Tag Archives: food insulin index

how optimize your diet for your insulin resistance

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

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

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

The importance of monitoring blood glucose levels

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

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

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

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

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

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Optimal ketone levels

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The relationship between ketones and glucose

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

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

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

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

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

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

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

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

But it works until it doesn’t

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

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

What gives?

What do you do now?

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

It can be confusing on the interwebs!

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

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

What is insulin resistance anyway?

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

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

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

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

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

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

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

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

Be a nutrient chaser

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

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

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

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

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

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

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

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

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

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

Ask the experts

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

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

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

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

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

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

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

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Are you really insulin resistant?

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

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

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

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

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

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

Oral glucose tolerance test

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

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

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

Kraft test

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

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Oral protein tolerance test

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

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

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

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

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

Optimal dietary approach survey

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

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

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

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

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

Can I take my insulin levels to zero?

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

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

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

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

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

So just tell me what to eat!

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

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

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

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

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

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

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

references

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[21] http://perfecthealthdiet.com/

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

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

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

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

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

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

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

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

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

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

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

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

optimising protein and insulin load

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

context matters

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

“What insulin load should I be aiming for?” 

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

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

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

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disclaimers

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

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

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

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

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

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insulin is not the bad guy

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

insulin load = total carbohydrates – fibre + 0.56 * protein

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

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

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

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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.

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ketogenic ratio

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

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

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

ratio of fat to protein

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

protein grams per kilogram of lean body weight

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

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

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

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

gluconeogenesis

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

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

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

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

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

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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.

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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.

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

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

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

what is ketosis?

“Ketogenic” simply means “generates ketones”.

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

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

insulin load = total carbohydrates – fibre + 0.56 * protein

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

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

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

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

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

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

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

insulin load versus nutrient density

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

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

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

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

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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.

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macronutrient splits

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

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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.

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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.

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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.

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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.

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

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

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

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

choosing the right approach for you

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

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

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

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

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

more numbers

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

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

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

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

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

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

what about mTOR?

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

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

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

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

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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.

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As my wise friend Raymund Edwards from Optimal Ketogenic Living says

“FAST WELL, FEED WELL.” 

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how much protein?

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

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

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

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

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

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

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

insulin load

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

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

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

summary

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

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

references

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

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

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

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

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

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

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

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

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

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

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

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

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

nutrient dense foods for weight loss and insulin resistance

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

optimal foods for diabetes and nutritional ketosis

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

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

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

img_7321-1

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

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

optimal foods for weight loss

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

2016-10-16-4

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

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

2016-10-16-6

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

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

finding the optimal balance between the extremes

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

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

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

weight-loss-insulin-resistant

vegetables

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

seafood

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

animal products

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

dairy and egg

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

other dietary approaches

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

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

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

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foods to avoid… the most processed, insulinogenic, energy dense low nutrient density foods

Generally I think it can be more useful to tell people what they should focus on rather than what they shouldn’t do.  It’s like the proverbial hot plate or ‘wet paint’ sign.  You can’t unsee it and you just want to touch it!  If you are busy focusing on the good stuff then you just won’t have any space left for the bad stuff, especially once you start feeling  the benefits.

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But when it comes down to it, what are the foods that everyone should avoid?

what’s so bad about sugar anyway?

For the past four decades mainstream food recommendations have been dominated by a fear of fat, particularly saturated fat and cholesterol, which if, taken to the extreme can lead us towards more processed, insulinogenic, nutrient poor, low fat foods.

More recently, a growing number of people are advising that we should eat less sugar… from Sarah Wilson’s I Quit Sugar, to Robert Lustig’s Sugar: The Bitter Truth and Damon Gameau’s That Sugar Film.  Even Gary Taubes seems to be softening his stance against carbohydrates and turning his attention to sugar as the bad guy in his new book The Case against Sugar.

The World Health Organisation are imploring people to reduce their sugar intake to less than 10% of energy, and ideally less than 5%.[1]

Image result for world health organisation

Investment bank Credit Suisse is predicting a turn away from sugar and and back towards fat, effectively advising people to ‘short sugar’.[2]

But what is it about sugar that makes it uniquely bad?  It just the ‘evaporated cane juice’ that we should avoid?

What about whole foods that contain some sugar?  Should we avoid them too?

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While added sugars are not good, they’re also an easy target that everyone can get behind.  It’s easy to swing from demonising one thing to another, from fat to carbs, to sugar.

But perhaps this paradigm is overly simplistic?

I think we need to avoid are foods that quickly boost insulin and blood glucose levels without providing any substantial nutrition in return.

Foods that should be considered universally bad are foods that are:

If you want to maximise the nutritional value of your food, give your pancreas a break so it can keep up, you should AVOID THESE FOODS.  Most diet recommendations succeed largely because they eliminate these foods which are typically processed foods.

The chart below (click to enlarge) shows the weightings used in the multi criteria analysis for the various dietary approaches.  The avoid list turns the system on its head to identify foods that have poor nutrient density as well as also being energy dense and insulinogenic.

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The charts below shows that, compared to the other approaches, the foods on the avoid list are energy dense…

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…highly insulinogenic…

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…as well as being nutrient poor, all at the same time!

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Considering any of these factors by themselves can be problematic.  But when we combine all these parameters them they  can be much more useful to identify the foods we should avoid, as well as the ones we should prioritise.

As you can see from this chart, the difference between the nutrients provided by the most nutrient dense foods and the avoid list  is vast!  You can see how you would be much more satiated with the more nutrient dense food and your cravings turned off.

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Also included in the table are the nutrient density score, percentage of insulinogenic calories, insulin load, energy density and the multicriteria analysis score score (MCA) that combines all these factors.

So without further ado, here is the avoid list.

drinks

Soft drinks provide very little nutritional value, are very insulinogenic and have no fibre so will raise your blood sugar and insulin levels quickly.

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food ND % insulinogenic insulin load (g/100g) calories/100g MCA
cream soda -20 100% 13 51 1.02
root beer -20 100% 11 41 1.00
grape soda -19 100% 11 43 1.00
cola -20 99% 10 37 1.00
cranberry-apple juice -19 98% 16 63 0.98
orange and apricot juice -17 97% 13 51 0.86

sweets

Sweets provide minimal nutrition while being very energy dense and highly insulinogenic.  Sugar tops the list of badness, however there are a bunch of other sweets not far behind.

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food ND % insulinogenic insulin load (g/100g) calories/100g MCA
candies -20 100% 99 394 1.34
sugar -20 100% 100 389 1.33
jellybeans -20 100% 93 375 1.31
fructose -20 100% 100 368 1.31
brown sugar -19 99% 97 380 1.29
sucralose -20 100% 91 336 1.29
fruit syrup -20 100% 85 341 1.28
skittles -20 90% 91 405 1.28
aspartame -19 99% 91 365 1.24
twizzlers -20 93% 81 348 1.24
marshmallows -19 99% 83 318 1.24
high fructose corn syrup -20 100% 76 281 1.23
maple sugar -18 99% 91 354 1.21
jams and preserves -19 98% 68 278 1.17
orange marmalade -19 99% 66 246 1.17
chocolate frosting. -18 86% 91 389 1.16
chocolate pudding -18 91% 86 378 1.16
Candies, butterscotch -17 92% 90 391 1.15
M&Ms -20 61% 73 475 1.14
tootsie roll -17 91% 89 387 1.13
Milky Way -20 61% 70 463 1.13
chocolate syrup -18 100% 67 269 1.12
butterscotch topping -18 99% 58 216 1.08
Kit Kat -19 49% 65 520 1.08
frosting -18 65% 68 418 1.04
fudge -15 87% 83 383 1.01
honey -19 63% 52 304 0.99
caramels -15 81% 80 382 0.98
tapioca pudding (fat free) -18 94% 22 94 0.91
chocolate frosting -16 61% 63 397 0.90
Twix -16 41% 57 550 0.88

fruits and fruit juices

Fruit in its natural state provides fibre, nutrients with a lower energy density.  However fruit juice and dried fruit has a much lower nutritional value and are much more insulinogenic.

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food ND % insulinogenic insulin load (g/100g) calories/100g MCA
candied fruit -20 98% 81 322 1.25
dried apples -17 85% 82 346 1.04
raisins -17 89% 73 296 1.03
dried pears -16 87% 64 262 0.96
dried currants -16 88% 70 283 0.95
apple juice -17 97% 12 47 0.88
litchis -14 89% 69 277 0.87
dried pears -17 83% 32 140 0.86

cereals and baked products

Processed grains are cheap and have a long shelf life, however the processing removes most of the fibre and most of the nutrients which means they are highly insulinogenic and energy dense.

food ND % insulinogenic insulin load (g/100g) calories/100g MCA
corn-starch -20 99% 91 381 1.31
rice puffs -17 93% 90 383 1.13
instant oatmeal -19 70% 68 353 1.06
fudge filled cookies -19 47% 63 533 1.06
girl scout cookies -19 51% 66 520 1.06
Grahams Crackers -17 73% 77 424 1.05
choc chip cookies -18 55% 69 498 1.04
cheesecake -19 49% 63 506 1.04
white flour -15 92% 82 367 1.04
white rice -15 95% 84 365 1.02
water biscuits -17 73% 70 384 1.01
rice flour -15 92% 82 366 1.00
wheat flour -14 91% 81 363 0.96
ice cream cones -13 88% 89 402 0.94
pound cake (fat free) -14 93% 64 283 0.90
Cookies -15 76% 69 348 0.90
cornmeal -13 89% 81 370 0.90
fruitcake -16 71% 60 324 0.88
white flour -12 92% 82 366 0.88
English muffins -16 83% 51 245 0.87

other approaches

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

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

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

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post updated April 2017

references

[1] http://www.who.int/mediacentre/news/releases/2015/sugar-guideline/en/

[2] https://www.credit-suisse.com/us/en/articles/articles/news-and-expertise/2013/09/en/is-sugar-turning-the-economy-sour.html

choosing the right sized low carb band aid

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

how important is insulin sensitivity?

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

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

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

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is low carb the best approach for everyone?

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

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

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

So who is right?

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

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As always, context matters.

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

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

As you can see from the chart below:

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

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

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

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

am I insulin resistant?

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

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

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

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

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

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

nutrient dense low carb foods for blood glucose control

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

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

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

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

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

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

Vegetables

Listed below are the highest ranking vegetables.

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

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

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

fruit

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

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

nuts, seeds and legumes

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

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

dairy and eggs

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

dairy20and20eggs

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

seafood

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

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

animal products

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

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

is low carb a band aid or cure?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  1. all foods,
  2. high nutrient density foods,
  3. nutrient dense low carbohydrate foods, and
  4. nutrient dense low calorie density foods.

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

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

image19

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

image20

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

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

references

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

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

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

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

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

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

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

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

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

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

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

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

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

insulin load… the greatest thing since carb counting?

In previous articles I have outlined the idea of the insulin load[1] [2]  which is similar to carbohydrate counting, but also accounts for the effect of protein, fibre ad fructose.

insulin load = total carbohydrates – fibre + 0.56 x protein

show me the data!

Most people understand that dietary carbohydrate is the primary nutrient that influences blood glucose and insulin as shown in the charts below.  However, indigestible fibre[3] and glucogenic amino acids (protein)[4] [5] also affect our blood glucose and our insulin response to food.

image13

image11

We can better predict the insulin and glucose response to our food if we also account for the effect of protein and indigestible carbohydrates (i.e. fibre).  People aiming to follow ketogenic diet will want to eat foods towards the bottom left of these charts.

image24

image22

I was pleased to see Jason Fung even mention the food insulin index and the Optimising Nutrition blog at the recent low carb conference in Vail Colorado  and it has been great to see a handful of people like Patricia and Mike put this theory into practice with great results as detailed in this article.

Patricia Berry Moore

This comment from Patricia Berry Moore made my day.

Marty! Are you the Low Carb Down Under Marty??!

You and Sarah Hallberg are why I started LCHF.  And went from a very unhealthy type 2 diabetic at 156 lbs to a very healthy 113 lbs.

THANK YOU!

Patricia had seen my presentation on the food insulin index, applied the theory, and it worked!

Patricia said:

I use the insulin load concept.

I find it helps me refine my macros.  A little less protein a bit more carbs and you can find that sweet spot.  For me 50g per day is perfect.

My doctor threatened me with insulin and so I started went digging and found your lectures. 

Over 10 months I lost 43 lbs (I’m 5’2″).  I was pre-diabetic for ten years and then type 2 diabetic for ten years. 

I am now off all my meds.  I was on eight different ones for high blood pressure, high cholesterol, arthritis, re-flux, diabetes.

I’m never going back, so thank you!

This is Patricia’s “before photo.”  You can see a ‘puffiness’ in her face characteristic of insulin resistance and hyperinsulinemia, which causes fluid retention.  I showed this photo to my 12 year old daughter who said “that’s how you used to look.”  Thanks dear…  I think.

image17

If you’ve hit a plateau it might be worth tracking the insulin load of your food for a while to fine tune your diet.   Patricia says:

I use the app Lose it! which helps me track macros. So it’s pretty easy to keep a running total of my insulin load too. 

I started at around 80g per day.  As I decreased it, my blood sugars improved. 

At this point my fasting blood glucose run at 65 – 75 mg/dL with an insulin load around 50g per day or so. 

LCHF has really saved my life Marty.

This is Patricia now.  Congratulations Patricia!

image16

a little closer to home

As mentioned by my daughter, this is me before and after trying out my low insulin load, high nutrient density foods.  I don’t think my hair moved in the 18 months between when these work profile photos were taken, but some inflammation and weight certainly did.  My family assures me that at my worst I was bigger and unhealthier looking than the photo on the left!

image07

The photo below on the left is my daughter’s “before photo” after spending 9 months in a high insulin environment.  Children born to mothers who are type 1 diabetic and dosing with lots of insulin tend to be delivered early via C-section due to their excessive size caused by the high levels of insulin from the mother.  The photo on the right is her twelve years later, all grown up!

image15

The photos below are the same child, “JL,” who was one of the first type 1 diabetic children to receive insulin treatment in 1922.  Without insulin he’s wasting away, literally eating his own fat and muscle, unable to metabolise carbohydrate.  Two months later the photo on the right shows that he’s been able to make a full recovery with insulin injections.

image06

The photo below is of another Type 1 sufferer before and after receiving exogenous insulin.  

image03

Hopefully from these photos you can see how there’s a “Goldilocks zone” for insulin.  Not too little.  Not too much.  Just right.  You can use the quantification of insulin load to find your sweet spot.

Mike Alward

I received similar feedback recently from Mike Alward who has also successfully applied the insulin load theory.  Mike says:

I just wanted to say thanks for your work on insulin load, food insulin index and glucose : ketone index.  It really helped me to understand what was holding me back from reaching and being able to maintain a state of optimal ketosis. 

I manage my insulin load to ~75g per day.  My BG has come down and my ketones are now in the optimal range.  My GKI is now below 3. 

I used to be pre-diabetic with blood glucose up around 6.5 mmol/L.  Now, I am in the 4.5 – 4.7mmol/L range. 

Being in optimal ketosis has helped to control my appetite and cravings (especially sugar), which has made intermittent fasting so much easier.

Keep up this important work!  

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With this reduced insulin approach Mike is able to accommodate a solid amount of protein into his diet while maintaining excellent blood glucose and ketone levels.  Like anything, you can have too much of a good thing, including protein.

Many people find that as their insulin resistance improves they are able to handle a higher insulin load diet which may enable a higher nutrient density and less fat.   If you are highly insulin resistant you may need to focus on a very low insulin load, high fat approach.  As your blood glucose levels stabilise you will be able to transition to more nutrient dense foods that may have a higher insulin load.

Mike says:

My insulin load target is ~90g – 100g of protein / day.  I am 6’0″.

Mike likes to track a range of different health makers.

I track my weight calories, macros, calculated insulin load, blood glucose, blood ketones and GKI.

Not everybody “geeks out” on this stuff.  I am totally into “nerd safaris” to research non-conventional wisdom health. 

I just got several folks to calculate their insulin load, and their heads almost exploded when I introduced them to GKI.  

You can see in the chart below how Mike’s ketones have increased as he has reduced the insulin load of his diet.

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The chart below shows how Mike’s glucose : ketone index (an approximation of insulin levels) has decreased as he lowered the insulin load of his diet.

image19

Tracking the insulin load of your diet is a little more complex than just counting carbs, but not that much more work if you’re already tracking your food intake.  Personally, I’m not a big fan of tracking everything you eat forever, but it can be useful to keep a food diary for a time to reflect and refine.

If you just want to know what you should eat these lists of optimal foods for different goals may be useful for you.

how to calculate your insulin load

So how do you calculate the insulin load of your diet?

If you’re already tracking your food intake it’s a pretty simple thing to do.  Below is an example output from MyFitnessPal[6] showing the food intake for the day comprising of:

  • carbohydrates (70g),
  • fibre (63g), and
  • protein (104g)

image09

So we start with the insulin load formula:

insulin load = carbohydrates (g– fibre (g) + 0.56 x protein (g)

Insert our values:

insulin load = 70g carbohydrates – 63g fibre + 0.56 x 104g protein

and calculate insulin load:

insulin load = 65g

It’s not that much different to tracking net carbs, but instead you also account for protein which also requires insulin.

I initially developed this calculation for people with Type 1 Diabetes (like my wife) who need to calculate their insulin dosage but it can work in a similar way for someone wanting to reduce the demand on their pancreas to the point that it can keep up and maintain normal blood glucose levels.

Reducing your insulin levels to normal healthy levels will allow your stored fat to be used for energy and manage your appetite.   As you track your insulin load you can keep eliminating the foods that are driving it up until the point that you see the weight loss and blood glucose levels that you’re chasing.  More recently I have incorporated this as a metric you can track in the Nutrient Optimiser to achieve your target glucose and ketone levels.

image21

The appropriate insulin load will vary from person to person.  A small woman aiming for weight loss using a lower protein ketogenic approach might have an insulin load as low as 40g per day while a larger man looking who is active and looking build muscle might have an insulin load as high as 300g per day.

A higher insulin load diet would allow more plant based foods, less fat and potentially a higher nutrient density (e.g. 40 to 50% of insulinogenic calories).  The first priority will be to reduce the insulin load of your diet to the point where you can normalise your blood glucose levels and reduced insulin (e.g. 20 to 30% of insulinogenic calories).

The best idea is to start tracking where you’re currently at and look to reduce your daily insulin load until you achieve excellent blood glucose levels (i.e. average less than 5.6 mmol/L or 100 mg/dL).  Once you normalise your blood glucose levels you could keep winding it down further until you achieve your desired level of ketones.  As your body heals and you start to reduce the amount of fat around your organs you may be able to tolerate a higher insulin load diet and more nutrient dense diet in time.

a little more on the insulin load theory

So is it all about the insulin load?  What about calories and conservation of energy?

In a metabolic ward context we typically find conservation of energy / CICO holds true.  If anything someone on a high fat diet may be able to maintain their weight with less calories because fat is easier to digest and products less wasted energy (enthalpy).  But in a free living environment how much we eat is influenced by our appetite which is influenced by the nutrient density of our food choices as well as our levels of insulin resistance.

This video gives a good overview of how insulin (either injected or from our own pancreas) affects  whether we store fat on our body or release it to be used for fuel and how excess insulin can be problematic.

Most people think of macro nutrients in terms of carbohydrates, protein and fat as per the the picture below.   They think that if we eat too much fat it will be stored as body fat.  But the reality is a little bit more complex than that.

image04

In the chart below the grey slices of the pie chart (i.e. the non-fibre carbohydrate and the glucogenic protein) are the components of your food that are glucogenic and will require insulin to metabolise.

The blue components are ketogenic (i.e. the dietary fat and the ketogenic protein) and do not require insulin to metabolise.  If you’re lucky enough to be insulin sensitive you will burn the food you eat and your appetite will be well regulated with minimal change in body weight.

image05

Indigestible fibre (black slice) doesn’t significantly affect our insulin response or even contribute to calories for us but rather is used to feed the bacteria in our gut.  Fibre is a true ‘free food’.

If the insulin load of our diet is too high we are more likely to store a portion of the food.  If we are insulin resistant our body will have to generate more insulin to deal with the non-fibre carbohydrate and glucogenic protein while increasing our chances that some of the food we eat will be stored on our body.  We feel hungry and need to keep eating to obtain adequate energy.  Calories still matter, but outside a controlled metabolic ward, body fat accumulation is more about managing fat storage and appetite than about counting calories.  

image08

Calories still matter, but outside a controlled metabolic laboratory, body fat accumulation is more about managing fat storage and appetite than consciously counting calories. Many people refer to insulin as the thermostat that controls our metabolism and our fat storage.

The good news here is that we can use our understanding of the storage properties of insulin to our advantage.  If we are able to decrease the insulin load of our diet we are less likely to store fat and more likely to be able to use some of our stored body fat for energy.  This will mean that we feel less compelled to eat because we are able to use up our own body fat rather than constantly eating.   This reduced dietary insulin load scenario will lead to lower insulin levels, less storage, more use of body fat for fuel, a decreased appetite and a reduction in energy intake.  

image10

So, to reduce the insulin load of diet include you can:

  1. eat more fibre,
  2. eat less digestible carbohydrates, and
  3. make sure your protein intake is not excessive.

can you eat too much fat?

Can you still eat too fat much while keeping the insulin load of your diet low?

The short answer is yes, especially if you’re chasing a certain macro nutrient value or high ketone values.  Some people are able to stay very lean on a high fat ketogenic diet, but others need to also manage their dietary fat inputs to achieve their goal of body fat output.

The good news is that a low insulin load nutrient dense diet diet will typically lead to increased satiety and reduced energy intake.

The bad news is that excess energy, whatever the source, will lead to fat gain, inflammation and insulin resistance.

Many people recommend that you should eat ‘fat to satiety’.  Unfortunately, high fat foods can be easy to overeat, at least for some individuals. There is no need to force yourself to eat extra fat if you are trying to lose weight.  There’s no need to go out of your way to add extra fat and oils to your food.  If your goal is weight loss, you can obtain more than enough fat from whole-food sources.

basal insulin and insulin resistance

The other unfortunate fact is that the insulin produced in response to food is less than half of the amount of insulin that your body produces.  You pancreas is constantly producing basal insulin to manage the flow of energy out of your liver and to remove excess energy from your blood stream.

In addition to reducing the insulin load of your diet you may also need to increase the periods between your meals (intermittent fasting) and focus on building lean muscle mass to improve your insulin sensitivity.  This will allow your insulin levels to decrease even more so that body fat can be accessed for fuel.

Implementing an intermittent fasting regimen can be useful for people who find that reducing the dietary insulin load doesn’t lead to enough reduction in appetite.

As detailed in the how to use your glucose metre as a fuel gauge article, waiting until your blood glucose levels drop can be a useful way to increase the timing between meals and to understand whether your hunger is real.  Once your blood glucose levels normalise you can even use your your bathroom scale to help time your fasting / feasting cycle to achieve your weight loss goals.

You can get a substantial decrease in insulin levels with a regular 18 to 24 hour fast.  After this drop in insulin you may find your hunger levels actually decrease after a longer period of not eating.  image23.png

summary

  • To regain control of your appetite you need to insulin load of your diet to the point that your pancreas can keep up and maintain normal blood glucose levels consistent with your personal metabolic health and level of insulin sensitivity.
  • If your blood glucose and insulin level are high then you should work to decrease the insulin load of your diet.
  • As the insulin load of your diet decreases you should see your blood glucose levels come down, your appetite reduce and your ketone levels come up.
  • If you’re still not seeing the results you want then the next step is to try intermittent fasting to further reduce your insulin and blood glucose as well as mitigate your overall food take.
  • As your blood glucose levels start to normalise you can start to focus on more nutrient dense foods with a lower energy density that may be helpful if weight loss is your goal.

The foods lists in the table below have been optimised to suit different levels of insulin resistance and tailored to your weight loss goals.

approach

average glucose

waist : height

(mg/dL)

(mmol/L)

therapeutic ketosis

> 140

> 7.8

diabetes and nutritional ketosis

108 to 140

6.0 to 7.8

weight loss (insulin resistant)

100 to 108

5.4 to 6.0

> 0.5

weight loss (insulin sensitive)

< 97

< 5.4

> 0.5

bulking

< 97

< 5.4

< 0.5

nutrient dense maintenance

< 97

< 5.4

< 0.5

 

post last updated: April 2017

references

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

[2] https://optimisingnutrition.com/2015/03/22/ketosis-the-cure-for-diabetes/

[3] https://en.wikipedia.org/wiki/Dietary_fiber

[4] https://optimisingnutrition.com/2015/07/06/insulin-index-v2/

[5] https://en.wikipedia.org/wiki/Glucogenic_amino_acid

[6] https://www.myfitnesspal.com/

the most nutrient dense foods for different goals

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

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

image001

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

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

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

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

essential nutrients

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

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

essential fatty acids

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

amino acids

  1. cysteine
  2. isoleucine
  3. leucine
  4. lysine
  5. phenylalanine
  6. threonine
  7. tryptophan
  8. tyrosine
  9. valine
  10. methionine
  11. histidine

vitamins

  1. choline
  2. thiamine
  3. riboflavin
  4. niacin
  5. pantothenic acid
  6. vitamin A
  7. vitamin B12
  8. vitamin B6
  9. vitamin C
  10. vitamin D
  11. vitamin E
  12. vitamin K

minerals

  1. calcium
  2. copper
  3. iron
  4. magnesium
  5. manganese
  6. phosphorus
  7. potassium
  8. selenium
  9. sodium
  10. zinc

the lists

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

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

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

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

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

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

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

all nutrients

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

no insulin index contribution

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

  1. liver,
  2. cod,
  3. parsley,
  4. white fish, and
  5. spirulina / seaweed

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

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

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It certainly seems to be working for him.

Duane Johnson 2 - Copy

athlete and metabolically healthy

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

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

  1. basil,
  2. parsley,
  3. spearmint,
  4. paprika, and
  5. liver

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

Aaron Tait Photography

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

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

weight loss

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

  1. wax gourd (winter melon),
  2. basil,
  3. endive,
  4. chicory, and
  5. dock

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

image008

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

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

diabetes and nutritional ketosis

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

  1. wax gourd (winter melon),
  2. chia seeds,
  3. flax seeds,
  4. avocado, and
  5. olives

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

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therapeutic ketosis

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

  1. flax seeds,
  2. fish oils,
  3. wax gourd,
  4. avocado, and
  5. brazil nuts.

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

ganze und halbe reife avocado isoliert auf weissem hintergrund

fatty acids

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

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

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

no insulin index contribution

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

  1. salmon,
  2. whitefish,
  3. shad,
  4. fish oil, and
  5. herring

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

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

image014

athlete and metabolically healthy

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

  1. salmon,
  2. marjoram,
  3. chia seeds,
  4. shad, and
  5. white fish

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

image016

weight loss

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

  1. brain,
  2. chia seeds,
  3. sablefish,
  4. mackerel, and
  5. herring

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

image018

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

diabetes, nutritional ketosis and therapeutic ketosis

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

  1. Fish oil – menhaden,
  2. Fish oil – sardine,
  3. Fish oil – salmon,
  4. Fish oil – cod liver, and
  5. Oil – seal

image019

amino acids

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

no insulin index contribution

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

  1. cod,
  2. egg white,
  3. soy protein isolate,
  4. whitefish, and
  5. whole egg

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

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

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

image021

athlete and metabolically healthy

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

  1. parmesan cheese,
  2. beef,
  3. tofu,
  4. whole egg, and
  5. cod.

image023

weight loss

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

  1. bratwurst,
  2. basil,
  3. beef,
  4. chia seeds, and
  5. parmesan cheese

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

image025

diabetes and nutritional ketosis

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

  1. chia seeds,
  2. flax seed,
  3. pork sausage,
  4. bratwurst, and
  5. sesame seeds

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Therapeutic ketosis

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

  1. flax seed,
  2. pork sausage,
  3. sesame seeds,
  4. chia seeds, and
  5. pork

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vitamins

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

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

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

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

no insulin index contribution

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

  1. red peppers,
  2. liver,
  3. chilli powder,
  4. coriander, and
  5. egg yolk

Peppers (or capsicums as they’re called in Australia) are great in omelettes. image031

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

athlete and metabolically healthy

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

  1. paprika,
  2. chilli powder,
  3. liver,
  4. red peppers, and
  5. sage

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

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Good food doesn’t have to taste bland!

weight loss

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

  1. chilli powder,
  2. chicory greens,
  3. paprika,
  4. liver, and
  5. spinach

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

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diabetes and nutritional ketosis

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

  1. chilli powder,
  2. endive,
  3. paprika
  4. turnip greens, and
  5. liver

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

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therapeutic ketosis

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

  1. chilli powder,
  2. liver,
  3. liver sausage,
  4. egg yolk, and
  5. avocado

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minerals

no insulin index contribution

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

Here’s your answer:

  1. coriander,
  2. celery seed,
  3. basil,
  4. parsley, and
  5. spearmint

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

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

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athlete and metabolically healthy

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

  1. basil,
  2. spearmint,
  3. wheat bran (crude),
  4. parsley, and
  5. marjoram

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

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

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weight loss

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

  1. basil,
  2. caraway seed,
  3. marjoram,
  4. wheat bran (crude), and
  5. chilli powder

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diabetes and nutritional ketosis

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

  1. basil,
  2. caraway seed,
  3. flax seed,
  4. chilli powder, and
  5. rosemary.

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therapeutic ketosis

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

  1. flaxseed,
  2. sesame seed,
  3. pine / pinon nuts,
  4. sunflower seeds, and
  5. hazel nuts.

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application

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

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

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

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

references

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

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

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

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

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

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

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

insulin dosing options for type 1 diabetes

  • This article reviews a range of approaches to calculating insulin requirements for people with type 1 diabetes.
  • The simplest approach is standard carbohydrate counting, which may be ideal for someone whose diet is dominated by carbohydrates.
  • Bernstein recommends standardised meals for which the insulin dose is refined based on ongoing testing and refinement.
  • Stephen Ponder’s ‘sugar surfing’ builds on carbohydrate counting, with correcting insulin given when blood glucose levels rise above a threshold due to gluconeogenesis.
  • The food insulin index approach predicts insulin requirements based testing in healthy people of the insulin response to popular foods.
  • The total available glucose (TAG) advocates a ‘dual wave bolus’ where insulin for the carbohydrates is given with the meal, with a second square wave bolus given for the protein which is typically slower to digest and metabolise.

introduction

In the article Standing on the Shoulders of Giants we met a handful of people who have achieved excellent blood sugar control in spite of having type 1 diabetes.  Common elements of their success include:

  • keeping carbohydrates low to prevent the blood sugar roller coaster,
  • accurately dosing for a controlled amount of dietary carbohydrate,
  • targeting normal blood sugar ranges (i.e. 83mg/dL or 4.6mmol/L) with regular correcting doses,
  • regular exercise and / or intermittent fasting to improve insulin sensitivity, and
  • having a reliable method to account for the insulinogenic effect of protein.

Everyone’s diabetes management regimen is going to be different.  There will be a degree of trial and error to find what will work best for you.  This article reviews a number of approaches that you can learn from to see what suits you.

carbohydrate counting

In the 1970s Dr Richard Bernstein got hold of a blood glucose meter (long before they were easily available) and started experimenting on himself to understand how much a certain amount of carbohydrate raised his blood glucose levels and how much insulin he required to bring his blood glucose back down.

From this style of experimentation we can determine the “carbohydrate to insulin ratio” (i.e. how much insulin is required for a certain amount of carbohydrates).

Carbohydrate counting is now the standard approach that most people with type 1 diabetes are taught.  This approach involves estimating the grams of carbohydrate in your food for each meal.  With this knowledge you can then program the amount of carbohydrates eaten into the insulin pump which calculates the insulin dose based on a pre-set carbohydrate to insulin ratio.

The advantage of this approach is that it is relatively simple.  However it does not consider the insulin required for protein which is typically addressed with correcting doses or sometimes basal insulin.

Carbohydrate counting is a good starting point, but it is by no means perfect. [1] [2]

Bernstein’s own approach

Dr Richard Bernstein advises that his patients, in addition to restricting carbohydrates (i.e. no more than 6g of carbohydrates for breakfast, 12g for lunch and 12g dinner), to have the same meals every day which allows insulin doses to be refined to optimise for blood sugars.  If your blood glucose levels run high one day you can add a little more insulin the next day or a little less if they are running low.

Bernstein also advises targeting an average blood glucose of 83mg/dL (4.6mmol/L), and that you correct if blood glucose levels go outside a ten point range from this target (i.e. 73mg/dL to 93mg/dL or 4.0mmol/L to 5.2mmol/L).  A small bolus of insulin is given to bring blood glucose levels down and a certain portion of a glucose tablet is used to bring blood sugars back up precisely.

Bernstein advises that people with type 1 diabetes modulate the quantity of protein to manage their weight.  If you’re a growing child, protein is essentially unrestricted.  If you’re trying to lose weight protein can be reduced to further reduce insulin.

Bernstein says that protein requires about half as much insulin as carbohydrates and outlines how to dose for it in this video from Dr Bernstein’s Diabetes University.  In practice, though, his approach to dosing for protein requires consistent meals and fine tuning of insulin dose.

sugar surfing

Another popular method is ‘sugar surfing’ which is effectively a ‘bolt-on’ to carbohydrate counting developed by Dr Stephen Ponder to manage the glucose response to things other than carbohydrates.

This approach involves dosing for carbohydrates with the meal, and then watching the continuous glucose monitor (CGM) and giving regular ‘micro doses’ of insulin to keep blood sugar under around 93mmol/L (5.2mmol/L).  Typically two or three separate doses will be required to bring a ‘protein spike’ under control for someone with type 1 diabetes.

Injected insulin works over a period of up to eight hours and it is difficult to match the timing of the insulin action with digestion.  The advantages of this approach are that it allows for the variability in the time of protein digestion which varies from person to person and is different for different foods and hence difficult to predict accurately.

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I think the secret to making ‘sugar surfing’ work is to turn the waves that you’re surfing into more manageable ripples by following a diet with a reduced insulin load.

food Insulin Index

“It is possible that other methods of matching insulin with food are not being studied because of the belief that carbohydrate counting is a well-founded, evidence-based therapy,” the researchers concluded. “Indeed, this meta-analysis shows the scarcity of high-level evidence.” [3]

One of the experiments documented in Clinical Application of the Food Insulin Index to Diabetes Mellitus (Bell, 2014) [4] demonstrated that type 1 diabetics calculating their insulin requirement using the food insulin index approach achieved significantly improved blood glucose control compared with those using standard carbohydrate counting.

Estimating the insulin required for the meal from carbohydrate and protein rather than carbohydrate alone is potentially a massive step forward in improving blood sugar control for people with type 1 diabetes.

The limitation of using the approach practiced in the study is that the food selection tested is limited to the one hundred or so popular processed supermarket foods.

If you’ve read my blog you’ll know that I’ve tried to develop a robust method for calculating the insulin requirement for foods based on their macronutrients without having to test them in vivo (i.e. in real, living people). [5] [6] [7]  The chart below shows how we can use the food insulin index test data to more accurately predict the insulin demand of a particular food using this formula.

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image005

Rather than separating doses for carbohydrates and protein, the food insulin index approach assumes that all of the insulin is given with the meal.  The risk with this is that the insulin will take action before the protein digests which will lead to low blood glucose.

Total Available Glucose (TAG)

The TAG (Total Available Glucose) approach is based on a book by Mary Joan Oexmann published in 1989. [8]  This method calculates the insulin required for carbohydrate, protein (54% of carbohydrate) and fat (10% of carbohydrate).

If we gave all the insulin calculated for both carbohydrates and protein when we sat down to eat a high protein meal it is possible that the insulin would take effect before the protein digested, leading to low blood glucose before the gluconeogenesis from the protein had time to kick in.

To deal with the fact that glucose from protein can take longer to show up in the blood stream people who follow the TAG approach typically use a ‘dual wave bolus’.  The insulin for the carbohydrates is dosed with the meal, while the insulin for the protein is infused slowly as a separate “square wave bolus” over a period of three hours or so.  The need for the carbohydrate and protein boluses to be split will depend on the amount of protein in your meal and how quickly protein raises your blood sugars.

image007

separate boluses for carbohydrates and protein

A few people who achieve excellent blood sugar control simply use two separate boluses – one for carbohydrates before the meal with another one for protein around an hour after the meal.

This approach requires that the insulin for the protein and carbohydrate are calculated separately with the protein bolus being given a number of hours after the meal.

This approach can be refined using a CGM to confirm when the blood sugar response to the protein kicks in and hence when the bolus for protein is required.

insulin calculator

To assist in calculating the bolus for carbohydrates and protein Ted Naiman of Burn Fat Not Sugar has created this insulin calculator.

You can run it on your computer or phone, enter the properties of the food that you are about to eat and it will calculate the appropriate dose for carbohydrate and protein.  The outputs from this calculator will give you all the required data to follow any of the insulin dosing strategies above.

People who have used it so far have found it beneficial.

image009

image010

An example screen grab from the calculator is shown below with the explanation of inputs and outputs following.

image013

inputs

  • If you are using a manufactured food product in a packet you can simply use the nutritional details per serve (protein, fat, carbohydrates) and then factor for the number of serves.
  • If you are in the US you will need to enter the total carbohydrates and fibre values. If you’re in the UK or Australia you don’t need to enter the fibre as it is already subtracted from the carbohydrate count.
  • The protein multiplier is based on the food insulin index testing in non-diabetic people, [9] however you can modify this if you want, based on your own trial and error testing. The analysis of the quantity of amino acids (as detailed in the article the insulin index v2) suggests that this value is unlikely to exceed 80 to 90%.
  • A default carb to insulin ratio of 22 has been used, however you can enter yours from your pump or calculate it based on this article.  [10]
  • You can enter your bolus insulin on board (BoB) which will be subtracted from the carbohydrate insulin dose.

outputs

  • The first line of the outputs is the percentage of insulinogenic calories. As a reference keep in mind that a whole egg is about 25% insulinogenic calories.  A high percentage of insulinogenic calories is not ideal for people with diabetes and insulin resistance.  It may be helpful to select nutritious foods with a low insulin load from this list.
  • The insulin load is calculated using the following formula (i.e. for both carbohydrates and protein).

image015

  • The percentage of glucose from carbohydrate could be used if you were going to split your dose into an initial bolus for carbohydrates with a separate bolus for protein. This value can be entered into your pump if you’re using a dual wave bolus, with the protein bolus typically given over a longer period.
  • You can use the grams of carbohydrates or the quantity of insulin for the carbohydrates and the protein if you’re using separate boluses.

meals

If you are following the meals from the blog you will notice that the net carbs, total insulin load and percentage of insulin for carbohydrates have been included in a table at the end of each recipe assuming a standardised 500 calorie meal.

our experience

Moni has experimented with dosing separately for the protein component of the meal, however it typically turns out that her blood glucose has risen by the time she doses for the protein.  It seems that for her, the glucose from the protein (via gluconeogenesis) hits her bloodstream quickly and hence delaying the dose for protein is not appropriate for her.

We are also trying to focus on a handful of nutrient dense meals with pre-determined insulin doses.  The table below shows the insulin required for a 500 calorie serving for a range of meals.  All of these have limited carbohydrates and the insulin dose for the protein is greater than the carbohydrate dose.  I have provided hyperlinks to some of the meals that are already published on the blog.

If you can’t handle the thought of weighing and measuring and then calculating the insulin dose for everything you eat, as a ‘rule of thumb’ all of these meals require dosing as if they were about 20 to 25 grams of carbs.  If you are choosing meals with a low insulin load then the insulin dosing for food ends up representing only about 20% of the daily dose.

meal

carbs (g)

protein (g)

 insulin load (g)

bacon, eggs, avocado and spinach

4

15

19

spinach and cheddar scrambled eggs

6

18

24

steak, broccoli, spinach, haloumi

6

20

26

coffee with cream and stevia

1

1

2

chia seed pudding – no fruit

7

4

11

broccoli, bacon, cream and mozzarella

3

17

20

sausages, avocado, sour cream, tomato

7

13

20

bacon, eggs, spinach and pesto

4

16

20

bacon and eggs

3

18

21

bacon, eggs, avocado and sauerkraut

5

21

26

fathead pizza with anchovies and pesto

4

13

17

bacon asparagus and eggs

3

18

21

For us, this approach combines a number of aspects from the various approaches discussed above:

  • all of these meals having less than 12g of carbs as recommended by Bernstein,
  • calculated insulin dose for both protein and carbohydrates,
  • nutrient dense meals, and
  • relatively low percentage of insulinogenic calories (i.e. high fat meals) meaning that the overall insulin dose stays relatively low.

We’re all on a journey.  I hope this helps you move towards finding a strategy that is optimal for you.

References

[1] http://www.thelancet.com/journals/landia/article/PIIS2213-8587(13)70144-X/abstract

[2] http://www.medpagetoday.com/Endocrinology/Diabetes/42610

[3] http://www.thelancet.com/journals/landia/article/PIIS2213-8587(13)70144-X/abstract

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

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

[6] https://optimisingnutrition.wordpress.com/the-insulin-index/

[7] https://optimisingnutrition.wordpress.com/?p=2637

[8] http://www.amazon.com/T-A-G-A-Diabetic-Food-System/dp/0688084583

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

[10] http://www.bd.com/us/diabetes/page.aspx?cat=7001&id=7303

trends, outliers, insulin and protein

  • The carbohydrate content of a food alone does not accurately predict insulin response.  Protein and fibre content of food also influence in insulin response.
  • The food insulin index data indicates that dietary fat is the one macronutrient that does not does not require a significant amount of insulin.
  • Net carbohydrates plus approximately half protein correlates well with observed insulin response.
  • This knowledge can be used to help select low insulin foods and more accurately calculate insulin doses for diabetics.

background

Back before the GFC I used to dabble in share trading.  I don’t know much about financial systems, but I spent a good deal of time designing and testing “trend following” trading systems.

One of the pitfalls for newbies is to design a system with excessive “curve fitting”.  That is, to design a complex system that would work fantastically on a specific set of historical data.  If you ran an overly curve fitted system on another set of data or tried to trade it in real time it would fail because it was too finely tuned to the discrete set of historical data.

“Everything should be as simple as possible, but no simpler.”

Albert Einstein

Another lesson from trading is that you should be able to describe simply why a good system works.  My trading system scanned the market for stocks that were moving up quickly over a number of time periods with minimal volatility so that I could place a close ‘stop loss’ that would take me out of the trade quickly if the trend turned.

When the GFC hit things got too volatile and I got out of the market.  It was no longer fun.  However the skills I learned as an amatuer a quantitative trader (along with my day job running multi criteria analyses to identify motorway alignments, road investments and the like) have given me an interesting angle on nutrition that I hope people find useful.

On the Optimising Nutrition blog I have tried to describe a system to manage nutrition that makes sense to me.  I want to document the things that I wish someone had shown us when we started out trying to understand diabetes and nutrition.

If we want to understand and predict the behaviour of insulin, the master regulator hormone of the human body, we need to first determine what we know that is accurate, significant and useful that we can use.

Kirstine Bell’s PhD thesis Clinical Application of the Food Insulin Index to Diabetes Mellitus[1] (Sept 2014) details the results of the latest food insulin test data for more than one hundred foods.  It also evaluates the relationship between insulin demand and protein, fat, carbohydrates, glycaemic index, glycaemic load, indigestible fibre, individual amino acids and blood glucose.

Previously I have discussed in a moderate amount of detail how to calculate how much insulin may be required based on the carbohydrate, protein and fibre ingested.  Given the importance of this issue, this article looks in more detail at what can be learned from the test data included in this thesis about the relationship between these parameters, with a view to better manage blood glucose and insulin demand.  You will see that I have tried to look at the issue from a number of different directions and have also included a more rigorous statistical analysis.

carbohydrate

Most people know that carbohydrates require insulin.  As shown in the chart below, carbohydrates goes some way to explaining insulin response.  However it is far from a perfect relationship (R2 = 0.44, r = 0.67, p < 0.05).

image001

indigestible fibre

Taking indigestible fibre into account (i.e. net carbohydrates) improves the relationship (R2 = 0.48, r = 0.69, p < 0.05).  The best correlation is achieved when we subtract all the indigestible fibre from the total carbohydrate value.  However we can see from the cluster of data points on the vertical axis there is something going on that is not explained by carbohydrates alone.

image002

The importance of dietary fibre should not be discounted, especially when trying to reduce insulin demand.  Some recommend that diabetics limit total carbohydrates, rather than considering net carbohydrates, or non-fibre carbohydrates.  The danger with a total carbohydrates approach is that people will avoid fibrous non-starchy vegetables that provide vitamins and minerals that cannot be obtained from other foods (unless you’re consuming a significant amount of organ meats), as well as feeding the gut bacteria which is also important to help improve insulin sensitivity and the body’s ability to digest fats. [2]

fat

The food insulin index data indicates that foods that are largely comprised of fat have a negligible insulin response (R2 = 0.38, r = 0.631, p < 0.001).

image003

To put this another way, the chart below shows the sum of carbohydrate plus protein (i.e. the non-fat content of foods) versus the insulin index (R2 = 0.38, r = 0.62, p < 0.001) indicating that:

  • the greater the proportion of fat in a particular food the less insulin is required; and
  • the more carbohydrates and / or protein ingested the more insulin is required.

image004

Hence, it appears that to reduce insulin demand we need to reduce carbs and / or protein!

The figure below shows a similar chart for the glucose score (i.e. the area under the curve of the blood glucose rise over three hours after ingestion of the food).  Again, this indicates that the blood glucose response is lowest for foods that contain a higher proportion of calories from fat (R2 = 0.45, r = 0.68, p < 0.001).

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While it appears that insulin demand is triggered by carbohydrates and protein, what is not clear is the relative degree to which carbohydrates and protein contribute to insulin demand.  Are they equivalent or does protein cause a smaller insulin  response?

protein

Another observation from trading is that you can learn a lot by considering outliers.  You have to decide whether the data points that don’t quite fit the trend are garbage or ‘black swans’ need to be accounted for in the system.

In the carbohydrate vs insulin relationship the outliers are the high protein foods that trigger a higher insulin response than can be explained by considering carbohydrates alone.

As shown in this plot, high protein foods are typically lower in carbohydrates which produce the greatest amount of glucose.  Choosing higher protein foods will generally reduce insulin (R2 = 0.10, r = 0.47, p < 0.001).

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Increasing protein will also typically lead to a spontaneous reduction in intake due to the thermic and satiety effects of protein. [3] [4]   Protein is critically important for many bodily functions.  It is vital to eat adequate protein.

However protein in excess of the body’s needs for growth and repair can be converted to glucose.  The fact that protein can turn to glucose represents a potential ‘hack’ for diabetics trying to manage their blood glucose as they can get the glucose required for brain function without spiking blood glucose as much as carbohydrates.

Choosing higher protein foods will generally lead to better blood glucose control.  Although high protein foods still raise the blood glucose somewhat, particularly if you are not insulin sensitive, however the blood glucose response is gentler and hence the pancreas can secrete enough insulin to balance blood glucose.

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For most people, transitioning to a reduced carbohydrate whole foods diet will give them most of the results they are after.  However for people with Type 1 Diabetes or people trying to design a therapeutic ketogenic diet, consideration of protein may be important to further refine the process to achieve the desired outcomes.

For a healthy bodybuilder the glucogenic and insulinogenic effect of protein might be an anabolic advantage, with the post workout protein shake providing an insulin spike to help build muscle.

However for someone struggling to lose weight on a low carb diet, considering the insulinogenic effect of protein might just be what they need to reduce insulin and normalise blood sugars and thus enable them to reach their goals.

glycaemic index

The glycaemic index is a reasonable predictor of insulin demand in terms of correlation (R2 = 0.54, r = 73, p < 0.01), however the ‘elephant in the room’ again is the high protein low carbohydrate foods (e.g. white fish, low fat cheese, lean beef etc).

image009

The other issue is that the glycaemic index is an empirical measurement that has to be measured in humans “in vivo” and can’t easily be calculated based on commonly available food properties.  And again, the glycaemic index does not deal with the insulin response from high protein foods.

glycaemic load

The same issues apply to glycaemic load.  There is a reasonable correlation between glycaemic load and insulin demand.  However it still does not explain the insulin effect of high protein foods (R2 = 0.57, r = 0.75, p < 0.01).  And you have to run these tests in real people “in vivo”.

image010

glucose score

Like the food insulin index, the glucose score is measured “in vivo” based on the area under the curve of a healthy person’s glucose rise due to a particular food.

Glucose score is interesting in that it actually achieves an excellent correlation with insulin demand (R2 = 0.75, r = 0.87, p < 0.001), however there is still a disconnect when it comes to high protein foods.

image010

It seems that some foods that do not raise blood glucose significantly over three hours still elicit an insulin response.  High protein foods digest slowly although they do still require insulin to metabolise.  In a normal healthy person the body’s insulin response to protein is balanced by release of glycogen from the liver, with blood glucose being kept in balance by insulin and glycogen. [5]

In a normal person the insulin keeps up with this slow blood glucose rise and hence we do not see a pronounced blood glucose spike due to high protein foods.

The interesting outliers here are processed low fat milk products that seem to require more insulin than would be anticipated by the blood glucose response.  On the other side of the trend line we have brown rice, pasta and other less processed whole foods which raises the blood glucose but does not require as much insulin as might be expected.

Accounting for fibre (i.e. net carbs rather than total carbs) goes some way to help anticipate the effect of processing.  However the effect of processed foods is an interesting area for future study that is beyond the capacity of this dataset to address.

I ran a number of correlation analysis and could not find an explanation of why a certain food sat above or below the trend line, whether it be carbohydrates, sugar, fibre or protein.

sugar

The sugar content of a food is not a particularly useful predictor of insulin demand (R2 = 0.10, r = 0.32, p = 0.001) compared with net carbohydrates (R2 = 0.48, r = 0.69, p < 0.05).  Quitting sugar is only part of the solution.  Most people struggling with diabetes or obesity should ideally consider their total carbohydrate intake.

image011

curve fitting

Kirstine Bells’ Clinical Application of the Food Insulin Index to Diabetes Mellitus[6] documents the development of a number of formula to explain the relationship between food properties and the food insulin index response.  The aim of this her thesis was essentially to build an improved glycemic index to predict insulin response rather than only considering changes in blood glucose.

The chart below shows the best relationship developed using a stepwise multiple linear regression analysis of the various parameters to forecast insulin demand documented in Clinical Application of the Food Insulin Index to Diabetes Mellitus. [7]

The correlation is excellent (R2 = 0.78, r = 0.89, p < 0.001).  However this relationship relies heavily on the glucose score (GS) which has to be tested “in vivo”.

image012

If we strip out the glucose score then the best relationship achieved in the thesis is the one shown below using carbohydrates and protein with a correction factor (R2 = 0.46, r = 0.68, p < 0.001).

The problem with this approach is that it assumes that high fat foods have some insulinogenic effect.  However we have seen above that high fat foods have a negligible insulin response.  This formula also does not account for indigestible fibre which should be subtracted from the total carbohydrate count.  And according to this formula a food with zero carbohydrate and zero protein would still have a significant insulin index response of 10.4, which does not make sense.

image013

simple is true

If we take out indigestible fibre (net carbs), assume that fat has a negligible insulin response and refine the protein factor to maximise the correlation with the test data, we end up with this chart which has an improved correlation compared to the model above (R2 = 0.49, r = 0.70, p < 0.001).

image014

This approach also does a good job of predicting blood glucose (R2 = 0.59, r = 0.77, p < 0.001) as shown in the chart below.

image015

practical application

Individual foods can be ranked and prioritised based on their proportion of insulinogenic calories using the following formula:

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Foods with the lowest proportion of insulinogenic calories will have the gentlest impact on blood glucose and have the lowest insulin demand, a consideration which will be very useful for people who are insulin resistant (i.e. Type 2 Diabetes or Pre-Diabetes) or not able to produce adequate insulin themselves (i.e. Type 1 Diabetes).

You can find a detailed list of foods ranked by their proportion of insulinogenic calories here and with consideration of nutrients and other factors based on different goals here.

Diabetics and people wanting to reduce the insulin demand of their diet can track the total insulin load (as opposed to carbohydrate counting) using the following formula:

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The total insulin load can be reduced by decreasing carbohydrates, increasing fibre, moderating protein to the body’s optimum requirement and increasing fat until target blood glucose are achieved.

can we design a “perfect” system?

There is still quite a degree of in this real life data.  This could be due to measurement error in the macronutrients, food quantity, individual characteristics of the people that the food was tested on, or something else.

This approach considering the insulinogenic effect of protein and carbohydrates does however help to better predict insulin demand than carbohydrate alone.

The fact that there is still a high degree of variability in the data and hence limited ability to accurately predict the insulin response to food can be mitigated by keeping the overall insulin load of the diet reasonably low.

Dr Richard Bernstein talks about the ‘law of small numbers’ whereby the compounding errors in the calculation of insulin requirement and the mismatch of insulin response with the rate of digestion misalign means that it is impossible to accurately calculate insulin dose.

The only way to manage the high level of variability is to reduce insulin demand to manageable levels.  This is especially beneficial for people who are injecting insulin, but also relevant for the rest of us.

summary

Building on the analysis of the food insulin index data, the key assumptions that underpin this system are:

  1. carbohydrates require insulin,
  2. indigestible fibre does not require insulin, and
  3. the glucogenic portion of protein that is not used for growth and repair and not lost in digestion also requires insulin.

In order to reduce our insulin load we should do the following, in order of priority:

  1. Reduce insulin load until you normalise blood glucose levels (i.e. reduce digestible carbohydrates and moderate protein if necessary),
  2. Increase nutrient density as much as you can while still maintaining good blood glucose levels (note: this will likely also include fibre from non-starchy veggies which will also increase fibre which reduces insulin and slows digestion),
  3. Reduce dietary fat if you still need to reduce body fat levels, and
  4. Implement an intermittent fasting routine to improve your insulin sensitivity and to kick-start ketosis.

references

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

[2] http://www.amazon.com/Brain-Maker-Power-Microbes-Protect/dp/0316380105

[3] http://wholehealthsource.blogspot.com.au/2013/04/glucagon-dietary-protein-and-low.html

[4] http://www.ncbi.nlm.nih.gov/pubmed/16002798

[5] http://wholehealthsource.blogspot.com.au/2013/04/glucagon-dietary-protein-and-low.html

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

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

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

the blood glucose, glucagon and insulin response to protein

  • The food insulin index data indicates that there is both a blood sugar and an insulin response to the glucogenic component of protein. [1]
  • A higher protein intake tends to lead to better blood sugar control, increased satiety and reduced caloric intake.
  • Digested amino acids from protein circulate in the bloodstream until they are required for protein synthesis, gluconeogenesis or the production of ketones.
  • The release of glucose from protein from gluconeogenesis is a demand driven process that is much smoother and slower compared to carbohydrate.
  • Someone who is insulin resistant and/or whose pancreas is not producing adequate insulin may benefit from higher protein with lower carbohydrate (LCHP) in order to smooth out the blood sugar response while still obtaining adequate protein.

background

Protein doesn’t significantly raise blood sugars, at least compared to carbohydrates.

At the same time however, it is generally acknowledged (at least by people with Type 1 Diabetes) that protein requires insulin.  Managing the blood glucose response to protein is a real challenge for diabetics, particularly if they are minimising carbohydrates and hence have likely increased their protein intake.

Recently an increasing number of people trying to achieve nutritional ketosis have found that they need to moderate protein in addition to limiting carbohydrates to reduce insulin to the point where significant levels of ketones can be measured in the blood.

My aim here is not to knock protein, but to better understand the insulin and glucose response to protein based on the recent food insulin index data.

My wife is a type 1 diabetic, hence anything that can be done to refine insulin dosing calculations or help inform food choices that will lead to more stable blood sugars is of interest to me.

Personally I have a tendency towards obesity and pre-diabetes (based on my 23andMe testing and a lifetime of personal experience trying to keep the weight off) so I am also interested in how I can optimise my blood sugars and reduce the insulin load of my diet so that my pancreas can keep up.  I would also love to dodge the weight creep that seems to come with middle age for most people.

This has been a challenging topic to get my head around.  It is complex and there is a lack of definitive research to provide clear guidance.  Hopefully more data and discussion can help to progress the understanding and the practical application of the theory.

I do not claim to have all the answers, but rather plenty of observations and questions.  I hope that by documenting some of these I can help move this discussion forward.   If you have some thoughts or insights on this topic be sure to leave your comments below once you’ve finished reading this article to add to the discussion.

the blood glucose response to protein

The food insulin index data contained in Clinical Application of the Food Insulin Index to Diabetes Mellitus by Kirstine Bell (Sept 2014) [2] continues to intrigue me.

There is a lot to be learned from looking at the body’s insulin response to food and the interrelationship to other parameters such as fat, protein, carbohydrates, fibre or blood glucose.

The data points on the right hand side of the chart below [3] indicate that high protein foods (e.g. fish, tuna and steak) cause a rise in blood glucose.  However the blood sugar response to protein is still small relative to the high carbohydrate foods on the left hand side of the plot.

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For most people, the discussion ends there.  Protein does not raise blood sugar much, therefore it is a non-issue.  Pass the extra-large steak and post workout protein shake with an extra scoop of whey thanks!

But is it really that simple?  What does the recently expanded food insulin index data tell us?

the insulin response to protein

One of the challenges I see for type 1 diabetics is that, even if they eat a low carbohydrate diet, they still struggle with high blood sugars after a high protein meal.

Type 1s who have a continuous glucose monitor know that they need to watch out for a rise in their blood glucose three or four hours after a high protein meal and apply correcting doses of insulin to keep their blood sugar from going too high.

Looking at the plot of protein versus insulin index below, we can see that the insulin response to protein is more significant than the blood glucose response to protein.

image003

For instance, the insulin index score for white fish is 42%, however it only receives a 20% glucose score (note: both are compared to the response to pure glucose which has a glucose score and a food insulin index score of 100%).

Maybe there is something going on that can’t simply be explained by the blood sugar response alone?

If we plot the glucose score versus the insulin index we see that glucose and insulin are not directly proportional.

image005

Low carbohydrate high protein foods such as chicken, cheese, tuna and bacon require a lot more insulin than would be anticipated if insulin was directly proportional to the blood glucose response.

On the lower side of the trend line we have high carbohydrate foods from whole food sources such as raisins, wholemeal pasta, brown rice and water crackers having less of an insulin response than would be anticipated from the blood glucose response.

I have run a correlation analysis with different parameters but could not find any meaningful relationship with any other parameter in the available data (i.e. total carbohydrate, sugar, fibre, protein or fat).

Perhaps this would be an interesting area for future study to see if there is some component of food processing or some other Paleoesque characteristics that influences the relationship between blood sugar and insulin, or maybe it is just the scatter that you get with real life data from in-vivo testing?

diabetic versus normal response to protein

Moving on from the food insulin index data, the figure below compares the blood sugar and insulin response to 50g of protein (200 calories) in type 2 diabetics (yellow lines) and healthy non-diabetics (white lines). [4]  We can see that:

  • Blood glucose remains fairly stable for healthy people after eating 50g of protein. However when the type 2 diabetic eats a high protein meal the insulin secreted seems to bring the blood sugar down from elevated levels!
  • Insulin is elevated for more than five hours after ingestion of protein, particularly for the insulin resistant type 2 diabetic. There’s definitely something going on with insulin in response to high protein foods, even if we don’t see a sharp increase in blood sugar.
  • The diabetic requires a lot more insulin to deal with the same quantity of protein and it takes a lot longer for the insulin levels to peak and come down.

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We can also see from the insulin response that protein takes more than three hours to digest and metabolise.  It is likely that the food insulin index data (which is based on the measurement of insulin over only three hours) underestimates the insulin response to protein-containing foods and that the insulinogenic demand of protein is actually higher than predicted by the food insulin index data (i.e. protein requires more than 56% of the insulin relative to carbohydrate).

what happens when we eat a lot of protein?

The question of what happens to ‘excess’ protein that is not required for muscle growth and repair is controversial and the science is not exactly clear.

Does the energy from unused protein magically disappear?  If it did then protein would be the ultimate macronutrient that everyone should eat to lose weight.  We could effectively ignore calories from protein.

Does it turn into nitrogen and get excreted in the urine?

Or does it turn into glucose ‘like chocolate cake’?

There is limited authoritative information on this topic, however some helpful guidance that I’ve found on the topic is outlined below:

  • Richard Feinman says that “…after digestion and absorption, amino acids not used for protein synthesis may be trashed.  The nitrogen is converted to ammonia which is converted to urea and excreted.  The remaining carbon skeleton can be used for energy either directly or converted to ketone bodies, particularly on a very low carbohydrate diet.” [5]
  • Richard Bernstein says “Dietary protein is not the only source of amino acids.  The proteins of your muscles continually receive amino acids from and return them to the bloodstream.  This constant flux ensures that amino acids are always available in the blood for conversion to glucose (gluconeogenesis) by the liver or to protein by the muscles and vital organs.” [6]
  • According to David Bender “In fasting and on a low carbohydrate diet as much of the amino acid carbon as possible will be used for gluconeogenesis – an ATP-expensive, and hence thermogenic, process.” [7]

So it appears that amino acids from digestion or from the muscles circulate in the blood stream and these can be used as required for protein synthesis or to stabilise blood glucose levels.

The figure below [8] shows a comparison of the blood glucose response to ingestion of glucose and 600g of lean beef (i.e. a very big serving of steak!).

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During the more than eight hour period that the steak takes to digest you can see the nitrogen levels continue to rise.  Meanwhile blood glucose rises only slightly until around four hours after the meal and comes back down.

tbonesteakongrill

What appears to be happening here is that the amino acids from digestion are being progressively released into the blood stream (over a period of digestion of more than eight hours) but are not immediately converted to blood glucose.  Thus the digestion of protein does not cause a sharp rise in in blood glucose.

It is said that gluconeogenesis is a demand driven process, not a supply driven process.  What I think this means is that the body can draw on the amino acids circulating in the blood stream for muscle growth and repair (protein synthesis) or to balance the blood sugar (via gluconeogenesis) depending on requirements from moment to moment.

The fact that we don’t see a sharp rise in blood glucose in response to protein indicates that excess protein does not immediately turn into glucose.  Gluconeogenesis occurs slowly over time with the amino acids being used up as required.

However as noted by David Bender above, if we are fasting or minimising carbohydrates then our body will maximise the use of protein to produce glucose via gluconeogenesis.  Conversely, if we eating more carbohydrates and less protein the body doesn’t need to rely on protein as much for glucose.

do amino acids spill over into glucose in the bloodstream?

Most people aren’t eating so much protein that their amino acid stores in their blood are full to overflowing like peoples’ livers are typically overflowing with glucose from a higher carbohydrate diet.

It would be interesting to see what happens in someone whose blood stream became saturated with amino acids from long term consistently high protein consumption.

Would we see more protein excreted or perhaps a larger amount removed from the blood via gluconeogenesis with subsequent conversion to fat using insulin?

By comparison, when carbohydrate is eaten we typically see glucose causing an immediate rise in blood sugar because the liver is often already full.

glucagon response

A healthy non-diabetic person will release both insulin and glucagon in response to a high protein meal.

Insulin helps to metabolise the protein and grow and repair muscles (i.e. insulin is ‘anabolic’).   Glucagon helps to keep blood sugar stable and prevent it from going too low due to the action of the insulin used in the muscle growth and repair process.

The body secretes both glucagon and insulin in response to a high protein meal (as shown in the figure below [9]).  In a healthy insulin-sensitive non-diabetic person the glucagon will effectively cancel out the insulin response to the protein used for protein synthesis.  Hence we see a flat line blood glucose response in the insulin-sensitive non-diabetic.

image012

In a diabetic, particularly type 1s, we often see blood sugar rising after a high protein meal due to the initial glucagon response and then gluconeogenesis as some of the protein converts to glucose.  In the diabetic the insulin response is either inadequate (due to poor pancreas function) or ineffective (due to high insulin resistance) and therefore the blood sugar does not remain stable as it would in a metabolically healthy person.

By contrast, after we eat a high carbohydrate meal glucagon decreases as the insulin increases and the body moves into fat storage mode as shown in the following figure. [10]  The basic thesis of Protein Power is that we want to do whatever we can to maximise glucagon which promotes fat burning rather than insulin  which leads to fat storage.

image014

Even though glucogon offsets the insulinogenic effect of protein used for protein synthesis, it seems that the glucogenic portion of protein requires insulin.

I haven’t found any data on the subject, but I wonder if the body does not secrete glucagon to negate the effect of the ‘excess’ protein over and above the body’s requirement for protein synthesis (say 7 to 10% of calories)?

If this were the case then the glucogenic proportion of excess protein will behave largely like a carbohydrate with no glucagon to counteract the insulin?

glucagon, the antidote to insulin?

The observation that glucose does not rise significantly in response to protein is often taken to mean that protein is a non-issue.  [11]  [12]

This may be largely true for someone who is insulin sensitive, however diabetics with impaired pancreatic function may not be able to secrete adequate insulin to offset the effects of glucagon and keep their blood sugars stable.

If you are a type 2 diabetic or someone with impaired insulin sensitivity I suggest that it would be better to keep your carbohydrate AND protein intake to the point where your body can keep up and maintain normal blood sugars?

The image below shows the continuous glucose monitor (CGM) plot of a type 1 diabetic after ingestion of a protein shake (46.8g protein and  5.6g of carbs).

Without insulin there is a blood sugar rise over a period of more than eight hours, not dissimilar to what you would see from carbohydrates.

image016

Is this blood glucose rise from gluconeogenesis of the protein or is the blood glucose rise from glucagon in response to the ingested protein or a bit of each?  It’s hard to know.

What we do know is that there is a rise in blood glucose that needs to be managed if we are going to achieve optimal blood sugar control.

letting your pancreas keep up

For a diabetic who is insulin resistant and/or whose pancreas is not producing adequate insulin, the issue is that the total insulin load of their diet (from carbohydrates and the glucogenic component of protein) is in excess of their body’s ability to keep blood glucose under control.

From the insulin index data we know that the body’s blood sugar and insulin response are proportionate to carbohydrate plus about half of the ingested protein.

So potentially we can balance our blood glucose response by managing the glucogenic inputs, that is, by moderating protein and keeping carbohydrates adequately low.  And by doing this we can minimise, or perhaps eliminate, the need for insulin or other medications.

image019

image017

the high protein ‘hack’ for diabetics

To some extent, obtaining glucose from protein rather than carbohydrate is a beneficial ‘hack’ for someone who is not able to manage their blood sugars given:

  • eating higher levels of protein will ensure that the body’s needs for essential amino acids are met or exceeded;
  • the blood sugar rise from protein is much slower than it is for carbohydrate foods and hence it is easier to keep blood sugars under control;
  • protein takes more energy to convert to glucose than using carbohydrate directly, hence there is additional energy lost in the process (i.e. a calorie of protein is not really a calorie if you have to convert it to glucose before it can be used), [13] and
  • protein is more satiating than carbohydrates.

Paul Jaminet argues that obtaining glucose from protein is not ideal given that it’s not as energy efficient as obtaining it directly from carbohydrates.

However I think that the optimal approach is to ensure that you maximise vitamins, minerals, fibre and amino acids from carbohydrate and protein containing foods while at the same time not overwhelming your body’s ability to maintain optimal blood sugars due to excess glucose from either carbohydrates or excess protein.

To some extent it’s a balancing act between gaining adequate nutrition from things that will raise blood glucose while at the same time not overwhelming the ability of your pancreas to produce insulin to keep blood sugars in the ideal range.

The food ranking and meal ranking systems have been designed around this approach.

what is the optimum amount of protein and carbohydrates?

I find Steve Phinney’s well formulated ketogenic diet chart helpful when it comes to understanding how to optimise protein and carbohydrate intake.

image022

  • The minimum protein intake is around 10% of calories or 0.8g/kg body weight. [14] At this point the vast majority of the protein will go to muscle growth and repair.  Based on the guidance given by the WFKD triangle you might even be able to tolerate up to 20% carbohydrates and stay in nutritional ketosis if you were to keep your protein levels low.  At this point you won’t have to worry too much about gluconeogenesis messing up your blood sugars because all of the protein will be used up in protein synthesis.
  • If you are active then you will likely want higher levels of protein, with 1.2 to 1.7g/kg body weight recommended for athletic performance. [15] Higher levels of protein will ensure that you have enough amino acids for optimal physical and mental function rather than just being adequate.
  • As we move to higher levels of protein above the minimum 10% of calories we should consider also reducing carbohydrate and increasing fat, due to the fact that the glucogenic portion of the protein that is over and above the basic needs for growth and repair will likely be turned into glucose, requiring increased levels of insulin which will work against you if your goals are reducing your insulin load in order to stabilise blood sugars or to lose weight.

I have discussed the concept of balancing glucose load from protein and carbohydrates with your body’s ability to produce insulin in more detail in the article the Goldilocks glucose zone.  However if you are keeping track of your food intake you can use the formula below to calculate and track your insulin load.

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If you are not yet achieving normal blood sugar levels then you could try winding back your insulin load.  Most people find that they will achieve stable blood sugars and nutritional ketosis with an insulin load of around 125g, however your mileage may vary and you will likely have to tweak this level to find your optimum based on your goals and your situation.

What do you think of all this?  I would love to hear your response in the comments below.

references

[1] See http://en.wikipedia.org/wiki/Glucogenic_amino_acid,   https://www.dropbox.com/s/4dkl03mz2fci71v/The%20metabolism%20of%20%E2%80%9Csurplus%E2%80%9D%20amino%20acids.pdf?dl=0 and http://www.medschool.lsuhsc.edu/biochemistry/Courses/Biochemistry201/Desai/Amino%20Acid%20Metabolism%20I%2010-14-08.pdf

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

[3] Glucose score is the area under the curve of the rise in blood glucose response over three hours relative to pure glucose tested in healthy non-diabetics.

[4] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC524031/

[5] Chapter 5 of The World Turned Upside Down: The Second Low Carbohydrate Revolution.

[6] Dr Bernstein’s Diabetes Solution, page 96.

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

[8] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC424828/pdf/jcinvest00541-0071.pdf

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

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

[11] http://caloriesproper.com/dietary-protein-does-not-negatively-impact-blood-glucose-control/

[12] http://www.ketotic.org/2013/01/protein-gluconeogenesis-and-blood-sugar.html

[13] See chapter 15 of Richard Feinman’s The World Turned Upside Down: The Second Low Carbohydrate Revolution for an in depth discussion of this topic.

[14] This is based on the point where at least half of the population has adequate protein!  Not exactly an ideal goal to be shooting for!

[15] https://www.dropbox.com/s/zelfo3n0q8kvtfx/Paoli%20et%20al.%20(2015)%20The%20Ketogenic%20Diet%20and%20Sport%20A%20Possible%20Marriage.pdf?dl=0