A popular adage suggests we should “eat breakfast like a king, lunch like a prince and dinner like a pauper”. [1][2][3][4][5][6]
We interrogated more than half a million days of food diaries to see whether it is actually helpful.
Breakfast
The chart below shows the proportion daily calories consumed at breakfast versus the proportion of a person’s daily target calories consumed based on their food diaries. A score of 100% would mean that they achieved their calorie goal. A score of less than 100% indicates the individual was able to consume less than their goal intake for the day.
The data from people eating three or more times a day indicates that, on average:
people who ate the least for breakfast tended to eat more across the day, while
people who consumed more of their daily calories at breakfast tended to eat less during the day.
People who front-loaded their calories at breakfast tended to eat around 20% less across the day!
Lunch
Looking at the data for lunch, we see a similar trend.
If you can fit it into your lifestyle, a larger lunch seems to be better.
Dinner
Where this data gets interesting is when we look at dinner.
People seem to do OK if their dinner is similar in size to breakfast and lunch. However, we tend to overeat if we consume the majority of our calories at night.
Putting it all together
When we overlay all three meals, we see that prioritising breakfast is a good idea if you want to get or stay lean.
To prevent overeating, try to start your day with a hearty breakfast with a solid dose of protein and you’ll be less likely to overeat later in the day.
If you are already lean and need to recover from a hard day of activity, then eating at night will help you consume more energy and store it more effectively.
But is this result due to behaviour or biology? Or perhaps a bit of both?
Behavioural
It’s possible to explain why we overeat at night from a purely behavioural perspective.
It can be hard to eat a lot at breakfast when you need to get off to work or at lunch when we might be at work or school and have to prepare a lunch and bring it from home.
But then at night, we have the fridge.
We have our friends and family.
We have Netflix.
We have the perfect storm of comfort food, social eating and self-soothing combined with being surrounded by less than optimal food choices that we tend to fill our patry and fridge with.
Food eaten later also has to be stored, at least until the next day to be used when we are more active.
Locking in your circadian rhythm
There have also been a number of interesting studies looking at the relationship between food timing and how it affects our body.
Compressing your feeding window to give your body a chance to spend time in a fasted state is useful. However, it seems shifting your eating window earlier in the day is also beneficial. This is commonly known as Early Time-Restricted Feeding (or eTRF).
Just like it’s beneficial to get sunlight in the morning and not gaze at blue light from our screens all night, it seems it’s also important to lock in our circadian rhythm with food in the morning and not overdo it at night.[8]
Being a shift worker is not good for your health. Neither is eating like one. [9][10]
While keeping body fat levels low is important for diabetes management, eating earlier seems to improve our insulin sensitivity independent of weight loss.
We have greater insulin sensitivity in the morning. Our body is primed to use food. Food eaten later in the day is more likely to be stored for longer.
How to do it
eTRF is not always the most convenient thing.
Lots of people are not hungry in the morning, particularly if they tend to eat a large evening meal.
Left to our own devices, we tend to optimise for maximum storage to prepare for the coming winter.
Most people find it takes a week or two to get into the new groove of eating earlier.
Eating your main meal with the family at night is more social and eating in front of the TV when you’re relaxing can be fun. But if you need that extra edge to manage your weight or diabetes then moving some of your dinner calories to breakfast might just be worth the effort.
I recently shared Dr Ted Naiman’s latest “insulinographic” that attempts to explain the adipose centric theory of diabetesity.
It created some great discussion as well as some confusion, so I thought it would be worth an article to unpack the critical insights about how insulin really works in our body and what we can do to reduce body fat and avoid diabetes.
The first clarification is that this isn’t a meme or a graph. It’s more an infographic that attempts to explain how insulin is anti-catabolic and works like a dam to hold back the flood of stored energy in our body.
However, with all the focus on carbs, fat and protein, I fear we may have neglected the most important thing that influences our insulin response to the food we eat.
Majoring in the minors
Before we switched to a lower carb dietary approach, my wife Monica was taking about 50 units of insulin per day to manage her Type 1 diabetes. ABout half of that was for food (bolus) and half was her background insulin (basal).
These days, Monica takes about half the insulin that she used to. However, now about 80% of her daily insulin dose is basal insulin while only 20% of her insulin is taken to manage her blood sugars levels around meals.
basal insulin
bolus insulin (for food)
total daily insulin
Higher carb diet
25 units
25 units
50 units
Low carb diet
20 units
5 units
25 units
Monica’s basal insulin demand has reduced a little due to some weight loss and improved insulin sensitivity.
The most interesting observation is that the vast majority of the insulin required by someone on a low carb diet is not related to the carbohydrates or even the protein in the food they eat.
While carbs and protein raise insulin in the short term, the fat on our body and the fat in our diet have the most significant influence on our insulin levels.
The grey area in the chart below shows the insulin released across the day by someone with a functioning pancreas. The pink line shows how someone with Type 1 diabetes tries to mimic this with an insulin pump.
A lower carb diet is a no-brainer for someone with diabetes to help them stabilise their blood sugars and appetite.[1] However, we get to a point of diminishing returns when we only focus on the carbohydrate and protein in our diet while ignoring the fat in our diet and the fat on our body.
Elevated fasting (or basal) insulin is the elephant in the room for many people on a low carb or keto diet. Many people on a low carb or ketogenic stabilise their blood sugars and improve HbA1cs, but are still obese with high fasting insulin levels.
The harsh reality is that replacing the carbs and protein in your diet with fat will not reverse your hyperinsulinemia unless it also reduces the amount of fat stored on your body!
But what is going on?
But what can we do?
That’s where Ted Naiman’s “insulinographic” comes in.
Many people think that elevated insulin is the cause of obesity. But, I’m coming to realise that most of the time it’s actually the other way around.
It is actually obesity (or at least being overfat relative to our Personal Fat Threshold) that causes hyperinsulinemia.
Insulin is anti-catabolic
We typically think of insulin as an anabolic hormone that forces amino acids into muscles and glucose into our cells. But it can actually be more useful to think of insulin’s anti-catabolic properties.[2][3][4][5][6][7]
Rather than just building our muscles and fat stores or forcing glucose into the cells, insulin also works to keep fat and muscle in storage.
Insulin prevents entropy (or chaos) and ensures that we don’t melt into a puddle like Olaf the Snowman.
Someone with Type 1 diabetes does not have enough insulin to prevent catabolism. Their protein, fat and glucose stores in their body get released into their bloodstream in an uncontrolled manner and result in high glucose, high free fatty acids and high BHB ketones.
The good news though is that if your pancreas is working, you will produce insulin when you’re not eating to enable you to regulate the amount of fuel being released from storage into your bloodstream.
Healthy fasting insulin levels in hunter-gatherers range between 3 – 6 mIU/mL.[8] In western populations, the average fasting insulin level is about 8.6 mIU/mL.[9] People with insulin resistance or diabetes have much higher levels of fasting insulin.
Insulin is the hormonal signal that raises the dam wall to slow the flow from stored energy via our liver while the energy in our bloodstream is being used up.
The more fat you have to hold back in storage, the higher your insulin levels need to be.
This helps us to understand why many people low carbers who are obese have high fasting insulin levels. Even though they may be eating minimal amounts of carbs and protein in an effort to keep their insulin levels low, their body is keeping insulin high in an effort to hold their energy in storage until the energy in their bloodstream is used up.
To help elaborate on this I have fleshed out what various scenarios would look like in terms of body fat, insulin levels and energy in the blood (i.e. glucose, ketones and free fatty acids) in the table below.
Dr Jason Fung points out that people using exogenous (injected) insulin to manage their diabetes can develop obesity and insulin resistance because of their medications.
Dr Robert Lustig also explains how someone injected with a little bit of extra insulin at each meal will store more fat and not be able to mobilise their body fat (lipolysis).
To some extent, this is what happens when someone with diabetes injects insulin to cover a crappy nutrient-poor insulinogenic diet. With large doses of exogenous insulin to cover a high carb processed diet they never quite get the insulin dosing right. They end up overdosing with insulin and having to eat more to rescue themselves from low blood sugars. The great thing about a low carb more less processed foods for these people is that it helps stabilise blood sugar and insulin doses which is easier to manage with smaller doses of insulin.
To go back to our “dam” analogy, excessive exogenous insulin for someone who already has hyperinsulinemia is like building our dam wall higher than it needs to be. The higher dam wall will hold back more energy in storage than it needs to and less of the energy we eat will be released into the bloodstream.
We feel hungrier because the excessive exogenous (injected) insulin is not allowing energy to be released into circulation.
We will end up eating more, and this excess energy will be stored more easily. We will become more and more resistant to the insulin we are injecting as our fat stores become fuller, and we need more insulin to hold our fat in storage.
The solution here is a low carb diet to help stabilise blood sugars and hunger driven by excessive swings in insulin and blood sugar.
The fatal flaw in the insulin-centric view of obesity
Where this insulin-centric view of diabetes and obesity fails is that it doesn’t translate to someone who is not taking exogenous injected insulin or drugs that stimulate insulin release from their pancreas.
Our bodies optimise for efficiency. Unless you have an insulinoma (a tumour on your pancreas), your pancreas will not secrete more insulin than it needs to.
Our pancreas will not build the dam wall higher than it needs to be to hold back the energy coming into our system!
Irrespective of insulin levels, you cannot store energy we do not eat.
At the risk of doing your head in, we can look at the function of insulin as anabolic (building) and anti-catabolic (preventing breakdown) and get to the same conclusion:
Anabolic – Although dietary fat doesn’t raise insulin much in the short term, you will always have enough basal insulin on board to store the fat you eat on your body (note: this is the anabolic.
Anti-catabolic – Your pancreas will always produce enough insulin to slow the flow of energy out of the stores on your body while you use up the energy from the food coming in from your mouth.
Our fasting insulin is proportional to the amount of fat stuffed away in storage which is directly proportional to the amount of food that we have eaten.
We cannot really blame obesity on insulin resistance. It is our insulin sensitivity that enables our fat cells to grow. Once we become insulin resistant, we actually find it harder to store excess energy in our adipose tissue.
How to keep your basal insulin low
There a number of things that help us lower our dam wall, including:
exercise,
fasting,
a low energy diet, or
a high nutrient density diet.
Exercise
Exercise, particularly resistance excercise or HIIT, is a great way to build insulin sensitivity and helps us to burn off fat and sugar without the need for insulin.[13] People with Type 1 diabetes find they need to reduce their insulin dose when they are active and increase their basal by about 25% when they don’t exercise.
Fasting
Not eating for a period of time is a great way to reduce your insulin.
Once you use up the glycogen in your liver, your body turns to the fat stores and lowers insulin levels to allow more stored body fat to flow over the dam into the system.
However, for some people, the problem with fasting is that it’s easy to overdo the refeed.
When I was fasting regularly to try to lose some extra fat, I found I would permit myself to eat more than I would otherwise have eaten. And the foods that I chose to eat were often less nutrient dense and more energy dense dense than usual.
In spite of the saint-like deprivation for days, I found I didn’t lose much weight over the long-term. In the end, I seemed to eat back my deficit. My wife Monica would say ‘I don’t think this fasting thing is working for you! Why don’t you try eating a little less each day?’
I have talked about using your bathroom scale or blood sugar readings to refine the frequency and quantity of your feeding to make sure you are moving towards your goal. Unfortunately, just like tracking calories, these approaches to fine tuning your food intake require self-discipline and deprivation which is not fun.
Even better than tracking blood glucose or your weight, another way to manage your fasting/feeding frequency and food intake would be to measure your blood insulin level to ensure it was going down to new lows before you ate, and then ensure that when you refeed that you didn’t drive insulin too high with too much food.
Unfortunately, there is no home test for insulin yet, so our blood glucose metre and the bathroom scale are the best we can do for now.
Many believe that they will keep insulin levels low if they focus on higher fat foods when they refeed. However, it is possible to drive higher levels of insulin with a high-fat intake in only a short amount of time.
A relevant example of this is Jimmy Moore’s recent high protein experiment where he reduced his fasting insulin from 14.2 to a very respectable 8.8 mIU/mL in five days on a high protein energy restricted diet.[14][15][16]
Afterwards, he finished the fast on Sunday (8 April as per the date on the Instagram image below) he proceeded to boost his fasting insulin to 18 mIU/mL after a day of high fat refeeding before the laboratory was open to measure his post-experiment labs on Monday. This post refeed insulin was actually higher than his 14.2 mIU/mL insulin before the experiment began.
This also aligns with the study results shown below where participants lowered their insulin and triglycerides more higher protein lower carb diet.[17]
Similarly, this twelve month randomised control low carb study found that people had better outcomes in terms of weight, body fat, insulin, HOMA-IR, HDL, hunger and emotional eating with higher levels protein.
It will be interesting to see how Jimmy’s upcoming high-fat bio hack goes. I hypothesise that Jimmy’s short-term insulin level may be lower after meals, but his longer-term fasting insulin will be higher on the high-fat approach.
Once we account for the Thermic Effect of Food (TEF), there is actually more available energy in the high-fat approach as shown in the calculations below.
high protein (3:1)
80% fat
fat (g)
90
168
protein (g)
270
95
fat (cal)
810
1512
protein (cal)
1080
378
energy consumed (cal)
1890
1890
TEF (cal)
405
265
available energy (cal)
1485
1625
short-term insulin
higher
lower
long-term (fasting) insulin
lower
higher
With less energy actually available to the body in the high protein scenario, the pancreas will produce less insulin to allow more energy to be released from storage compared to the high-fat scenario.
Low energy diet
As noted in Ted’s insulinographic, a low energy density diet is another way to keep your basal insulin levels down.
You can achieve this by focusing on foods with a lower energy density which will make it harder to overeat. This will ensure your body fat stores are used. With less fat to hold back in storage, your insulin levels will decrease.
This is why we see some people who make the switch to a whole foods plant-based diet reduce their insulin requirements and reverse their diabetes. As long as they stick to whole foods, they will not be able to ingest enough energy to maintain their weight, so their insulin comes down. However, this does not hold for processed vegan junk food which can still be energy dense, highly processed, hyperpalatable and easy to overconsume.
What about trying to eat less food?
Another option is to try to simply eat less food. While this can be helpful, it shouldn’t be the only technique used as simply restricting the intake of nutrient-poor junk food is a recipe for nutrient cravings and rebound binge eating.
Nutrient-dense diet
Maximising nutrient density is my favourite hack because it addresses the following factors:
Adequate protein. If you eat foods that contain the vitamins, minerals and essential fatty acids you need you will obtain plenty of protein which, on a calorie for calorie basis, is the most satiating macronutrient. There is a lot of confusion around protein, but the reality is, if you are eating foods that contain adequate levels of vitamins, minerals and essential fatty acids you will be getting plenty of protein. Conversely, actively avoiding protein may lead to nutrient deficiencies. Whether you approach this in terms of higher nutrient densitym, targeting the most satiating macronutrients or the foods that will naturally provide you with greater satiety you arrive at pretty much the same point.
Energy density. A nutrient-dense diet typically has plenty of whole foods that have lower levels of refined carbs and processed fats which have a lower energy density and hence are hard to overeat.
Minimally processed.Quantifying nutrient density is a foolproof way to ensure that the food contains the micronutrients you need rather than hyperpalatable flavourings and colours from Frankenfoods that are designed to look like they are good for you (but they’re not). These minimally processed foods are also satiating without being hyperpalatable so are self-limiting.
Prevents cravings. Good nutrition, avoiding diabetes, weight control and lower insulin levels seems to boil down to getting the nutrients you need without too much energy. Focusing on nutrient-dense foods also gives the best chance of avoiding nutrient cravings that will unnecessarily drive your appetite.
Fat raises insulin too, it just takes longer
Most of the time we focus on carbs (and to a lesser extent protein) as being the culprit when it comes to raising insulin levels. But does this hold true when we look at the big picture?
The insulin index data suggests that higher fat foods have a lower insulin response. But is this simply because the insulin index testing only measured the insulin response over three hours?
The chart below on the left shows that insulin rises more slowly for a high-fat meal compared to glucose or a mixed meal.[18] However, it still rises and looks like it will keep on going for a while after the 120-minute measurement.
If we were able to test the insulin response over 24 hours, I think we would see that insulin response is actually more closely related to the available energy in our food rather than a specific nutrient.
Is our long-term insulin response simply related to the amount of energy in our food and hence the amount of energy needs to be held back in storage by the liver?
Is it only because carbs and protein have a higher oxidative priority than fat that we see a greater short-term spike in insulin (i.e. the body needs to act more quickly with a sharper insulin response to hold back energy from carbs in storage compared to fat or protein)?
The adipose centric model of diabesity
The insulin-centric view of obesity, diabetes and insulin resistance focuses on reducing insulin by switching carbs out for fat to control our (short term) insulin response to food.
Meanwhile, the adipose-centric view of diabetes is a little bit more sophisticated and complete as it also considers the long-term insulin response to the food we consume.
Someone who is lean and insulin sensitive will have healthy levels of adipose tissue that can quickly swell to take on more energy and then release it. If you are insulin sensitive like these guys, you store precious energy very efficiently when it is available.
But our fat stores can only take in so much energy before they become full. There is a limit to how high you can build your dam wall.
When your fat cells become stuffed and can’t take on more energy, they are said to be “insulin resistant”. At this point, any excess energy spills out into the bloodstream as elevated glucose, free fatty acids or ketones. Excess energy is also pumped into our vital organs, and we develop fatty liver, fatty pancreas, heart disease and the other complications of western civilisation.
To be clear, it’s not being obese that causes diabetes. Instead, it’s a matter of being overfat relative to your Personal Fat Threshold. Some people are “blessed” to be able to store a lot more energy in their fat stores before they become insulin resistant and diabetic, while others find that can only store a little bit of energy in their adipose stores before it overflows and ends up being stored in their vital organs and bloodstream.
Disease progression and reversal
Listed below is the progression from health to disease, with hyperinsulinemia building progressively throughout.
Insulin-sensitive healthy fat levels that are able to easily absorb and release any excess energy for later use.
Expansion and filling of insulin-sensitive adipose tissue with sustained energy excess.
Fat cells become full and exceed your Personal Fat Threshold (largely influenced by genetics).
Fat cells become full and “insulin resistant” relative to other parts of the body.
Excess energy builds up as visceral fat in vital organs and spills over into the bloodstream (aka diabetes).
Excessive swings in blood sugar and insulin cause a dysregulated appetite driving further overeating.
Complications of western disease due to (i.e. obesity, diabetes, heart disease, Parkinsons, Alzheimers, dementia etc).
To reverse these steps and reduce insulin to normal levels we need to follow to:
Stabilise blood sugars and insulin swings by reducing processed carbohydrates to help improve appetite control and eliminate the need for exogenous insulin.
Focus on more nutrient dense, less energy dense foods to improve satiety and induce an energy deficit.
A sustained energy deficit causes a reduction in visceral fat which improves the function of the heart, liver, pancreas and brain.
Reduced pressure on the adipose fat allows to below the Personal Fat Threshold allows incoming energy to be buffered in fat stores without overflow into the bloodstream (i.e. reversal of diabetes).
Fat loss further reverses insulin levels and blood sugars to achieve optimal levels for longevity and performance.
So what’s the solution?
So, if insulin and carbs aren’t to blame for our obesity and diabetes then what can we do?
Is it back to just eat less, exercise more?
Well sort of, but not exactly.
There are a number of practical steps that we can take to avoid diabesity including:
Minimise cheap hyper-palatable processed food that overrides our satiety signals and tricks our taste buds.
Invest in quality food and learn to cook at home from fresh whole ingredients.
Monitor your nutrient intake by logging your food using Cronometer.
Eat your meals mindfully with other people rather than in front of a screen alone.
Don’t use food as a source of comfort.
Sleep and rest enough so you don’t need to use energy dense food as a pick me up.
Be active and build as much lean muscle as you can in order to efficiently burn the carbs and fat you consume.
Focus on nutrient-dense foods that are minimally processed that will minimize cravings. If you focus on maximising the good stuff in your diet, you will not have to worry as much about avoiding the processed food that are full of sugars, flavourings and seed oils.
Moderate carbs if you need to stabilise blood sugar and insulin swings which can help stabilise appetite. Diabetes and longevity expert, Dr Peter Attia, recommends that we eat foods that will keep our blood sugar low (i.e. less than 90 mg/dL) and with a relatively tight standard deviation of less than 10 mg/dL.[19][20]
Don’t demonise macronutrients, but instead prioritise nutrient-dense whole foods.
If all of the above still don’t get you to where you want to be then you may need to track your intake for a while and titrate down your calorie intake to recalibrate your version satiety. The good news is that many people find when focusing on maximising the nutrient density of their diet managing the quantity of food isn’t such a big deal.
Unfortunately, I was underwhelmed with what I heard.
I shared my frustration on Facebook.
Robb Wolf suggested I put together a response to some of the misinformation in the teleseminar. Hence this post. [Robb did an excellent breakdown on the claims in the What the Health Netflix doco, What the Health: A Wolf’s Eye View, which I highly recommend checking out if you haven’t already.]
What’s actually wrong with the keto diet for diabetes?
If I were was going to attack keto for diabetes management, then there would have been a couple of ‘free kicks’ I think they could have taken. So, in fairness to both sides, I’ll touch on a few of what I see as legitimate issues with ‘popular keto’ before I dissect the Mastering Diabetes presentation.
Giving fat a free pass
Humans like things to be straightforward and binary.
Yes or No.
Black or white.
High fat or low fat.
Low carb or high fat.
High protein or low protein.
Plants only or animals only.
For the last four decades, we have been told that fat, particularly saturated fat, is bad because it causes heart diseases and should be avoided.
The tide is now turning. However, there will always be people who take things to the extreme.
Now fat is healthy. But is more is better?
Ketones are good. So more is better?
For many people, a higher fat diet will be more satiating, particularly compared to processed grains and sugars. However, not everyone can ‘eat fat to satiety’ without some level of restraint and self-discipline. We can’t all trust our appetite to kick in to effortlessly provide the lean and chiselled body that they dream of.
My personal experience is that you can overdo the fat and drive insulin resistance by pushing fat too hard. If you exceed your ‘personal fat threshold’[1], your adipose tissues will become insulin resistant, and the body will start pushing excess energy to the vital organs.
While there is no need to fear fat, there is no reason to go hog wild to compensate for the butter and bacon deficiencies that we all developed over the past four decades.
When it comes to nutrition, you need to get your big rocks in place first (i.e. the nutrient dense foods). You can then fill up with fuel such as fattier foods if you do not want to burn any body fat. You could even add some starchy carbs if your blood sugars allow.
Having some level ketones is an indication that your insulin levels aren’t too high and your metabolism is working. However, if you are not yet metabolically healthy, chasing ‘fauxtosis’ by loading up on butter, coconut oil, cream and exogenous ketones to achieve high blood ketone levels can be a recipe for hypercaloric metabolic disaster that will drive insulin resistance.
People with type 1 diabetes (such as the Mastering Diabetes guys and my wife Monica) have a unique insight into the various factors that affect their insulin sensitivity. They can monitor their daily insulin dose.
I know some people with type 1 diabetes who have made an effort to chase higher ketones with more refined fat and less protein but found that they ended up needing more insulin. Retreating to a moderate to high protein approach with less added fat (as per Dr Bernstein’s recommended approach for Type 1 diabetes) enabled them to improve their insulin sensitivity (e.g. check out Allison’s Nutrient Optimiser analysis here).
This phenomenon is not unique to people with type 1 diabetes. There seem to be more and more people start out believing calories don’t count, only hormones. They then put their faith in the ‘magic ketone fairy’ and end up driving insulin resistance and obesity chasing ‘optimal ketone levels’ with more and more added fat.[2]
I have a dream
Before we get into the nutritional analysis, permit me this indulgence to share my vision (with a hat tip to Martin Luther King) from Martin Laurence Kendall.
I have a dream that one-day nutrition will be defined by the nutrients that a food contains and the health benefits that it confers rather than religious and ethical beliefs or commercial interests.
I have a dream that all people, mothers and children, fathers and brothers, would be able to clearly understand the foods that are truly optimal for them.
I have a dream that one day all people afflicted with diabetes will be able to choose foods that will enable them to achieve normal blood sugars and restore the health and vitality that they deserve.
Further, that they will be able to choose optimal foods, with engineering precision, without being affiliated with the needless ridicule that they will needlessly die of a heart attack due to unnecessary fears about ‘artery-clogging saturated fat’ or ‘harmful animal proteins’.
I have a dream that one day people will have, freely in their grasp, quality nutritional information that enables them to make informed choices that will, in turn, bring about a new day in the commercial food environment.
I dream that one day all people, obese, diabetic, children and athletes alike, will be free from the corruption of Big Food and Big Pharma working through diabetes educators, diabetes associations, heart associations, medical institutions and animal welfare advocates.
Free at least. Free at last.
I hope that one day we will be free at last.
Indulgence over. On with the data.
On with the data.
Nutrient deficiencies in a high-fat diet
Another fact that I thought Cyrus and Robby would mention was that very high-fat foods tend to have a weak nutrient profile, especially compared to non-starchy vegetables.
The chart below shows the nutrients provided by the 800 highest fat foods out of the 8000 foods in the USDA database. If we prioritise fat, we will likely be lacking in around half of the essential nutrients.
A summary of some of the highest fat foods is shown below.
[For some real-life examples of the poor nutrient profiles achieved by people chasing high ketone levels in the misguided pursuit of weight loss check out the Nutrient Optimiser reports here, here, herehere and here.]
Vitamins and minerals, in particularly electrolytes such as potassium, magnesium and calcium are critical to support our mitochondria, enabling them to produce energy and maximise insulin sensitivity.
People in the keto community are conscious that electrolytes are essential and go out of their way to supplement with magnesium, calcium, sodium and potassium as well as taking bone broth.
The kidneys let go of water and electrolytes when insulin levels drop. A ketogenic diet without attention to green leafy veggies is at risk of being very low in electrolytes. This will cause the pancreas to secrete more insulin to hold onto the scarce electrolytes. This increase in insulin levels may[3] ironically drive insulin resistance.
Whether you call them electrolytes or alkaline foods[5], our bodies need enough substrate to allow our kidneys to maintain a good acid/base balance without having to work too hard. Focusing on minerals can helps us maximise insulin sensitivity and ensure oxygen is efficiently be carried around our bloodstream.
There are plenty of foods available to provide the micronutrients that you need if you actually require therapeutic ketosis as an adjunct to cancer, epilepsy or dementia. We can achieve the Daily Recommended Intake (DRI) for most of the nutrients while still maintaining a low dietary insulin load.
The short list of foods that comprise a ‘well formulated ketogenic diet’ are shown below.
However, if you just need to manage diabetes with a low-carb diet (rather than therapeutic ketosis), you can achieve even higher levels of nutrition while maintaining stable blood sugars.
Given my family history of Type 2 and my wife Monica’s Type 1 diabetes, we generally focus on the foods listed below. Lots of people have found these lists useful. You can pin them to the fridge as a reminder of what you should focus on or print it out to take shopping next time when you need some inspiration. (There is a complete list of nutrient dense foods to suit different goals at the end of this article.)
Now my blood glucose levels are more stable, I’ve been trying to back off on the higher fat foods and focus on more nutrient-dense foods to build muscle and lose fat.
The ‘problem’ with the most nutrient-dense foods (as shown below) is that they typically have a very low energy density so it will be nearly impossible to get enough energy to prevent rapid weight loss.
Prioritising nutrient-dense foods is the secret to obtaining the nutrients you need with the lowest energy intake. If you don’t want to keep losing weight or want to run a marathon then adding some higher energy density foods will be useful.
High carbohydrate foods are not nutritious
After watching the Mastering Diabetes teleseminar, you will get the feeling that the Mastering Diabetes guys believe carbohydrate can do no wrong and we should only fear fat.
The reality, however, is that the foods with the least fat are generally even more nutritionally corrupt than the highest fat foods.
Not all of the low-fat foods are going to be beneficial.
Defining your nutritional approach as ‘high carbohydrate’ is not wise, especially if you are trying to manage diabetes. The foods with the most carbohydrates in our food system are typically very nutritionally deficient as well as highly insulinogenic.
If a ‘low carb diet’ leads you to avoid processed foods you may be better off. However, I don’t think defining nutrition in terms of macronutrient extremes is particularly useful. [6]
Plant-based versus animal-based foods
One area where vegans potentially have it over carnivores is vitamins and minerals. As shown in the chart below, a zero carb diet does not provide really high levels of many nutrients.
At the same time, there are plenty of people who appear to be thriving on a zero carb dietary approach. Many people with severe autoimmune related digestive issues succeed when they switch to a zero carb approach. Zero carb advocates will also tell you that they don’t need the recommended daily intake levels of the various micronutrients that are based on limited data or deficiency studies in people eating a standard high carb western diet.
A plant-based diet can provide a reasonably nutrient dense outcome. However, it will be hard to get adequate levels of omega 3, vitamin D and vitamin B-12. People following a strictly plant-based approach may need to supplement with these nutrients.
Achieving the minimum protein intake levels is possible. However, many people have concerns about the reduced bioavailability of plant based proteins and whether or not the minimum protein intake levels are actually optimal, particularly if you are active or older.
It’s also worth noting that other nutrients such as iron, vitamin A and omega 3 will be more bioavailable from animal-based sources. So it’s not as simple as comparing the nutrients in the food, what gets into your body is what really matters.
If you are going to follow a plant-based diet then prioritising the food listed below will give you the best chance of success. Most people are going to do best somewhere on the spectrum between exclusively plant-based and solely animal-based foods.
The real problem comes when we start to heavily process our food. Rather than prioritising the most nutrient dense and minimally processed vegetables, fruits and legumes, many vegans end up living on processed grains, cereal, sugar and soy products that have been treated with a host of fertilisers and pesticides. Meanwhile, many zero carbers or keto peeps end up living on nothing but bacon or processed meats from animals that were fed nutrient poor corn and grains with added antibiotics to make them grow quicker.
The vegan echo chamber
I have spent a good chunk of time hanging out in many vegan or plant-based groups trying to understand their position and gain insights about nutrient density. I have learned a lot from people like Professor Christopher Gardner, Ray Cronise and Dr Joel Fuhrman. Much of the analysis in this is based on the integration of my learnings their work with Dr Richard Bernstein and Dr Matt Lalonde.
Unfortunately, it seems that the vast majority of vegan/plant-based education comes from Dr Michael Greger through his sanitised, highly processed and hyper-palatable “Nutrition Facts” videos.
While Greger covers a lot of relevant research and raises some valid points, a lot of the time he seems to twist the science to ensure that the moral of the story is always ‘eat plants, not animals’. Plant-based is better. Eating animals will be bad for your health.
Without evolutionary context, we are asked again and again to believe that fat (particularly saturated fat) and ‘animal protein’ (whatever the hell that is!) is the primary cause of heart disease, the complications of diabetes and practically every other modern health ill.
There is no demonstrated biochemical mechanism provided as to how we suddenly became allergic to animal products. Meanwhile, vegans advocates generally give a free pass to sugar and processed grains.
With more than six million views and an estimated earnings of more than $100k per year from YouTube[7] (not to mention donations[8]), there appear to be a LOT of people eager to lap up the nutritional and medical justification of their ethical position.
The mission of the Humane Society is to celebrate animals, confront cruelty and shape public opinion.
I wonder if Greger does his researching, writing, filming and editing the Nutrition Facts videos as a hobby after he gets home after working 50 hours a week and commuting? Or perhaps he creates these videos as an employee of the Humane Society as part of their stated goal to shape public opinion on animal cruelty?
It seems Mangoman and Robby are pretty tight with Greger.[10] Makes me wonder if Mastering Diabetes is a coordinated and strategic assault by the Humane Society on the low carb/keto/diabetes community who have become immune to Dr Greger.
I am by no means advocating animal cruelty. However, as a human, if you are looking for the best advice on humannutrition, is it wise to put your blind faith and unswerving trust in someone whose explicitly stated primary goal is animal welfare?
Do you really want to save the planet?
Worrying about whether we eat plants or animals exclusively is a modern luxury, an intellectual indulgence of sorts.
For the majority of human history, we have been opportunistic omnivores. When plants were the only thing that was available, we would eat them. When we could, we would chase down an animal to get the protein we need to thrive. We never had to worry about nutrient density because the foods we ate grew in fertile soil without pesticides. The animals we ate were eating their natural foods which were also nutritious for them.
Humans thrived and were able to populate the world because we learned to hunt, store, cook and process food. We became very good at getting the nutrients we needed with the minimum amount of effort.[11][12] [13]
Unfortunately, we have now become too good at processing food.
Many of us are now fantasising nostalgically about Paleo times.
It’s one thing to worry about saving animals, but ultimately we need to save the planet and our human race from accelerated extinction.
Our newfound ability to harvest fossil fuels enables us to move around in cars and grow a massive amount of food with chemical fertilisers. These foods grow quickly and give us plenty of energy, but few nutrients that we then process and feed to animals or humans.[14]
Take a moment to think about how your life would be different if we had never discovered fossil fuels (e.g. coal or oil). For as long as it lasts we are gorging ourselves on stored energy that is making us lazy and obese and driving not just us, but life as we know it to an early grave. If you want to care about something it should be the sustainability of the global environment (including animals and humans).
If you want to care about something it should be the sustainability of the global environment (including animals and humans).
While humans are probably the biggest threat to the long-term sustainability of earth as we know it, most of us aren’t willing to volunteer ourselves or our family as the first ones to check out to save the planet.
[If you want some challenging thoughts on this topic you should check out Daniel Vitalis’ Why I Hunt podcast.]
They look like they’re happy and thriving on a plant-based diet full of fruits and vegetables.
To be honest, they look a lot healthier than many recovering diabetics in the low-carb scene.
But at the same time, the zero carbers will hold up anecdotes of people who have not eaten a plant for decades and look as great as the Johnson Family.
Or Dr Shawn Baker who is setting world records as a masters athlete since cutting plants out of his diet.
Then the keto folks will point to Dr Dominic D’Agostino who thrives on high fat and exogenous ketones and is exceptionally smart and can lift very heavy stuff at the same time.
While it’s useful to look at populations of people following a particular diet to look for trends, anecdote does not equal data.
It is more useful to look at underlying metrics (such as nutrient density and insulin load) that we can use to identify the optimal diet for humans.
I thought they would know better
Cyrus Khambatta is a smart guy. He was studying mechanical engineering at Stanford before he got type 1 and changed course to study nutritional biochemistry.
However, for all his ability in nutrition, engineering and mathematics (I took those classes, and I know how hard they are!), I thought he would have more to offer than what was presented!
People with diabetes get screwed around by the mainstream medical system and ‘diabetes education’ system. The system doesn’t really understand how it works, so they give them bad advice (e.g. “just eat like we tell everyone else to and cover it with insulin”)!
I remember clearly the anxiety and confusion we experienced after going to an appointment with the hospital endocrinologist when my wife Monica was pregnant with our daughter.
At her visits, she would routinely be told that she needed to reduce her blood sugars to avoid the many serious risks and complications and risks for her and the baby. Monica asked what else she could do to get the blood sugars down, but they had no advice. They just wanted to see them lower.
We now have two healthy and wonderful kids, but I if I can I would love to see other people spared the anxiety as well as minimise the genuine health risks related to diabetes. Hence my quest to understand how we can make intelligent food choices to optimise blood sugar and insulin levels.
What is the actual relationship between insulin and the food we eat?
The food insulin index data is a highly valuable resource that helps us to understand what causes us to secrete insulin and our blood sugars to rise. The chart below shows the results of the food insulin index testing on more than 100 different foods (click to enlarge).
The food insulin index testing demonstrates clearly that we have the lowest insulin response to fats and oils while we have the highest insulin response to high carbohydrate foods like jelly beans and rice bubbles. However, when we plot this data, we see that carbohydrate does not fully explain our insulin response.
We get a much better prediction of our insulin response when we account for protein (which requires insulin to metabolise) and non-digestible fibre.
Eating more fat will decrease the amount of insulin required to keep our blood sugars stable.
Eating more protein will reduce the amount of insulin your pancreas has to produce because it will push the more insulinogenic processed carbohydrates and sugar out of your diet.
How to improve your insulin sensitivity
If you reduce your intake of processed carbs and sugars, your insulin requirements will come down. Once your organs and muscles are no longer swimming in insulin, you will become more insulin sensitive (just like you become more sensitive to coffee or alcohol if you cut back your intake).
If you are injecting insulin, reducing the insulin load of your diet will enable you to significantly reduce your insulin dosage which will, in turn, allow you to more easily access your own body fat stores for fuel.[16]
This data is an inconvenient truth for both high carb vegans or the nutritional recommendations such Food Pyramid / My Plate generated by the US Dept of Agriculture. But I think it could be beneficial for people who want to effectively manage their diabetes.
Granted, if you switch your processed grains and sugar for fruits and vegetables, you will do better. But is it really optimal?
If you can’t win, move the goalposts!!!!
So what do you do if you can’t win with science?
You change the rules! You move the goalposts.
It was Cyrus and Robby’s unique definition of insulin resistance that really frustrated me.
So you can understand my frustration, I need to explain the difference between basal and bolus insulin which is a daily reality for someone with type 1 diabetes.
Bolus insulin is taken with food and is proportional to the insulin load of the food they eat (i.e. carbs – fibre + half protein)[17].
Basal insulin is the insulin that your pancreas would produce through the day and night whether or not you eat anything. It’s the basal insulin that keeps your fat in storage and your muscles from being used for fuel.
You need both, but their function is different.
For someone eating a standard western diet about one-third to a half of their insulin will be basal insulin with the majority being bolus insulin for the food you eat.
When you switch to a low carb or keto diet this ratio flips and the majority of your insulin is basal insulin. You only need a little bit of bolus insulin to cover the small amount of carbohydrates and protein that you eat. With less glucose to deal with, you don’t need as much insulin, and your blood sugars stabilise.[18]
A significant portion of the Mastering Diabetes video was devoted to explaining their new creative definition of insulin sensitivity. The fundamental problem with this central piece of the Mastering Diabetes argument is that it conflates basal and bolus insulin. Your basal insulin is irrelevant if you are trying to do this sort of insulin sensitivity calculation!
It’s just the bolus insulin (i.e. for food) that matters when it comes to insulin sensitivity. The calculations in the table below demonstrate my point. If you take the denominator to your insulin sensitivity calculations to be the basal + bolus insulin, then the high carb approach has a better insulin sensitivity. If you only consider the bolus insulin (the only sensible approach in my view), then you declare the low-carb approach to be the winner.
low carb
high carb
conclusion
ISF (g carb/unit insulin)
6
5
carbs (g)
50
500
bolus insulin (units)
8.3
100
basal insulin (units)
20
20
total daily insulin (per day)
28
120
24 carb / 24-hour insulin (basal + bolus)
1.8
4.2
High carb is better
24 carb / 24-hour insulin (bolus only)
6.0
5.0
Low carb is better
The chart below shows the difference in the daily blood sugar fluctuations of someone on a standard western diet and then after switching to a lower carb diet. The difference in the blood sugar levels is night and day! The difference in the quality of life between these two situations when it comes to energy levels, anxiety, depression, mood etc. is also immensely different.
I pinged Mastering Diabetes on their Facebook page to clarify if the cornerstone of their whole argument includes basal and bolus insulin. Unfortunately, my fears were confirmed (though they have since deleted their response and kicked me out of their Facebook Group).
Tight blood sugar control isn’t that important after all?
The next argument they try to run is that tight blood sugars really aren’t that necessary.
Cyrus (who is very active and practices intermittent fasting) has a Hba1c in the high 5s.
Robbie has a Hb1c in the low 6s.
Granted, this is good compared to the majority of the Type 1 population. They’ll have a better chance of thriving with good blood sugars if they are eating lots of vegetables and fruit compared to more processed grains and sugars that make up the typical diet. But it’s still a far cry from the blood sugar control of people following the type of low-carb approach advocated by Dr Richard Bernstein.
The problem I see with defining your diet as vegan or plant-based is that most people don’t have the self-discipline to stick with eating only vegetables and fruit and end up filling up on more processed (but still technically vegan) processed junk food.
Cyrus and Robbie argue that normal blood glucose fluctuations are between 70mg/dL to 145 mg/dL or 3.8 to 8.0mmol/L.
The problem with this argument is that what currently passes for ‘normal’ is far from optimal.[19] Complications from diabetes start to kick in well below what is widely considered “normal”.
Just because it’s normal for most people to do Facebook on their phone while they drive doesn’t mean it’s ideal or optimal. Just because it’s normal to have poor blood sugar and most people are dying of metabolic diseases doesn’t sound like a persuasive argument for plant-based diet being optimal to me!
If you’re happy to settle for less than optimal blood sugar control because you have a strong ethical position, then that’s fine, but don’t construe it as optimal for everyone when it’s not.
The reality is that many people over at Type 1 Grit following Dr Bernstein’s approach are doing fabulously! Not everyone will achieve optimal, but it’s useful to know what to aim for and how to get there.
If you had a child or loved one with Type 1 diabetes would you want the opportunity to choose the approach that would yield the best results or would you prefer your advice to be tainted with ethical or commercial bias?
Check out the video the Type 1 Grit group put together for Dr B’s 83rd birthday to thank him for changing their lives.
Insulin resistance and metabolic syndrome are a big deal, so let’s not ruin more lives than we need to with bad advice that is based on bad math or putting ethical convictions or religious beliefs ahead of human health.
Understanding physiological insulin resistance
Cyrus and Robbie argue that someone on a low carb diet won’t deal with carbohydrate well when they are exposed to them. This phenomenon is real, but is typically due to what is termed ‘physiological insulin resistance’.
Someone who eats a lot of carbohydrates will have high levels of insulin floating around in their bloodstream. Then when they eat a carb bolus, their pancreas is primed to shoot out some more insulin to mop up the glucose and stop more glucose being released into the bloodstream via the liver. By contrast, someone who doesn’t eat a lot of carbohydrates will have low levels of insulin in their bloodstream and need to wind up their pancreas to produce insulin to bring down the glucose.
This phenomenon is also referred to the first phase versus second insulin response. Someone who is not eating a lot of carbs will have a slower first phase insulin response.
It’s like comparing someone’s time over 100m when they are starting from a standstill versus someone using a rolling start. It’s not a relevant comparison. This phenomenon will go away after a few days on a high carb diet.
At the same time though, micronutrients such as potassium, magnesium and calcium are critical to maintaining healthy insulin sensitivity and glucose uptake. Metabolic acidosis (caused by a lack of dietary electrolytes) appears to cause an upregulation in insulin by the pancreas to hold onto precious electrolytes. Over the long term, this could be another driver of insulin resistance, metabolic syndrome and diabetes. [20]
Getting adequate dietary electrolytes from green leafy vegetables will make it easier for our body to maintain acid/base balance. However, I don’t think we need to feed all diabetics a high carbohydrate exclusively plant-based diet to achieve this.
Eating fat makes you fat?
The vegan community seems to confuse eating fat and storing fat. The Ancel Keys / vegan story is that we store fat in our body because we overeat dietary fat. However, the reality is that we get fat because we eat more than we burn.
As shown in the graphic below from Ray Cronise’s Oxidative Priority paper, we will only burn fat (from our body or diet) once we’ve burned through the alcohol, ketones, protein and carbohydrate and fat that we eat (in that order).[21]
When we eat our body prioritises the refilling of our glucose and glycogen stores in our blood stream and liver (which can hold about 1200 to 2000 calories) before we start to store the excess energy in our adipose tissue. Our body fat stores can hold a lot more energy, but not an unlimited amount. Once our fat stores are full and can hold no more, they become insulin resistant. We then start to store the excess energy in our vital organs such as our liver, kidney, brain, eyes, heart, etc.
The trick to weight loss is to keep your blood sugar levels low enough so that your liver glycogen is being replenished from your body fat rather than always having overfull glycogen stores, so we need to offload excess energy to our fat stores.[22]
One of the many roles of insulin is to shut off the flow of stored energy from the liver into the bloodstream. If energy is coming in the pancreas will upregulate insulin to stop the flow of glucose from the liver back into the bloodstream (regardless of whether you’re eating carbs, fat or protein from animal or plant-based sources). The best way to reduce insulin is to stop eating and let your stored energy flow back into your bloodstream.
If you are insulin sensitive, the bad news is that you can easily store excess energy as body fat very efficiently. Insulin is an anabolic hormone that will help you to grow. However, when you are insulin sensitive, you can lose fat relatively quickly when you reduce energy intake. If you are insulin sensitive your circulating insulin levels will be low, and fuel will more easily flow from storage. Hence you won’t be such a mindless slave to your uncontrollable appetite.
If you are insulin resistant and have high levels of circulating insulin, you may struggle to release your stored body fat. Your appetite will drive you to seek out food because you can’t efficiently access it from your body stores. You won’t be able to go very long between meals.
A low-carb diet can be helpful for someone who is insulin resistant because it can help lower insulin which in turn help them to normalise their appetite. Teaching that we get fat because we eat fat is just outdated science.
Even Dr Joel Fuhman will tell you that actively avoiding fat is stupid. He will also tell you that there is some value in eating fish on a regular basis to ensure you get adequate amounts of omega 3s and vitamin B-12.
Complications on a ketogenic diet
There are plenty of studies that show the shortcomings of a ketogenic diet. Sarah Ballantyne did a great job of summarising these on her Paleo Mom Blog here.
When you look in detail however you find that the adverse reactions the ketogenic diet are typically due to ‘keto in a can’ formula products.
While these food substitutes will help achieve therapeutic ketosis to help manage epilepsy or other chronic conditions, many of these keto formula products end up being very low in micronutrients.[23]
Obtaining a significant amount of your energy intake from processed food-like products that have been separated from nutrients is not a good idea (e.g. whether it be sugar, processed grains, refined oils or exogenous ketones).
Anyone who is on the fence about using a low-carb diet to manage diabetes should check out this paper which shows that a low-carb diet is better for weight, HbA1c, glucose, HDL and triglycerides compared to low GI or a grain-based diet.
Another well-known study is Christopher Gardener’s A to Z trial[24] where they found that the Atkins diet did much better than the low-fat, particularly if you were already insulin resistant.[25]
What should you eat if you are a vegan with diabetes?
So, after all this, what should we eat to maintain optimal blood sugar levels? Cyrus and Robby’s view is shown below. Unfortunately, it appears that their recommendations are driven more by their philosophical and ethical views rather than the nutrient content of the food or their ability to stabilise blood sugars.
In the green column, most people with diabetes aren’t going to do too well with a lot of fruits, starchy veggies, and beans. Intact whole grains do contain substantial nutrients but are very hard to find in our modern food system. Who actually eats wheat bran as a significant part of their diet? The vast majority of grains are processed with the nutrients discarded, so they are tasty and shelf stable.
In the red column, dairy eggs, meat, fish and poultry can be nutrient dense and keep your blood sugars stable (as long as you’re not afraid of fat in whole foods or ‘animal protein’).
In the orange column, higher fat foods like nuts, seeds, avocados, coconut and olives can be useful to help stabilise your blood sugars, but it is possible to overconsume them if your goal is to lose weight.
We want to maximise nutrient density as much as possible while keeping the insulin load of our diet down to the point that we keep blood sugars stable.
This does not end up being super high fat or super low fat. Fat just comes along with nutritious whole foods.
If you have diabetes, then a little more dietary fat initially may help to stabilise blood sugars. Once your blood glucose levels have stabilised, you can start to decrease the dietary fat and increase nutrient density as much as you can while still maintaining excellent blood sugar levels.
A low insulin load diabetes-friendly plant-based nutritional approach will be lacking omega 3 and vitamin B-12.
The shortlist of nutrient dense low insulin load plant-based foods is shown below. The foods at the top of each section should be reasonably safe for most people with diabetes. You should test your blood sugars to see how you respond to some of the foods further down the list.
Many people who are conscious of animal welfare will eat fish (i.e. pescetarian). Adding some fish will provide a much better nutritional profile than eating plants alone, with plenty of vitamin B12 and omega 3 available from the seafood.
I hope this is helpful for people who want to choose a plant-based approach to maximise nutrient density and maintain excellent blood sugar control.
If you’re still confused, I have designed the Nutrient Optimiser to identify what foods you should add or remove from your diet to ensure you are getting the nutrients you need while maintaining excellent blood sugar levels.
So which approach is optimal?
It depends.
The optimal approach for you will depend on your situation and goals.
Going plant based may be an improvement if your diet is currently full of sugar and processed grains, but it is not the singular solution to every ill. (For an excellent example of a very nutrient dense plant-based dietary approach check out David’s Nutrient Optimiser analysis here.)
To help you make more informed food choices, I have devised two different ways of measuring food quality:
Proportion of insulinogenic calories, and
Nutrient density.
The proportion of insulinogenic calories is the percentage of the food you eat that will require insulin to metabolise. The table below lists a range of nutritional approaches ranked by the percentage of insulinogenic calories (right-hand column).
If you’re interested in any of these approaches, you can download the list and save it to your phone or print it out to take shopping for some inspiration.
Simply switching to a plant-based nutritional approach will leave you with 73% of your diet requiring insulin to metabolise. The diabetes-friendly plant-based approach will be an improvement, but a low-carb or ketogenic diet may be better if your goal is stable blood glucose levels.
Another way to look at things is nutrient density. You may have noticed the nutrient profiles shown above have a red dotted box. If a particular nutritional approach provides two times the Daily Recommended Intake for all essential nutrients, then you would get a perfect score of 100%. You can see below that the most nutritious foods below are pretty close to 100%.
By contrast, if we only focus on ‘plant-based foods’ nutritional outcome is not so flash. Thinking only in terms of plant-based is not automatically nutrient dense.
I have sorted the various food lists in the table below based on their nutrient score. My suggestion is to start at the top with the most nutrient dense foods and work your way down until you find an approach that suits your ethical framework or religious beliefs that will also enable you to stabilise your blood glucose levels (i.e. lower % insulinogenic calories).
There is a lot of controversy and confusion over 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
All but two 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. Thirteen amino acids can be converted to glucose.
Once your body has used 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 bloodstream and replenish glycogen stores in the liver via gluconeogenesis.
The fact that protein can be converted to glucose is of particular interest to people with diabetes who go to great lengths to keep their blood sugar under control.[2]
Someone on a very low carbohydrate diet may end up relying more on protein for glucose via gluconeogenesis compared to someone who can get the glucose they need directly from carbohydrates.[3]
Obtaining 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.
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. 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 short-term 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?
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.
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 glucosein the form of glycogenin the liver.
Glucagonis the hormone that pushes glycogenout into the bloodstream as blood glucose.
Insulinis the opposing hormone that keeps glycogenstored 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), eating less, or 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 bit geeky, let’s look at how our hormones respond to different types of meals.
As shown in the chart below, 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 nice balance between the insulin (brake) and the glucagon (accelerator). 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.
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, needs to rise a lot more while you metabolise the protein to build muscle and repair your organs.
Unfortunately, people who are insulin resistant may struggle to build muscle effectively due to 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. 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. The advent of continuous glucose meters makes this more evident as you can watch blood sugars rise over a long period after a high protein meal.
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 good 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 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, 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.
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 or avoid protein to manage insulin resistance. However, there’s no need to go to the other extreme and binge on protein if you are injecting insulin.
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. If you are injecting insulin you may need to dose with more insulin to allow you to utilise the protein in your diet to build and repair your body.
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.
An article in Business Insider, “A Nutritionist Shares Pictures of Everything She Eats in a Day”, caught my eye recently. I thought it would be interesting to run the numbers to see how the food diary logged by this nutritionist compared to the four hundred or so meals that I’ve analysed.
Check out the original article if you want to see the daily food log chronicled in photos by the popular and published “Registered Dietician”, who claims to specialise in diabetes and is “passionate about being a good role model.”[1]
The quantities and foods that I analysed in the recipe builder at SELFNutritionData are shown below. Besides the fact that the only green things she ate during the day were M&M’s, the food log is not particularly divergent from mainstream dietary advice (i.e. no full-strength Coke or McDonald’s). The nutritional analysis would be much worse if it was a diet full of junk food, which is pretty common for a lot of people these days in this fast-paced convenience-loving world.
This dietician is a national media spokesperson for the Academy of Nutrition and Dietetics. She has published books and written for several magazines.[2] Like most nutritionists, she argues for less fat and more whole grains.[3]
So, let’s see how her daily diet stacks up. The analysis below shows that, when we compare this daily diet against mainstream dietary advice that nutritionists prescribe, it ticks the following boxes:
avoids trans fats,
is low in fat, and
is low in cholesterol.
However, even though the diet is fairly low in fat, it has 29g of saturated fat which is greater than the Heart Association’s recommendation for a maximum of 16g of saturated fat per day.[4] Unfortunately, the recommended limit of saturated fat is actually quite hard to achieve without relying on low fat highly processed foods.
Ironically, due to the focus on avoiding fat and trying to incorporate more “heart healthy whole grains”, the food recommended by nutritionists ironically tends to be lacking in nutrients. It makes no sense!
The registered nutritionist’s daily food log also contains more than 400 grams of carbohydrates which will be a massive challenge to someone who is insulin resistant, would likely generate insulin resistance and eventually diabetes in someone who isn’t there yet.
For comparison, check out the analysis shown below of one of my regular meals (stir-fry veggies with some butter and sardines) which has a muchhigher vitamin and mineral score (94 compared to 55) and better protein score (139 compared to 66).
When it comes to nutrient density and being diabetic friendly, this nutritionist’s daily food log ends up at the bottom of the pile of the four hundred meals that I’ve analysed!
It’s sad that this myopic one-size-fits-all dietary advice is forced on anyone who asks what they should be eating, or anyone whose food is influenced by government nutritional guidelines (e.g. hospitals, schools, jails, nursing homes etc).
Then we are told that dieticians are the only ones that are qualified to give dietary advice, even though the dietary advice that they give revolves around avoidance of saturated fat and more “heart healthy whole grains” and does not actually lead to high levels of micronutrition.
Where it gets even sadder is that this sort of short sighted advice is also given to the people who are the most vulnerable. The photo below is of Lucy Smith in hospital after being diagnosed with Type 1 Diabetes. The diet given to her, as a newly diagnosed Type 1 Diabetic, is Weet-Bix, low fat milk, bananas, low fat toast, orange juice, and peaches.
The analysis for Lucy’s hospital-provided breakfast is shown below.
This single meal contains more than 200 grams of carbohydrates (82% of calories). This breakfast would require a ton of insulin to be injected into her little body, and she would be on a blood glucose / insulin rollercoaster for days to come.
Unfortunately, things don’t seem to have changed much from thirty years ago when my wife Monica was diagnosed with Type 1 Diabetes. In hospital, after diagnosis, she was given so many carbs that she hid the food in pot plants in her hospital ward room because she just couldn’t eat anymore! Twenty-five years later, she learned about the low carb dietary approach and she was finally able to reduce the high levels of insulin required to cover her food.
I’ve witnessed firsthand the massive improvements in quality of life (body composition, inflammation, energy levels, dental health etc) when someone comes off the blood glucose/insulin roller coaster!
Monica has been able to halve her daily insulin dose since no longer ascribing to the dietary advice she has been given by the dieticians and diabetes educators. Her blood glucose levels are now better than ever and when she goes to the dentist, podiatrist and optometrist they tell her she’s doing great and they wouldn’t even know she’s diabetic. And I get to have my wife around for an extra decade or two!
By the way, Lucy is doing well now too. Her parents are some of the most knowledgeable people I know when it comes to optimal foods for diabetics and monitoring blood glucose (as shown in this video from her father Paul).
My friend, Troy Stapleton, is another example of someone living with Type 1 Diabetes who has benefited immensely from a low carbohydrate dietary approach that aligns with his metabolic health. His story and approach have been an inspiration to me. You can also check out the Standing on the Shoulders of Giants article for a few more encouraging stories of people with Type 1 who got their life back after going against nutritionists orders.
As detailed in the article How to optimise your diet for your insulin resistance, if you have the luxury of being more metabolically healthy (i.e. not diabetic) you can focus on more nutrient dense foods or lower energy density if you’re looking to lose some weight.
It amazes me that dieticians can be so militant and belligerent when they are largely passing on the recommendations of the US Department of AGRICULTURE (i.e. the USDA, also known as “Big Ag”), whose mission it is to promote the economic opportunity and production of AGRICULTURE[5] (i.e. grains and seed oils). Talk about putting the fox in charge of the hen house!
Speaking of conflicts of interest, it’s worth noting that major nutritionist organisations funding ‘partners’ are big food manufacturers.[6] Does this influence the recommendations they give? They claim not.
It’s hard to believe their published research or dietary recommendations could be impartial when so heavily sponsored by the food industry.
Despite these conflicts of interest and a poor track record of success over the past four decades, I don’t think we should be gagging the Accredited Dietitians from publishing poor nutritional advice. Everyone should be entitled to their freedom of speech and freedom to choose what they eat.
What I do find ironic is that dieticians can bring spurious cases of malpractice against doctors to their governing bodies when they are acting in line with the latest research and their personal, professional and clinical observations (e.g. Tim Noakes in South Africa and Gary Fettke in Australia). At the same time, the Registered Dieticians have no governing body to report to, only their board of directors[7] and their ‘partners’.
While they purport to be protecting the public interest, one could be excused for thinking that the dieticians’ associations are another marketing arm for big food companies and are protecting commercial interest rather than acting on behalf of public health.
Is it just a coincidence that Nestle’s Milo, which is half sugar, is prescribed by hospital dieticians for pregnant and breastfeeding mothers with diabetes?
Unfortunately, the situation isn’t that much different with the diabetes associations.[8] Why would these institutions ever make recommendations to their members that reduced the amount of medications they needed or reduce the amount of processed food when their financial partners are pharmaceutical companies who manufacture insulin and drugs for diabetes?
What would happen to this financial structure if a significant amount of people started eating whole unprocessed food without a bar code? The share price of these massive medical and pharmaceutical companies would tank!
After battling cancer himself and studying the role of nutrition in metabolic and mitochondrial disease in depth, Gary Fettke now spends his days as an orthopaedic surgeon amputating limbs mainly due to the complications of diabetes.
No, it’s not pretty, but unfortunately it’s very very real.
Each year Gary volunteers as an orthopaedic surgeon in Vanuatu.[9][10] The contrast between the native people living in their natural environment, eating their native foods, and their relatives in town, eating processed foods, is stark.
I took this photo in a traditional village during our holiday in Vanuatu a couple of years ago. These people eat lots of coconuts (which contains plenty of saturated fat, one of the remaining nutrients that Registered Dieticians still say we should avoid) and fish. These Vanuatu natives are some of the most beautiful, healthiest and happiest people I have ever seen!
Unfortunately, in the capital Port Vila, it’s not so pretty. The diabetes rates are the third highest in the world. One in fifty Vanuatu natives have had an amputation!
It is such a big problem. Their diet has changed quite rapidly over the years, so instead of eating their island’s food, they now eat very large quantities of white rice and of course all the liquid sugar, like Coca-Cola and Fanta, and it’s literally killing them.[11]
After seeing the impact of diet, Gary has been outspoken in Australia, bringing attention to the quality of food that people are eating, especially in hospitals.[12]
Gary and his Nutrition for Life Centre also worked with Chef Pete Evans on the “Saving Australia Diet” on national TV with great results achieved.[13]
Then, in return for his efforts, Gary has been reported by the certified dieticians to the Australian Health Practitioner Regulation Agency; and he has been told he can no longer tell his patients to limit sugar even if they have just had their leg amputated due to the complications of diabetes.
Similarly, Tim Noakes has developed a massive following after realising that he needed to go against his own previous publications and advice when he found he was developing diabetes. The recipe book that he helped write, The Real Meal Revolution, is filled with nutrient dense low carb meals that help people with diabetes achieve normal blood glucose levels, has been massively popular.
Despite his impressive track record of real results, which goes against the general trend of the explosion of diabetes and obesity in western society, Professor Noakes has been reported to the Health Professionals Council of South Africa (HPCSA) and charged with unprofessional conduct, after suggesting that a mother wean her baby on to whole foods rather than processed “baby food”.
This has led to a long and expensive court case which really appears to be more about maintaining the status quo on the supermarket shelves rather than public health.[14]
I think most nutritionists believe that they are doing the right thing by advising their clients to prioritise the avoidance of fat, cholesterol and saturated fat, and eat “heart healthy whole grains”. However, the foundation of this advice seems to be crumbling from underneath them with the most recent updates to the US Dietary Guidelines that now remove the upper limit on fat and removing cholesterol a nutrient of concern.[15][16]
However, if we have to rely on Big Food to provide processed food products to achieve the reduced saturated fat aspirations of the dietary guidelines (and in so doing produce very otherwise nutrient poor foods), then perhaps we need to declare them broken and look for new ones?
Makes you wonder how we survived (let alone thrived) with the food that was available to us before the highly-processed foods and the low fat dietary guidelines that came to dominate our food choices in the 1970s.
Unfortunately though, fear of saturated fat still dominates the majority of mainstream dietary recommendations out there and leads to nonsensical food rankings that only suit the grain based food industry.[17][18]
For example, the simplistic Australian Health Star Rating is based on the energy, saturated fat, sodium, sugar content along with the amount of fruits and vegetables in a product.[19] This avoidance-based process gives little consideration for the amount of essential nutrients in a product, regardless of where they came from, and hence often returns nonsensical results.
It’s hard to tell whether the attacks on people like Fettke and Noakes are motivated by:
Well-meaning nutritionists who earnestly believe that higher levels of fat and a lack of “heart healthy whole grains” is going to harm people,
Nutritional institutions sensing that they are becoming irrelevant and making a last-ditch attack at their adversaries in an effort to hold onto their jobs,
Processed food manufacturers (i.e. big food) using their “partner organisations” to attack these outspoken thought leaders so they can maintain their strangle hold on nutritional advice that suits them and sells more of their product (i.e. it’s not a conspiracy, it’s just business), or
Some combination of each of these options.
To cut through the confusion and conflicts of interest, wouldn’t it be great if there was an unbiased quantitative way to judge whether a particular food or meal was optimal based its nutrient density? Perhaps we could even tailor food choices based on blood glucose and metabolic health (i.e. using insulin load), or by manipulating energy density of someone who is insulin sensitive but just needs to lose weight.
If you’ve been following this blog, you may have seen the optimal food lists tailored to specific goals. To this end, I have devised a system to identify foods for different goals and situations. The table below will help you choose your ideal dietary approach and optimal foods based on your blood glucose levels and waist to height ratio.
The first step in improving your nutrition is to minimise processed food that is laced with sugar. These food lists can help you further optimise your food choices to suit your goals whether they be blood glucose management, weight loss or just maintaining optimal health.
Once you normalise your blood glucose levels, you can then start to focus more on nutrient density. If you still have weight to lose, then you can focus on foods with a lower energy density to force more energy to come from your body while still maximising nutrition. You can also find the highest ranking of the four hundred meals that I have analysed listed here.
Several people recently have suggested that I turn the nutrient density ranking system into a mobile app for easy implementation of the ideas and theories outlined on the blog in the real world.
So, my current project is to develop a Nutrient Optimiser that would rank the foods you have eaten based on your current goals (e.g. therapeutic ketosis, diabetes management, weight loss or maximising nutrient density) and recommend new foods to try. The Nutrient Optimiser would progressively retrain your eating patterns towards ideal by helping you to maximise the more optimal foods, and progressively eliminate the foods that don’t align with your goals. Whether you are trying to eat less Maccas, or you are practising Calorie Restriction with Optimal Nutrition (CRON) and trying to live to 120, the Nutrient Optimiser would push you forward to truly optimise your nutrition.
The idea is not to simply create another calorie counting app. There are plenty of those out there already. Rather, the Nutrient Optimiser will help you to maximise nutrient density as much as you can while catering to your other goals.
Rather than being centred on outdated “science” and avoiding boogeymen such as cholesterol, fat and saturated fat, or serving the interest of “financial partners” (e.g. BigFood and BigPharma), the Nutrient Optimiser uses a quantitative algorithm that will help you maximise the nutritional value of the food you eat.
The Nutrient Optimiser, based on the foods logged in the past few weeks, helps you to identify foods that would provide the nutrients that you haven’t been getting as much of. Rather than just tracking calories, the app will continually adapt to what you eat, ensure that you are getting a broad range of foods that contain the nutrients you need, and ensure you don’t get stuck in a nutritional rut.
For people just starting out, it will help them gently move forward, without the judgement of someone looking over their shoulder. It will suggest foods they should buy more of, new foods to try, and maybe which foods they should bin and never buy again.
For people who are truly wanting optimal nutrition, it will hopefully be the ultimate tool to continue to refine their food choices to maximise nutrient density while optimising blood glucose, insulin and body fat levels.
As you continue to log your weight, blood glucose levels and whatever other metrics you want to track, the app will progressively prompt you to “level up” to a more optimal nutritional approach. Then, with your nutritional deficiencies filled, the cravings will dissipate and you will naturally be satisfied with less food.[20][21]
If something like this is of interest to you and you want to be an early adopter or just check it out the nutritional analysis of other people food logs that have been done so far then then take a look at the Nutrient Optimiser Facebook page and to stay posted as things develop.
There’s a lot of talk about “nutrient density” and “superfoods”, but what do these terms really mean? Which foods actually give the most nutritional bang for your calorie buck? That is, which foods provide the most nutrients for the least number of calories?
Some approaches to quantifying nutrient density (e.g. Joel Fuhrman’s Aggregate Nutrient Density Index) have looked at vitamins and minerals (along with other parameters that are only available for fruits and vegetables) per calorie, but do not consider essential fatty acids and amino acids.
Meanwhile, Registered Dietitians’ recommendations and mainstream food ranking approaches revolve around avoiding nutrients such as saturated fat, cholesterol and salt. Unfortunately, this avoidance based approach to ranking foods does nothing to increase beneficial nutrients.
Avoidance of these demonised food elements typically ends up ignoring the whole unprocessed foods that contain the most nutrients. Instead, current ranking systems encourage prioritisation of processed foods that have been manufactured to be low in fat, saturated fat, salt or cholesterol.
The resultant fat-free manufactured products are so nutrient poor that they must be fortified with a smattering of synthetic vitamins to prevent the malnutrition that would otherwise occur. Food manufacturers also add sugar and synthetic flavours to make them palatable. After a few decades, food scientists have now learned to optimise sweetness to target “bliss point”[1] which continues to drive upwards in sweetness.[2]
With synthetic flavourings, we can make hyperpalatable food stuffs that taste so much more intense than real foods that are found in nature. After a generation or two of fake food we have forgotten what real food, in its natural form, tastes or even looks like. Unfortunately, at the same time our food production is becoming more reliant on fertilisers to grow crops bigger and faster but the end result is food that doesn’t naturally taste as good as they used to because they don’t contain the same number of nutrients. Our senses of taste and smell don’t have a chance of being able to find real nutrients amongst the plethora of super sweet and unnaturally flavoured foods. This industrialized chemical storm also taxes your liver, kidneys, and digestive system and encourages disease instead of leading to health.
So, if we can’t trust our senses anymore to find the nutrients we need what can we do?
As much as food technology has got us into this mess, the good news is that by quantifying nutrient density we can identify the foods that contain the most nutrients. Then after a period without the distraction of sweeteners and artificial flavours and we can re-learn trust our tongue, nose, appetite and cravings to find the real nutrients that our body need.
The chart below shows the nutrients contained in the eight thousand foods in the USDA database per 2000 calories. While it’s easy to get the minimum levels of iron, vitamin C and several the amino acids (at the bottom of the chart), it’s harder to obtain adequate quantities of omega 3 fatty acids, vitamin D, choline, vitamin E and potassium (shown at the top of the list).
Rather than trying to get more of all the essential micronutrients, we can prioritise the following nutrients that are harder to find:
alpha-Linolenic acid (Omega 3 fatty acids)
Vitamin D
Choline
Vitamin E
EPA + DHA (Omega 3 fatty acids)
Potassium
Calcium
Magnesium
Pantothenic acid
Tyrosine
Thiamin
Zinc
The chart below lists the nutrients provided by the average of all food in the USDA database (orange bars) compared to the nutrients provided by the most nutrient dense foods (blue bars). But focusing on the most nutrient dense foods, not only do we get more of the harder-to-find nutrients, we also improve the quantity of all the essential nutrients!
Macronutrient split
The chart below shows a comparison of the macronutrients in the most nutrient dense foods compared to the average of all foods in the USDA database. Although we have prioritised for only one amino acid (Tyrosine), it appears that the food that contain the most essential fatty acids, vitamins and minerals are also higher in protein.
The quantity of fibre also increases substantially. Nutrient dense vegetables come with large amounts of fibre which makes these foods more filling and harder to overeat.
The most nutrient dense foods also have a much lower energy density. This makes these nutrient dense foods harder to overeat. As well as feeling physically full, your body is likely to feel satiated once it has obtained the nutrients it needs.[3][4]
Notice the proportion of fat and non-fibre carbohydrates are lower in the most nutrient dense foods. In a way, I think we need to consider foods as nutrients and fuel separately. The initial goal is to eat the foods that contain the nutrients to live an awesome life and support your bodily functions. The secondary goal is to get enough fuel from higher energy density foods to support your activity and maintain ideal body fat. Too often we sacrifice essential nutrients and nutrient density and instead choose irresistibly tasty and high calorie food products for a “quick rush”.
The most nutrient dense foods
The most nutrient dense foods (i.e. the top 10% of the eight thousand foods in the USDA database) are listed below along with their nutrient density scores (ND) which is based on the harder to find nutrients.
If you’re interested in all the gory details of the nutrient density score is calculated you can check out the Building a Better Nutrient Density Index article. But in short the system compared the nutrients per calorie across all the foods in the USDA database. A score is given based on the standard deviation from the mean. If a certain food contains a lot of a certain nutrient it gets a large score. If it contains an average amount of a certain nutrient it gets a zero score. If it contains a little bit or none it gets a negative score. We then sum all these individual nutrients scores for the nutrients that are harder to find that we want to emphasise.
If you want to check whether a particular food is nutrient dense I recommend Googling “nutrient data self [insert your favourite food here]” to see how it ranks. For example, the image below shows that spinach does exceptionally well in both the nutrient balance (vitamins and minerals) and protein quality score.
Vegetables
Fibrous green vegetables are the highest-ranking nutrient dense foods. Few people argue with the idea that veggies are good for you. The nutrient density analysis confirms this.
Spices add flavour and nutrients and plenty of vitamins and minerals.
food
ND
basil
14
dill
9
paprika
7
cloves
6
thyme
6
sage
6
curry powder
5
marjoram
5
tarragon
4
pepper
3
Seafood
Seafood provides amino acids as well as Omega 3 fatty acids which are harder to get from other foods.
food
ND
crab
12
lobster
11
fish roe
10
oyster
9
crayfish
9
caviar
8
salmon
8
cod
8
trout
8
halibut
8
pollock
8
rockfish
7
sturgeon
7
shrimp
7
white fish
7
flounder
7
octopus
7
haddock
6
perch
6
whiting
6
anchovy
6
clam
6
sardine
5
scallop
5
tuna
5
Dairy and eggs
Only low fat cream cheese makes the list in terms of nutrients per calorie as other dairy products typically have more fat and not as many essential nutrients per calorie.
It’s true that eggs are a nutritional powerhouse of vitamins, minerals and protein. However, when it comes to the harder to find nutrients per calorie non-starchy veggies still win out.
It’s a similar story for nuts which don’t make the list. Full fat dairy and nuts can be a great source of energy and nutrition, particularly if you are insulin resistant or have diabetes, but if you’re just looking to maximise the harder to find nutrients per calorie the list of dairy and nuts isn’t that long.
food
ND
cream cheese (fat free)
8
whole egg
6
egg yolk
5
cottage cheese (low fat)
4
egg white
2
Animal products
Organ meats do well as well.
food
ND
turkey liver
9
veal liver
9
chicken liver
8
lamb liver
8
lamb kidney
7
ham (lean only)
6
pork liver
6
chicken breast
5
pork chop
5
turkey drumstick
4
turkey meat
4
lamb heart
4
leg ham
4
chicken liver pate
4
pork shoulder
4
veal
4
Pros and cons of nutrient density
The most obvious benefits of eating the most nutrient dense foods are that they:
provide the most essential nutrients with the fewest calories,
assist to normalize body weight (both lean tissue and body fat),
minimise cravings and the binge eating relating to nutrient hunger[5],
provide the nutrients your body needs to thrive and optimise mitochondrial health, and
help achieve and maintain overall good health.
Maintaining a healthy weight with adequate protein and while avoiding excess energy intake will help you to avoid a lot of the diseases of aging. These foods will also be quite filling and hard to overeat due to the low energy density and high fibre content.
At the same time, it will be hard to get enough energy if you just ate from the foods in this list. If you are very active you will also find it hard to in down enough energy for a lot of intense activity. If you are insulin resistant you may want to start out with higher fat foods that will still provide plenty of energy without raising causing blood sugar swings.
Nutrient density plus…
Eating exclusively from the list of the most nutrient dense foods may not be appropriate for everyone, particularly if you are just starting out on your health food journey. The table below lists several nutritional approaches that are suitable for different people depending on their blood glucose levels / insulin resistance and weight goals.
If you’re interested in optimising your diet for nutrient density as well as tailoring it to your blood glucose and weight loss goals I would love you to check out an a new tool I’ve been developing, the Nutrient Optimiser. It will review your food log and, rather than just tracking calories it will identify your biggest nutrient deficiencies and the most nutrient dense foods to fix them. You can also tailor the insulin load of the food recommendations to help normalize blood sugars and then energy density if you still have weight to lose. It’s still early days, but the future looks very exciting!
“Low carb”, “ketogenic” or “nutrient dense” mean different things to different people. Defining these terms numerically can help us to choose the right tool for the right application.
Decreasing the insulin load of your diet can help normalise blood glucose levels and enable your pancreas to keep up. However, at the same time, a high fat therapeutic ketogenic approach is not necessarily the most nutrient dense option, and may not be optimal in the long term, particularly if your goal is weight loss.
Balancing insulin load and nutrient density will enable you to identify the right approach for you at any given point in time.
This article suggests ideal macro nutrient, protein and insulin load, and carbohydrate levels for different people with different goals to use as a starting point as they work to optimise their weight and/or blood glucose levels.
Unfortunately, it’s hard to give a simple answer without some context.
The answer to this question depends on a person’s current metabolic health, age, activity level, weight, height and goals etc.
This post is my attempt to provide an answer with some context.
disclaimers
Full disclosure… I don’t like to measure the food I eat. I have developed the optimal foods lists to highlight what I think are the best foods to suit different goals and levels of metabolic health.
I think food should be nutritious and satiating. If your goal is to lose weight it will be hard to overeat if you limit your food choices to things like broccoli (which contains sulforaphane), celery, salmon and tuna.
At the same time, some people like to track their food. Tracking food with apps like MyFitnessPal or Cron-O-Meter can be useful for a time to reflect and use as a tool to help you refine your food choices. If you’re preparing for a bodybuilding competition you’re probably going to need to track your food to temporarily override your body’s survival to force it to shed additional weight.
Ideal macronutrient balance is a contentious issue and a lot has already been said on the topic. I’ll try to focus on what I think I have to add to the discussion around the topics of insulin load and nutrient density.
If you want to and skip the detail in the rest of this article, this graphic from Dr Ted Naiman does a good job of summarising optimal foods and ideal macronutrient ranges. If you’re interested in more detail on the topic, then read on.
insulin is not the bad guy
The insulin load formula was designed to help us more accurately understand the insulin response to the food we eat, including protein and fibre.
insulin load = total carbohydrates – fibre + 0.56 * protein
Insulin only really becomes problematic when we have too much of it (i.e. hyperinsulinemia[1]) due to excess processed carbohydrates (i.e. processed grains, added sugar and soft drinks) and/or a lack of activity which leads to insulin resistance.
The concepts of insulin load and proportion of insulinogenic calories can provide us with a better understanding of how different foods trigger an insulin response and how to quantitatively optimise the insulin load of our diet to suit our unique situation and goals.
different degrees of the ketogenic diet
Words like “ketogenic”, “low carb” or “nutrient dense” mean different things to different people. This is where using numbers can be useful to better define what we’re talking about and tailor a dietary approach. For clarity, I have numerically defined a number of terms that you might hear.
ketogenic ratio
The therapeutic ketosis community talks about a “ketogenic ratio” such as 3:1 or 4:1 which means that there are three or four parts fat (by weight) for every part protein plus carbohydrate.[2]
For example, a 3:1 ketogenic diet may contain 300g of fat plus 95g of protein with 5g of carbs. This ends up being 87% fat. A 4:1 ketogenic ratio is an even more aggressive ketogenic approach that is used in the treatment of epilepsy,[3] cancer or dementia and ends up being 90% fat.
These levels of ketosis are hard to achieve with real food and are hard to sustain in the long term. Hence, it is typically used as a short term therapeutic treatment.
ratio of fat to protein
People in the ketogenic bodybuilding scene (e.g. Keto Gains) or weight loss might talk about a 1:1 ratio of fat to protein (by weight) for weight loss. A diet with a 1:1 ratio of fat to protein could be 120g of fat plus 120g of protein. If we threw in 20g of carbs this would come out at 66% fat (which is still pretty high by mainstream standards). A 1:2 protein:fat ratio would end up being around 80% fat.
protein grammes per kilogramme of lean body weight
Some people prefer to talk in terms of terms of percentages or grammes of protein per kilo of lean body mass. For example:
The generally accepted minimum level of protein is 0.8g/kg/day of lean body mass to prevent malnutrition.[4] This is based on a minimum requirement of 0.6kg to maintain nitrogen balance and prevent diseases of malnutrition plus a 25% or two standard deviations safety factor.[5]
In the Art and Science of Low Carb Performance Volek and Phinney talk recommend consuming between 1.5 and 2.0g/kg of reference body weight (i.e. RW). Reference weight is basically your ideal body weight say at a BMI of 25kg/m2. So, 1.5 to 2.0kg RW equates to around 1.7 to 2.2g/kg lean body mass (LBM).
There is also a practical maximum level where people just can’t eat more lean protein (i.e. rabbit starvation[6]) which kicks in at around 35% of energy from protein.
The table below shows a list of rule of thumb protein quantities for different goals in terms of grams per kilogram of lean body mass and as a percentage of calories assuming weight maintenance.[7]
scenario
% calories
g/kg LBM
minimum (starvation)
6%
0.4
RDI/sedentary
11%
0.8
typical
16%
1.2
strength athlete
24%
1.8
maximum
35%
2.7
gluconeogenesis
You may have heard that body will convert ‘excess protein’ to glucose via gluconeogenesis, particularly if there are minimal carbohydrates in the diet and/or we can’t yet use fat for fuel.
For some people, this is a concern due to elevated blood glucose levels, but it may also mean that more protein is required because so much is being converted to glucose that you need more to maintain muscles growing your muscles. As we become more insulin sensitive we may be able to get away with less protein because we are using it better (i.e. we are growing muscles rather than making glucose).
Most people eat more than the minimum level of protein to prevent malnutrition. People looking to gain muscle mass will require higher levels. Although keep in mind you do need to be exercising to gain muscle, not just eating protein.
Ensuring adequate protein and exercise is especially important as people age. Sarcopenia is the process of age related muscle decline which is exacerbated in people with diabetes.
Sadly, many old people fall and break their bones and never get up again. When it comes to longevity there is a balance between being too big (high IGF-1) and too frail (too little IGF-1).
carbohydrate counting
Then there is carb counting.
People on a ketogenic approach tend to limit themselves to around 20g (net?) carbohydrates.
Low carbers might limit themselves to 50g carbs per day.
A metabolically healthy low carb athlete might try to stay under 100g of carbs per day.
Limiting non-fibre carbohydrates typically eradicates most processed foods (e.g. sugar, processed grains, sodas etc). Nutrient density increases as we decrease the amount of non-fibre carbohydrates in our diet.
protein, insulin load and nutrient density
In the milieu of discussion about protein, I think it’s important to keep in mind that minimum protein levels to prevent the diseases of malnutrition may not necessarily optimal for health and vitality.
Protein is the one macronutrient that correlates well with nutrient density. Foods with a higher percentage of protein are typically more nutrient dense overall.
Considering minimum protein levels may be useful if you are looking to drop your energy intake to the bare minimum and while still providing enough protein to prevent loss of lean muscle mass (e.g. a protein sparing modified fast). However, if you are looking to fill up the rest of your energy intake with fat for weight maintenance then you should be aware that simply eating foods with a higher proportion of fat will not help you maximise nutrient density.
Practically though very high levels of protein will be difficult to achieve because they are very filling, thus it is practically difficult to eat more than around 35% of your energy from protein. Protein is also an inefficient fuel source meaning that you will lose around 25% of the calories just digesting and converting it to glucose via digestion and gluconeogenesis.
If you are incorporating fasting then I think you will need to make sure you are getting at least the minimum as an average across the week, not just on feasting days to maintain nitrogen balance. That is, you might need to try to eat more protein on days you are eating.
what is ketosis?
“Ketogenic” simply means “generates ketones”.
An increase in ketosis occurs when there is a lack of glucogenic substrates (i.e. non-fibre carbohydrates and glucogenic protein). It’s not primarily about eating an abundance of dietary fat.
I think reducing insulin load (i.e. the amount of food that we eat that requires insulin to metabolise), rather than adding dietary fat, is really where it’s at if you’re trying to ‘get into ketosis’. We can simply wind down the insulin load of our diet to the point that out blood glucose and insulin levels decrease and we can more easily access our stored body fat.
insulin load = total carbohydrates – fibre + 0.56 * protein
Whether a particular approach is ketogenic (i.e. generates ketones) will depend on your metabolic health, activity levels and insulin resistance etc.
Whether you want to be generating ketones from the fat on your excess belly fat rather than your plate (or coffee cup) is also an important consideration if weight loss is one of your goals.
While people aiming for therapeutic ketosis might want to achieve elevated ketone levels by consuming more dietary fat, most people out there are just looking to lose weight for health and aesthetic reasons. For most people, I think the first step is to reduce dietary insulin load until they achieve normalised blood glucose levels (i.e. average BG less than 5.6mmol/L or 100mg/dL, blood ketones greater than 0.2 mmol/L). People with diabetes often call this “eating to your meter”.
Once you’ve achieved normal blood glucose levels and some ketones the next step towards weight loss is to increase nutrient density while still maintaining ketosis. Deeper levels of ketosis do not necessarily mean more fat loss, particularly if if you have to eat gobs of eating processed fat to get there.
What this suggests to me is that if you want to burn your own body fat you need to minimise the alcohol, protein and carbohydrate which will burn first. To me, this is another angle on the idea that insulin levels are the signal that stops our body from using our own body fat in times of plenty. And if we want to access our own body fat we need to reduce the insulin load of our diet to the point we can release our own body fat.
insulin load versus nutrient density
The risk however with the insulin load concept is that people can take things to extremes. If our only objective is to minimise insulin load we’ll end up just eating bacon, lard, MCT, olive oil… and not much else.
In his “Perfect Health Diet” book Paul Jaminet talks about “nutrient hunger”, meaning that we are more likely to have an increased appetite if we are missing out on particular nutrients. He says
“A nourishing, balanced diet that provides all the nutrients in the right proportions is the key to eliminating hunger and minimising appetite.“
In the chart below shows nutrient density versus proportion of insulinogenic calories. The first thing to note is that there is a lot of scatter! However, on the right-hand side of the chart, there are high carb soft drinks, breakfast cereals and processed grains that are nutrient poor. But if we plot a trend line we see that nutrient density peaks somewhere around 40% insulinogenic calories.
If you are metabolically challenged, you will want to reduce the insulin load of your diet to normalise blood glucose levels. But if you reduce your insulin load too much you end up living on purified fats that aren’t necessarily nutrient dense.
If we are trying to avoid both carbohydrates and protein we end up limiting our food choices to macadamia nuts, pine nuts and a bunch of isolated fats that aren’t found in nature in that form. Rather than living on copious amounts of refined oils I think we’re in much safer territory if we maximise nutrient density with whole foods while still maintaining optimal blood glucose levels.
The chart below shows the proportion of insulinogenic calories for the highest-ranking basket of foods (i.e. top 10% of the foods in the USDA foods database) for a range of approaches, from the low insulin therapeutic ketosis, through to the weight loss foods for someone who is insulin sensitive and a lot of fat is coming from their body. At one end of the scale, a therapeutic ketogenic may only contain 14% insulinogenic calories while a more nutrient dense approach might have more than half of the food requires insulin to metabolise.
macronutrient splits
It’s one thing to set theoretical macro nutrient targets, but real foods don’t come in neat little packages of protein, fat and carbohydrates. The chart below shows the macro nutrient split of the most nutrient dense 10% of foods for each of the four nutritional approaches. The protein level for the weight loss approach might seem high but then once we factor in an energy deficit from our body fat it comes back down.
In reality, you’re probably not going to be able to achieve weight maintenance if you just stick to the nutrient dense weight loss foods. You’ll either become full and will end up using your stored body fat to meet the energy deficit or you will reach for some more energy dense foods to make up the calorie deficit. If you look at the macronutrient split of the most nutrient dense meals for the different approach you find they are lower in protein and higher in fat as shown in the chart below.
nutrient density
The chart below shows the percentage of the daily recommended intake of essential vitamins, minerals, amino acids and fatty acids you can get from 2000 calories for each of the approaches.
You can meet most of your nutritional requirements with a therapeutic ketogenic diet, however, you’ll have to eat enough calories to maintain your weight to prevent nutritional deficiencies.
As you progress to the more nutrient dense approaches you can meet your nutrient requirements with less energy intake. The beauty of limiting yourself to nutrient dense whole foods is that you can obtain the required nutrition with less energy and you’ll likely be too full to overeat.
As far as I can see the holy grail of nutrition, health and longevity is adequate energy without malnutrition.
If we look in more detail we can see that the weight loss (blue) and nutrient dense approaches (green) provide more of the essential micronutrients across the board, not just amino acids.
While the protein levels in the “weight loss” and “most nutrient dense” approaches are quite high, keep in mind that the food ranking system only prioritises the nutrients that are harder to obtain.
The table below shows the various nutrients that are switched on in the food ranking system for each approach.
This table shows the number of vitamins, minerals, amino acids and fatty acids counted for each approach.
In the weight loss and nutrient dense approach, of the twelve essential amino acids, only Tyrosine and Phenylalanine has been counted in the density ranking system.
It just so happens that protein levels are high in whole foods that contain essential vitamins, minerals and fatty acids.
It appears that if you set out to actively avoid protein it may be harder to get other essential nutrients. The risk here is that you may be setting yourself up for nutrient hunger, and rebound/stall inducing cravings in the long term as your body becomes depleted of the harder to obtain nutrients.
choosing the right approach for you
I believe one of the key factors in determining which nutritional approach is right for you is your blood glucose levels which give you an insight into your insulin levels and insulin sensitivity.
As shown in the chart below, if your blood glucose levels are high then it’s likely your insulin levels are also high which means you will not be able to easily to access your fat stores. I have also created this survey which may help you identify whether you are insulin resistant and which foods might be ideal for you right now.
While you may need to start out with a higher fat approach, as your glucose levels decrease and ketone levels rise a little you will be able to transition to more nutrient dense foods.
The table below shows the relationship between HbA1c, glucose, ketones and GKI. Once you are getting good blood glucose levels you can start to focus more on nutrient density and weight loss.
The table below shows what the different nutritional approaches look like in terms of:
ketogenic ratio
ratio of fat to protein
protein (g)/kg LBM
insulin load (g/kg LBM)
approach
keto ratio
fat : protein
protein g/LBM
insulin load (g/LBM)
therapeutic ketosis
1.8
2.2
1.0
0.9
diabetes
0.9
1.0
1.8
1.5
weight loss (incl. body fat)
0.5
0.6
2.5
2.4
nutrient dense
0.3
0.3
3.0
2.8
The 1.0g/kg LBM for therapeutic ketosis is greater than the RDA minimum of 0.8g/kg LBM so will still provide the minimum amount while still being ketogenic. It’s hard to find a lot of foods that have less than 1.0g/kg LBM protein in weight maintenance without focussing on processed fats.
At the other extreme most nutrient dense foods are very high in protein but this might also be self-limiting meaning that people won’t be able to eat that much food. As mentioned earlier, it will be hard to eat enough of the nutrient dense foods to maintain your current weight. Either you will end up losing weight because you can’t fit as much of these foods in or reaching more energy dense lower nutrient density foods. Also, if you found you were not achieving great blood glucose levels and some low-level ketones with mean and non-starchy veggies you might want to retreat to a higher fat approach.
The table below lists optimal foods for different goals from most nutrient dense to most ketogenic. Hopefully, over time you should be able to work towards the more nutrient dense foods as your metabolism heals.
Many people are concerned about excess protein causing cancer or inhibiting mTOR (Mammalian Target of Rapamycin).[8][9]
From what I can see though, the story with mTOR is similar to insulin. That is, constantly elevated insulin or constantly stimulated mTOR are problematic and cause excess growth without being interspersed with periods of breakdown and repair.
Our ancestors would have had times when insulin and mTOR were low during winter or between successful hunts. But during summer (when fruits were plentiful) or after a successful hunt, insulin would be elevated and mTOR suppressed as they gorged on the nutrient dense bounty.
These days we’re more like the futuristic humans from Wall-E than our hunter gather ancestors. We live in a temperature controlled environment with artificial lighting and tend to put food in our mouths from the moment we wake up to the time we fall asleep.[10]
Rather than chronic monotony (e.g. eating five or six small meals per day every day), it seems that periods of growth (anabolism) and breakdown and cleaning (catabolism) are optimal to thrive in the long term. We need periods of both. One or the other chronically are bad news.
Optimal protein levels are a contentious topic. There is research out there that says that excess protein can be problematic from a longevity perspective. Protein promotes growth, IGF-1, insulin and cell turnover which can theoretically compromise longevity. At the same time, there are plenty of studies that indicate that we need much more protein than the minimum RDI levels.[11]
In the end, you need to eat enough protein to prevent loss of lean muscle and maintain strength. If you’re trying to build lean muscle and working out, then higher levels of protein may be helpful to support muscle growth. If you are trying to lose weight, then higher levels of protein can be useful to increase satiety and prevent loss of lean muscle mass. Maintaining muscle mass is critical to keeping your metabolic rate high and avoiding the reduction that can come with chronic restriction.[12][13]
In addition to building our muscles, protein is critical for building our bones, heart, organs and providing many of the neurotransmitters required for mental health. So protein from real whole foods is generally nothing to be afraid of. It’s typically the processed high carb foods that make the detrimental impact on insulin and blood glucose levels.
The table below shows a starting point for protein in grammes depending on your height. This assumes that someone with a lean body mass (LBM) of 80 kg is burning 2000 calories per day and your lean body mass equates to a BMI of 20 kg/m2. LBM is current weight minus fat mass minus skeletal mass which again is hard to estimate without a DEXA.
There are a lot of assumptions here so you will need to take as a rule of thumb starting point and track your weight and blood glucose levels and refine accordingly. It’s unlikely that you will get to the high protein levels of the most nutrient dense approach because either you would feel too full or your glucose levels may rise and ketones disappear, so most people, unless your name is Duane Johnson, will need to moderate back from that level.
Example: Let’s say for example you were 180cm and were managing diabetes and elevated blood glucose levels. You would start with around 117g of protein per day as an initial target and test how that worked with your blood glucose levels. If your blood glucose levels on average were less than say 5.6mmol/L or 100mg/dL and your ketones were above 0.2mmol/L you could consider increasing transitioning to more nutrient dense foods.
If you want to see what this looks like in terms of real foods and real meal meals check out the optimal food list and the optimal meals for the different approaches.
insulin load
Using a similar approach, we can calculate the daily insulin load (in grammes) depending on your height and goals. The values in this table can be used as a rule of thumb for the insulin load of your diet.
If you are not achieving your blood glucose or weight loss goals, then you can consider winding the insulin load back down. If you are achieving great blood glucose levels, then you might consider choosing more nutrient dense food which might involve more whole protein and more nutrient dense green leafy veggies.
Example: Let’s say for example you are an 180cm person with good glucose control but still wanting to lose weight, your initial target insulin load would be 156g from the superfoods for fat loss list. If you were not losing weight at this level, you could look to wind it back a little until you started losing weight. If you are consistently achieving blood glucose levels less than 5.6mmol/L or 100mg/dL and ketones greater than 0.2mmol/L you could consider transitioning to more nutrient dense foods.
summary
In summary, reducing the insulin load of your diet is an important initial step. However, as your blood glucose and insulin levels normalise there are a number of other steps that you can take towards optimising nutrient density on your journey towards optimal health and body fat.
Reduce the insulin load of your diet (i.e. eliminate processed carbage and maybe consider moderating protein if still necessary) to normalise blood glucose levels and reduce insulin levels to facilitate access to stored body fat.
If your blood glucose levels are less than say 5.6 mmol/L or 100mg/dL and your ketone levels are greater than say 0.2 mmol/L then you could consider transitioning to more nutrient dense foods.
If further weight loss is required, maximise nutrient density and reduce added fats to continue weight loss.
Consider also adding an intermittent fasting routine with periods of nutrient dense feasting. Modify the feasting/fasting cycles to make sure you are getting the results you are after over the long term.
Once optimal/goal weight is achieved, enjoy nutrient dense fattier foods as long as optimal weight and blood glucose levels are maintained.
If blood glucose levels are greater than optimal blood glucose levels, return to step 1.
If current weight is greater goal weight return to step 3.
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 CompleteGuide 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.
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.
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.
In Robb Wolf’s new book Wired to Eat he talks about the dilemma of optimal foraging theory (OFT) and how it’s a miracle in our modern environment that even more of us aren’t fat, sick and nearly dead.[1]
But what is optimal foraging theory[2]? In essence, it is the concept that we’re programmed to hunt and gather and ingest as much energy as we can with the least amount of energy expenditure or order to maximise survival of the species.
In engineering or economics, this is akin to a cost : benefit analysis. Essentially we want maximum benefit for minimum investment.
In a hunter-gatherer / paleo / evolutionary context this would mean that we would make an investment (i.e. effort / time / hassle that we could have otherwise spent having fun, procreating or looking after our family) to travel to new places where food was plentiful and easier to obtain.
In these new areas, we could spend as little time as possible hunting and gathering and more time relaxing. Once the food became scarce again we would move on to find another ‘land of plenty’.
The people who were good at obtaining the maximum amount of food with the minimum amount of effort survived and thrived and populated the world, and thus became our ancestors. Those that didn’t, didn’t.
You can see how the OFT paradigm would be well imprinted on our psyche.
OFT in the wild
In the wild, OFT means that native hunter-gatherers would have gone bananas for bananas when they were available…
… gone to extraordinary lengths to obtain energy dense honey …
… and eat the fattiest cuts of meat and offal, giving the muscle meat to the dogs.
OFT in captivity
But what happens when we translate OFT into a modern context?
Until recently we have never had the situation where nutrition and energy could be separated.
In nature, if something tastes good it is generally good for you.
Our ancestors, at least the ones that survived, grew to understand that as a general rule:
sweet = good = energy to survive winter
But now we have entered a brave new world.
We are now surrounded by energy dense hyper-palatable foods that are designed to taste good without providing substantial levels of nutrients.
Our primal programming is defenceless to these foods. Our willpower or our calorie counting apps are no match for engineered foods optimised for bliss point.
These days diabetes is becoming a bigger problem than starvation in the developing world due to a lack of nutritional value in the foods they are eating.[3]
The recent industrialisation of the world food system has resulted in a nutritional transition in which developing nations are simultaneously experiencing undernutrition and obesity.
In addition, an abundance of inexpensive, high-density foods laden with sugar and fats is available to a population that expends little energy to obtain such large numbers of calories.
Furthermore, the abundant variety of ultra processed foods overrides the sensory-specific satiety mechanism, thus leading to overconsumption.”[4]
what happens when we go low fat?
So if the problem is simply that we eat too many calories, one solution is to reduce the energy density of our food by avoiding fat, which is the most energy dense of the macronutrients.
Sounds logical, right?
The satiety index demonstrates that there is some basis to the concept that we feel more full with lower energy density, high fibre, high protein foods.[5][6] The chart below shows how hungry people report being in the two hours after being fed 1000 kJ of different foods (see the low energy density high nutrient density foods for weight loss article for more on this complex and intriguing topic).
However the problem comes when we focus on reducing fat (along with perhaps reduced cost, increased shelf life and palatability combined with an attempt to reach that optimal bliss point[7]), we end up with cheap manufactured food-like products that have little nutritional value.
Grain subsidies were brought in to establish and promote cheap ways to feed people to prevent starvation with cheap calories.[8] It seems now they’ve achieved that goal.[9]
Maybe a little too well.
The foods lowest in fat, however, are not necessarily the most nutrient dense. Nutritional excellence and macronutrients are not necessarily related.
I am pretty burned out on the protein, carbs, fat shindig. I’m starting to think that framework creates more confusion than answers.
Thinking about optimum foraging theory, palate novelty and a few related topics will (hopefully) provide a much better framework for folks to affect positive change.
The chart below shows a comparison of the micronutrients provided by the least nutrient-dense 10% of foods versus the most nutrient dense foods compared to the average of all foods available in the USDA foods database.
The quantity of essential nutrients you can get with the same amount of energy is massive! If eating is about obtaining adequate nutrients then the quality of our food, not just macronutrients or calories matters greatly!
Another problem with simply avoiding fat is that the foods lowest in fat are also the most insulinogenic, so we’re left with foods that don’t satiate us with nutrients and also raise our insulin levels. The chart below shows that the least nutrient dense food are also the most insulinogenic.
what happens when we go low carb?
So the obvious thing to do is eliminate all carbohydrates because low fat was such a failure. Right?
So we swing to the other extreme and avoid all carbohydrates and enjoy fat ad libitum to make up for lost time.
The problem again is that at the other extreme of the macronutrient pendulum we may find that we have limited nutrients.
The chart below shows a comparison of the nutrient density of different dietary approaches showing that a super high fat therapeutic ketogenic approach may not be ideal for everyone, at least in terms of nutrient density. High-fat foods are not always the most nutrient dense and can also, just like low-fat foods, be engineered to be hyperpalatable to help us to eat more of them.
The chart below shows the relationship (or lack thereof) between the percentage of fat in our food and the nutrient density. Simply avoiding or binging on fat does not ensure we are optimising our nutrition.
While many people find that their appetite is normalised whey they reduce the insulin load of their diet high-fat foods are more energy dense so it can be easy to overdo the high-fat dairy and nuts if you’re one of the unlucky people whose appetite doesn’t disappear.
what happens when we go paleo?
So if the ‘paleo diet’ worked so well for paleo peeps then maybe we should retreat back there? Back to the plantains, the honey and the fattiest cuts of meat?
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