that health authorities got it wrong about fats, and that our fear of fat has led us to the over-consumption of carbs which has caused to the current obesity epidemic. [3] [4] [5]

There are essential fatty acids that the body cannot produce, such as alpha-Linolenic acid and linoleic acid, which we need to obtain from our diet. The body also needs amino acids from dietary protein which form the building blocks for the cells which it is unable to make from other nutrients.

Glucose however can be produced from protein via gluconeogenesis, and hence it is not technically necessary to eat carbohydrates.

Consequently, often asked (and debated) questions are:

If there is no such thing as an essential carbohydrate why do we need to be eating any carbohydrates?
If we took food insulin theory to its logical extreme, could (or should) we live off just fat and “adequate” protein?
How low (carb) can we go while still getting adequate nutrition?

How do we find the optimal balance between obtaining adequate nutrition and energy while avoiding the negative impacts of excess insulin caused by high carbohydrate consumption?

[this post is part of the insulin index series]

[Like what you’re reading? Skip to the full story here.]

[1] http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/how-to-eat-healthy/art-20046590

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

[3] http://blog.joslin.org/2015/02/nutrition-revolution-the-end-of-the-high-carbohydrates-era-for-type-2-diabetes-prevention-and-management/

[4] http://en.wikipedia.org/wiki/Tim_Noakes

[5] http://www.peterbrukner.com/category/diet/

articles, blood sugar, carbohydrates

the Goldilocks glucose zone

June 4, 2015 Marty Kendall 21 Comments

The body requires somewhere between 160 and 600 calories per day from glucose.
This glucose can be sourced both from ingested carbohydrates as well as the glucogenic portion of protein not used for growth and repair.
Rather than raising blood glucose immediately, amino acids from protein circulate in the blood until they are required.
Excessive glucose from either carbs or protein will lead to increased insulin requirement, insulin resistance, diabetes, obesity and a range of other issues associated with hyperinsulinemia and metabolic syndrome.
Someone who is insulin resistant and/or has diminished pancreatic function does not produce adequate insulin to maintain normal blood glucose. Rather than using diabetes medications or exogenous insulin, the alternative option is to decrease one’s dietary insulin load to a point that the body’s natural insulin production can keep up.
We can manage our dietary glucose to achieve normal blood sugars by considering the total insulin load from carbohydrate plus the glucogenic portion of protein.

background

Rather than simply focusing on the ideal macronutrient split, this article endeavours to take the discussion one step further to look at how we can optimise the split between dietary glucose and fat given that glucose can be obtained from both carbohydrates, and the glucogenic portion of protein in excess of the body’s requirement for growth and maintenance.

the Goldilocks glucose zone

This article outlines a basis upon which to determine the optimum balance between what are often polar extremes.

On the high glucose end of the argument we are faced with the following issues:

high insulin levels,
obesity and excess fat accumulation,
high blood glucose levels,
heart diseases risk, and
the plethora of issues that accompany metabolic syndrome and hyperinsulinemia.

At the ketogenic extreme, we have concerns about a range of issues including:

inadequate fuel for the brain,
limited food options,
a lack of vitamins and minerals,
low fibre,
stunted growth,
impaired athletic performance, and
high cholesterol levels.^{^[1]}

Somewhere in the middle, there must be an optimal balance of fuel for each individual, a balance between the extremes.

But how do we find this balance point? Then what do we monitor to ensure we stay there?

Not too hot. Not too cold.

Not too hard. Not too soft.

What we are searching for is the “Goldilocks glucose zone”.

the safe starches debate

The ‘safe starches debate’ has been intriguing and has informed my thinking on this controversial issue.

The discussion started at the 2012 Ancestral Health Symposium with a panel hosted by Jimmy Moore. [2] It continued on the blogs of the two lead representatives of each side of the argument, Paul Jaminet [3] and Ron Rosedale [4].

the case for limiting carbohydrates

On the low carb end of the debate, we have Ron Rosedale who argues that:

1. Non-fibre carbohydrates are:

detrimental as they lead to increased insulin levels, oxidation and accelerated ageing, and
unnecessary as we can obtain our glucose needs via gluconeogenesis from protein.

2. Glucose can be manufactured from glycerol or from lactate and pyruvate recycling. In some respects, this is even better than making glucose from protein. [5]

natural glucose utilisation level

On the not so low carb end of the argument, Paul Jaminet argues that the human body runs on a fuel mix of about 30 to 35% of calories from carbohydrates (say 600 calories per day). The remaining 70% or so of our fuel comes from fat.

Jaminet recommends that people follow a ‘low carb’ diet, however, Jaminet’s version of low carb is a carbohydrate intake somewhere less than the body’s 30% requirement for glucose. This forces some proportion of the glucose needs to come from gluconeogenesis.

The figure below from The Perfect Health Diet represents this concept graphically. [6]

some perspective

When you look at this in the context of the fact that the typical western diet has 40 to 50% of calories coming from carbohydrates,[8] we are really arguing over whether a low carb diet or a very low carb diet is best for our metabolic health.

Jaminet’s glucose flux has a lot of similarities with Mark Sisson’s Primal Blueprint Carbohydrate Curve. [9] Jaminet’s 600 calories equates to 150g of carbohydrates which aligns with the top end of Sisson’s ‘effortless weight maintenance zone’.

But what if limiting carbohydrates to less than 150g per day is not working for you (e.g. your blood sugars are not in normal range or you are not achieving weight loss)?

What can we learn from the food insulin index data to help us build on standard carbohydrate counting?

How can we determine the optimum fuel mix for our individual situation, body and goals?

minimum carbohydrate requirement

One of the concerns about a low carbohydrate diet centres on the understanding that the brain needs carbohydrates.

This seems to stem from Institute of Medicine’s advice that the brain needs about 400 calories per day from glucose. This equates to 100g of carbs which most people wind up to 130g to provide a safety factor.

The IOM, however, notes that a person who is fat adapted can run on lower amounts of carbohydrates as their brain is fuelled by ketones and there is no minimum requirement for carbohydrates, only glucose which can also be obtained from gluconeogenesis. [10] [11] In spite of this, nutritionists still recommend a minimum carbohydrate intake.

Jaminet makes a similar differentiation that a typical sedentary person requires about 600 calories for glucose per day, however, this may decrease to 300 calories per day for someone on a ketogenic diet.

The understanding of the absolute minimum glucose requirement comes from research by George Cahill who undertook extreme starvation experiments and found that people could survive on as little as 40g of glucose per day (i.e. 160 calories). [12]

In the fed state the body will rely on glucose from ingested carbohydrates. After a period of fasting, it transitions to using glucose from the glycogen stores in the liver and muscles. Once the glycogen stores are exhausted the body will obtain glucose via gluconeogenesis from cannibalising muscle.

At this point however the brain and the rest of the body have largely transitioned to being fuelled by fat so it only needs to obtain 40g of glucose per day from protein via gluconeogenesis. This would equate to around 5% of calories from glucose (not necessarily from carbohydrates).

I am not suggesting that starvation ketosis is optimal for most people. The point is that the body can survive on very little glucose if it needs to for quite a long time.

The longevity crowd will tell you that this is an evolutionary advantage so you can prolong life until a time when there is enough nutrition to reproduce and thrive. People who could use their fat and muscle for fuel survived to be your ancestors, and those that couldn’t didn’t.

what is the minimum protein requirement?

According to Nuttall and Gannon [13] the body requires between 32 and 46g of high-quality dietary protein to maintain protein balance.

This equates to around 6 to 7% of calories in a 2000 to 2500 calorie diet being taken “off the top” for growth and maintenance, with everything else potentially available as excess.

The same paper notes that the American diet typically consists of between 65 and 100g of protein per day (i.e. 13 to 16% of calories).

three macros or two fuel sources?

Something that has been very interesting to me that I had not understood until recently was that protein is made up of glucogenic and ketogenic amino acids. Some amino acids can turn into either glucose or fat. [14] [15]

The table below shows the differentiation of amino acids into different categories.

	glycogenic	ketogenic	both
non-essential	Alanine Arginine Asparagine Aspartate Cysteine Glutamate Glutamine Glycine Proline Serine		Tyrosine
essential	Histidine Methionine Valine	Leucine Lysine	Isoleucine Phenylalanine Tryptophan Threonine

glycogenic

ketogenic

both

non-essential

Alanine

Arginine

Asparagine

Aspartate

Cysteine

Glutamate

Glutamine

Glycine

Proline

Serine

Tyrosine

essential

Histidine

Methionine

Valine

Leucine

Lysine

Isoleucine

Phenylalanine

Tryptophan

Threonine

I will be discussing this concept in more detail in a separate article (The Insulin Index v2), however in essence, what this means is that there are really only two fuel sources for the body, glucose and fat, with “excess” protein being turned into one or the other.

the “well formulated ketogenic diet”

Steve Phinney is probably the most well respected authority on the ketogenic diet. This figure shows a comparison of what Phinney calls the “well formulated ketogenic diet” (WFKD) as a triangle with a number of possible dietary approaches shown for comparison. [16]

A WKFD can contain 30% protein and 5% carbs or 20% carbs and 10% protein. A WKFD, however, cannot, however, contain 30% protein and 20% carbs because we would get too much glucose which would increase insulin and suppress ketosis.

As shown in the WFKD figure above the protein content of a ketogenic diet can range between 0.8 and 2.4g/kg lean body mass. However, if we are running higher levels of protein we will only achieve ketosis if we also limit carbohydrates.

Listen to Steve Phinney discuss this concept from 2:51 in this video.

Interestingly, the slope of the line along the face of the WKFD triangle corresponds with the assumption that 7% of protein goes off to muscle growth and repair with 75% of the remaining ‘excess’ protein being glucogenic. This also aligns nicely with the observation from the food insulin index data and the theoretical proportion of glucogenic amino acids in protein.

the Goldilocks glucose zone

Listed below are the various levels of glucose requirement in terms of calories discussed above along with the equivalent carbohydrates and the percent of glucogenic calories in a 2250 calorie diet.

approach	glucogenic calories	insulin load (g)	glucogenic (%)
glucose utilisation (Jaminet)	600	150	26.7%
ketogenic threshold (Phinney)	500	125	22.2%
ketogenic maintenance (Jaminet)	300	75	13.3%
starvation (Chaill)	160	40	7.1%

The glucose utilisation is Jaminet’s approximation of the glucose calories used by a non-ketogenic person each day. If we run above this level our glycogen stores will become overfull, with excess glucose spilling into the blood, requiring insulin and being stored as fat. Below this level, we need to obtain some of our glucose from protein via gluconeogenesis.
The ketogenic threshold represents the theoretical boundary between the WFKD and the rest of the world according to Phinney’s protein vs carbohydrates plot. Below this point, our glycogen stores will become depleted to a point that we be forced to rely on our protein and fat stores for energy rather than carbohydrate. After a period of consuming fewer carbs than required to keep our glycogen stores topped off, we will start to show ketones in our blood and rely on ketones and fat more than glucose. This level is about 500 calories per day which is about 22% of a 2250 calorie per day diet.
The ketogenic maintenance level is based on the 300 calories per day that Jaminet says we need from glucose if we are fat adapted. With a greater proportion of energy coming from fat in the form of ketones we require less glucose for brain function.
The starvation level represents what people can survive on as an absolute minimum. In this extreme starvation state, the body is cannibalising muscle via gluconeogenesis to convert to glucose to survive. This is not something I recommend you try at home. However, it is useful to know that the body can survive (but not necessarily thrive) at very low levels of glucose for a significant period of time.

The chart below shows these glucose levels superimposed on a plot of protein versus carbohydrate. The points on the left-hand side of the chart labelled with calorie values represent the point at which all glucogenic calories come from carbohydrates with only the minimum 7% protein for maintenance ingested (i.e. no “excess” protein).

As we move to the right we have increasing levels of protein and decreasing levels of carbohydrates to maintain the same total number of glucogenic calories (assuming that 75% of “excess” protein converts to glucose).

The only thing we can be certain of here is that the concepts shown graphically in this figure will not be accurate due to the fact that it is built on a number of layers of theory. And everyone’s body is different. However, this chart gives us a conceptual framework with which to manipulate our diet to achieve our goals.

The take home message is that, if we are trying to reduce the glucose load of our diet to the point at which our own pancreas can keep up, we need to think, not just in terms of carbohydrates, but in terms of total glucose (or insulin load) from carbohydrates plus excess protein.

I don’t think the body minds that much whether it gets glucose from carbohydrates or protein. [17] My view is that it is better to maximise vitamins (generally from carbohydrate containing foods) and amino acids (from protein containing foods) as far as possible while at the same time keeping our glucose load within our own pancreas’ ability to keep our blood sugars at normal levels. What this means is that some people may need to restrict their carbohydrates and their protein more than others to achieve normal blood sugars.

what about the Kitavans?

When faced with the hormonal theory of obesity many people are quick to point to hunter gatherer populations such as the Kitavans that do quite well on high levels of carbohydrates.

Some people seem to tolerate high levels of carbohydrate from whole food sources. Perhaps they are metabolically flexible such that they can store carbohydrates as fat and quickly use them again, or they are very active and hence using up their glycogen stores regularly, and are very insulin sensitive and adapted to handle significantly more than 600 carbohydrate calories per day from whole food sources.

It may also be that people eating predominantly unprocessed high fibre foods are less likely to be in a caloric excess meaning that they do not have a lot of left over calories to store as fat or to require excess insulin.

Dr Jason Fung points out in this video that in spite of a higher glucose load the Kitavans managed to keep low insulin levels, which seems to be the critical factor.

If you are highly active with great insulin sensitivity and you can consume high levels of carbohydrates while maintaining normal blood glucose and staying lean then good luck to you. I’m jealous. Enjoy, at least while it lasts!

It is worth noting that a number of the champions of the low carbohydrate movement such as Tim Noakes, [18] Ben Greenfield [19] and Sami Inkenen [20] found that they had or were becoming diabetic after decades of extreme exercise on a high carbohydrate diet, hence transitioned to a low carbohydrate approach to manage their blood sugars.

comparison of dietary approaches

To help make more sense of this concept I have shown a number of dietary approaches from the article Diet Wars… Which One is Optimal? on the protein vs carbohydrate chart below.

Bernstein’s approach is designed to be high protein, low carb, to provide diabetics with their glucose needs from protein which releases glucose more slowly than carbohydrate.
This version of the Atkins diet is unlikely to be ketogenic due to the high levels of protein. Reducing carbohydrates and/or protein is likely to be necessary to achieve ketosis, and possibly the weight loss that is typically the aim of the Atkins diet.
The Zone and Mediterranean diets, though generally thought to be moderate carbohydrate dietary approaches, are still well above Jaminet’s glucose utilisation threshold.
Terry Whals’ Paleo Plus approach achieves a good balance between maximising nutrition through the use of high fibre vegetables and MCT oil without excess protein.
The 80% fat diet approach is below the ketogenic maintenance level of 300 glucogenic calories per day but still above starvation ketosis. Personally, I think it would be hard for most people to get optimal levels of vitamins, minerals, fibre and possibly protein at these levels without supplementation or focussing on nutrient dense organ meats. However it may be desirable for someone using ketosis therapeutically for something like cancer or epilepsy.

The typical western diet contains between 40 to 50% carbohydrates, 35 to 40% fat and 15 to 20% protein. [21] The figure below shows that between 1970 and 2000 carbohydrate intake increased from around 42% to around 49% for men while protein intake has largely stayed constant. During this period obesity increased from 14.5% to 30.9%. [22]

what is our light on the horizon?

So how do you decide what dietary approach is optimal for each individual? What is right for you? What is the lighthouse on the horizon that you can guide your boat of metabolic health towards?

Back in the Diabetes 102 article we reviewed a number of risk factors that appear to be related to blood sugar control such as the heart disease risks shown in the chart below. [23]

Building on this I developed this table showing the relationship between HbA1c, average blood sugar and ketone values for different heart disease risk categories.

	HbA1c	average blood sugar		ketones
	(%)	(mmol/L)	(mg/dL)	(mmol/L)
low normal	4.1	3.9	70	4.0
optimal	4.5	4.6	83	2.5
excellent	< 5.0	< 5.4	< 97	> 0.3
good	< 5.4	< 6	< 108	< 0.3
danger	> 6.5	7.8	> 140	< 0.3

Everyone should be striving for optimal blood sugar control in order to manage their overall health and reduce a plethora of risks.

The point where you achieve excellent blood sugar control (i.e. average blood glucose less than 5.4mmol/L) is about where most people will start to show low levels of ketones in their blood. This is likely to be somewhere around Phinney’s ketogenic threshold (orange line in the protein / carb plot).

People with more severe issues such as extreme insulin resistance, epilepsy, morbid obesity or cancer may choose to push deeper into ketosis beyond the point of simply achieving normal blood sugars and normal HbA1c. This may require more discipline, intentional supplementation and limitation of food selection than most people are willing to invest.

what gauges do we use to steer the boat?

The most successful diets are the ones that people can stick to.

To this end I have developed a list of optimal foods that prioritises low insulin load, high fibre, nutrient dense foods based on your personal goals (e.g. weight loss, blood sugar control, nutritional ketosis, athletic performance or therapeutic ketosis). I have also developed this database of optimal meals that will enable you to easily choose simple everyday meals that will provide high levels of nutrition while achieving a low insulin load.

If you have diabetes or insulin resistance then I recommend that you track your blood sugars and ‘eat to your meter’. You will quickly learn what meals raise your blood sugars and hence what to avoid.

With the understanding that non-fibre carbohydrates plus excess protein raise blood sugar and require insulin you can work to manage your diet until you achieve the excellent blood sugar levels with a reduced or ideally eliminated reliance on medications.

Many people benefit from journaling or tracking food intake on an app such as MyFitnessPal or Cronometre. Rather than looking at calories or carbohydrates I encourage you to consider insulin load which can be calculated using this formula.

As shown in the table above, you will likely need to get below an insulin load of 150g per day to be under the blue line and under 125g per day to be ketogenic.

While I don’t think it is healthy, natural or normal to consciously monitor everything you eat for extended periods, many people find it useful for a period of time to retrain their habits or to help guide them toward a short term goal.

As a worked example I have calculated the insulin load, % insulinogenic calories as well as the % carbs and % protein for Deshanta from the Optimising Nutrition Facebook group who provided her MyFitnessPal food diary which is summarised in the table below.

carb (g)	fat (g)	protein (g)	fibre (g)	insulin load (g)	% insulinogenic	% carb	% pro
143	92	113	42	164	39%	24%	27%
99	99	125	41	128	32%	14%	31%
129	102	134	40	164	36%	20%	30%
50	81	125	17	103	30%	10%	37%
86	88	125	19	137	35%	17%	32%

I’ve also plotted this on the chart below indicating that her diet puts her just outside the realm of a ‘well formulated ketogenic diet’. If she wanted to improve her blood glucose control further she could consider moving back towards the more ketogenic bottom left of the chart by reducing carbohydrates and / or protein.

If you’re interested in seeing how you can refine your diet to balance your blood sugars with consideration of your blood sugars and glucose load as well as your vitamins and amino acid you could join this closed Facebook group.

what are the levers we can use to steer the boat?

In order to reduce the insulin load of our diet we should do the following:

Increase fibre from non-starchy vegetables (e.g. spinach, mushrooms, peppers, broccoli etc). These will provide vitamins and minerals as well as indigestible fibre that will feed the gut which will also improve insulin resistance. [24] Increasing fibre in our diet will increase the bulk and the weight of our food without increasing calories or insulin and will tend to decrease our cravings for processed carbohydrates.
Reduce carbohydrates, particularly ones that come in packages with a bar code. Enough said.
If you are not getting the desired results, look to reduce your protein intake until you are achieving excellent blood sugar control and/or your target HbA1c.
If you are still not getting the results you want then look at some form of intermittent fasting to improve your insulin sensitivity and to kick-start ketosis. [25]

Once you are achieving normal blood sugars you may want to occasionally test your blood ketones to confirm you have achieved nutritional ketosis; however tracking your blood sugars will be adequate for most people.

Once you have achieved your desired level of blood sugars, weight and metabolic health you can drop back to monitoring less frequently, just to make sure you are not regressing and then ramp up the efforts again if required.

Then, go outside. Move. Have fun. Find a hobby. Enjoy life! And stop thinking so much about food!

references

[1] http://www.thepaleomom.com/2015/05/adverse-reactions-to-ketogenic-diets-caution-advised.html

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

[3] http://perfecthealthdiet.com/2012/11/the-safe-starches-panel-from-ahs-2012/

[4] http://drrosedale.com/blog/2011/11/22/is-the-term-safe-starches-an-oxymoron/

[5] http://drrosedale.com/blog/2012/08/18/a-conclusion-to-the-safe-starch-debate-by-answering-four-questions/#ixzz3aDeqQiQ9

[6] http://perfecthealthdiet.com/2011/11/safe-starches-symposium-dr-ron-rosedale/

[7] http://perfecthealthdiet.com/2011/02/ketogenic-diets-i-ways-to-make-a-diet-ketogenic/

[8] http://www.mayoclinic.org/healthy-living/nutrition-and-healthy-eating/in-depth/how-to-eat-healthy/art-20046590

[9] http://www.marksdailyapple.com/press/the-primal-blueprint-diagrams/#axzz3aSDCTDIi

[10] http://lcreview.org/main/130g-carbsday-rda/

[11] See also discussion in Chapter 7 of Richard Feinman’s “The World Turned Upside Down: The Second Low-Carbohydrate Revolution”.

[12] http://www.med.upenn.edu/timm/documents/ReviewArticleTIMM2008-9Lazar-1.pdf

[13] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636610/

[14] http://en.wikipedia.org/wiki/Glucogenic_amino_acid

[15] https://www.dropbox.com/s/4dkl03mz2fci71v/The%20metabolism%20of%20%E2%80%9Csurplus%E2%80%9D%20amino%20acids.pdf?dl=0

[16] https://youtu.be/8NvFyGGXYiI?list=PLrVWtWmYRR2BlAsGG9tr6T-B4xSum8SCc&t=1234

[17] Though it does take more energy to convert protein to glucose, hence a calorie is not a calories when it comes to protein being converted to glucose via gluconeogenesis.

[18] http://thenoakesfoundation.org

[19] http://www.bengreenfieldfitness.com/2013/05/low-carb-triathlon-training/

[20] http://www.samiinkinen.com/post/86875777832/becoming-a-bonk-proof-triathlete-fat-chance

[21] http://www.ncbi.nlm.nih.gov/pubmed/23324441

[22] http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5304a3.htm

[23] http://www.cardiab.com/content/pdf/1475-2840-12-164.pdf

[24] http://www.amazon.com/Brain-Maker-Power-Microbes-Protect-ebook/dp/B00MEMMS9I

[25] https://intensivedietarymanagement.com/tag/fasting/

post updated July 2017

blood sugar, carbohydrates, diabetes, ketosis, nutrient density

the carbohydrate debate

June 2, 2015 Marty Kendall Leave a comment

On the low carbohydrate end of this debate you have people like Dr David Perlmutter, Nora Gedgaudas, Ron Rosedale and Dr William Davis arguing that you should restrict carbohydrate for metabolic and brain health as well as the prevention and cure of a range of diseases.

Below is one of the more confronting charts from Dr Perlmutter’s Grain Brain showing that the rate of brain shrinkage with age increases dramatically once we get an HbA1c of more than 5.2%.

Increasing HbA1c is correlated with an increased risk of cancer, particularly once we get an HbA1c over about 6% (i.e. average blood sugar of 7.0mmol/L or 126mg/dL).

The risk of cardiovascular disease, coronary heart disease and stroke all increase once an HbA1c greater than 5.0%, and especially over 5.4% is reached.

It is also worth noting that being on antidiabetic medication, even if it reduces your blood sugar, does not reduce your risk of heart disease.

Perhaps keeping your blood sugar under control is the most important thing you can do to manage your health and slow the aging process, regardless of whether you have been formally diagnosed with diabetes.

If you are not getting HbA1c checked regularly you can use the average blood glucose results from your home blood sugar meter (i.e. fasting, before meals and after meals).

The conversion between HbA1c and average blood sugar are shown below. I have also added risk level values based on the cardiovascular disease data above, and ketone values based on my data as discussed in this article.

	HbA1c	average blood sugar		ketones
	(%)	(mmol/L)	(mg/dL)	(mmol/L)
low normal	4.1	3.9	70	2.1
optimal	4.5	4.6	83	1.3
excellent	< 5.0	< 5.4	< 97	> 0.5
good	< 5.4	< 6.0	< 108	< 0.3
danger	> 6.5	> 7.8	> 140	< 0.3

One of the most extreme proponents of the restricted carbohydrate dietary approach is Dr Ron Rosedale who says that carbohydrates cause oxidation in the body, and that we should do everything we can to minimise oxidation by minimising carbohydrates ingested.

While the body does need glucose, it is preferable to have the body make it via gluconeogenesis (from protein) rather than directly feeding the body carbohydrates which will lead to oxidation. [3]

mainstream recommendations

On the other extreme you have dieticians recommending the USDA food pyramid telling us that we can’t survive without our healthy whole gains and that our brains run on glucose and hence we need to eat carbs or else.

The generally accepted diagnosis levels for type 2 diabetes are shown below. Currently one in twelve adults worldwide are classified as diabetic based on this criteria. This number is forecast to grow by more than half over the next two decades to 592 million people by 2035. [4]

	Fasting		After meal
	(mg/dL)	(mmol/L)	(mg/dL)	(mmol/L)
“normal”	< 100	< 5.6	< 140	< 7.8
Pre-diabetic	100 – 126	5.6 – 7.0	140 – 200	7.8 – 11.1
Type 2 diabetic	> 126	> 7.0	> 200	> 11.1

Comparing these diabetes diagnosis criteria with the optimal levels it is clear that blood glucose levels that are considered “normal” are far from optimal. By the time you are “pre-diabetic” you are well into the danger zone!

the middle ground?

Somewhere between the dieticians and the low carb zealot you have people such as Paul Jaminet, Chris Kresser and Robb Wolf who advocate for some carbohydrates for the majority of the population.

When you listen to the argument a little closer though, it is interesting to find that even these respected health experts are all talking about a level of carbohydrates much lower than the typical western dietary intake and the typical mainstream recommendation.

Chris Kresser recommends 20 to 30% carbs for healthy people and says that a lower carb ketogenic approach will likely be beneficial for people with Alzheimer’s, dementia or neuro-degenerative disorders. [5]

Paul Jaminet’s definition of “low-carbohydrate” means eating less than the body’s glucose utilisation which forces the body to make up the deficit via gluconeogenesis. [6] Jaminet says that the body’s preferred source of fuel is fat. However the body typically runs on a mix of around 30% glucose for fuel (or about 600 calories per day).

Jaminet notes that if we eat more than around 30% carbohydrates the liver will end up with more glucose than it can store and we will end up with excess glucose in the blood. The pancreas will secrete insulin to remove this excess sugar and store it as body fat.

If we eat less than 30% carbohydrates the body will convert protein to glucose through gluconeogenesis, and the risk of excess sugar in the blood is reduced. This balance is represented graphically in the figure below.

the big picture

When you stand back and look at the big picture, most recommendations are that that the general population should be consuming significantly less carbohydrates than are consumed in the typical western diet.

There is no perfect diet or level of carbohydrates that suits everyone. Active people or those who are not metabolically broken will be able to tolerate more carbohydrates because they will be burning them quickly rather than storing them.

People who are sedentary or obese (i.e. 70% of the western population these days) or those with blood sugar dysregulation should opt for a carbohydrate restricted approach.

Jaminet also points out that there is an ideal range for blood sugar. While people operating in ketosis can tolerate lower blood glucose levels while being asymptomatic, extremely low levels of blood sugar will lead to decreased health and eventually death. That is, there is a lower limit for blood sugar, however your body will do everything it can to stop you from getting there. So in the absence of injecting too much insulin it is probably not going to be an issue for most people.

Similarly, at high levels of blood sugar we will get the numerous complications of high blood glucose and diabetes. Somewhere between these two extremes is an optimal blood sugar level which Dr Richard Bernstein puts at about 83mg/dL or 4.6mmol/L. [8]

so just tell me what to do!

In view of the fact that the various health markers shown above start to go pear shaped beyond a HbA1c value of about 5.0mmol/L and then really start to fall apart above a HbA1c of 5.4mmol/L, I think it makes sense to reduce your insulin load until you get your blood sugar into the ‘good’, if not ‘excellent’ or ‘optimal’ ranges as shown in the table below.

	HbA1c	average blood sugar		ketones
	(%)	(mmol/L)	(mg/dL)	(mmol/L)
low normal	4.1	3.9	70	2.1
optimal	4.5	4.6	83	1.3
excellent	< 5.0	< 5.4	< 97	> 0.5
good	< 5.4	< 6.0	< 108	< 0.3
danger	> 6.5	7.8	> 140	< 0.3

If you’re a Kitavin eating fruit in the jungles of Papua New Guinea or Rich Froning living off peanut butter and sweet potato, that might mean you should keep on doing what you’re doing.

If you look in the mirror and see a bit more body fat than you’d like, it probably means you might benefit from actively managing the glucose levels and insulin load of your diet.

Once you get them into the excellent range you will automatically tap into ketosis which will mean that you will be burning fat for fuel and losing weight without feeling like you are starving yourself!

If you are looking for more inspiration on what to do at this point check out the list of optimal foods here and optimal meals here.

Learn more about how to bring your blood sugars in line here, how to lose weight here, and what to eat if you’re lucky enough to be a metabolically healthy and fit athlete here.

[Like what you’re reading? Skip to the full story here.]

[1] http://www.drperlmutter.com/important-blood-test/

[2] http://www.cardiab.com/content/12/1/164

[3] https://vimeo.com/52872503

[4] http://www.dailymail.co.uk/health/article-2997882/Diabetes-epidemic-400-million-sufferers-worldwide-Number-condition-set-soar-55-20-years-unless-humans-change-way-eat-exercise.html

[5] http://chriskresser.com/how-to-feed-your-brain from 9:25

[6] http://perfecthealthdiet.com/2011/10/jimmy-moore%E2%80%99s-seminar-on-%E2%80%9Csafe-starches%E2%80%9D-my-reply/

[7] http://perfecthealthdiet.com/2011/11/safe-starches-symposium-dr-ron-rosedale

[8] https://www.youtube.com/watch?v=zJGAbZIvRh8

[9] http://www.dietdoctor.com/lose-weight-by-achieving-optimal-ketosis

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