Tag Archives: HbA1c

standing on the shoulders of giants

  • People who have type 1 diabetes and excellent blood glucose control are statistically rare.
  • These ‘overachievers’ typically have been influenced by the work of Dr Richard Bernstein.
  • People successful in their management of type 1 diabetes control the amount of carbohydrate in their diet to prevent “the blood sugar roller coaster”.
  • As well as calculating the insulin required for carbohydrate, those who manage type 1 diabetes well typically also have a way to calculate their insulin dose for protein.
  • Exercise and fasting also help to improve insulin sensitivity.

background

According to the T1D Exchange [1], 1.2% of type 1 diabetics in the US have a ‘normal’ HbA1c of less than 5.7%.  Twenty nine (29) of the twenty five thousand type 1 diabetics in the database (i.e. 0.1%) have an HbA1c of less than 5.0%.

I am privileged to know quite a few people who are conquering type 1 diabetes through the TYPEONEGRIT Facebook group [2] where you will regularly see posts like this one.

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Rather than just talking about the theory I thought it would be useful to profile a handful of the people that have been an inspiration to us and have shown what it takes to not just survive but thrive with type 1 diabetes.

What do each these people have in common that we can learn from?  What do they do differently based on their situation?

Dr Richard Bernstein

Dr Richard K Bernstein [3] has been the ‘voice in the wilderness’ of the low carbohydrate movement for four decades.  I first came across Dr Bernstein in episode 683 of Jimmy Moore’s LLVLC Show.[4]

Despite having type 1 diabetes himself since the age of twelve he is still going strong at eighty one years of age.  Bernstein’s is a fascinating story and an example of what can be achieved.

Richard Bernstein started his working career as an engineer.  His wife is a doctor so he was able to purchase one of the early blood glucose metres in 1969.  In those days blood glucose metres were primarily used to determine if someone who landed in the hospital emergency department at night was unconscious because they were drunk or had high blood glucose levels.

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Bernstein, an avid self-experimenter, measured his blood sugars six times a day, and over time gained an understanding of how much a certain amount of carbohydrate raised his blood glucose levels, and conversely, how much a certain amount of insulin lowered them.

At the time he was told it was a waste of time encouraging people with diabetes to measure their blood glucose levels because there was no value in people with diabetes achieving normal blood glucose levels. [5]  In spite of this, Bernstein’s early learnings are now the basis of the basal / bolus insulin dosing calculations built into every insulin pump which is used today by the majority of type one diabetics.

At 45 years of age Bernstein went to medical school in an effort to get people to listen to his theories.  These theories are still considered fringe today, possibly because they do not align with the dietary recommendations generated by the USDA.

Bernstein documented his system in the comprehensive book Dr Bernstein’s Diabetes Solution[6]  He is also in the process of recording a series of YouTube videos, Dr Bernstein’s Diabetes University. [7]  I find it fascinating to hear him talk about his Body By Science-style heavy lifting workouts at eighty-one! [8]

He recommends that people with type 1 diabetes eat no more than 6g of carbohydrate at breakfast, with no more than 12g of carbohydrates at lunch and dinner.  This enables people with diabetes to stay off the blood sugar roller coaster and manage their blood glucose levels with smaller doses of insulin.

Bernstein also acknowledges that protein requires insulin, [9] however, for the most part he accounts for this by eating consistent meals and refining insulin doses based on blood glucose measurement after each meal.

Troy Stapleton

I had the privilege of meeting Dr Troy Stapleton at a screening of Cereal Killers [10] in Brisbane in August 2014 where he was on a panel fielding questions after the movie.  After the session we cornered him for about an hour.

It was inspiring for us to see someone thriving with type 1 diabetes.  At the time my wife Monica was struggling to even think of working because she didn’t have the energy to make it through the day without an afternoon nap before picking up the kids from school.  But here was Troy successfully running a radiology department!

The photo below shows Troy (right) with Tim Noakes [11] (centre) and Ron Raab [12] (left) when they debated Carbohydrates – Victims or Villains at the  Annual Scientific Meeting of the Australian Diabetes Society and Australian Diabetes Educators Association in Melbourne in August 2014.

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I got to catch up with Troy again at the Low Carb Down Under seminar in Brisbane in November 2014. [13]  His presentation was excellent and I got to spend some time with him during the Steve Phinney masterclass [14] the next day.  He warmly asked how Moni was doing and took a real interest in helping us on our journey.

Troy’s story is worth checking out if you have not seen it yet.

There is nothing confrontational about Troy’s approach.  Troy just eats real whole healthy food.  Troy  just shows what can be done and gets on with doing it.

Rather than saying that everyone should do what he is doing he just says that people should be educated about the options and given the choice.

As well as following Bernstein and Taubes he’s also a fan of Mark Sisson’s primal / Paleo approach and likes to check everything against the evolutionary template rather than relying on associational studies.

When he initially self-diagnosed himself with type 1 diabetes and he went to the endocrinology department of his hospital, they told him to eat 240g of carbs each day and cover it with insulin.

Troy says “Within one week I went back to ask about low carb but was told I needed carbs and that low carb would not work. I continued reading for the next 2 months and became increasingly convinced that low carb was the way to go. I switched to low carb in December 2012 and have never looked back. My blood glucose lowered and stabilised, my insulin dose reduced, my hypos almost vanished and my depression/anxiety resolved.”

He explains how he has been able to extend the ‘honeymoon phase’ [15] of his type 1 diabetes in spite of having the disease for two and a half years.  By keeping his carbohydrates low he is able to maintain the function of the beta cells of his pancreas.    At this point in time he only needs to dose with long acting insulin, and with only an occasional bolus of insulin with a meal.

Unfortunately people newly diagnosed with type 1 diabetes often burn through their remaining pancreatic beta cells by following the standard dietary guidance and hence their ‘honeymoon phase’ is short (and sweet?), with insulin doses increasing as the pancreas gives out and insulin resistance progressively worsens.

Troy told me his HbA1cs are running in the low fives.  His diabetes is controlled with long acting insulin, a low insulin load diet and regular cycling and surfing which he loves!  He said if his HbA1c starts to drift up in the future he will add more regular insulin boluses with meals.

Dave and RD Dikeman

I came across Dave Dikeman and his father RD Dikeman via episode 831 of Jimmy Moore’s LLVLC show. [16]  I still remember nine year old Dave saying “finger pricks now or amputations later, the choice is pretty simple”.

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It seemed so clear and logical for young Dave.  However, what he was saying was radical to us after muddling around with mainstream advice for diabetes and no clear direction on how to achieve excellent blood sugar control.

Dave’s father, RD, is a theoretical physicist and chief scientist for Department of Defence contractor Lockheed Martin.  RD became passionate about diabetes after finding Dr Bernstein’s book, and after floundering with standard diabetes advice in the months following diagnosis.

Dave is now thriving on the Bernstein plan which includes lots of protein foods for growing kids.

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Like many family members of diabetics who find low carb, RD he also has his own story of how a reduced carbohydrate diet has helped him to turn his health around.

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The continuous glucose metre plot below shows RD’s own blood glucose levels after a few years of implementing Dr Bernstein’s advice in his family.

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This article by RD and Dave [17] offers a fascinating window into their thinking and the secrets of their success in managing type 1 diabetes.  Their analysis demonstrates that it is not possible to achieve normal blood sugars with large amounts of carbohydrate in the diet.

“It would be impossible for an artificial pancreas based on a CGM and automated insulin dosing via a pump – both of which have inherent lags – to respond quickly enough to high blood sugars caused by large doses of carbohydrate before unsafe levels of hyperglycemia occur.”

The Dikemans set up the TYPEONEGRIT Facebook group [18] to support others with type 1 diabetes on the journey following Bernstein’s protocols.  As recommended by Troy Stapleton, we joined the group late last year  and I can’t say enough about how helpful it has been to see people actually implementing Bernstein’s recommendations in day to day real life.

It is one thing to read the theory, but it’s a whole different thing to see all these people with flat line blood sugars, be able to ask lots of ‘dumb questions’ and share day to day struggles of what is a fairly radical departure from what most people consider ‘normal’.

Once you see the theory in practice you realise that you might be able to do it too.  When you see these healthy, vibrant passionate people you stop worrying about whether you’ll have a heart attack tomorrow due to the high fat diet.

The Dikemans also produce Dr Bernstein’s Diabetes University [19] which is getting the word out to a whole new audience through YouTube videos of Dr B.

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Lisa & Daniel Scherger

Lisa Scherger is a lady with a fire in her belly when it comes to managing her son Daniel’s type 1 diabetes!  If you haven’t seen her short presentation from the Low Carb Down Under seminar in Brisbane in November 2014 [20] make sure you take the time to do it now!

Lisa recently obtained a Dexcom continuous glucose metre [21] which has enabled them to take blood glucose management to a new level and further refine their dosing for protein.

On Lisa’s blog [22] she recently shared her ‘secret’ to flat line blood sugars and how to deal with the blood glucose ‘spike’ caused by protein.

So, for the carbs and fibre I bolused 40 minutes before dinner. Then I bolused for the protein conversion to glucose (gluconeogenesis) 1 hour after the end of the meal so that the insulin would start circulating around the time the spike was due to occur.

Lisa is adamant that accounting for protein in addition to carbohydrates is critical to optimising blood glucose control.

Last night I forgot to set my alarm to do the protein bolus, and I was up until 4am trying to get blood glucose levels down. Daniel’s protein spike starts exactly 2 hours after the meal, and once it starts I can’t stop it. He needs to inject for the protein 1.25 hours after the meal so that the insulin is circulating at the right time.

Learning to dose for protein as well as carbohydrate is a learning curve.  Getting flat line blood sugars typically takes some trial and error to refine and perfect.

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However the results of Lisa’s attention to detail speak for themselves, with an HbA1c consistently less than 5.0%…

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…and a son who is thriving in both his academic and athletic pursuits.

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Angela Erickson

Angela is another member of the TYPEONEGRIT Facebook group who recently completed an eighty hour fast in an effort to reset her insulin sensitivity.  During the fast she was measuring ketone levels of up to 3.4mmol/L and soon after recorded an HbA1c of 4.7%.

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When I asked her what she would say were the secrets of her success were she said:

  1. learning my proper formula for protein that works for me,
  2. exercise, and
  3. fasting.

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Angela boluses for carbohydrates 15 minutes before the meal and then doses for the protein 1.5 hours after the meal using the pump, or two hours after with a faster acting intra muscular (IM) shot.

As well as ‘barely eating carbs’ she also manages her protein to make sure it’s not excessive, averaging about one gram per kilogram of body weight per day.

Angela also said she boluses to correct back to 83mg/dl (4.6mmol/L) whenever she hits 90mg/dL (5.0mmol/L) unless she has eaten within the past two hours.

Fasting is not a critical piece of Dr Bernstein’s regime, however, Angela found that she was able to improve her insulin sensitivity with periods of fasting.  After one day of fasting she found she had to decrease her basal rates to 70% and to 50% after three days of fasting.  And this improved insulin sensitivity continued after the fasting was over.

Periods of fasting can be useful for people with type 1 diabetes to refine their basal rates.   Similarly, fasting can also reset insulin resistance for people who do not have type 1 diabetes.  The fact that you can see it numerically on an insulin pump is a clear demonstration of what is occurring in the rest of the population after they fast.

When I asked whether she thought the fasting or the low insulin load diet was most important she said, “I’m not sure which is more important. I think ketones are powerful healers.  I feel somewhat euphoric after longer fasts and it gives my body a break.  I’m trying to heal and drop my few extra pounds.”

Lucy Smith

We met this gorgeous family at the Type 1 GRIT picnic in Brisbane recently.  Lucy is the one in the middle in the photo below with her new diabetes alert dog in training.

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The photo below shows Lucy with her hospital food when she was diagnosed with type 1 diabetes a bit over a year ago.  Let’s just say she doesn’t eat like that any more.

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This video of Lucy’s first year with type 1 diabetes is a touching insight into what it’s like for a young person to live with type 1 diabetes.

The Smiths are part of the CGM in the cloud crew [23] who have managed to hack their daughter’s CGM via an Android phone in her backpack that broadcasts her blood glucose level every five minutes to the cloud.  The most amazing thing about all this is that it has been created as an aftermarket hack by parents. DEXCOM have rushed the DEXCOM Share to market to keep up with this technology (US only).

Both her parents and Lucy’s teacher wear a pebble watch [24] with the Nightscout app [25] on it that that enables them to see Lucy’s current blood sugar level.  If they see it’s going out of range the parents will SMS her teacher who usually advises that she has just done a finger prick  and is treating the low.

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And it’s working!  Though at 4.8%, Lucy’s last HbA1c was outside the target range of 7.8-8.5 for someone her age!

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Allison Bleckley Herschede

Alison is one of the admins of the TYPEONEGRIT Facebook group [26] and coaches the nearly one thousand members who have type 1 diabetes and their carers towards achieving better blood sugar control.

When it comes to dealing with protein, Allison practices what some refer to as ‘sugar surfing’ [27] with a bolus given for carbohydrates with the meal.  She then watches her CGM and doses with small ‘micro doses’ to bring blood sugar back down if it goes above 93mg/dL (or 5.2mmol/L).

The difference for Allison though between normal ‘sugar surfing’ and her Bernstein-influenced approach is that she keeps her carbohydrates low so the ‘waves’ are more like ripples that are easier to manage.

Allison has developed some guidelines for achieving an excellent HbA1c, including:

  1. Target 4.6mmol/L (i.e. 83mg/dL).
  2. Veggies and protein before carbs.
  3. Multiple injections may be necessary for a high protein meal. Watch the CGM two to three hours post meal.
  4. If female, modify basal rates around monthly cycle.
  5. Take insulin sensitising supplements R-Alpha Lipoic Acid, Biotin, Chromium.
  6. Take one unit bolus upon waking to account for the Dawn Phenomenon. [28]

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You can read more about Allison’s journey with type 1 on her My Primal Nest blog including her experience with type 1 diabetes and pregnancy.

Recently she recorded these videos demonstrating how to use a home HbA1c metre…

… and her own surprise at the result is priceless.

In the comments to these videos where she showed that she’d clocked HbA1c of 4.4% she said “…I’m doing this fasting diet thing. Less than 800 cal, 5 days on 2 off. Supposed to mimic the fasting state. Well my insulin needs have greatly dropped.  It’s nuts.”

our journey

We are still on the journey but we learned so much from these awesome people!

My wife Monica has done an awesome job implementing the recipes posted on the TYPEONEGRIT Facebook group in our kitchen and has made low carbohydrate cooking a delicious art form.  After three decades of HbA1cs of around 8% she is now under 6% and the improvement in quality of life is enormous!

The greatest improvement to date for our family has been following a reduced insulin load diet which means that the insulin dose for food and correcting insulin dose is lower overall and the fluctuation in blood glucose levels are greatly reduced.

After seeing the success of all these people with CGMs, we’re now looking at getting a DEXCOM CGM for Moni, although unfortunately there are no subsidies in Australia so it’s not cheap!

It’s never going to be perfect, but when the correcting doses are smaller you’ve got a better chance of having more stable blood sugars.

The improvements to date have enabled Monica to have the energy to work as a supply teacher pretty much full time while still doing a great job of looking after the family!

When her blood sugars are under control she needs much less sleep, and her mood and energy levels are much better.

It’s always a journey.  You don’t arrive.  It’s a constant challenge.

Is it worth it?  Yes it is!  The quality of life for our whole family has seen a massive change and we’re eager to keep it moving forward.

 

references

[1] https://t1dexchange.org/pages/

[2] https://www.facebook.com/groups/660633730675058/

[3] http://www.diabetes-book.com/

[4] http://www.thelivinlowcarbshow.com/shownotes/7930/683-llvlc-classic-low-carb-diabetes-doctor-richard-bernstein/

[5] https://www.youtube.com/watch?v=WFNGdKSXx64

[6] http://www.diabetes-book.com/

[7] https://www.youtube.com/channel/UCuJ11OJynsvHMsN48LG18Ag

[8] https://www.youtube.com/watch?v=Z80-c0CXYqc

[9] https://www.youtube.com/watch?v=ctaaN9U3sGQ

[10] http://www.cerealkillersmovie.com/

[11] http://www.thenoakesfoundation.org/prof-noakes

[12] http://www.diabetes-low-carb.org/about-ron.html

[13] http://www.lowcarbdownunder.com.au/events/low-carb-brisbane-november-22nd-2014/

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

[15] http://www.diabetes.co.uk/blood-glucose/honeymoon-phase.html

[16] http://livinlavidalowcarb.com/blog/the-llvlc-show-episode-831-dave-dikeman-is-a-10-year-old-type-1-diabetic-on-fire-for-low-carb-living/22923

[17] https://myglu.org/articles/our-journey-with-the-low-carb-diet-and-the-manual-artificial-pancreas

[18] https://www.facebook.com/groups/660633730675058/

[19] https://www.youtube.com/channel/UCuJ11OJynsvHMsN48LG18Ag

[20] http://www.lowcarbdownunder.com.au/events/low-carb-brisbane-november-22nd-2014/

[21] http://www.dexcom.com/au

[22] http://diabeticalien.blogspot.com.au/2015/04/preventing-protein-spike.html

[23] https://www.facebook.com/groups/cgminthecloud/

[24] https://getpebble.com/#/.0kvx26:Fuqt

[25] http://www.nightscout.info/

[26] https://www.facebook.com/groups/660633730675058/

[27] http://stephenpondermd.com/

[28] https://en.wikipedia.org/wiki/Dawn_phenomenon

is this really all so important?

When my wife Monica was diagnosed with type 1 diabetes at ten she was advised to eat at least 130g of carbohydrates with every meal.

The insulin dose was kept fixed to cover this fixed amount of carbohydrates.  If she went low she had to eat more carbs to bring her blood glucose back up.

Welcome to the everyday blood sugar roller coaster that takes over your life when you have diabetes!

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It wasn’t till after we were married in 2002 and started thinking about having kids that she found a doctor with an interest in diabetes who told her that she could tailor her insulin dose to what she wanted to eat.

Up until this time even the visits to the endocrinologist were to get more scripts for insulin and thyroid medication.  No useful advice was provided about how to manage diabetes.

It’s amazing that the concept of carbohydrate counting was new and shiny in 2003 when Richard Bernstein developed the concepts back in 1970s!

Today, the standard of care for diabetes seems to have incorporated Bernstein’s carbohydrate counting, however the nutritionists and diabetes associations still advises that diabetics should not have to deprive themselves of any food in the pursuit of health.  And like everyone else, they should eat a diet full of “healthy whole grains”.

It wasn’t until we discovered Paleo and then low carb through family members and social media that she found that she could improve blood sugar control through diet.

More recently by refining our diet to prioritise low insulin load, high fibre and high nutrient density foods I’m pleased to say that she has been able to find another level of improved blood sugar control, increased energy and reduced depression and anxiety that so often comes with blood sugar dis-regulation.

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It is still not easy and we are still learning, however she is now able to enjoy working as a supply teacher rather than just getting through the morning and needing to sleep during the afternoon before picking up the kids from school.

Her big regret is that she did not discover this earlier, which would have saved her from spending decades living in a fog with limited energy.

The chart below shows the difference diet can make in the management of blood glucose, particularly for a type 1 diabetic (notice that these plots are only two months apart!).  People who find success with this dietary approach find a substantial improvement in quality of life and their state of well being that makes it well worth the effort.

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Below is a recent post on the TYPEONEGRIT Facebook group from a mother of a type 1 diabetic child describing their interaction with her health care team.  It’s still not simple to go against the main stream dietary advice.

We had our team meeting today to discuss LCHF…  they are so terrified of this, even though we have great BG readings, behaviour improvements and learning improvements (noted by us, family, friends and his school) which they didn’t even acknowledge.

The nutritionist is concerned that he won’t be getting the micronutrients that only come from grains and the higher carb vegetables (grains are fortified), then her concern was the B vitamins 1, 3 and 6. 

Then the concern about Iron (what?! have you seen the meat and spinach listed?). Then it was calcium and magnesium (clearly they don’t have a clue about LCHF).

They said they are afraid this diet may cause future developmental harm. We said your diet WILL cause future harm and way more than developmental. Back and forth and on it went. We addressed their concerns with peer reviewed research, and respect to their limited knowledge.

We will be an open book and comply because I want them to learn that T1D care can be so much better than it has been up to now, and pave the way for the next families that wishes to do LCHF.

They will check for vitamins and minerals at his 3 month blood work (again special for our case, which we have to pay for).

The good news here is that after running an intense battery of tests they decided to use this child as Canada’s first case study in LCHF paediatrics for the management of type 1 diabetes.

This post inspired me to run some numbers on a range of diets to see whether there was any issue with the nutritional content of higher fat diets.   It turns out that diets with higher levels of fat can be very nutritious while the grain based diet that everyone is recommended does very poorly, particularly when you take the insulin of these higher carbohydrate diets into account (see the Diet Wars… Which One is  Optimal article for more details).

It breaks my heart to see diabetics living with a highly diminished quality when there is the potential to greatly reduce the impact of diabetes by more informed food choices.

For people with diabetes and their carers diet is important and maybe a matter of life and death, or at least a decision that will greatly affect their quality and length of life.

physiological insulin resistance and coffee addiction

I have a confession…  I like coffee.

I like coffee in the morning.

I like coffee in the afternoon.

I like coffee black.  I like it white.

I like it with sugar, with chocolate, or just plain.

I like the taste of coffee.

I like the way it makes me feel and helps me stay focused.

getting more out of my coffee

Do you know how I could enjoy coffee more?

I could stop drinking so darn much of it, that’s how.

If I drank less coffee I would restore my sensitivity to it.

It would then give me more of a hit when I did occasionally have it.

getting less out of my insulin

In a similar way that many of us have become addicted to coffee that leaves us less sensitive to the impact of caffeine, many of us have also become addicted to cheap processed simple carbohydrates that leave us insensitive to insulin.  We become more sensitive to carbohydrate and insulin if we have less of it.

the physiological insulin resistance straw man argument

One of the criticisms that is levelled at low carbohydrate diets is that it causes what is called ‘physiological insulin resistance’.

This can mean that a person who is restricting carbohydrates may end up with higher fasting blood sugars and may have higher blood sugars after a higher carbohydrate meal.

Check out this video to see how some interpret ‘physiological insulin resistance’ to be a bad thing and a reason to eat lots of carbohydrates.

diabetes diagnosis criteria

There are a number of factors that are considered in the diagnosis of someone with type 2 diabetes: [1]

  1. HbA1c, which is a measure of your average glucose over the past three months,
  2. random blood sugar,
  3. fasting blood sugar, and
  4. oral glucose test.

what is physiological insulin resistance?

One of the clearest explanations of physiological insulin resistance I’ve seen comes from Paul Jaminet who says that physiological insulin resistance is a protective response of the body that ensures that the brain gets the benefit of a limited supply of glucose.

Because the rest of the body is refusing to take up glucose, and the liver takes it up slowly, a meal of carbohydrates is followed by higher blood glucose levels in someone on a low carbohydrate diet.

The human body is very adaptive to different situations and different fuel sources.  Just because our reference data is from the past few decades when we have typically eaten large amounts of processed carbohydrates, we take that as the new normal.

Is physiological insulin resistance such a bad thing?

Maybe, maybe not.

Let’s look at what this means when it comes to the various tests that are done to diagnose diabetes.

oral glucose tolerance test

Yes, you may fail an oral glucose test if you are on a low carbohydrate diet due to physiological insulin resistance.  But this guy will probably see a rise in his blood sugars too if you fed him the equivalent of two cans of Coke in one hit. [2]

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If you have a large dose of fast digesting carbohydrates your body is not primed to dump a pile of insulin into the system.  It takes a while to wind up and adjust to large amount of carbohydrates. You also don’t have a high level of insulin washing around in your system from the last pizza meal.

It’s sort of like me and my coffee addiction.  Because there is not a lot of time when I don’t have some caffeine in my system I am not as sensitive to caffeine as I would be if I only had an occasional cup.

If you do want to pass an OGTT all you have to do is increase your carbohydrates for a few days before the test and your pancreas will increase the amount of insulin in your system and be better prepared for a high dose of carbohydrates. [3]

fasting blood sugar

Some people may find that their fasting blood sugars rise a little when they start consuming more fat and decrease carbohydrates, particularly if they increase their fat intake.

This is an area where your mileage may vary.  I have seen some people run at very low carbohydrate levels and end up with progressively higher fasting blood sugars.  Others see their fasting blood sugars continue to come down and ketones go up as they decrease the insulin load of their diet.

When on a lower carbohydrate diet you won’t have high levels of insulin floating around in your system and your body may choose to run blood glucose levels a little bit higher by secreting more glucose from the liver.  This is not really a problem if you feel OK.

Many people find this to be a passing phase and after a time of keeping the insulin load of their diet low see their blood sugars come down.

As you keep the glucose load of your diet low you will ‘dry up the root’ and eventually after glucose stores in the liver are depleted, your fatty liver is resolved and your body fat levels are reduced you just won’t have as much glucose available for your liver to keep pumping into your bloodstream.

If you find that you don’t feel good at very low carbohydrate levels then by all means increase your carbohydrates and protein particularly to ensure that you are getting adequate nutrition.  Check out the Goldilocks glucose zone article for more thoughts on how to find the right level of glucose for you.

Most people find that their calorie intake decreases with a LCHF approach, however as this study from Dr Thomas Syfriend shows long term excess calories even with a high fat diet is probably not going to end well.  Intermittent fasting or tracking your calories to make sure you’re not overdoing the butter may be helpful if you’re not achieving normal fasting blood sugars.

random blood sugar

Carbohydrates are the most potent thing that raises blood sugar.  If you are on a low carbohydrate diet chances are your random blood sugar (i.e. non-fasting) will be much lower than if you were on a high carbohydrate diet.

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With a smaller amount of dietary carbohydrates you should see much lower post meal blood sugars.

Generally the small amount of insulin that you generate after meals will bring your blood sugar down quickly.

HbA1c

With lower post meal blood sugars your average blood sugar will likely be much lower on a low carbohydrate diet.  Therefore your HbA1c, which is a measure of your average blood sugar over three months, [4] should be lower.

insulin levels

We are now understanding more and more that insulin resistance is public health enemy number one.  Insulin resistance is a better predictor of heart disease than HDL, LDL, BMI and smoking! [5]

Making sure you have some time when high levels of insulin are not floating around in your blood stream will help increase your insulin sensitivity and enable your body to manage your blood sugars.

Consistently high levels of carbohydrates will ensure that your insulin resistance stays high!

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I am probably not going to stop drinking coffee any time soon, but in view of the evidence I do try to make sure that I have periods where I give my body a chance to restore its sensitivity to insulin!

If you are interested in reducing your insulin load while ensuring that you achieve great nutrition that supports your goals, check out this list of optimal foods and meals.

 

[1] http://www.webmd.com/diabetes/tc/criteria-for-diagnosing-diabetes-topic-overview

[2] 1922 photograph of an Aboriginal hunter (from the National Museum of Australia) via http://www.primalbody-primalmind.com/the-australian-indigenous-health-project/ .  It’s sad to see how the Aborigines in Australia have done on the white man’s diet when they were such a proud healthy people before we came along!

[3] http://www.marksdailyapple.com/does-eating-low-carb-cause-insulin-resistance/#axzz3besTwOta

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

[5] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628708/pdf/361.pdf

the Goldilocks glucose zone

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

background

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

the Goldilocks glucose zone

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

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

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

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

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

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

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

Not too hot.  Not too cold.

Not too hard.  Not too soft.

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

the safe starches debate

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

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

the case for limiting carbohydrates

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

1. Non-fibre carbohydrates are:

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

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

natural glucose utilisation level

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

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

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

image001

some perspective

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

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

image003

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

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

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

minimum carbohydrate requirement

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

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

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

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

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

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

image005

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

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

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

what is the minimum protein requirement?

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

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

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

three macros or two fuel sources?

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

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

  glycogenic ketogenic both
non-essential Alanine

Arginine

Asparagine

Aspartate

Cysteine

Glutamate

Glutamine

Glycine

Proline

Serine

Tyrosine
essential Histidine

Methionine

Valine

Leucine

Lysine

Isoleucine

Phenylalanine

Tryptophan

Threonine

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

the “well formulated ketogenic diet”

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

image007

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

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

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

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

the Goldilocks glucose zone

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

approach glucogenic calories insulin load (g) glucogenic (%)
 glucose utilisation  (Jaminet) 600 150 26.7%
 ketogenic threshold (Phinney) 500 125 22.2%
 ketogenic maintenance (Jaminet) 300 75 13.3%
 starvation (Chaill) 160 40 7.1%
  • The glucose utilisation is Jaminet’s approximation of the glucose calories used by a non-ketogenic person each day. If we run above this level our glycogen stores will become overfull, with excess glucose spilling into the blood, requiring insulin and being stored as fat.  Below this level we need to obtain some of our glucose from protein via gluconeogenesis.
  • The ketogenic threshold represents the theoretical boundary between the WFKD and the rest of the world according to Phinney’s protein vs carbohydrates plot. Below this point our glycogen stores will become depleted to a point that we be forced to rely on our protein and fat stores for energy rather than carbohydrate.  After a period of consuming less carbs than required to keep our glycogen stores topped off we will start to show ketones in our blood and rely on ketones and fat more than glucose.  This level is about 500 calories per day which is about 22% of a 2250 calorie per day diet.
  • The ketogenic maintenance level is based on the 300 calories per day that Jaminet says we need from glucose if we are fat adapted. With a greater proportion of energy coming from fat in the form of ketones we require less glucose for brain function.
  • The starvation level represents what people can survive on as an absolute minimum. In this extreme starvation state the body is cannibalising muscle via gluconeogenesis to convert to glucose to survive.  This is not something I recommend you try at home.  However it is useful to know that the body can survive (but not necessarily thrive) at very low levels of glucose for a significant period of time.

The chart below shows these glucose levels superimposed on a plot of protein versus carbohydrate.  The points on the left hand side of the chart labelled with calorie values represent the point at which all glucogenic calories come from carbohydrates with only the minimum 7% protein for maintenance ingested (i.e. no “excess” protein). Microsoft Word Document 19052015 35145 AM.bmp

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

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

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

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

what about the Kitavans?

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

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

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

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

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

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

comparison of dietary approaches

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

image011

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

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

image014

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

what is our light on the horizon?

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

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

image016

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

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

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

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

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

what gauges do we use to steer the boat?

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

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

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

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

image017

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

image017

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

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

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

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

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

image021

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[18] http://thenoakesfoundation.org

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

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

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

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

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

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

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

the carbohydrate debate

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

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

Chrome Legacy Window 22032015 14339 PM.bmp

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

image002

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

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

image003

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

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

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

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

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

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

mainstream recommendations

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

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

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

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

the middle ground?

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

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

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

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

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

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

image014

the big picture

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

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

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

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

image015

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

so just tell me what to do!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

diabetes 102

  • Elevated insulin and blood glucose levels are associated with a wide range of health issues including obesity, mental health, cancer, cardiovascular disease, and stroke.
  • “Normal” blood sugars are not necessarily optimal for long term health.
  • Most people are somewhere on the spectrum between optimal blood sugars and full blown type 2 diabetes.
  • Maintaining blood sugars close to optimum is possibly the most important thing you can do to manage your health, reduce body fat, and slow ageing.
  • A diet with a low insulin load will lower blood glucose and allow you to access your body fat for energy.

what is diabetes?

“Diabetes” refers to a group of metabolic diseases where a person has high blood sugars over an extended period of time.

Type 2 diabetes occurs when people become insulin resistant and their blood sugars drift higher.  The generally accepted diagnosis levels for type 2 diabetes are:

  fasting after meal
  (mg/dL) (mmol/L) (mg/dL) (mmol/L)
“normal” < 100 < 5.6 < 140 < 7.8
pre-diabetic 100 – 126 5.6 to 7.0 140 to 200 7.8 to 11.1
type 2 diabetic > 126 > 7.0 > 200 > 11.1

Currently one in twelve adults worldwide are classified as diabetic based on this diagnostic riteria.  This number is forecast to grow by more than half over the next two decades to 592 million people by 2035. [1]

Approximately ten percent of people classified as diabetic have type 1 diabetes which is a condition where a person’s immune system attacks the cells in their pancreas and from that time on they have to inject insulin to survive. [2]   While less common, we can learn a lot from type 1s who successfully manage their blood sugars.

what are the risks?

Low carb health advocates such as Dr David Perlmutter, [3] Nora Gedgaudas [4], Dr Ron Rosedale [5] and Dr William Davis [6] tell us that we should restrict carbohydrate for metabolic and brain health as well as to prevent a range of diseases.

Hba1c [7] is a test that gives an indication of your average blood sugar over the past three months.  The chart below shows one of the more confronting charts from Dr Perlmutter’s Grain Brain [8] demonstrating that the rate of brain shrinkage with age increases with increasing blood sugar.Chrome Legacy Window 22032015 14339 PM.bmp

This chart shows that an increase in HbA1c is also associated with an increased risk of cancer.

image002

This chart shows that here is a very close relationship between insulin secretion and body mass index (BMI).

jcinvest00481-0161.pdf - Adobe Reader 23042015 33022 AM.bmp

These charts show that the risk for cardiovascular disease, coronary heart disease and stroke all increase with higher blood sugar levels.

image003

Antidiabetic medication, even if it reduces your blood sugar, doesn’t help reduce your risk of cardiovascular disease, which is the number one cause of death globally.

The link between your blood glucose control and your chance of requiring a cardiac bypass is hard to argue with. [22]

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Keeping your blood sugar under control is possibly the most important thing you can do to manage your health, manage body fat, gut health, reduce your risk of cancer [11] and slow aging, regardless of whether you have been formally diagnosed with diabetes. [12] [13]

Diabetes is expensive.  In 2012 it cost the US a quarter of a trillion dollars in hospital costs and lost productivity [14] and the cost of “diabesity” is forecast to triple by 2050 grow and become a major burden our economy.

what are optimal blood sugars?

If you’re not a diabetic getting your HbA1c checked by your doctor regularly you can use your average blood sugar values from a home blood glucose metre to see how you’re tracking compared to optimal.  Blood glucose metres are available readily online or at your local chemist.  You can pick them up for less than $10.  The higher end ones will also measure your blood ketone levels. [15]

The conversion between HbA1c and average blood sugar are shown in the table below.  I have also shown various risk levels based on the cardiovascular disease data above.  If you want to calculate your average blood sugar simply take the average of all your blood sugar tests – fasting, before meals and after meals.

risk level HbA1c average blood sugar
 (%)  (mmol/L)  (mg/dL)
optimal 4.5 4.6 83
excellent < 5.0 < 5.4 < 97
good < 5.4 < 6.0 < 108
danger > 6.5 > 7.8 > 140

Comparing the diabetes diagnosis criteria in the first table with these optimal levels it’s clear that blood sugars that are considered “normal” are far from optimal.

By the time you’re “pre-diabetic” you’re well into the danger zone.  By the time your blood sugars become elevated it’s likely that your pancreas has been trying to pump out extra insulin for some time and you are well and truly losing the battle of metabolic health.  Dr Ron Rosedale says that if you’re exposed to modern processed foods then it’s likely that you are somewhere on the spectrum between optimal and full blown diabetes. [16]

Doctor Richard Bernstein recommends an ideal blood sugar of 83mg/dL (or 4.6mmol/L) for type 1 diabetics. [17]  Paul Jaminet notes that the optimal range for blood sugar is between 70 and 100mg/dL (3.9mg/dL and 5.6mmol/L). [18]

A type 1 diabetic will carefully balance their carbohydrates and insulin doses throughout the day to try to keep their blood sugar within this narrow range.  However this is impossible on the diet recommended to them in line with the Food Pyramid / MyPlate with lots of “healthy whole grains”.

The continuous glucose monitor plot below shows the typical blood sugar roller coaster experienced by a type 1 diabetic.  This style of blood sugar fluctuation occurs to some extents in all of us to some degree, depending on our diet and our insulin sensitivity.

image004 - Copy (2)

what does insulin do?

The hormone insulin allows us to clear excess sugar from the blood and store it for later as body fat.  This adaptation was a great advantage for our ancestors who would consume sweet fruits in summer and store some body fat for winter.   It’s said that our ability to store fat via insulin enabled your ancestors to survive through the ice age. [19]  The people who couldn’t do this so well aren’t your ancestors, if you know what I mean.

Achieving nutritional ketosis is all the rage these days, but what it means in simple terms is that you have low enough levels of insulin to enable stored body fat to be used for energy. [20]  If your insulin levels are too high you’ll end up storing more of your food as fat.  You’ll then need to eat extra to make it through the day. [21]

In the next article we’ll look at what you can do to normalise your blood glucose levels by choosing foods with a low insulin load.

references

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

[2] http://en.wikipedia.org/wiki/Diabetes_mellitus_type_1

[3] http://www.drperlmutter.com/

[4] http://www.primalbody-primalmind.com/about-nora-gedgaudas/

[5] http://drrosedale.com/#axzz3TzvVehTb

[6] http://www.wheatbellyblog.com/

[7] http://www.diabetes.co.uk/what-is-hba1c.html

[8] http://www.amazon.com/Grain-Brain-Surprising-Sugar-Your-Killers/dp/031623480X

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

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

[11] http://freetheanimal.com/2009/02/sugar-feeds-cancer.html

[12] http://chriskresser.com/how-to-prevent-diabetes-and-heart-disease-for-16

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

[14] http://care.diabetesjournals.org/content/36/4/1033.full

[15] http://www.ebay.com.au/itm/like/251841014229?limghlpsr=true&hlpv=2&ops=true&viphx=1&hlpht=true&lpid=107&chn=ps

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

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

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

[19] http://www.primalbody-primalmind.com/

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

[21] https://www.youtube.com/watch?v=Yo3TRbkIrow

[22]  http://www.cardiothoracicsurgery.org/content/3/1/63