Tag Archives: insulin resistance

does insulin resistance REALLY cause obesity?  

Many people believe that insulin resistance causes obesity. But as you’ll see in this article, it may very well be the other way around.

Excess body fat appears to drive insulin resistance.  But first, your fat cells need to be insulin sensitive to fill and expand beyond your Personal Fat Threshold.

Once your adipose tissue becomes resistant any excess energy is then shunted into your bloodstream and vital organs, leading to the most prevalent modern diseases such as diabetes, heart disease, Alzheimer’s and Parkinson’s.

What does insulin do?

There is a lot of focus at the moment in some circles on insulin and how to minimise if not eliminate it.  But we need to keep in mind that insulin actually performs a range of critical functions in your body, such as:

  • Facilitating the use of protein to build and repair our muscles and organs,
  • Acting like a brake on our liver to regulate the release of glucose into the bloodstream,
  • Storing excess energy (ideally in our adipose tissue) for later use, and
  • Suppressing the use of our body fat (lipolysis) while the energy from your food is used up.

What happens if we have no insulin?

You may not always like the fat storing function of insulin, but we have to take the good with the bad.  We simply cannot live without it.

Not producing enough endogenous insulin is called type 1 diabetes.  If you develop type 1 diabetes you will:

  • Not be able to use protein to build your muscles and vital organs,
  • Experience elevated blood sugar levels as your liver produces excess glucose,
  • Experience uncontrolled lipolysis, meaning that your fat stores will be quickly mobilised, and
  • Experience elevated blood glucose and BHB ketones (a.k.a. diabetic ketoacidosis).

You may be a little bit jealous of people with type 1 diabetes, thinking that if you could only decrease your insulin a little bit, you’d lose weight.

But having zero insulin is a life-threatening situation.  It’s been less than a century since we’ve been able to treat people with type 1 diabetes (like my wife Monica) with exogenous insulin to keep them alive.

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As shown in the photos below, people with uncontrolled type 1 are essentially falling apart.  They are quickly leaching their stored energy into their bloodstream via uncontrolled gluconeogenesis and lipolysis.

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However, as demonstrated in the ‘after’ photos on the right-hand side, once they receive insulin treatment, people with type 1 are able to use the energy from the food they eat, and no longer consume their muscles for fuel.

The most successful approach for people with type 1 diabetes tends to involve fewer carbohydrates without limitations on protein, particularly for growing children.

Adequate insulin dosing is critical to maintaining healthy blood sugar levels as well as enabling the use of protein for growth, repair and maintenance of muscle.

A more modern example is Dave Dikeman, son of RD Dikeman who is one of the admins of Type 1 Grit who follow Dr Bernstein’s recommendations for the treatment of diabetes.

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Dave is shown here in hospital after diagnosis and below recently with his dad.  While some people warn nitrogen poisoning, Dave seems to be thriving on about 250g of protein per day (i.e. about 4.7 g/kg LBM).

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Getting adequate insulin to metabolise the protein required for growth and repair while limiting carbohydrates to maintain normal blood sugar levels appears to be crucial to success for people with diabetes.

What happens if I am insulin sensitive?

Being “insulin sensitive” means that don’t need much insulin to get the job done.

  • Glucose can enter your cells to be used for energy.
  • Your liver responds to insulin and controls the release of glucose and ketones into the bloodstream.
  • You will build muscle relatively easily.
  • Your body can efficiently store excess energy as fat, and your adipose tissue can grow quickly.

Having great insulin sensitivity is a double-edged sword.  While you can control the release of glucose and ketones from your liver into your bloodstream and build muscle, you can also build fat stores quickly.   You need to be insulin sensitive to become morbidly obese.

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I used to believe that if I could become insulin sensitive by reducing carbohydrates and protein.  I thought the key to success was to increase my ketones by eating more fat so I could melt away my body fat, a bit like someone with untreated type 1 diabetes.  (There is a practice called diabulimia where some type 1s intentionally restrict their insulin dosing to lose weight, however, this is a very dangerous practice which drives ketoacidosis, fatigue, muscle wasting, high cholesterol and death).

But ironically it turns out that having insulin-sensitive adipose tissue actually enables your body fat stores to expand to accept more and more energy from the food you eat before they start being channelled into other areas of your body.

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People who are obese are often insulin resistant.  However, this is not always the case.  You can be insulin resistant and still be lean.  You can be obese and still be relatively insulin sensitive.  If you are both insulin resistant and obese, the obesity probably came first.

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How do I become insulin resistant?

Professor Roy Taylor has done some fascinating work showing that different people develop diabetes at different body fat levels.[1]  He coined the term ‘Personal Fat Threshold’ to describe this observation.

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For whatever reason, some people develop diabetes at a low level of body fat while other people need to become obese before they experience elevated blood sugars.[2]  Some people are ‘blessed’ with the ability to expand their fat stores a lot more than others before their fat stores become full.

While most people want to be lean with low levels of body fat, the ability to continue to expand your fat stores can be an advantage.  People who could successfully store lots of energy in their adipose tissue were more likely to survive a famine or a long journey in a canoe to settle a new island or continent.  This phenotype is sometimes called metabolically healthy obese.

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Unfortunately, these populations appear to suffer the most when exposed to hyper-palatable nutrient poor insulinogenic western food.   Highly insulin sensitive and primed for storage of available foods, they very quickly become obese and eventually, after gaining a lot of body fat, diabetic.

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They also seem to be genetically programmed to ensure that they survive the next famine more than others, so when given the opportunity they become more ‘addicted’ to these energy-dense obesogenic foods.  For example, sales of Coca-Cola are the highest on a per person basis in Australia’s Northern Territory in where there is a high proportion of indigenous Aborigines.

Even today, when famines are less common, being able to build large energy stores in your adipose tissue is still an advantage.  These people can store more energy on their body before it gets funnelled into places that fat does not belong (e.g. your liver[3], pancreas, heart[4], eyes and brain[5]).

It’s when your fat stores become insulin resistant and cannot store any more energy things get ugly.[6][7]  When your fat stores get full and can not accept any more energy we say they become resistant to the effects of insulin.[8] Your pancreas ramps up its efforts to store energy.

But in spite of the increasing levels of insulin, less and less energy can be forced into fat stores.  It’s at this point that the excess energy starts to get funnelled into areas of your body that are now more insulin sensitive than your body fat like your liver, pancreas, heart, eyes and brain.

In this video, Ivor Cummins discusses the concept of adipose tissue hypertrophy and how diabetes begins in the fat cells.

I also highly recommend this widely shared podcast with Mike Julian and Alex Leaf, where they share their insights.

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Like many of my posts, most of the insights in this article are gleaned from them based on the latest research that they share in the Optimising Nutrition Facebook Group.

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If you haven’t seen it yet, this video from Ted Naimin is a must watch on the topic of insulin resistance.

 

 

 

 

People who have lower personal fat threshold are sometimes called TOFI (i.e. thin on the outside, fat on the inside).  These people may look skinny because they have less body fat stored underneath the skin (subcutaneous fat) but they often have lower levels of muscle and much higher amounts of fat stored around their vital organs (visceral fat) and will see elevated blood sugars much earlier.[9]  Being TOFI is arguably more dangerous than to be metabolically healthy obese.

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An extreme example of TOFI is lipodystrophy were people cannot gain body fat and quickly develop diabetes, hyperinsulinemia, fatty liver, hypertriglyceridemia and heart disease because they aren’t able to buffer their energy in their fat stores before it goes to their vital organs.

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So as you can see, if we want to be accurate, it’s not obesity per se that is causing metabolic dysfunction, it is being overfat relative to your Personal Fat Threshold.

Optimal vs insulin resistant blood sugar and ketone levels

As your body fat stores start to fill, you will also see elevated levels of energy in your bloodstream in the form of elevated glucose, ketones and free fatty acids.

The table below shows the official diagnosis criteria for Type 2 diabetes in terms of fasting glucose, blood glucose after eating and HbA1c.

  

fasting

after meal

HbA1c

% pop

mg/dL

mmol/L

mg/dL

mmol/L

 %

“normal”

< 100

< 5.6

< 140

< 7.8

< 6.0%

50%

pre-diabetic 100 – 126

5.6 to 7.0

140 to 200 7.8 to 11.1

6.0-6.4%

40%

type 2 diabetic

> 126

> 7.0

> 200

> 11.1

> 6.4%

10%

However, while the diagnostic criteria define half the population currently as ‘normal’, normal is far from optimal.  If you’re chasing optimal health, the table below shows target blood sugar and HbA1c values that correspond to optimal blood sugar control.

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

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The body tends to find a balance between glucose and ketones depending on available fuel sources.  However, the presence of higher BHB ketones is not necessarily a sign of optimal health.  Higher BHB ketone levels can be a bad sign, especially when they are accompanied by higher blood glucose and free fatty acids.

The chart below shows the sum of about three thousand data points from glucose and BHB ketones measurements for people following a low carbohydrate or ketogenic diet.

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It appears from this data that people who are metabolically healthy tend to have lower blood glucose and lower ketone values, even if they are following a ketogenic diet.  If your goal is to use body fat for fuel, then you will want to be further to the left of this chart with a lower total energy in your bloodstream from glucose and ketones.

Initially, in an energy deficit, you will lose water weight quickly as you empty your glycogen stores, then your blood sugars will reduce.  Then eventually once the faster burning fuel sources are consumed your body will turn to stored body fat.

The table below shows the blood glucose and ketone values if we divide the three thousand data points in the chart above into five quintiles.  It appears that lower blood glucose levels are typically associated with lower ketone levels even on a ketogenic diet.

You may see higher ketone values during a long-term fast or calorie restriction, but generally, ketone levels in the fed state in healthy person on a low carb or ketogenic diet might range between 0.3 and say 1.1 mmol/L with blood glucose less than 5.0mmol/L or 90 mg/dL.

quintile average BG (mmol/L) BG (mg/dL) ketones (mmol/L) total energy (mmol/L)
25th average 75th
1 4.5 80 0.3 0.6 0.7 5.0
2 4.9 88 0.4 0.8 1.1 5.7
3 5.1 92 0.6 1.1 1.5 6.2
4 5.1 92 1.2 1.8 2.3 6.9
5 5.1 92 2.2 3.2 4.0 8.3

To use an engineering analogy, you can think of your liver as dam wall holding back the floodgates of energy in your body while insulin is the signal to raise the floodgates.  If you have a flood of energy coming in your liver will have to release some of the excess energy into the bloodstream.

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If you have lower levels of energy coming in from your diet you will need less insulin to force the liver to hold back the flood of energy stored in your body.

Once you decrease the energy coming in from your diet, your pancreas will be able to slow the production of insulin, which will allow your body fat stores to fill the energy gap.

The ketone data from the recent Virta study[10] below also supports the case for ketones being correlated with body fat levels for people on a ketogenic diet.

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The participants’ ketone levels initially jumped to around 0.6 mmol/L as they switched from a more insulinogenic standard western diet to a ketogenic diet.  But as you can see ketone levels continued to decrease over time to about 0.3 mmol/L as:

  • They lost body fat and then their weight loss stabilised,
  • The amount of energy in their system decreased,
  • Their blood sugars decreased, and
  • Their overall metabolic health improved.

The chart below shows the weight loss over the same period of decreasing ketone values.

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As detailed in this article, BHB ketones can be seen as a storage or transport form of ketones that can be used by the brain and heart but need to be converted back to Acetoacetate to be used by the rest of the body.  While they appear to be useful in some therapeutic situations, higher BHB, for the most part, should be seen as an indication of excess energy status rather than excellent metabolic health.

How do I become insulin sensitive?

Professor Taylor’s research also demonstrated that people become insulin sensitive again once they come back under their own ‘Personal Fat Threshold’ by reducing the pressure in their adipose tissue cells (i.e. lose weight).

With only a small amount of weight loss, their blood sugars come back into line and they start to lose fat from in and around their vital organs.[11][12][13][14]  Or to think of it another way, once you use up the surplus energy in your bloodstream, your body will start feeding on the fat stored in your vital organs as the first priority.

Once our body fat levels decrease to below our Personal Fat Threshold, it seems that they quickly become insulin sensitive and can take in any excess energy.  There is less overflow of energy from the fat cells to spill out into the bloodstream.

The bad news here is that once your adipose tissue becomes insulin sensitive again it can grow quite easily given an environment with surplus energy.  Being more insulin sensitive is part of the reason why it’s so easy to regain weight.

While a low carb diet masks the symptoms of diabetes by stabilising blood glucose levels without a significant reduction in body fat levels, people who lose a significant amount of body fat below their Personal Fat Threshold are no longer diabetic and can pass an oral glucose tolerance test.  Their fat stores can quickly expand to absorb the incoming energy.  Unfortunately, as soon as they put the weight back on (i.e. refill their fat stores), they become diabetic again.

One criticism of Professor Taylor’s work is that it was done with Optifast shakes to ensure rapid weight loss while still getting adequate nutrition (even though it was from meal replacement shakes full of supplements).  The ideal would be that people could learn to create nutrient-dense whole food meals.  Many people find this hard to do in real life, hence the use of meal replacement shakes in order to remove this variable.  The Nutrient Optimiser has been designed to help people form new habits of eating nutrient dense meals that are aligned with their goals. 

How do I know if I’m insulin resistant or insulin sensitive?

There are a range of ways to test to if you are insulin resistant.

Blood sugar

The simplest way is just to test your blood sugar fasting and before a meal.  The tables above show some suggested levels at which you should start to be concerned.  If your blood sugars are elevated then it’s an indication that you are exceeding your Personal Fat Threshold.

Fasting insulin

Fasting insulin levels are also a good guide to determine if you are starting to develop insulin resistance.

  • Healthy hunter-gatherer populations have a fasting insulin of 3 – 6 mIU/mL.[15]The average insulin levels in western populations are 8.6 mIU/L.
  • Meanwhile, the western reference range for fasting insulin is anything less than 25 mIU/L.[16] (This is not optimal.)

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Oral glucose tolerance test

One of the most common tests used in diabetes is the OGTT which is where you drink a sugary drink and see how much your glucose rises over time.[17]  image24

Insulin response patterns (Kraft test)

A more accurate way to understand you are insulin resistant is to test your insulin response to food.

In the chart below the negligible insulin response (blue) is Type 1 diabetes (i.e. insufficient insulin), the green is a healthy insulin response, while the yellow (pattern II), orange (pattern III) and red (pattern IV) are indicative of diabetes and insulin resistance.

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While you may have great blood sugar levels, your pancreas may still be working overtime to store the energy from your food in your fat stores, so it doesn’t spill over into your bloodstream.

A Kraft insulin dynamics test, while expensive, is the gold standard in insulin testing.  Dr Kraft’s analysis suggested that 80% of people are using excess insulin to suppress glucose, while a normal glucose screen would suggest that only two-thirds of people are fine.[18][19]

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HOMA-IR

If you have your fasting insulin and glucose data, you can calculate your HOMA-IR which is a measure of the amount of insulin that you need to maintain your blood sugars.  This can be useful for low carbers who sometimes have higher fasting glucose but lower insulin.

The formula is shown below or you can use an online calculator like this one.

  • Less than 1.0 means you are insulin-sensitive which is optimal.
  • Above 1.9 indicates early insulin resistance.
  • Above 2.9 indicates significant insulin resistance.[20]Triglyceride:HDL ratio

You can also use your blood cholesterol test data to understand if you are really insulin resistant. A triglyceride:HDL ratio greater than 3 (in US units) suggests that you may be insulin resistant.  A trig:HDL ratio less than 1.1 is optimal.[21][22]  You can use a calculator like this one to make sure you get the units right.

Abdominal obesity

Waist to height ratio is a simple and effective way to understand if you need to take evasive action to lose weight.

A waist to height ratio of greater than 0.5 for men and 0.46 for women is associated with increased risk mortality.[23]image34

Regardless of whether you are insulin sensitive or insulin resistant, it is highly advisable to do what it takes to reduce your body fat to get your waist to height ratio in check.

Some people will find that they still need to lose further weight to get within their personal fat threshold to get optimal blood glucose and insulin levels.

If you are insulin resistant, your fat tends to get stored in your organs so you may have a big hard ‘beer’ belly.  Someone with abdominal obesity may find their belly is hard because more fat is stored inside around their organs.

If you are insulin sensitive, you may have a big belly but it might hang down more like a floppy garbage bag.  Someone like this is ‘blessed’ to have insulin sensitive adipose tissue that continues to expand more before they develop diabetes and the complications of metabolic syndrome.[24]Screenshot 2018-04-12 08.15.43

Summary

The table below shows values for various parameters that are indicative of insulin resistance.[25]  If you are looking for optimal health, you should target values similar to those in the Quartile 1 column.

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Do medications help?

While replacement of normal healthy levels of insulin is critical for people with type 1 diabetes, supraphysiological doses of insulin only mask symptoms of a poor diet for people whose pancreas is still functioning well.

The chart below shows that complications of diabetes (i.e. cardiovascular disease, stroke, coronary heart disease) increase with higher HbA1c.  Lowering HbA1c however by just using anti-diabetic medications to suppress blood sugar does not help the outcome.

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Excess exogenous insulin forces the excess energy into our fat stores, and then subsequently into other more sensitive areas of the body such as our vital organs, brain and eyes.

You can’t just keep eating loads of processed insulinogenic crap and trust that all will be well because your blood sugars are lower.  Exogenous insulin combined with a poor diet actually exacerbates the complications of diabetes.

You need to fix your diet and then add enough insulin to maintain healthy blood glucose levels and effectively use the protein in your diet to build and repair your muscles.

Basal vs bolus insulin

Insulin-dependent diabetics dose with both bolus (or burst) insulin and basal (or background) insulin.  Bolus insulin is mealtime insulin and basal is needed whether you eat or not to enable you to keep your stored energy behind the floodgates of your liver.  

You can reduce the amount of bolus insulin required for food in the short term by reducing the insulin load of your diet.

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For someone on a standard mixed diet, about half of their insulin dosing will be bolus with half as basal.  For someone on a low carb diet with a lower insulin load, the majority of their insulin demand will be for basal insulin, with only a small amount required to cover food.

Most low carbers or ketogenic dieters focus on reducing the insulin load of their diet by removing carbohydrates, and sometimes protein, without paying much attention to incoming energy from fat.

This is fine on a whole food Atkins type diet because reducing carbs will typically force a reduction in overall energy intake.  Ignoring energy balance becomes a problem though when you start to ‘hack’ your low carb/keto diet with refined fats, fat bombs and fatty coffee that enable you to get heaps of energy with few carbs and negligible micronutrients.

The irony here is that, in the bigger picture, insulin demand is actually related to your overall stored energy status, as described in this video from Chris Masterjohn.

 

 

As shown in the chart below, people with a larger BMI typically have higher levels of insulin  because, as the stored energy in your system continues to increase (regardless of the macronutrient source), our insulin levels have to increase to hold back the flood of stored energy while the excess energy in our system is used up.

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The chart below shows that someone who is obese and insulin resistant will have higher insulin levels when they are fasting.  They will also have much higher excursions of insulin after eating due to their insulin resistant adipose tissue not accepting the excess energy.

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As our body fat stores continue to build and we keep on taking in energy, our pancreas continues to ramp up insulin production to keep energy in storage until you need it.  In the “good old days” this wasn’t a problem because there were always times when we didn’t have food available.  These days food is relatively cheap, easy to obtain and always associated with celebrations, family, social occasions and self-soothing.  So you are always in storage mode.

As you remain obese, you become resistant to your own insulin and need more and more insulin to do the job.[26][27]  Eventually, your pancreas can burn out through overuse, and you become an insulin-dependent Type 2 diabetic.

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Overall, the macro-nutrient composition of our diet only has a relatively small influence on our insulin levels.  Our basal insulin has a much more significant effect on our fasting insulin levels.

We can manipulate our diet by reducing carbohydrates to reduce the bolus insulin demand of our food.  However, we can have a much more dramatic impact on our insulin levels by reducing the total energy levels in our body by finding a way to maintain a long-term energy deficit.

How to reverse insulin resistance?

TL;DR… Reduce body fat while preserving lean muscle mass.

How to preserve lean muscle mass

Lean muscle mass is important because it burns both fat and glucose.  Without muscle, you won’t be able to quickly use the energy from fat and carbs that you eat.

Lean muscle mass is also critical to insulin sensitivity and longevity.  As you get older, it becomes harder to maintain lean muscle mass.[28]  You will need more protein as you get older to slow the inevitable loss of muscle mass.  Once you become weak and frail, your chances of falling and breaking your hip and never getting up again increase!

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There is ongoing discussion/argument/controversy about how much protein is ‘too much’.  My analysis of nutrient density suggests that getting a minimum of 1.8 g/kg LBM or about 20% of energy is a good starting point.  More can be better if you are active, lifting heavy or trying to lose fat.

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If you focus on getting the nutrients that are harder to find, adequate protein is really a non-issue.  The nutrient profile of the most nutrient-dense foods shown below is generated by prioritising foods that contain the harder to find micro-nutrients (i.e. choline, calcium, magnesium, vitamin E, potassium, pantothenic acid & zinc).

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By contrast, if we focus on avoiding protein, we get an abysmal nutrient profile as shown below.  This is why I get so frustrated when people get worked up about ‘too much protein’ or minimising protein in order to achieve elevated ketones as if that was the ultimate goal of health.

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We also risk malnutrition if we focus on the most ketogenic foods (i.e. high fat, low carb, low protein).  For most people, their primary goal is health and weight loss and to look great naked, not having high ketones.

So, unless you need a therapeutic ketogenic diet to manage epilepsy, Parkinson’s, Alzheimer’s, dementia or something similar, then there is no need to compromise your nutrition profile by trying to avoid protein or maximise ketones.

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Ironically, it’s the people who are insulin resistant that probably needs more protein because they are not able to use the protein available as effectively and they are also losing more amino acids into the blood stream via poorly controlled gluconeogenesis in the liver.

For comparison, the three nutrient profiles are shown below (most nutrient dense, low protein and most ketogenic).  Incorporating more of these nutrient dense foods is a great ‘hack’ to ensure you are getting enough nutrients without excessive energy intake.

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How to lose body fat

The short, boring, answer that won’t sell a million gimmicky diet books is to maintain an energy deficit for a long enough period.  This can take the form of:

  • Intermittent fasting (ideally with nutrient dense feeding to prevent malnutrition and binge eating),
  • Calorie counting (perhaps with occasional diet breaks),
  • Maximising nutrient density with whole foods which tends to lead to fewer cravings and less energy dense foods which are harder to overeat, or
  • Some other approach that works for you that enables you to maintain an energy deficit in the long term.

We have designed the Nutrient Optimiser to help you get started on your journey to optimise your nutrition.  Free Report will give you:

  • Recommended macronutrient ranges,
  • Recommended calorie intake to suit your goals,
  • Suggested foods to maximise nutrient density, and
  • Suggested meals to start you off on your journey into nutritious eating.

Some people may find some of the concepts in this post hard complex and difficult to implement.  The Nutrient Optimiser which will continue to adapt as you improve your metabolic health.  We are also working on a dashboard that will track your the biometric data that you have (e.g. weight, blood sugars, waist:height ratio, food logs, ketones etc.) to guide you on the path to help you reach your goal.

Who needs a low carb diet?

So, if insulin resistance is primarily about managing our energy levels, does anyone need a low carb diet?

Insulin-dependent diabetics

Being married to someone with type 1 diabetes and involved in the online diabetes community I have seen firsthand the importance of managing carbohydrate intake.

For someone injecting insulin to cover carbohydrates and protein, a low carb diet enables them to match the smaller dietary insulin load with smaller doses of exogenous insulin.

There will always be errors in calculations in matching insulin to food, so a smaller insulin load enables you to reduce the errors in insulin dosing.  Dr Richard Bernstein calls this The Law of Small Numbers.

Similarly, if you have type 2 diabetes and are injecting insulin, reducing the insulin load of your diet can help you reduce the amount of exogenous insulin you require.  This can in turn help reduce the swings in blood sugar which can help to stabilise appetite and reduce overall food intake which will lead to weight loss.

Conversely, dosing with lots of insulin to cover a poor diet will lead to worsening insulin resistance with larger and larger doses of insulin to cover their poor diet.  This vicious cycle of progressively larger doses ends in tragedy as it becomes more difficult to maintain safe levels of glucose control and typical diabetic symptoms such as peripheral neuropathy, kidney and eyesight disease become unavoidable.

Lots of exogenous insulin will also suppress lipolysis and make you hungrier which will drive appetite further.

So, if you are taking antidiabetic medications, then a lower carb diet is a no-brainer.

What about everyone else?

For people who are insulin resistant but not full-blown diabetic, I’m still a big believer in reducing the insulin load of your diet to the point that you can achieve stable blood glucose levels, but not so much that you compromise nutrient density.  There is a trade-off between insulin load and nutrient density.

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Unfortunately, some people get so caught up in being ketogenic that they end up decreasing nutrient density and increasing the energy density of their diet so much that they end up putting on weight due to an excess energy intake.

There is now a growing movement of online groups of people who have been burned by this ‘keto or bust’ mentality, chasing ketone readings by ingesting copious amounts of refined dietary fats or exogenous ketones.

I think a more prudent approach is to titrate carbs down to the point that you achieve great blood sugars and then focus on improving food quality and nutrient density.

For most people, reducing carbohydrates is helpful, not because it may increase ketones, but because it is a means to manage and minimize chronically elevated blood glucose and insulin levels which are the primary drivers of metabolic complications.  Ultimately, we still need to address the cause of the problem (insulin resistance) via creating an energy deficit and losing body fat to below your Personal Fat Threshold.

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There are a range of studies that suggest that a lower carbohydrate diet is better for weight loss for people who are insulin resistant.[29][30][31][32] However, the recent DIETFITS Randomised Clinical Trial of 609 obese participants at Standford led by Christopher Gardner indicates that there wasn’t a statistically significant difference between the effects of a healthy lower fat versus a healthy lower carb diet for people who do not have diabetes.

The chart below shows that people who were more insulin resistant lost slightly more weight on a low carb diet (but not enough to be deemed statistically significant)/

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On average, both diet groups reduced their energy intake by about 500 calories, not by tracking, but by focusing on improving their diet quality (though again, the healthy low carb diet group reduced their energy intake by about 50 calories more than the healthy low-fat group).

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Perhaps one of the main reasons that a low carb diet works so well for so many people is that so many of them are insulin resistant.  A low carb diet quickly helps to stabilise blood glucose and insulin levels which in turn helps to normalise appetite as well as eliminating many processed nutrient poor hyper-palatable foods.

In this video, Chris Gardner explains that study and points out that it was the people who changed their relationship with food and learned to make more nutrient-dense whole food from fresh ingredients at home that did the best overall.

 

In line with these insights, the Nutrient Optimiser algorithm firth helps you to stabilise your blood glucose levels with a lower carbohydrate diet and then guides you to focus on more nutrient-dense whole foods which tend to be more satiating and enable you to spontaneously reduce your energy intake.

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Summary

  • If you are insulin sensitive, you will be able to grow both muscle and fat more effectively.
  • While many people think that insulin resistance causes obesity, you actually need to be relatively insulin sensitive to get morbidly obese.
  • You become insulin resistant when your fat cells become too full to hold the excess energy that you are taking in.
  • When you reach your Personal Fat Threshold, your body can no longer force excess energy into storage in your fat cells and it gets stuffed into other places that are more sensitive like your liver, your brain, your heart, your pancreas.
  • When your fat can no longer take up excess energy, it overflows into your bloodstream in the form of elevated glucose, ketones and free fatty acids.
  • Reducing carbohydrates can help manage the symptoms of diabetes and stabilise blood sugars. It can also avoid the excess fat storage that can often come with the use of excess exogenous insulin.  However, for people who do not have diabetes, focusing on nutrient-dense whole foods and maintaining an energy deficit will likely be more important to reverse diabetes and improve insulin resistance.
  • You can reverse insulin resistance by maintaining an energy deficit until you are below your Personal Fat Threshold. Your adipose stores will then have room to take up the extra energy without spilling it into the bloodstream and your vital organs.

 

Thanks

Special thanks for Mike Julian for sharing many of the insights and synthesis of ideas contained in this article as well as RD Dikeman (Type One GRIT), Alex Leaf (Examine.com), Raphi Sirt (BreakNutrition.com). Ben McDonald (Impulsive Keto), Carrie Burns Diulus, Mattias Lindberg (Diet Doctor), Phil Thompson, Robin Reyes and Gillian Ferwerda for their review comments!

 

References

[1]https://www.ncbi.nlm.nih.gov/pubmed/25515001

[2]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4405637/

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

[4]https://www.nhs.uk/conditions/coronary-heart-disease/causes/

[5]https://www.medicalnewstoday.com/articles/298729.php

[6]https://www.medicalnewstoday.com/articles/265405.php

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

[8]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4405637/

[9]https://en.wikipedia.org/wiki/File:Coronal_Image_of_a_TOFI_and_a_Normal_Control.jpg

[10]https://link.springer.com/article/10.1007%2Fs13300-018-0373-9

[11]https://www.ncbi.nlm.nih.gov/pubmed/26628414

[12]https://www.express.co.uk/life-style/health/623499/losing-one-gram-fat-cure-diabetes

[13]https://idmprogram.com/fatty-pancreas-t2d-9/

[14]https://www.dietdoctor.com/how-losing-one-single-gram-of-fat-might-cure-diabetes

[15]http://wholehealthsource.blogspot.com.au/2009/12/whats-ideal-fasting-insulin-level.html

[16]https://emedicine.medscape.com/article/2089224-overview

[17]https://cf.research.chop.edu/ogtt.php

[18]https://www.facebook.com/BurnFatNotSugar/photos/a.364522923705531.1073741827.364516160372874/532154686942353/?type=3&theater

[19]https://www.amazon.com/Diabetes-Epidemic-You-Joseph-Kraft/dp/142517812X

[20]https://www.thebloodcode.com/homa-ir-calculator/

[21]https://www.thebloodcode.com/know-your-tghdl-ratio-triglyceride-hdl-cholesterol/

[22] The disposal of triglycerides provides insight into what your body is able to do with excess energy. Normal areas of short-term energy storage, like the liver, are at capacity. This proxy informs the actual behaviour of free nutrient. If the trigs are high, especially if the HDL is also diminished, it is implied that nutrient is unable to find easy storage locations with the current level of basal insulin.

[23]http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0103483

[24]http://www.mdpi.com/2072-6643/7/11/5475

[25]https://www.ncbi.nlm.nih.gov/pubmed/19789156

[26]https://www.ncbi.nlm.nih.gov/pubmed/8168647

[27]http://sci-hub.tw/10.2337/diab.43.5.696#

[28]https://www.nrv.gov.au/nutrients/protein

[29]https://onlinelibrary.wiley.com/doi/full/10.1002/oby.21331

[30]https://www.ncbi.nlm.nih.gov/pubmed/17063925

[31]https://www.ncbi.nlm.nih.gov/pubmed/15897479

[32]https://www.ncbi.nlm.nih.gov/pubmed/16306558

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]

image13

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]

image19

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.

image03

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]

image21

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

image18

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).

image26

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 loose 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.

2016-11-15-10-58-17

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.

image06

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 a 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 ageing[12]) and lower NADH levels are more likely to produce more breath acetone (which can be measured with the Ketonix) and fewer BHB ketones in the blood.   Hence, higher consistent levels of breath acetone may be a more useful indicator than blood ketones that you are burning fat rather than just eating fat.[13]

image27

“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 of 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.

image28

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.

image16

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]

image24

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.)

image02

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!

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.

image00

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.

image22

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.

image02

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.

image30

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.

image01

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.

image25

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.

image23

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.

image10

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.

image17

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.

image15

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.

image20

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 significantlyafter eating a large protein only meal?
  12. Do you have a big hard belly (fat stored around the organs , ot 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.

image14

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.

image08

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.

image07

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.

image11

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 wants 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

 

post last updated July 2017

nutrient dense foods for weight loss and insulin resistance

I found a number of people that were using 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 are fairly low in dietary fat to allow for to come from 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 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.

2016-10-10 (1).png

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 shows 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 (MCA) that combines all these factors.

The chart below shows the amount of each nutrient provided by the more balanced approach compared to the 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

image09

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

image08

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.

image02

 

Post last updated July 2017

hyperinsulinemia, food, infection and the monthly female cycle

  • A wide range of the major health issues that we face in the western world appear to be associated with high levels of insulin (hyperinsulinemia).
  • More people have impaired insulin sensitivity but wouldn’t know it just from looking at their blood glucose levels.
  • Insulin sensitivity is influenced by a wide range of factors including food, infections, fasting and hormones.
  • Fasting can be helpful for people who are unable to optimise their insulin with a low carbohydrate diet alone.
  • Insulin requirements tend to increase by about 10 to 15% in the three or four days leading up to the monthly menstrual period.

introduction

You may be aware of the work of Dr Joseph Kraft that has recently been re-discovered by Catherine Crofts and Ivor Cummins.  Dr Kraft carried out insulin response tests in more than 14,000 people and found that t he majority of them had some form of insulin resistance.  People who are insulin resistant need to secrete more insulin to maintain normal blood glucose levels.  These high levels of insulin can lead to fat gain and other metabolic issues.[1]

image001.png

Catherine Crofts, Caryn Zinn, Mark Wheldon and Grant Schofield recently published a paper looking at the various diseases that are affected by hyperinsulinemia including:

  • cancer
  • atherosclerosis
  • cardiomyopathy
  • endothelial dysfunction
  • thrombosis
  • diabetes (gestational and type 2)
  • non-alcoholic fatty liver disease
  • chronic inflammation
  • obesity
  • Alzheimer’s diseases and vascular dementia
  • retinopathy
  • osteoporosis
  • nephropathy [2]

In view of this ominous list of health issues it would make sense to try to actively avoid hyperinsulinemia.  Managing insulin resistance and optimising fat metabolism is critical for your overall health.  This article looks at the wide range of things that influence insulin sensitivity and what you can do about it.

food

While our food intake is not the only factor that influences hyperinsulinemia it is one that we can actively manage.

Measuring insulin in the blood stream is expensive and not commonplace.  Individuals with type-1 diabetes, however, provide a unique opportunity to understand the things that affect insulin demand.

Measuring the insulin requirement for someone with type 1 diabetes is as simple as downloading the data form their insulin pump into a spreadsheet.  My wife Monica’s daily insulin usage over eighteen months is shown in the chart below.

image003.jpg

Diabetes is an ongoing struggle!  Monica has been torn between mainstream advice that says that fat is bad and you’ll get fat and have a heart attack if you have too much of it, and her husband who keeps banging on about low carbohydrate, Paleo and ketogenic dietary approaches that might help her improve her diabetes control!

After generally trying to follow a paleo template for a couple of years in July 2014 she started taking the low carb thing a bit more seriously in an effort to gain control of her blood glucose levels.  Between August and December 2014 her insulin requirements came down from about 36 units per day to about 28 units per day!

Then, in January, when we came across the TYPEONEGRIT Facebook group and saw what people were eating to get flat line blood sugars, she ramped up her efforts to further refine how we ate, with a renewed motivation and belief that it could make a difference.

We also spent a week in Vanuatu around Christmas which likely helped to improve the cortisol levels and improve gut health with the sunshine, salt water and nutrient dense food.  In the period between January and March 2015 her insulin requirements came down even further to about 24 units per day from up to 40 units per day six months before.  During this period she had the best blood glucose levels in the thirty years of being a type 1 diabetic.

In April, because of her increased health and vitality, she started working more which may have affected her stress which may have influenced her insulin requirements.  In June she got a kidney infection with her insulin demand increasing significantly as her body fought the infection.  I even wonder if the period where the insulin requirement is building before June suggests that she might be getting run down and possible the insulin requirements building up.

People with diabetes who take insulin will also put on weight.  This is generally true for people with both type 1 and type 2 unless their carbohydrates are restricted.  Even though the insulin demand has varied during this time Monica has managed to lose about ten kilograms to achieve an ideal body weight that puts her in the middle of the ideal BMI range.

fasting

Jason Fung has been instrumental in highlighting that insulin drives obesity and notes that the most effective way to reduce insulin is to increase the time between meals.

People with type 1 diabetes find that they require much less insulin during fasting and for a period after fasting due to improved sensitivity.

Those of us with a functioning pancreas can track insulin by measuring blood glucose and blood ketones at the same time.  Cancer researcher Dr Thomas Seyfried suggests that the glucose : ketone index (GKI) is a good proxy for insulin levels (see this article for more detail on how the GKI).

Jimmy Moore recently did a seventeen day fast with daily Periscope video updates[3] where he documented his blood sugar and ketones which are shown in the chart below.  Jimmy usually maintains good blood sugar levels and high ketone levels with his ketogenic diet, however a few days into the fast the ketone levels kicked up even more (see orange dots in the chart below).

image005.png

I’ve also plotted Jimmy’s GKI values through this period which also gives us a feel for his insulin levels.  You can see that in the first few days his GKI plummeted as he exhausts his glycogen stores and is forced to start burning body fat, with ketones rising and glucose levels dropping.

image007.png

Although Jimmy was hoping to make it through to three weeks of fasting, towards the end of the fast he started to feel poorly with travel and stress (and perhaps an infection) and chose to terminate the fasting.   Sickness is often linked with poor blood glucose levels or insulin resistance.

Chris Kelly of Nourish Balance Thrive says:

“My experience has been whenever there is high blood sugar, there is yeast overgrowth.”

RD Dikeman who runs the TypeOneGrit Facebook group said

“You can spot the infections with blood glucose rise and increased insulin demand typically before symptoms present. It’s also important to make sure you – if you are low carb – track your basal totals…  if you are in a non-physiologic zone, 20u or more a day for example, and are not overweight/IR, you might have a chronic (typically dental) infection. Bernstein recommends a tooth tapping performance by the dentist, but also a quick home test is to drink a glass of very cold water and look for pain.”

The theory that infection can lead to poor blood sugar control and increased insulin demand also ties in with the our experience with Monica requiring much more insulin during periods when she’s had infections as highlighted in the chart of her insulin levels above.

Heart Rate Variability (HRV) has become popular lately as a way to track your health, stress and exhaustion.  Diminishing HRV scores will often suggest that you’re heading for burnout and will sometimes indicate that you have a sickness coming on.  It seems that tracking your GKI can also provide a similar indication of your overall metabolic health and indicate when you are getting an infection or starting to burn out and get inflamed.

infection

A diet low in processed carbohydrates is not just about reducing blood glucose and obesity.  It also has benefits in reducing infections such as SIBO (small intestinal bacterial overgrowth) and other conditions such as thrush.[4]

A diet high in sugar and processed carbohydrates will feed the ‘bad bacteria’ that will lead to SIBO[5] and other infections such as thrush that are related to too much sugar.

When Monica started to try to increase the fat in her diet her digestion struggled due to SIBO which meant that she was not able to digest the fats.  She worked with our naturopath Elizma to cleanse the SIBO with a vitamin C flush and then re-populate the gut again.

A diet low in sugar and processed carbs is the best thing to starve unwanted bacterial infections.

Belinda Fettke also told me:

I don’t have diabetes, but I was plagued with yeast overgrowth on a high carb diet. Since going low carb there has been not a single sign of it!!

To me, this is the biggest improvement in my health.  Gary told me I should do a TEDx talk in the impact of high carb vs low carb for someone like me who has had such nasty yeast infections in the past. Sounds trivial, but if it is severe it makes you lose concentration, sleep and impacts your sex life. 

Since going low carb I’ve had no thrush. I am surprised that I have also had only minimal symptoms of menopause, despite a family history of marked symptoms and medication.

I think it is SO important to discuss reducing carbohydrates and sugar for all women’s health, not just for women with diabetes. Every woman I speak to has their own health story.

the monthly female hormonal cycle

Insulin sensitivity is also influenced by the monthly female hormonal cycle.

I noticed that a few of the women on the TYPEONEGRIT Facebook group who achieve excellent blood glucose levels were talking about using different basal insulin patterns around their monthly cycle.

It’s surprisingly hard to find much information on the topic.  One useful piece of guidance is from Lois Jovanovic MD who says

Usually, a woman’s insulin requirement goes up 10 to 15% during the last 3 to 5 days of the menstrual cycle due to the hormone progesterone. This is the hormone that prepares the uterus to be full of extra tissue and blood to receive the egg, if it is fertilized. Rising levels of progesterone counteract that action of insulin.[6]

It seems that as progesterone increases through the luteal phase insulin resistance also increases.[7] [8] [9]

image011.jpg

For Monica it’s never been that scientific or precise.  There would typically be a time where she wouldn’t be feeling herself, “felt fat” and bloated and would then get frustrated that her blood sugars were all over the place and she’d lost control.  Then all of a sudden everything would be back to normal when her period hit.

On a Diabetes Unscripted podcast Katie Coleman discussed her approach to managing these variations, which includes tracking her monthly cycle with a reminder in her diary at ‘that time of the month’ including the new recommended basal insulin rates.  Katie uses the Kindara app to track her cycle and hence can forecast when she will need to adjust the basal rates on her pump.

After hearing Katie’s story I thought it would be interesting to see if we could learning anything from Monica’s insulin pump data.   While there is a lot of variation in the data in the plot above you can see that there is certainly a regular monthly cycle to the data.  When I looked at the numbers there was definitely one day every four weeks or so when the insulin requirement spiked in the lead up to her period.

The chart below shows the average of the monthly variation in insulin demand (in terms of percentage of average across that month).  The period proper hits one or two days after this insulin demand spike and everything returns to normal in terms of mood and insulin demand.  The lowest insulin demand appears to be around ovulation in the middle of the month.

image012.png

What this means is that in the four days leading up to the period each month a woman with type 1 diabetes could set her basal insulin to about 10% more than her normal basal insulin rate to manage her blood glucose levels over these four days.

For the rest of the population who do not have type 1 diabetes it’s interesting to see the correlations between higher insulin demand and water retention, mood, food cravings and blood sugar control that are often part and parcel with ‘that time of the month’.

other issues

I know from personal experience (as a male) that when I transition into ketosis with lower insulin levels my overall fluid retention and overall puffiness decrease.   I find myself heading to the toilet more often.  This makes me wonder to what degree oscillating insulin levels (along with estrogen and progesterone) play in the symptoms relating to the monthly female cycle.  Could a diet lower in processed carbohydrates that lowers insulin levels help decrease the mood swings and other fluctuations that come with the monthly hormonal cycle?

While there are anecdotal stories out there about how a paleo or ketogenic diet can lead to Amenorrhoea[10] (i.e. loss of regular menstrual cycle); however many would say that is the body’s response to a lack of calories rather than a well formulated ketogenic diet.  At the same time though there are heaps of anecdotes around the negative symptoms relating to ‘that time of the month’ being reduced on a ketogenic diet.[11] [12]

Perhaps this is another case for finding your optimal dietary glucose load where you can optimise blood glucose levels and possibly moderate hormonal fluctuations without going to the point of starvation where your body decides that survival is more important than reproduction.

it’s not just about the food

Again though, it’s not just about the food.  There are many other factors that will affect your insulin sensitivity such as sleep, genetics, exercise, circadian rhythms and gut bacteria as eloquently discussed in this video by Tommy Wood.

references

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

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

[3] https://vimeo.com/user21838277

[4] http://www.diabetes.co.uk/diabetes-complications/diabetes-and-yeast-infections.html

[5] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3099351/

[6] http://diabeticmommy.com/sp-pregnancy-diabetes-bd-faq-answers.html

[7] http://theathleterx.com/progesterone-and-insulin-what-is-the-relationship/

[8] http://www.ncbi.nlm.nih.gov/pubmed/23318859

[9] http://www.ncbi.nlm.nih.gov/pubmed/21768169

[10] https://en.wikipedia.org/wiki/Amenorrhoea

[11] https://zuzkalight.com/nutrition/my-experience-with-ketogenic-diet/

[12] https://www.youtube.com/watch?v=LunZgG8EvUk

the latest food insulin index data

Understanding the various factors that affect your insulin requirement is critical to diabetes management and optimal health.

Living with someone who has Type 1 Diabetes for seventeen years I’ve gained a deep appreciation of how different foods affect your blood glucose levels.  Poor food choices can send you on a blood glucose rollercoaster that can affect your appetite, mood and energy levels.

Luckily, the latest insulin index testing data can help us to better manage our food choices to manage our blood sugars and insulin levels.

In this article, I will share my analysis, experience and insights about how we can use the insights from insulin index testing to optimise your metabolic health.

The blood glucose roller coaster

Since she was ten, my wife Monica has had to manually manage her blood sugars as they swing up with food and then drop again when she injects insulin.

The continuous glucose monitor chart below shows a typical daily experience for someone with Type 1 Diabetes.

image16

High blood glucose levels make her feel “yucky”.  Then, plummeting blood glucose levels due to the mega doses of insulin don’t feel good either.

Low blood glucose levels drive you to eat until you feel good again.  This wild blood glucose roller coaster ride leaves you feeling exhausted.

These days Monica has an insulin pump which means she doesn’t have to insert a needle six times or more a day.  But we’ve found that good blood glucose control still comes down to managing the food you eat.  To stabilise the massive swings in blood sugars you need to make intelligent food choices to reduce the amount of insulin you need.

2-442e2-1315_112[1].png

The dietary advice that Monica has received over the past three decades living with Type 1 has been sketchy at best.  When she was first diagnosed with Type 1, Monica tells the story of being told to eat so much high carb food that she hid it in the pot plants in her hospital room.

These days the story is pretty much the same.  The photo below is of the daughter of some friends of ours, Lucy Smith, in the hospital just after she was diagnosed with Type 1 Diabetes.

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When we decided we wanted to have kids, we found a great doctor who helped us to understand how to match insulin with carbs.  However, no one told us how to make better food choices to reduce the amount of insulin required, including physicians, endocrinologists or diabetes educators.

We eventually stumbled across the low carb, and Monica has been able to significantly improve her blood glucose control.  This has enabled her to have a lot more energy to invest in to being a mother as well as going back to work as a teacher which she is loving.

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So, low carb produces great results for people trying to stabilise their blood sugars.  But there is still more to the story for people who need to actively manage insulin.

The latest food insulin index data

In early 2014, I came across Jason Fung’s Aetiology of Obesity series on YouTube where he discussed the food insulin index research that had been carried out at predominantly the University of Sydney which seemed to provide more insight into our insulin response to food.

xUSydLogoBlack.png.pagespeed.ic.KddStR_bgk[1]

I hoped that by gaining a better understanding how different foods affect our requirement for insulin, I might be able to help further optimise our food to normalise Monica’s blood glucose swings.

However, unfortunately, while the concept of insulin index testing is exciting, the data that is commonly available is hard to make sense of.  The initial research into the food insulin index was detailed in a 1997 paper An insulin index of foods: the insulin demand generated by 1000-kJ portions of common foods by Susanne Holt, Jennie Brand-Miller and Peter Petocz who tested the insulin response to thirty-eight different foods.  The insulin score of the various foods tested is shown in the image below.

insulinindex

The food insulin index score of various foods was determined by feeding 1000kJ (or 239 kcal) of a range of foods to non-diabetic participants and measuring their insulin response over three hours.  Some example insulin responses to different foods are shown in the chart below

FII versus time chart

This value is then compared to the insulin response to pure glucose (which is assigned a value of 100%) to arrive at a “food insulin index” value for each food.  All foods tested were then ranked relative to pure glucose.

Considering how significant this information could be for people trying to manage their insulin levels I was surprised that there hadn’t been a lot of further research or discussion on the topic.  I found a few references and mentions in podcasts, but no one was quite sure what to do with the information.  The chart showing the insulin index of the original 38 foods tested was really more confusing than useful for most people.

But then I found the mother load of data!

But then, after searching some more, I came across a PhD thesis Clinical Application of the Food Insulin Index to Diabetes Mellitus (Kirstine Bell, September 2014).   Appendix 3 of the thesis contained an extensive food insulin index database of foods that had now been tested.  The figure below shows all the foods tested plotted from smallest to largest insulin response.

[I know this is a bit hard to read.  You can click on the image to expand it.  I’ve uploaded these charts to Tableau online here so you can make more sense of the data.]

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The chart below shows the relationship between carbohydrates and insulin response for all the foods tested to date.

carbohydrates vs food insulin index.png

As you can see, the relationship between the carbohydrates we eat and the insulin we require to metabolise our food is not straightforward.

Some high protein and low-fat foods (e.g. fish and steak) are sitting quite high up on the vertical axis while there are some high fibre foods (e.g. all bran and navy beans) and high fructose foods (e.g. raisins and apples) with a lower insulin response than you might expect.

However, once we account for the effect of protein, fibre we are able to more accurately predict our body’s insulin response to food.  The foods in the bottom left corner of this chart will require the least insulin (e.g. butter, olive oil and avocado) while the foods in the top right will require the most insulin (e.g. rice bubbles, cornflakes and jellybeans)

carbohydrates fibre protein and vs food insulin index.png

It’s also interesting to note that fructose (a form of sugar found in fruit) requires only about 25% as much insulin as glucose.  The glycerol backbone in fat can also be converted to glucose via gluconeogenesis if there is no other glucose availabe from glucose or protien in the diet.  However, neither of these have a massive influence compared to carbohydrates, protein and fibre.

How is this useful?

This improved ability to quantify our insulin response to food enables us to precisely identify foods that require less insulin and reduce the amplitude of our blood sugar swings in response to food.

Many people trying to follow a therapeutic ketogenic diet (for the management of cancer, epilepsy, Alzheimers, dementia etc.) have found it very useful to reduce their insulin requirements and increase their ketone levels.

Similarly, people with diabetes who are injecting insulin have also found it be invaluable to help them more accurately.

Calculating the proportion of insulinogenic calories is useful for people who require a very low insulin therapeutic ketogenic diet while insulin load is useful for people managing hyperinsulinemia, insulin resistance or diabetes (see Insulin dosing for Type 1 Diabetes article)

Monica’s daily insulin dose has dropped from more than fifty units a day to closer to 20 units of insulin per day, and the amplitude of her blood glucose swings is much smaller.  The improvement in the quality of life, energy levels and mood for someone with diabetes when they stabilise their blood sugars is massive.  I’ve seen and experience this first hand, hence my passion to get this message out!

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The problem with the food insulin index

The problem with looking at things purely from a food insulin index perspective is that the resultant high-fat foods do not provide a broad range of micronutrients.

A diet with a low proportion of insulinogenic calories also tends to be very energy dense which can make portion control more challenging for people wanting to lose weight.

While stabilise the glucose swings is related mainly to the quality of the food we eat, bringing down the overall blood sugar levels is mostly about weight loss and the quantity of food we eat.

Once we stabilise blood sugars with a lower insulin load diet, we then need to focus on reducing the energy density of your food to enable you to lose weight and allow then fat stores to function optimally.

Diabetes occurs when our fat stores become too full, and they can no longer expand and contract to absorb and release the food from our meals, and the excess energy spills into the bloodstream.  Increasing the nutrient:energy ratio of our food will allow us to get the nutrients we need with less energy which will, in turn, help us to achieve and maintain an optimal body fat level.

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optimal foods for different goals

This refined understanding of how to calculate our insulin response to food is a useful parameter, along with nutrient density and energy density, which enables us to prioritise our food choices to suit different goals.

Building on the ability to quantify insulin load, nutrient density and energy density, more recently I have been developing an exciting new tool.

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The Nutrient Optimiser reviews your food log diet and helps you to normalise your blood glucose and insulin levels by gradually retraining your eating habits by eliminating foods that boost your insulin level and blood glucose levels using our ability to calculate the insulin load.

As shown in the chart below, some nutrients are easy to find.  However, most of us have a large number of micronutrient gaps and need to prioritise the foods and meals that will provide those harder to find nutrients.  Once your glucose levels are normalised, the Nutrient Optimiser starts to focus more on providing you with the nutrients you need with less energy.

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Then, if you still have weight to lose, the Nutrient Optimiser will focus on the energy density of your diet until you have achieved your desired level of weight loss.

It’s early days for the Nutrient Optimiser, but the initial results are very promising.   I’d love it if you’d head over to NutrientOptimiser.com to get your free report to find your optimal dietary approach and which foods, meals will be ideal for you.

 

 

Post last updated January 2018