Tag Archives: insulin

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

the complete guide to fasting (review)

October 29, 2016 Marty Kendall 15 Comments

Considering the massive amount of research and interest in the idea of fasting, not a lot has been written for the general population on the topic.

Brad Pilon’s 2009 e-book Eat Stop Eat was a great, though fairly concise, resource on the mechanisms and benefits of fasting.

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

Michael Mosley’s 2012 documentary Eat, Fast and Live Longer documentary piqued the public interest and was followed by the popular 5:2 Diet book.

Then in 2013, Jason Fung emerged onto the low carb scene with his epic six part Aetiology of Obesity YouTube Series in which he detailed a wide range of theories relating to obesity and diabetes.

Essentially, Jason’s key points are that:

simply treating Type 2 diabetes with more insulin to suppress blood glucose levels while continuing to eat the diet that caused the diabetes is futile,
people with Type 2 diabetes are already secreting plenty of insulin, and
insulin resistance is the real problem that needs to be addressed.

Jason’s Intensive Dietary Management blog has explored a lot of concepts that made their way into his March 2016 book, The Obesity Code. However surprisingly, given that Jason is the fasting guy, the book didn’t talk much about fasting.

my experience with fasting

I have benefited personally from implementing an intermittent fasting routine after getting my head around Jason’s work. I like the way I look and perform, both mentally and physically, after a few days of not eating. I also like the way my belt feels looser and my clothes fit better.

Complete abstinence is easier than perfect moderation.

St Augustine

I recently did a seven day fast and since then I’ve done a series of four day fasts, testing my glucose and blood and breath ketones with a range of different supplements (e.g. alkaline mineral mix, exogenous ketones, bulletproof coffee/fat fast and Nicotinamide Riboside) to see if they made any difference to how I feel and perform, both mentally and physically.

Fasting does become easier with practice as your body gets used to accessing fat for fuel.

I love the mental clarity! My workout performance and capacity even seem to be better when I’ve fasted for a few days.

My key fasting takeaways are:

Fasting is not that hard. Give it a try.
You can build up slowly.
If you don’t feel good. Eat!

The more I learn about health and nutrition, the more I realise how critical it is to be able to burn fat and conserve glucose for occasional use. We get into all sorts of trouble when we get stuck burning glucose.

Our body is like a hybrid car with a slow burning fat motor (with a big fuel tank) and high octane glucose motor (with a small fuel tank). If you’re always filling the small high octane fuel tank to overflowing, you’ll always be stuck burning glucose and your fat burning engine will start to seize up (i.e. insulin resistance and diabetes).

Reducing the processed carbs in our diet enables us to lower our insulin levels and retrain our body to burn fat again. But nothing lowers insulin as aggressively and effectively as not eating.

Even though lots of Jason’s thoughts on fasting seem self-evident, his blog elucidating them has been very popular, perhaps because the concept of fasting is novel in the context of our current nutritional education.

We’ve been trained, or at least given permission, to eat as often as we want by the people that are selling food or sponsored by them.^[1]

context

Jason’s angle on obesity and diabetes comes from his background as a nephrologist (kidney specialist) who deals with chronically ill people who are a long way down the wrong track before they come to his office. Jason also talks about how he had tried to educate his patients about reducing their carbs, however, after eating the same thing for 70 years, this is just too hard for many people to change.

Desperate times call for desperate measures!

Many of these patients come to him jamming in hundreds of units a day of insulin to suppress blood glucose levels, even though their own pancreas is still likely secreting more than enough insulin.

Rather than continuing to hammer more insulin to suppress the symptom (high blood glucose), the solution, according to Jason, is to attack the ultimate cause (insulin resistance) directly.

Jimmy Moore is well known to most people that have an interest in low carb or ketogenic diets. Whether you agree with his approach, it’s safe to say that low carb and keto would not be as popular today without his role.

Meanwhile, Jason talks about trying to educate people about reducing the processed carbs from their diet not working, not because of the science but more due to people not being able to change their eating habits after 70 years.

the Complete Guide to Fasting

You’ve probably heard by now that Jason has teamed up with Jimmy to write The Complete Guide to Fasting which captures Jason’s extensive thoughts on fasting from the blog along with Jimmy’s n=1 experiences and wraps them up in a cohesive comprehensive manual with a colourful bow.

Jason and Jimmy both sent me a copy of their new 304-page book, The Complete Guide to Fasting, to review (thanks guys). So here goes…

Similar to The Obesity Code, TCGTF is a compilation of ideas that Jason has developed on his Intensive Dietary Management blog. Blogging is a great way to get the ideas together and thrash them out in a public forum. Some people love to read the latest blog posts and debate the minutiae, however, most people would rather spend the $9 and sit down with a comprehensive book and get the full story.

Unlike The Obesity Code, TCGTF is a bright, ffull-colourproduction with great graphics that will make it worth buying the hard copy to have and to hold.

TCGTF did originally have the working title Fasting Clarity as a follow on from Jimmy’s previous Cholesterol Clarity and Keto Clarity. However, other than Jimmy’s discussion of his n=1 fasting experiences, TCGTF is predominantly written in Jason’s voice building from his blog, so it wouldn’t be appropriate for it to have become the third in Jimmy’s Clarity series.

What is similar to Jimmy’s clarity series is that it’s easy to read and accessible for people who are looking for an entry level resource. This book will be great for people who are interested in the idea of fasting. It is indeed the complete guide to fasting and is full of references to studies, however, it doesn’t go into so much depth as to lose the average reader with scientific detail and jargon.

The book covers:

Jimmy’s n=1 experience with fasting,
Dr George Cahill’s seminal work on the effects of fasting on metabolism, glucose, ghrelin, insulin, and electrolytes,
the history of fasting over the centuries,
myth busting about fasting,
fasting in weight loss,
fasting and diabetes, physical health, and mental clarity,
managing hunger during a fast,
when not to fast, and
when fasting can go wrong.

The book is complete with a section on fasting fluids (water, coffee, tea, broth) and a range of different protocols that you can use depending on what suits you. What did seem out of place are the recipes for proper meals. Apparently, the publisher insisted they include these to widen the appeal (If you don’t like the fasting bit you’ve still got some new recipes?)

Overall, the book will be an obvious addition to the library (or Kindle) of people who are already fans of Jason and / or Jimmy and want a polished, consolidated presentation of all their previous work with a bunch of new material added.

TCGTF will also be a great read for someone who is interested learning more about fasting and wants to start at the beginning. TCGTF is the most comprehensive book on the topic of fasting that I’m aware of.

my additional 2c…

Jason doesn’t mind weighing into a controversial argument, using some hyperbole or dropping the occasional F-bomb for effect and Jimmy’s no stranger to controversy either, so I thought I’d take this opportunity to give you my 2c on some of the topical issues at the fringe that aren’t specifically unpacked in the book. We learn more as we thrash out the controversial issues at the fringes. Many arguments come down to context.

target glucose levels

Jason has come under attack for using the word ‘cured’ in relation to HbAc1 values that most diabetes associations would consider non-diabetic,^[2] though are not yet optimal.^[3]

In the book Jason does discuss relaxing target blood glucose levels during fasting. This makes sense for someone taking a slew of diabetic medications. They’re probably not going to continue the journey if they end up in a hypoglycaemic coma on day one.

The chart below shows the real life blood glucose variability for someone with Type 1 Diabetes on a standard diet. With such massive fluctuations in glucose levels, it’s impossible to target ideal blood glucose levels (e.g. Dr Bernstein’s magic target blood glucose number of 4.6 mmol/L or 83 mg/dL).

If your glucose levels are swinging wildly due to a poor diet coupled with lots of medication, your glucose levels are simply going to tank when you stop eating. Hence, a safe approach is to back off the medication, at least initially, until your glucose levels have normalized.

Being married to someone with Type 1 Diabetes, I have learned the practical realities of getting blood glucose levels as low as possible while still avoiding dangerous lows.^[4] My wife Monica doesn’t feel well when her blood glucose levels are too low, but neither does she feel good with high blood glucose levels. Balancing insulin and food to get blood glucose levels as low as possible without experiencing lows requires constant monitoring.

The chart below shows how scattered blood glucose levels can be even if you’re fairly well controlled. Ideally you want the average blood glucose level to be as low as possible while minimising the number of hypoglycaemic episodes (i.e. below the red line). If you can’t reduce the variability you just can’t bring the average blood glucose level down. The last thing you want is to be eating to raise your blood glucose levels because you had too much blood glucose lowering medication.

Pretty much everyone agrees that it’s dumb to be eating crap food and dosing with industrial levels of insulin to manage blood glucose levels. High levels of exogenous insulin just drive the sugar that is not being used to be stored as fat in your belly, then your organs, and then in the more fragile places like your eyes and the brain.

Jason’s perspective is that people who are chronically insulin resistant and morbidly obese are likely producing more than enough insulin. The last thing they need is exogenous insulin which will keep the fat locked up in their belly and vital organs. Dropping insulin levels as low as possible using a low insulin load diet and fasting coupled with reducing medications will let the fat flow out.

fasting to optimise blood glucose levels

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

Once you’ve broken the back of your insulin resistance with fasting, you can continue to drive your blood glucose levels down towards optimal levels.

One of the most popular articles on the Optimising Nutrition blog is how to use your glucose meter as a fuel gauge which details how you can time your fasting based on your blood glucose levels to ensure they continue to reduce.

Your blood glucose levels can help calibrate your hunger and help you to understand if you really need to eat. I think this is a great approach for people whose main issue is high blood glucose levels and who aren’t ready to launch into longer multi day fasts.

In a similar way, a disciplined fasting routine can help optimise blood glucose levels in the long term. The chart below shows a plot of Rebecca Latham’s blood glucose levels over three months where she used her fasting blood glucose numbers AND body weight to decide if she would eat on any given day.

While there is some scatter in the blood glucose levels, you can see that regular fasting does help to reduce blood glucose levels over the long term.

Once you’ve lost your weight , broken the back of your insulin resistance and stopped eating crap food, you may find that you still need some exogenous insulin or other diabetic medication to optimise blood glucose levels if you have burned out your pancreas.

fasting frequency

The TGTF book covers off on several fasting regimens such as intermittent fasting, 24 hours, 36 hours, 42 hours and 7 to 14 days. One concept that I’m intrigued by, similar to the idea of using your glucose meter as a fuel gauge, is using your bathroom scale as a fuel gauge.

The reality, at least in my experience, is that we can overcompensate for our fasting during our feasting and end up not moving forward toward our goal.

If your goal is to lose weight I like the idea of tracking your weight and not eating on days that your weight is above your goal weight for that day.

Again, Rebecca Latham has done a great job building an online community around the concept of using weight as a signal to fast through her Facebook group My Low Carb Road – Fasting Support.

The chart below shows Rebecca’s weight loss journey through 2016 where she initially targeted a weight loss of 0.2 pounds AND a reduction of 0.25 mg/dL in blood glucose per day. After three months, she stabilized for a period (during a period when she had a number of major family issues to look after). She is now using a less aggressive weight loss goal as she heads for her long-term target weight at the end of the year.

The chart below shows the fasting frequency required to achieve her goals during 2016. Tracking her weight against her target rate of weight loss has required her to fast a little more than one day in three to stay on track.

Eating quality food is part of the battle, but managing how often you eat is also an important consideration. After you’ve fasted for a few days, you can easily excuse yourself for eating more when you feast again. And maybe it’s OK to enjoy your food when you do eat rather than tracking every calorie and trying to consciously limit them.

The obvious caveat is that there are a lot of other things that influence your scale weight such as muscle gain, water, GI tract contents etc, but this is another way to keep yourself accountable over the long term.

FAST WELL, FEED WELL

Fasting is a key component of the metabolic healing process, but it’s only one part of the story.

Fasting is like ripping out your kitchen to put in a new one. You have to demolish and remove the old stovetop to put the new shiny one back in. You don’t sticky tape the new marble bench top over the crappy old Laminex. You have to clean out the old junk before you implement the new, latest, and greatest model.

In fasting, the demolition process is called autophagy, where the body ‘self eats’ the old proteins and aging body parts. The great thing about minimising all food intake is that you get a deeper cleanse than other options such as fat fast, 500 calories per day or a protein sparing modified fast (PSMF).

But keep in mind that it’s the feast after the fast that builds up the shiny, new body parts that will help you live a longer, healthier, and happier life.

“Fasting without proper refeeding is called anorexia.”

Mike Julian

Even fasting guru Valter Longo is now talking about the importance of feast / fast cycles rather than chronic restriction. In the end you need to find the right balance of feasting / fasting, insulin / glucagon, mTOR / AMPK that is right for you.

In TCGTF, Jason and Jimmy talk about prioritising nutrient dense, natural, unprocessed, low carb, moderate protein foods after the fast. I’d like to reiterate that principle and emphasise that nutrient density becomes even more important if you are fasting regularly or for longer periods.

In the long term, I think your body will drive you to seek out more food if you’re not giving it the nutrients it needs to thrive. Conversely, I think if you are providing your body with the nutrients it needs with the minimum of calories I think you will have a better chance of accessing your own body fat and reaching your fat loss goals.

optimising insulin levels AND nutrient density

It’s been great to see the concept of the food insulin index and insulin load being used by so many people! In theory, when people reduce the insulin load of their diet they more easily access their own body fat and thus normalizes appetite.

Some people who are very insulin resistant do well, at least initially, on a very high fat diet. However, as glycogen levels are depleted and blood glucose levels start to normalise, I think it is prudent to transition to the most nutrient dense foods possible while still maintaining good (though maybe not yet optimal) blood glucose levels.

The problem with doubling down on reducing insulin by fasting combined with eating only ultra-low insulinogenic foods is that you end up “refeeding” with refined fat after your fast.

While lowering carbs and improving food quality is the first step, I think that, as soon as possible you should start focusing on building up your metabolic machinery (i.e. muscles and mitochondria). A low carb nutrient dense diet is part of the story, but I don’t see many people with amazing insulin sensitivity that don’t also have a good amount of lean muscle mass which is critical to ‘glucose disposal’, good blood sugar levels and metabolic health.

This recent IHMC video from Doug McGuff provides a stark reminder of why we should all be focusing on maximising strength and lean muscle mass to slow aging.

The chart below shows a comparison of the nutrient density of the various dietary approaches. Unfortunately, a super high fat diet is not necessarily going to be as nutrient dense and thus support muscle growth, weight loss, or optimal mitochondrial function as well as other options.

The chart below (click to enlarge) shows a comparison of the various essential nutrients provided by a high fat therapeutic ketogenic dietary approach versus a nutrient dense approach that would suit someone who is insulin sensitive.

I developed a range of lists of optimal foods that will help people in different situations with different goals to maximise the nutrient density that should be delivered in the feast after the fast. The table below contains links to separate blog posts and printable .pdfs. The table is sorted from highest to lowest nutrient density. In time, you may be able to progress to a more nutrient dense set of foods as your insulin resistance improves.

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

protein

Jason had a “robust discussion” with Steve Phinney over the topic of ideal protein levels recently during the Q&A session at the recent Low Carb Vail Conference.

To give some context again, Phinney is used to dealing with athletes who require optimal performance and are looking to optimise strength. Meanwhile Jason’s patient population is typically morbidly obese people who are on kidney dialysis and probably have some excess protein, as well as a lot of fat that they could donate to the cause of losing weight.

I also know that Jimmy is a fan of Ron Rosedale’s approach of minimising protein to minimise stimulation of mTOR. Jimmy and Ron are currently working on another book (mTOR Clarity?). Protein also stimulates mTOR which regulates growth which is great when you’re young but perhaps is not so great when you’ve grown more than enough.

The typical concern that people have with protein in a ketogenic context is that it raises blood insulin in people who are insulin resistant. ‘Excess protein’ can be converted to blood glucose via gluconeogenesis in people who are insulin resistant and can’t metabolise fat very well.

Managing insulin dosing for someone with Type 1 Diabetes like my wife Monica is a real issue, though she doesn’t actively avoid protein. She just needs to dose with adequate insulin for the protein being eaten to manage the glucose rise.

The chart below shows the difference in glucose and insulin response to protein in people who have Type 2 Diabetes (yellow lines) versus insulin sensitive (white lines) showing that someone who is insulin resistant will need more insulin to deal with the protein.

As well as insulin resistance, these people are also “anabolic resistant” meaning that some of the protein that they eat is turned into glucose rather than muscle leaving them with muscles that are wasting away.

People who are insulin resistant are leaching protein into their bloodstream as glucose because they can’t mobilise their fat stores for fuel. They are dependent on glucose and they’ll even catabolise their own muscle to get the glucose they need if they stop eating glucose.

While it’s nice to minimise insulin levels, I wonder whether people who are in this situation may actually need more protein to make up for the protein that is being lost by the conversion to glucose to enable them to maintain lean muscle mass. Perhaps it’s actually the people who are insulin sensitive that can get away with lower levels of protein?

As well as improving diet quality which will reduce insulin and thus improve insulin resistance, in the long term it’s also very important to maintain and build muscle to be able to dispose of glucose efficiently and also improve insulin resistance.

In TCGTF Jason talks about the fact that the rate of the use of protein for fuel is reduced during a fast and someone becomes more insulin sensitive. He goes to great lengths to point out that concern over muscle loss shouldn’t stop you trying out fasting (which is a valid point).

A big part of the magic of fasting is that you clean out some of your oldest and dodgiest proteins in your body and set the stage for rebuilding back new high quality parts. But the reality is that you will lose some protein from your body during a fast (though this is not altogether a bad thing).^[5] ^[6]

Bodybuilders often talk about the “anabolic window” after a workout where they can maximise muscle growth after a workout. Similarly, one of the awesome things about fasting is that you reduce your insulin resistance and anabolic resistance meaning that when at the end of your fast your body is primed to allocate the high quality nutrients you eat in the right place (i.e. your muscles not your belly or blood stream).

In the end, I think optimal protein intake has to be guided to some extent by appetite. You’ll want more if you need it, and less if you don’t.

I think if we focus on eating from a shortlist of nutrient dense unprocessed foods we won’t have to worry too much about whether we should be eating 0.8 or 2.2 g/kg of lean body mass.

However, avoiding nutrient dense, protein-containing foods and instead “feasting” on processed fat when you break your fast will be counter-productive if your goal is weight loss and waste a golden opportunity to build new muscle.

are you really insulin resistant?

Insulin resistance and obesity is a continuum.

Not everyone who is obese is necessarily insulin resistant.

If you are really insulin resistant, then fasting, reducing carbs, and maybe increasing the fat content of your diet will enable you to improve your insulin resistance. This will then help with appetite regulation because your ketones will kick in when your blood glucose levels drop.

However, if you continue to overdo your energy intake (e.g. by chasing high ketones with a super high fat, low protein diet), then chances are, just like your body is primed to store protein as muscle, you will be very effective at storing that dietary fat as body fat.

I fear there are a lot of people who are obese but actually insulin sensitive who are pursuing a therapeutic ketogenic dietary approach in the belief that it will lead to weight loss. If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help you identify your optimal dietary approach.

optimal ketone levels

Measuring ketones is really fascinating but confusing as well.

“Don’t be a purple peetone chaser.”

Carrie Brown, The Ketovangelist Podcast Ep 78

Urine ketones strips have limited use and will disappear as you start to actually use the ketones for energy.

In a similar way blood ketones can be fleeting. Some is better than none, but more is not necessarily better. As shown in the chart of my seven day fast below I have had amazing ketones and felt really buzzed at that point but since then I haven’t been able to repeat this. I think sometimes as your body adapts to burning fat for fuel the ketones may be really high but then as it becomes efficient it will stabilise and run at lower ketone levels even when fasting.

If your ketone levels are high when fasting then that’s great. Keep it up. They might stay high. They might decrease. But don’t chase super high ketones in the fed state unless you are about to race the Tour de France or if you want your body to pump out some extra insulin to bring them back down and store them as fat.

The chart below shows the sum of 1200 data points of ketones and blood glucose levels from about 30 people living a ketogenic lifestyle. Some of the time they have really high blood ketone levels but I think the real magic of fasting happens when the energy in our bloodstream decreases and we force our body to rely on our own body fat stores.

the root cause of insulin resistance is…

So we’ve worked out that large amounts of processed carbs drive high blood glucose and insulin levels which is bad.

We’ve also worked out that insulin resistance drives insulin levels higher, which is bad.

But what is the root cause of insulin resistance?

I think Jason has touched on a key component in that, as with many things, resistance is caused by excess. If we can normalise insulin levels, then our sensitivity to insulin will return, similar to our exposure to caffeine or alcohol.

However, at the same time, I think insulin resistance is potentially more fundamentally caused by our sluggish mitochondria that don’t have enough capacity (number or strength) to process the energy we are throwing at them, regardless of whether they come from protein, carbs, or fat.

A low carb diet lowers the bar to enable us to normalise our blood glucose levels. However, the other end of the spectrum is focusing on training our body and our mitochondria to be able to jump higher. In the long term this is achieved through, among other things, maximising nutrient dense foods and building lean body mass through resistance exercise.

summary

The Complete Guide to Fasting is, as per the title, the complete guide to fasting. It’s the most comprehensive guide to the nuances of fasting out there and there’s a good balance between the technical detail, while still being accessible for the general public.
Fasting can help optimise blood glucose and weight in the long term, with a disciplined regimen.
Fasting makes the body more insulin sensitive and primes it for growth. When you feast after you fast, it is ideal to make sure you maximise nutrient density of the food you eat as much as possible while maintaining reasonable blood glucose levels.
Understanding your current degree of insulin resistance can help you decide which nutritional approach is right for you. As you implement a fasting routine and transition from insulin resistance to insulin sensitivity you will likely benefit from transitioning from a low insulin load approach to a more nutrient dense approach.

references

^[1] https://intensivedietarymanagement.com/of-traitors-and-truths/

^[2] https://www.diabetes.org.uk/About_us/What-we-say/Diagnosis-ongoing-management-monitoring/New_diagnostic_criteria_for_diabetes/

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

^[4] https://optimisingnutrition.com/2015/08/17/balancing-diet-and-diabetes-medications/

^[5] https://www.dropbox.com/s/h3pi53njcfu4czl/Physiological%20adaptation%20to%20prolonged%20starvation%20-%20Deranged%20Physiology.pdf?dl=0

^[6] https://www.facebook.com/groups/optimisingnutrition/permalink/1602953576672351/?comment_id=1603210273313348&comment_tracking=%7B%22tn%22%3A%22R9%22%7D

athletes, calorie density, carbohydrates, cheat sheets, diabetes, insulin index, insulin load, insulin resistance, nutrient density, therapeutic ketosis

energy density, food hyper-palatability and reverse engineering optimal foraging theory

October 23, 2016 Marty Kendall 4 Comments

In Robb Wolf’s new book Wired to Eat he talks about the dilemma of optimal foraging theory (OFT) and how it’s a miracle in our modern environment that even more of us aren’t fat, sick and nearly dead.^[1]

But what is optimal foraging theory^[2]? In essence, it is the concept that we’re programmed to hunt and gather and ingest as much energy as we can with the least amount of energy expenditure or order to maximise survival of the species.

In engineering or economics, this is akin to a cost : benefit analysis. Essentially we want maximum benefit for minimum investment.

In a hunter-gatherer / paleo / evolutionary context this would mean that we would make an investment (i.e. effort / time / hassle that we could have otherwise spent having fun, procreating or looking after our family) to travel to new places where food was plentiful and easier to obtain.

In these new areas, we could spend as little time as possible hunting and gathering and more time relaxing. Once the food became scarce again we would move on to find another ‘land of plenty’.

The people who were good at obtaining the maximum amount of food with the minimum amount of effort survived and thrived and populated the world, and thus became our ancestors. Those that didn’t, didn’t.

You can see how the OFT paradigm would be well imprinted on our psyche.

OFT in the wild

In the wild, OFT means that native hunter-gatherers would have gone bananas for bananas when they were available…

… gone to extraordinary lengths to obtain energy dense honey …

… and eat the fattiest cuts of meat and offal, giving the muscle meat to the dogs.

OFT in captivity

But what happens when we translate OFT into a modern context?

Until recently we have never had the situation where nutrition and energy could be separated.

In nature, if something tastes good it is generally good for you.

Our ancestors, at least the ones that survived, grew to understand that as a general rule:

sweet = good = energy to survive winter

But now we have entered a brave new world.

We are now surrounded by energy dense hyper-palatable foods that are designed to taste good without providing substantial levels of nutrients.

Our primal programming is defenceless to these foods. Our willpower or our calorie counting apps are no match for engineered foods optimised for bliss point.

These days diabetes is becoming a bigger problem than starvation in the developing world due to a lack of nutritional value in the foods they are eating.^[3]

The recent industrialisation of the world food system has resulted in a nutritional transition in which developing nations are simultaneously experiencing undernutrition and obesity.

In addition, an abundance of inexpensive, high-density foods laden with sugar and fats is available to a population that expends little energy to obtain such large numbers of calories.

Furthermore, the abundant variety of ultra processed foods overrides the sensory-specific satiety mechanism, thus leading to overconsumption.”^[4]

what happens when we go low fat?

So if the problem is simply that we eat too many calories, one solution is to reduce the energy density of our food by avoiding fat, which is the most energy dense of the macronutrients.

Sounds logical, right?

The satiety index demonstrates that there is some basis to the concept that we feel more full with lower energy density, high fibre, high protein foods.^[5] ^[6] The chart below shows how hungry people report being in the two hours after being fed 1000 kJ of different foods (see the low energy density high nutrient density foods for weight loss article for more on this complex and intriguing topic).

However the problem comes when we focus on reducing fat (along with perhaps reduced cost, increased shelf life and palatability combined with an attempt to reach that optimal bliss point ^[7]), we end up with cheap manufactured food-like products that have little nutritional value.

Grain subsidies were brought in to establish and promote cheap ways to feed people to prevent starvation with cheap calories.^[8] It seems now they’ve achieved that goal.^[9]

Maybe a little too well.

The foods lowest in fat, however, are not necessarily the most nutrient dense. Nutritional excellence and macronutrients are not necessarily related.

In his blog post Overeating and Brain Evolution: The Omnivore’s REAL Dilemma Robb Wolf says:

I am pretty burned out on the protein, carbs, fat shindig. I’m starting to think that framework creates more confusion than answers.

Thinking about optimum foraging theory, palate novelty and a few related topics will (hopefully) provide a much better framework for folks to affect positive change.

The chart below shows a comparison of the micronutrients provided by the least nutrient-dense 10% of foods versus the most nutrient dense foods compared to the average of all foods available in the USDA foods database.

The quantity of essential nutrients you can get with the same amount of energy is massive! If eating is about obtaining adequate nutrients then the quality of our food, not just macronutrients or calories matters greatly!

Another problem with simply avoiding fat is that the foods lowest in fat are also the most insulinogenic, so we’re left with foods that don’t satiate us with nutrients and also raise our insulin levels. The chart below shows that the least nutrient dense food are also the most insulinogenic.

what happens when we go low carb?

So the obvious thing to do is eliminate all carbohydrates because low fat was such a failure. Right?

So we swing to the other extreme and avoid all carbohydrates and enjoy fat ad libitum to make up for lost time.

The problem again is that at the other extreme of the macronutrient pendulum we may find that we have limited nutrients.

The chart below shows a comparison of the nutrient density of different dietary approaches showing that a super high fat therapeutic ketogenic approach may not be ideal for everyone, at least in terms of nutrient density. High-fat foods are not always the most nutrient dense and can also, just like low-fat foods, be engineered to be hyperpalatable to help us to eat more of them.

The chart below shows the relationship (or lack thereof) between the percentage of fat in our food and the nutrient density. Simply avoiding or binging on fat does not ensure we are optimising our nutrition.

While many people find that their appetite is normalised whey they reduce the insulin load of their diet high-fat foods are more energy dense so it can be easy to overdo the high-fat dairy and nuts if you’re one of the unlucky people whose appetite doesn’t disappear.

what happens when we go paleo?

So if the ‘paleo diet’ worked so well for paleo peeps then maybe we should retreat back there? Back to the plantains, the honey and the fattiest cuts of meat?

Well, maybe. Maybe not.

For some people ‘going paleo’ works really well. Particularly if you’re really active.

Nutrient dense, energy dense whole foods work really well if you’re also going to the CrossFit Box to hang out with your best buds five times a week.

But for the rest of us that aren’t insanely active, then maybe simply ‘going paleo’ is not the best option…

… particularly if we start tucking into the energy dense ‘paleo comfort foods’.

If we’re not so active, then intentionally limiting our exposure to highly energy dense hyper palatable foods can be a useful way to manage our OFT programming.

enter nutrient density

A lot of people find that nutrient dense non-starchy veggies, or even simply going “plant-based”, works really well, particularly if you have some excess body fat (and maybe even stored protein) that you want to contribute to your daily energy expenditure.

Limiting ourselves to the most nutrient-dense foods (in terms of nutrients per calorie) enables us to sidestep the trap of modern foods which have separated nutrients and energy. Nutrient-dense foods also boost our mitochondrial function, and fuel the fat burning Krebs cycle so we can be less dependent on a regular sugar hit to make us feel good (Cori cycle).

Limiting yourself to nutrient dense foods (i.e. nutrients per calorie) is a great way to reverse engineer optimal foraging theory.

If your problem is that energy dense low nutrient density hyperpalatable foods are just too easy to overeat, then actively constraining your foods to those that have the highest nutrients per calorie could help manage the negative effects of OFT that are engrained in our system by imposing an external constraint.

But if you’re a lean Ironman triathlete these foods are probably not going to get you through. You will need more energy than you can easily obtain from nutrient-dense spinach and broccoli.

optimal rehabilitation plan?

So while there is no one size fits all solution, it seems that we have some useful principles that we can use to shortlist our food selection.

We are hardwired to get the maximum amount of energy with the least amount of effort (i.e. optimal foraging theory).
Commercialised manufactured foods have separated nutrients from food and made it very easy to obtain a lot of energy with a small investment.
Eliminating fat can leave us with cheap hyperpalatable grain-based fat-free highly insulinogenic foods that will leave us with spiralling insulin and blood glucose levels.
Eating nutrient dense whole foods is a great discipline, but we still need to tailor our energy density to our situation (i.e. weight loss vs athlete).

the solution

So I think we have three useful quantitative parameters with which to optimise our food choices to suit our current situation:

insulin load (which helps as to normalise our blood glucose levels),
nutrient density (which helps us make sure we are getting the most nutrients per calorie possible), and
energy density (helps us to manage the impulses of OFT in the modern world).

I have used a multi-criteria analysis to rank the foods for each goal. The chart below shows the weightings used for each approach.

The lists of optimal foods below have been developed to help you manage your primal impulses. The table below contains links to separate blog posts and printable .pdfs for a range of dietary approaches that may be of interest depending on your goals and situation.

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 you identify your optimal dietary approach.

I hope this helps. Good luck out there!

post last updated OCtober 2017

references

^[1] http://ketosummit.com/

^[2] https://en.wikipedia.org/wiki/Optimal_foraging_theory

^[3] http://www.hoajonline.com/obesity/2052-5966/2/2

^[4] https://www.ncbi.nlm.nih.gov/pubmed/24564590

^[5] http://nutritiondata.self.com/topics/fullness-factor

^[6] https://www.ncbi.nlm.nih.gov/pubmed/7498104

^[7] https://www.nextnature.net/2013/02/how-food-scientists-engineer-the-bliss-point-in-junk-food/

^[8] https://en.wikipedia.org/wiki/Agricultural_subsidy

^[9] http://blog.diabeticcare.com/diabetes-obesity-growth-trend-u-s/

healthy foods, nutrient density

the most nutrient dense autoimmune friendly foods

October 17, 2016 Marty Kendall 21 Comments

An “autoimmune disease” develops when your immune system, which defends your body against disease, decides your own healthy cells are foreign. As a result, your immune system attacks healthy body cells.^[1]

The list of diseases that are said to be autoimmune related are extensive,^[2] ^[3] and to add insult to injury, people with autoimmune issues often end up with challenging digestive issues.

An autoimmune dietary protocol eliminates foods that can trigger inflammation in people with more sensitive digestion that may be autoimmune related. The foods typically eliminated include nuts, seeds, beans, grains, artificial sweeteners, dairy, alcohol, chocolate and nightshades.

The remaining foods largely involve vegetables, seafood and animal products. Given that Type 1 Diabetes is an autoimmune condition I have also created a lower insulin load diabetes friendly autoimmune list of foods that that will be more gentle on blood glucose levels.

Although sticking to the autoimmune friendly list of foods is somewhat restrictive it is a very nutrient dense approach compared to other options as you can see in the comparison of the nutrient density of different nutritional approaches in the chart below where it came in at #2 of the thirteen approaches analysed. The nutrients provided by these foods in comparison to the USDA foods database is shown below.

The nutrient density of the diabetes friendly list is shown below.

An autoimmune protocol is often a short term ‘reset’ where inflammatory foods are eliminated for a period. Once things settle down potential other possible trigger foods are slowly reintroduced to see which foods can be tolerated.

For more information see Robb Woolf’s The Paleo Solution, Sarah Ballantyne’s The Paleo Approach or Chris Kresser The Paleo Cure.

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

autoimmune protocol (nutrient dense)

vegetables, spices and fruit

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
endive	11	23%	1	17	3.0
chicory greens	11	23%	2	23	2.9
spinach	12	49%	4	23	2.8
watercress	13	65%	2	11	2.8
dandelion greens	11	54%	7	45	2.5
beet greens	9	35%	2	22	2.4
basil	10	47%	3	23	2.4
escarole	8	24%	1	19	2.4
chard	10	51%	3	19	2.4
asparagus	10	50%	3	22	2.4
zucchini	9	40%	2	17	2.4
arugula	9	45%	3	25	2.3
lettuce	10	50%	2	15	2.3
Chinese cabbage	10	54%	2	12	2.2
sage	7	26%	26	315	2.2
alfalfa	7	19%	1	23	2.2
parsley	9	48%	5	36	2.1
curry powder	6	13%	14	325	2.1
summer squash	8	45%	2	19	2.0
okra	8	50%	3	22	2.0
paprika	6	27%	26	282	2.0
cloves	7	35%	35	274	1.9
broccoli	8	50%	5	35	1.9
collards	7	37%	4	33	1.9
turnip greens	7	44%	4	29	1.8
thyme	6	34%	31	276	1.8
brown mushrooms	9	73%	5	22	1.8
cucumber	6	39%	1	12	1.7
chives	7	48%	4	30	1.7
celery	7	50%	3	18	1.6
artichokes	6	49%	7	47	1.6
cabbage	7	55%	4	23	1.6
marjoram	5	31%	27	271	1.6
cauliflower	6	50%	4	25	1.6
sauerkraut	5	39%	2	19	1.5
portabella mushrooms	6	55%	5	29	1.5
edamame	5	41%	13	121	1.5
poppy seeds	3	17%	23	525	1.4
shiitake mushroom	6	58%	7	39	1.4
white mushroom	7	65%	5	22	1.4
celery flakes	6	53%	42	319	1.4
seaweed (wakame)	8	79%	11	45	1.3
radicchio	6	67%	4	23	1.3
rhubarb	5	55%	3	21	1.2
kale	6	60%	5	28	1.2
bamboo shoots	6	60%	5	27	1.2
radishes	4	43%	2	16	1.2
yeast extract spread	5	59%	27	185	1.2
seaweed (kelp)	7	77%	10	43	1.2
turnips	5	51%	3	21	1.2
Brussel sprouts	4	50%	6	42	1.1
Rutabagas, raw	5	57%	6	37	1.1
chayote	3	40%	3	24	1.1
onions	5	65%	6	32	1.0
blackberries	2	27%	3	43	1.0
tarragon	4	62%	56	295	0.9
pumpkin	6	76%	4	20	0.9
carrots	4	61%	4	23	0.9
peas	4	65%	7	42	0.9
spirulina	5	70%	6	26	0.8
avocado	-0	8%	3	160	0.8
red cabbage	3	55%	5	29	0.8

seafood

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
fish roe	9	47%	18	143	2.2
caviar	6	33%	23	264	1.8
mackerel	4	14%	10	305	1.6
trout	6	45%	18	168	1.6
salmon	7	52%	20	156	1.6
flounder	7	57%	12	86	1.6
oyster	7	59%	14	102	1.5
cod	8	71%	48	290	1.5
sardine	5	37%	19	208	1.5
sturgeon	6	49%	16	135	1.5
halibut	7	66%	17	111	1.5
crayfish	7	67%	13	82	1.5
crab	8	71%	14	83	1.4
cisco	4	29%	13	177	1.4
pollock	7	69%	18	111	1.4
perch	6	62%	14	96	1.3
rockfish	7	66%	17	109	1.3
anchovy	4	44%	22	210	1.3
lobster	7	71%	15	89	1.2
herring	3	36%	19	217	1.2
shrimp	6	69%	19	119	1.1
whiting	6	66%	18	116	1.1
haddock	6	71%	19	116	1.1
white fish	6	70%	18	108	1.1
clam	5	73%	25	142	0.9

animal products

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
beef brains	4	22%	8	151	1.6
lamb liver	5	48%	20	168	1.3
ham (lean only)	5	59%	17	113	1.1
lamb kidney	4	52%	15	112	1.1
turkey ham	3	45%	14	124	1.0
lamb sweetbread	3	43%	15	144	1.0
turkey liver	3	47%	21	189	1.0
lamb brains	2	27%	10	154	0.9
ground turkey	1	30%	19	258	0.8
turkey (skinless)	2	40%	16	170	0.8
turkey heart	3	47%	20	174	0.8
roast ham	2	41%	18	178	0.8

autoimmune protocol (diabetes friendly)

Vegetables, spices and fruit

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
endive	14	23%	1	17	2.5
chicory greens	13	23%	2	23	2.3
escarole	11	24%	1	19	2.1
alfalfa	10	19%	1	23	2.1
curry powder	6	13%	14	325	1.8
beet greens	11	35%	2	22	1.8
spinach	13	49%	4	23	1.7
zucchini	11	40%	2	17	1.7
paprika	7	27%	26	282	1.6
arugula	12	45%	3	25	1.6
basil	12	47%	3	23	1.6
sage	7	26%	26	315	1.6
asparagus	12	50%	3	22	1.5
chard	12	51%	3	19	1.4
watercress	15	65%	2	11	1.4
parsley	11	48%	5	36	1.4
avocado	0	8%	3	160	1.4
cucumber	8	39%	1	12	1.4
lettuce	11	50%	2	15	1.4
poppy seeds	3	17%	23	525	1.4
collards	7	37%	4	33	1.4
summer squash	9	45%	2	19	1.3
cloves	7	35%	35	274	1.3
broccoli	10	50%	5	35	1.3
thyme	6	34%	31	276	1.3
olives	-2	3%	1	145	1.3
dandelion greens	11	54%	7	45	1.3
okra	10	50%	3	22	1.3
Chinese cabbage	10	54%	2	12	1.2
marjoram	4	31%	27	271	1.2
chives	8	48%	4	30	1.2
turnip greens	7	44%	4	29	1.2
sauerkraut	6	39%	2	19	1.1
celery	8	50%	3	18	1.1
blackberries	3	27%	3	43	1.1
cauliflower	8	50%	4	25	1.1
chayote	5	40%	3	24	1.1
portabella mushrooms	9	55%	5	29	1.0
edamame	5	41%	13	121	1.0
radishes	5	43%	2	16	1.0
artichokes	7	49%	7	47	1.0
brown mushrooms	13	73%	5	22	1.0
shiitake mushroom	9	58%	7	39	0.9
raspberries	1	30%	4	52	0.9
cabbage	7	55%	4	23	0.9

seafood

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
mackerel	3	14%	10	305	1.5
caviar	8	33%	23	264	1.5
fish roe	9	47%	18	143	1.3
cisco	3	29%	13	177	1.1
trout	7	45%	18	168	1.1
sardine	5	37%	19	208	1.1
oyster	9	59%	14	102	1.0
herring	3	36%	19	217	0.9
salmon	7	52%	20	156	0.9
sturgeon	6	49%	16	135	0.9
anchovy	5	44%	22	210	0.9

animal products

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
beef brains	5	22%	8	151	1.5
lamb brains	3	27%	10	154	1.2
lamb liver	8	48%	20	168	1.1
sweetbread	-2	12%	9	318	1.1
liver sausage	-2	13%	10	331	1.0
turkey bacon	-1	19%	11	226	1.0
bacon	-3	11%	11	417	1.0
meatballs	-1	19%	14	286	1.0
kielbasa	-2	15%	12	325	0.9
bratwurst	-2	16%	13	333	0.9
ground turkey	2	30%	19	258	0.9
salami	-1	18%	17	378	0.9
turkey	-1	20%	21	414	0.9
turkey liver	6	47%	21	189	0.9
ham	1	29%	11	149	0.9
pepperoni	-3	13%	16	504	0.9
headcheese	-2	20%	8	157	0.9
lamb kidney	7	52%	15	112	0.9
bologna	-4	11%	9	310	0.9
pork ribs	-2	18%	16	361	0.9
bologna	-0	26%	11	172	0.9
pork sausage	-0	25%	13	217	0.9
pork sausage	-2	20%	16	325	0.8
knackwurst	-3	16%	12	307	0.8
turkey drumstick (with skin)	0	28%	15	221	0.8
chorizo	-2	17%	19	455	0.8
chicken liver pate	1	34%	17	201	0.8

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.

references

^[1] http://www.healthline.com/health/autoimmune-disorders

^[2] https://en.wikipedia.org/wiki/Autoimmune_disease

^[3] https://www.aarda.org/disease-list/

athletes, dom d'agostino diet, nutrient density, recipes

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

August 15, 2016 Marty Kendall 24 Comments

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

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

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

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

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

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

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

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

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

“Do you blend that up in the Vitamix?”

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

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

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

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

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

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

The ranking for the sans-oyster option is:

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

The stats for a 500 calorie serving are:

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

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

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

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

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

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

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

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

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

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

articles, blood sugar, diabetes, diabetes ketone, exogenous ketones, exogenous vs endogenous, insulin load, keto os side effects, keto/os, ketones, ketoos, ketosis, nutrient density, protein, therapeutic ketosis

are exogenous ketones right for you?

August 8, 2016 Marty Kendall 58 Comments

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

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

Exogenous vs. endogenous ketosis

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

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

Ketones vs glucose

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

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

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

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

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

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

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

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

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

hyperinsulinemia and metabolic disorders

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

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

exogenous ketones and the low carb flu

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

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

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

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

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

my experience with exogenous ketones

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

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

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

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

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

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

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

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

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

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

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

do exogenous ketones help with weight loss?

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

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

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

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

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

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

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

^{^[13]}

Confused?

I don’t blame you.

Metabolically healthy

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

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

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

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

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

I know Luis Villasenor from Ketogains finds the same thing.

total energy = ketones + glucose

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

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

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

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

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

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

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

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

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

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

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

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

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

My heart sank when I saw this video.

MORE investigation required?

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

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

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

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

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

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

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

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

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

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

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

The lower the better?

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

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

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

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

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

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

MORE is not necessarily BETTER when it comes to health.

Fast well, feed well

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

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

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

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

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

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

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

the real magic of ketones

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

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

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

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

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

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

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

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

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

nutrient density

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

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

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

the best exogenous ketone supplement

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

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

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

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

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

references

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

post last updated: July 2017

articles, diabetes, nutrient density, weight loss

choosing the right sized low carb band aid

May 30, 2016 Marty Kendall 34 Comments

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

how important is insulin sensitivity?

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

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

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

is low carb the best approach for everyone?

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

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

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

So who is right?

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

As always, context matters.

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

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

As you can see from the chart below:

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

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

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

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

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

am I insulin resistant?

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

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

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

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

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

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

nutrient dense low carb foods for blood glucose control

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

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

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

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

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

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

Vegetables

Listed below are the highest ranking vegetables.

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

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

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

fruit

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

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

nuts, seeds and legumes

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

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

dairy and eggs

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

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

seafood

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

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

animal products

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

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

is low carb a band aid or cure?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

references

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

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

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

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

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

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

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

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

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

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

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

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

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

articles, blood sugar, insulin index, nutrient density, protein

want to live forever?

March 21, 2016 Marty Kendall 18 Comments

Living a long, vibrant, healthy life is a common goal. But what can we do to extend our health span?

Should we eat more fruit and veggies? Less processed foods? More protein? Less protein? Exercise more? Lose weight? Sleep more? Get more sun? Less blue light?

Confused yet?

The numerous facets of health and longevity are complex and above my pay grade. However, I am willing to add my two cents to the discussion in the areas of insulin, blood glucose, fasting and nutrition along with some input from people I respect.

Dr Ted’s top tips

My wise mate Dr Ted Naiman recently commented on the topic of longevity.

I see centenarians at work, and as far as I can tell it is important to be:

– insulin sensitive,

– active, and

– relatively strong

Extreme careful protein restriction? Not so much. I for one will focus on the first three.

Not only is Ted enviably buff, he also has a neat way of condensing wisdom into short bites that are worth unpacking a little further.

insulin sensitive

The leading causes of death in adults in the western world (i.e. heart disease, stroke, cancer, Alzheimer’s and Parkinson’s)^{^[1]} all have something in common. They are diseases of modern society, related to metabolic health and exacerbated by excessive insulin and / or high blood glucose levels.

People who live longer still die from these same diseases, they just succumb to them later.

This chart (from Barbieri, 2001) shows that insulin resistance generally deteriorates with age. However if you’re one of the few to make it past 90 then chances are your insulin resistance is pretty spectacular!

Ted’s infographic below explains how insulin resistance and metabolic syndrome leads to hyperinsulinemia (elevated insulin) and hyperglycaemia (elevated blood glucose) and then to heart disease and many of the other diseases of modern society.

The chart below indicates that you have a much better chance of delaying the top two causes of death in western society (i.e. heart attack and stroke) if you have a lower HbA1c.^{^[2]} ^{^[3]}

And your chance of maintaining a big brain that is free of Alzheimer’s and Parkinson’s (causes of number four and five)^{^[4]} seems to be greatly improved if you keep your blood glucose levels low.

We’ll come back to cancer, cause of death number three, a little later.

relatively strong

While you might be able to make an argument for longevity around restricting protein or even calories based on laboratory experiments, people live in the real world and need adequate strength to move around, stay active and be relatively strong. People who are lean and strong intuitively look healthy and attractive to us.

Longevity research is typically done in yeast, worms, mice or other animals who live protected in captivity. Unfortunately, real people don’t live in protected laboratory environments in a petri dish. We live in the real world where real people break.

Loss of muscle as we age (i.e. sarcopenia) is a major issue. Many older people become brittle and weak. They take a fall, break their hip and never get up. Maintaining strength and lean muscle mass is important.

You don’t see many fat animals in the wild, but at the same time you don’t see skinny animals, unless they are sick. Animals that survive in their natural environment are lean, strong and fast. They have to be to survive, to catch food and avoid being eaten.

Humans in the wild also tend to be strong and lean.

Similar to Ted Naiman, Ian Rambo (pictured below), 62, is a fan of intermittent fasting and a moderate protein diet. Rambo doesn’t look like he’s about to trip and break his hip any time soon.

active

A lot can be said about exercise, longevity and metabolic health.

Peter Attia, who recently left NUSi to go back to practice medicine with a focus on longevity, says:

Glucose disposal is everything. The best way to get there is by increasing the muscle’s capacity to take up glucose and make glycogen, and that’s best accomplished through lifting heavy weights. Doing so also increases health span (i.e. reducing injuries, lowering pain, and increasing mobility through life).^{^[5]}

Exercise depletes the glucose in our blood, liver and muscles and causes us to tap into our fat stores. But it’s more than just about using up energy.

As metabolic health and mitochondrial density improves through exercise, our fat oxidation rate increases. We become metabolically flexible which means that we can easily use glucose or fat for fuel. Once we improve our fitness and insulin sensitivity we get to the point that we can even obtain some of the glucose we need from fat.

My friend Mike Julian commented:

Every triglyceride that is broken down gives up one glycerol molecule. Two glycerol molecules will make one glucose. So the more fat we are capable of burning, the more glucose we can make from fat oxidation, thus the better we get at restoring muscle glycogen without eating carbohydrates.

Also the glycogen that we do burn produces lactate, which is then recycled to make more glucose in the cori cycle, which also contributes to muscle glycogen stores during recovery.

The goal is to increase mitochondrial density so that we are very good at oxidizing fats. When we have poor mitochondrial density we are far more prone to switching over to anaerobic metabolism at low activity levels and anaerobic activities require glucose.

So if we can’t burn fat at high rates due to low numbers of mitochondria, we can’t make much glucose from glycerol via fat oxidation, so in turn our bodies go to plan B which is to make it out of amino acids in order to make up for the rest of what it needs.

So if you increase your mitochondrial density through exercise, you’ll oxidize a higher volume of fat, which will give a higher yield of glucose from glycerol and thus reduce your body’s need to break down aminos from dietary protein and lean mass.

Post exercise increased fat oxidation due to mitochondrial density produces more ketones during the recovery period which get used preferentially so the increased glucose production during that time can go towards refilling of glycogen stores rather than be oxidized for energy. This is why many top keto athletes will fast for a few hours post training. If they eat straight away they miss out on this phenomenon and actually will recover slower.

caloric restriction

Building on the prior trials in yeast and worms, the current dietary restriction longevity experiments in rhesus monkeys are looking positive. You can see the monkey on the right who has been living on 30% less calories looks younger and healthier than the monkey on the left who is the same age.

The monkeys who eat less have less age related disease and live longer.^{^[6]}

While avoiding excess energy intake is beneficial, there are differing opinions on how this translates to humans in the real world in terms of increased life span.

Peter Attia says:

Most people in this space, the super-in-the-weeds people on this topic that I’ve spoken with at length, do not believe caloric restriction actually enhances survival in the wild.

Nobody disputes that for most species it enhances survival in the laboratory, but once you get into the wild, you’re basically trading one type of mortality for another.^{^[7]}

So many things in life are a balance and involve compromise. While you need adequate nutrition to be strong and active, our bodies also age more slowly if we don’t subject ourselves to excess energy.

Another problem with calorie restriction is that unfortunately most of us don’t have the self-discipline to limit our food intake all the time. When we do eat we find it hard to stop until we are satisfied. Our survival instincts don’t know about the studies in the monkeys, the worms and the yeast.

Most people find it hard to maintain constant caloric restriction when they have free will and unlimited access to food. And then the cruel trick for people who do have the discipline to consistently reduce their energy intake is that the body will scale back its energy expenditure to stay within the reduced energy intake.

intermittent fasting

“Complete abstinence is easier than perfect moderation.”

Saint Augustine^{^[8]}

So if caloric restriction doesn’t necessarily work, then what’s the solution? Jason Fung makes a compelling case for the benefits of intermittent fasting rather than chronic calorie restriction.

When there is a lack of food a process called autophagy (from the Greek auto, “self” and phagein, “to eat”) kicks in and we turn to our own old cells for nutrients. Autophagy is nature’s way of getting the energy we need when we don’t eat in addition to cleaning out the old junk in our bodies and brains. When we get to eat again we build up new, fresh healthier cells.

But this process of cell clean up and regeneration cannot occur without giving the body the chance to clean out the old cells first.^{^[9]} We regenerate and slow aging when we don’t always have a constant supply of energy. One of the advantages of intermittent fasting over simply reducing calories is that you get a deeper cleanse of the old cells with total restriction of energy inputs.

In the video below David Sinclair explains how our body makes a special effort to repair itself when there is a lack of food. In a famine your body senses an emergency and sends out Sirtuin proteins to maximise the health of our mitochondria to increase the chance that you will survive the famine and have the best chance of living until a time when food is more plentiful and you can reproduce and pass on your genes. Unfortunately, this emergency repair function just doesn’t happen when food is plentiful. They’re working on drugs that will mimic this effect, but in the meantime, intermittent fasting is free.

As detailed in the how to use your glucose meter as a fuel gauge article, it can be useful to track blood glucose or weight to help guide the frequency and duration of intermittent fasting to make sure you’re moving towards your goals.

protein restriction?

Many people hypothesise that restricting protein is an important component to slow aging.

Dr Ron Rosedale talks a lot about the dangers of glycation and the kinase mTOR. His hypothesis, as articulated in the Safe Starches Debate and AHS 2012, is that we should avoid carbohydrates to avoid the dis-benefits of glycation, particularly as we can get the glucose we need from protein and to a lesser extent from fat. When you see that all the major diseases of aging are correlated with high blood sugars and high insulin levels you might think that he is onto something.

In his AHS 2012 talk Rosedale discusses the dangers of mTOR (mammalian target of rapamycin). mTOR is activated when we eat protein and raise insulin and leads to suppression of autophagy. In view of this Rosedale recommends relatively low levels of protein for people with diabetes (e.g. 0.6g/kg) and even lower for people who are battling cancer (e.g. 0.45g/kg).

Vegan luminary Dr Michael Gregor points to the various drawbacks of excess dietary protein and makes a compelling case for restricting animal protein by focusing on plant foods rather than caloric restriction or intermittent fasting.

There’s a fascinating August 2015 paper by Valter Longo et al that gives an overview of the current thinking in longevity.^{^[10]} While it mentions protein restriction as a possible area for future investigation, discussion of protein restriction generally seems to be in the context of intermittent restriction with subsequent re-feeding.

To date, very few studies have been performed in humans on the potential beneficial effects of protein and/or amino acid restriction on aging processes or age-associated chronic diseases.^{^[11]}

There are obvious benefits in having periods where the body can clean out old proteins, however you also need high quality nutrition to build back the new shiny parts.

While I have gone to great lengths to bring attention to the fact that protein contributes to the insulin load of the diet, I struggle with the concept of chronic protein avoidance when so many of the things I read talk about the mental health benefits of protein,^{^[12]} ^{^[13]} the benefits of lean muscle mass for metabolic health, the satiety benefits of protein and the importance of lean muscle as we get older to ensure we can be active and strong rather than brittle.^{^[14]}

Like everything though it’s a balancing act. Binging on protein supplements and egg whites to get big and jacked is not going to lead to optimal health and longevity. Some of these guys are even injecting extra insulin for its anabolic hypertrophy effects on top of the anabolic hormones. This is not healthy and not natural.

So how much protein do you need when you do eat? I think you need enough to be strong and active but at the same time without raising insulin and blood sugars and decreasing ketones.

Lean muscle = good

Insulin sensitivity = good

Excess body fat = bad

High insulin = bad

cancer

There’s also a growing momentum around the metabolic theory of cancer (the number three leading cause of death) which hypotheses that excess glucose feeds cancer growth and restricting glucose through a therapeutic ketogenic diet with intermittent fasting will reduce your risk of cancer.

There is some great work by Thomas Seyfried, Travis Christoferson and Domonic D’Agostino that is well worth your time if you haven’t already seen it.

When you hear Seyfriend talk he seems very proud of and excited about the glucose : ketone index (GKI) which he developed as a proxy for a person’s insulin levels. As you can see in the chart below, as our blood glucose levels decrease ketone levels rise.

More than blood glucose or ketones alone, the relationship between your blood glucose and ketones seems to be a good proxy for your insulin sensitivity.

It seems that someone with a GKI of less than 10 has fairly low insulin levels, someone with a GKI of less than 3 has excellent metabolic health, while someone battling cancer might want to target a GKI of 1.0.

Reducing the insulin load of your diet can reduce your glucose levels, increase your ketones and reduce your risk of metabolic syndrome and the most prominent causes of death (i.e. heart disease, stroke, cancer, Alzheimer’s and Parkinson’s).

Just to be clear, you people who achieve these excellent insulin resistance levels don’t get get there by simple adding more fat to their morning coffee but through disciplined intermittent fasting which tends to lead to reduction in body fat which improves insulin resistance.

finding the optimal balance

On one extreme too much food will make us fat and insulin resistant and stop the body from repairing itself.

On the other extreme calorie restriction will make us frail and vulnerable to disease and accidents.

So how do we find the middle ground?

On the topic of carbohydrates Peter Attia says:

You want to consume basically as much glucose as you can tolerate before you start to get out of glucose homeostasis. For me there’s a different number than for the next person, and you have to find what the level is.

I’ve been wearing a continuous glucose monitor for several months now. Every day I just have it spit out my 24-hour average of glucose plus a standard deviation, and I now know my sweet spot. I like to have a 24-hour average of between 91 and 93 mg/dL with a standard deviation less than 10.

We can’t measure insulin in real time. To me, the Holy Grail would be to have an area under the curve of insulin, but this becomes a pretty good proxy.

It’s fascinating to see that Attia, who is a super fit semi pro athlete is going to the effort of wearing a continuous glucose meter full time. CGMs are generally worn by people with type 1 diabetes like my wife.

The process he is describes of reducing dietary glucose intake to a point where blood glucose levels are normalised is essentially the process used by the people we see who are managing type 1 diabetes as well as possible.

The food insulin index testing measured the area under the curve response to various foods (i.e. what Attia describes as the Holy Grail) and has been really useful for us to understand which dietary inputs cause the greatest blood glucose swings and require largest amounts of insulin.

I think the reason that Attia is recommending ‘as much glucose as you can tolerate’ is to fuel your energy needs for activity, maximise nutrition and dietary flexibility. This level of blood glucose control will give him an HbA1c of 4.8% which will put him in the lowest risk category for the most common diseases of aging. But to maintain such a tight standard deviation he’s going to be managing the net carbs and protein in his diet so his blood sugar doesn’t go over 100mg/dL or 5.6mmol/L too often.

Dr Roy Taylor recently released an interesting paper where he proposes that each person has a personal fat threshold^{^[15]}. Rather than the BMI chart or body fat, there is a certain level at which the body fat becomes inflamed and insulin resistant which leads to diabetes and all the issues related to metabolic syndrome. What this means in practice is if your blood glucose levels are rising above optimal you need to eat less to lose body fat.

When it comes to protein Attia says:

What I’m telling my patients is really you only need as much protein as is necessary to preserve muscle mass.

You have a sliding scale, which is carbohydrate goes up until you hit your glucose and insulin ceiling, protein comes down until you’re about to erode into muscle mass and slip into positive nitrogen balance, and then fat becomes the delta.

So in somebody like me, that’s probably about 20% carb, 20% protein 60% fat.

I’ve done everything from vegan to full ketogenic. I’ve experimented with the entire spectrum of religions, but nevertheless, that’s the framework.^{^[16]}

It’s worth noting here that this quote from Peter is in the context him talking at length about mTOR, ROS, glucose control and protein restriction. Attia is one of the smartest guys in nutrition, medicine and anti-aging science, but he’s not avoiding protein. He’s making sure he gets enough to maintain lean muscle mass but not so much that it messes with his glucose levels or requires a significant glucose response.

Attia also talks about maximising glucose and minimising protein to normalise blood glucose and insulin. Given that the focus is on managing insulin levels, I think you could also take the opposite approach to minimise carbs and maximise protein as much as you can without disrupting glucose or losing ketones. People with type 1 diabetes will tend to consume medium to higher protein levels (which provide glucose but without the same degree of glucose swing) with lower levels of carbohydrates.

Or alternatively find your own balance of net carbs and protein that gives excellent blood glucose levels and some ketones.

When it comes to finding the optimal level of protein and energy Dr Tommy Wood said:

The anti-IGF-1 (insulin like growth factor) crowd confuse me. Lots = bad (cancer). Very little = also bad (sarcopenia and broken hips).[17]

caloric restriction

One of the pioneers in the field of longevity is Roy Walford,^{^[18]} who developed the concept of Calorie Restriction with Optimal Nutrition (CRON). Many of the ideas in this article and the blog overall are built around Walford’s ideas regarding optimising nutrition for health and longevity.

While Walford lived his theories in practice, he unfortunately died at 79 of ALS so we didn’t really get to find out whether calorie restriction delayed the major diseases of aging for him. The pictures below are taken of Dr Walford before and after two years living in Biosphere 2.^{^[19]}

Walford was the crew’s physician and meticulously recorded the health markers of the Biosphere 2 ‘crew members’^{^[20]}. It’s interesting to see how markers like the BMI chart, glucose, insulin and HbA1c all improved markedly with the semi-starvation conditions during the experiment, however they reverted to more normal levels after resuming normal eating.

optimal nutrition

If we are going to fast and / or restrict calories to optimise our metabolic health it’s even more important that we make sure that the food we do eat, when we eat it, provides all the nutrients that we need to thrive and build back new shiny parts of our body. Unfortunately it seems that the optimal nutrition component of Walford’s CRON concept is not discussed much these days.

In the article optimal foods for different goals I have detailed a system that can be tailored to identify nutrient dense foods for different goals to balance nutrient density and insulin load. I hope this will help to spark further discussion around the topic of nutrient density and which foods would be most helpful for different people.

summary…

So what does all this mean? What do we know about maximising our metabolic health and avoiding the primary diseases of aging?

Is too much energy bad… yes.

Is eating all the time bad…. yes.

Is excess protein bad… maybe, maybe not, however the vegans would say that we should avoid animal protein and stick to only plant based foods.

Are excess carbohydrates bad… maybe, maybe not, however the low carb / keto crowd would say that you need to avoid carbohydrates because they raise your insulin.

Is excess protein and excess non-fibre carbohydrates bad… most likely, yes.

Both carbohydrates and protein will raise insulin, blood glucose, IGF-1 and upregulate mTOR which all accelerate aging.

In the end though we have to eat. We are programmed for survival. While not eating too much and intermittent fasting are important considerations, when we do eat though we should maximise the nutrient density and prioritise foods that do not not raise our insulin and blood glucose levels. I think if you get that right a lot of the other things will follow.

There is no perfect dietary solution for all. What is best for you will come down to your situation, goals and preferences.

Some people will prefer zero carb with lots of meat.

Some people feel strongly about avoiding animal products and do well on a plant based diet with minimal processed foods.

Some will aim for a therapeutic ketosis approach to tackle major metabolic issues.

All of these extremes are viable but a balance somewhere in the middle might be easier to maintain in the long term while also maximising the nutrient density of the calories we consume.

What is almost certainly dangerous for most people is the low fat, high insulin load approach that has been recommended for the past few decades and seems to have led to increased consumption of low nutrient density highly processed food products by many.

references

^{^[1]} http://chriskresser.com/the-keys-to-longevity-with-peter-attia/

^{^[2]} http://cardiab.biomedcentral.com/articles/10.1186/1475-2840-12-164

^{^[3]} http://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/1749-8090-3-63

^{^[4]} http://chriskresser.com/the-keys-to-longevity-with-peter-attia/

^{^[5]} http://chriskresser.com/the-keys-to-longevity-with-peter-attia/

^{^[6]} http://www.nature.com/ncomms/2014/140401/ncomms4557/fig_tab/ncomms4557_F1.html

^{^[7]} http://chriskresser.com/the-keys-to-longevity-with-peter-attia/

^{^[8]} http://www.goodreads.com/quotes/6741-complete-abstinence-is-easier-than-perfect-moderation

^{^[9]} https://intensivedietarymanagement.com/fasting-and-autophagy-fasting-25/

^{^[10]} http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4531065/

^{^[11]} http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4531065/

^{^[12]} http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738337/

^{^[13]} https://www.moodcure.com/safe_alternatives_to_antidepressants.html

^{^[14]} http://www.webmd.com/healthy-aging/sarcopenia-with-aging

^{^[15]} http://www.clinsci.org/content/128/7/405

^{^[16]} http://chriskresser.com/the-keys-to-longevity-with-peter-attia/

[17] http://press.endocrine.org/doi/full/10.1210/jc.2011-1377

^{^[18]} https://en.wikipedia.org/wiki/Roy_Walford

^{^[19]} https://en.wikipedia.org/wiki/Biosphere_2

^{^[20]} https://m.biomedgerontology.oxfordjournals.org/content/57/6/B211.full

^{^[21]} http://www.walford.com/cronmeals1.htm

^{^[22]} https://www.drfuhrman.com/library/andi-food-scores.aspx

^{^[23]} https://www.youtube.com/watch?v=ZVQmPVBjubw

articles, blood sugar, diabetes, fasting, weight loss

Antonio C. Martinez II’s type 2 diabetes reversal

February 29, 2016 Marty Kendall 15 Comments

Can fasting improve blood glucose levels and reduce the need for diabetes medications? Antonio Martinez was eager to find out, so he set out on his own n = 1 experiment.

Antonio is an Attorney at Law (Martindale Hubbard Distinguished Rating and in The Legal Network Top Lawyers in New York) and businessman who worked for the late Dr Robert C. Atkins MD in government relations and appeared on his radio show in the 90s.

Antonio was one of the principal lobbyists and strategists involved in the passage of the Dietary Supplement Health and Education Act of 1994 (DSHEA) and has been involved in health care issues in law and policy throughout his career.

Back in the 90s Antonio adopted a low carb approach to lose weight for a time but says he then resumed a more moderate diet. It wasn’t until Antonio started to have his own health issues, including type 2 diabetes and a heart attack, that he realised he needed to intensify his efforts.

type 2 diabetes diagnosis

Antonio has a family history of Type 2 Diabetes, with both his mother and father suffering from the condition. Diagnosed with Type 2 Diabetes in 2002, Antonio was initially put on Metformin and eventually Janumet in 2008.

With the help of anti diabetic medications Antonio maintained a HbA1c in the 6s and was commended for his great blood glucose control. However even though he kept his blood glucose under the American Diabetes Association recommended maximum HbA1c of 7% Antonio was still at risk for cardiovascular disease.

As shown in the chart below, people with a HbA1c of less than 5.0% have the lowest risk of cardiovascular disease and stroke, however it doesn’t seem to count if you are using anti-diabetes medications to reduce blood glucose levels as they simply drive the excess energy back into storage as fat.

While anti-diabetic medications help to lower blood glucose levels (the symptom) these medications do not necessarily reduce your disease risk or allow the fat in your organs (the cause) to be released to restore insulin sensitivity (the solution).

Insulin is an anabolic hormone which means that it enables the body to build energy stores. If your problem is hyperinsulinemia, Type 2 Diabetes or fatty liver then your goal should be to lower your blood glucose and insulin levels to enable your stored body fat to be used for energy. Medicating high blood glucose without dietary changes will drive the energy back into storage as fat (including in your heart, liver and pancreas).

The diagram below from Dr Ted Naiman helps to explain how both high insulin levels (hyperinsulinemia) and high blood glucose levels (hyperglycemia) are interrelated and both bad news.

heart attack!

Sadly, on March 28, 2014, Antonio suffered a heart attack and had a stent placed in one artery.

Upon admission to the hospital he weighed 158 lbs and had a HbA1c of 7%. After the heart attack Antonio was prescribed aspirin, blood pressure medication, a statin, an anti-coagulant, and a beta blocker. Within a short time he began to experience side effects from the multiple medications.

Frustrated, he re-read a number of health and medical materials and told his doctors he would not be taking medications for the rest of his life. He also watched the documentary “Cereal Killers” which was a light bulb moment for him.

reduced carbohydrate approach

In July 2014, Antonio told his doctor and cardiologist that he was going on a high fat low carbohydrate diet. While his doctors did not advise against it, they were skeptical and warned him that he would have to have labs done frequently to monitor the impact of the diet.

Then in September 2014 Antonio received a call from his doctor who said

Congratulations. Whatever you are doing, keep doing it. You have a normal HbA1c! I’m taking you off Janumet. Take Metformin at the lowest dose as a control.

As shown below, Antonio’s HbA1c had come down from 6.6% to 4.9% with the low carbohydrate dietary approach. He had also dropped thirteen pounds to 145 lbs, his blood pressure had normalized, his HDL increased by 20 points and his triglycerides dropped below 100 mg/dL.

tackling dawn phenomenon

Despite eating only two low carb meals per day Antonio became concerned towards the end of 2015 that his morning blood sugar levels were starting to drift up.

Dawn Phenomenon is the process where the body secretes a range of hormones and glucose in preparation for the day, however if you are insulin resistant then the insulin response may not be adequate to maintain normal blood glucose levels. Having already experienced a heart attack he took this seriously and was eager to do whatever he could to reverse the situation.

So to kick off the new year Antonio adopted a regular fasting regime which involved going to bed without dinner on Sunday night and then not eating until Tuesday evening. This gives him a 44 to 48 hour fasting window each week.

The chart below shows Antonio’s blood glucose numbers through December before the fasting protocol and then through January and February with the fasting protocol in place.

Real life blood glucose numbers are always going to bounce around, however you can see that Antonio’s average blood glucose values have really improved.

I am getting the best numbers that I’ve ever had and no Dawn Phenomenon.

While the longer fasts are working well for Antonio he could also use shorter more regular fasting periods to keep his blood glucose down. Check out the Using your glucose meter as a fuel gauge article for some ideas on how you can make sure your average blood glucose is trending in the right direction.

One way of viewing high blood glucose levels and Dawn Phenomenon is the body’s way of releasing excess stored energy into the bloodstream to be used. If you are insulin resistant the body will use a process called gluconeogenesis to convert excess protein, and even fat to an extent, into glucose.

Once the excess fat decreases people will often become more insulin sensitive and the body will stop pumping out this extra glucose.

HbA1c

Starting out with an HbA1c of 5.1% Antonio was already doing pretty well due to his disciplined low carb approach. However the addition of the fasting protocol helped him break through the plateau and bring his blood glucose levels down even further towards optimal levels. Based on his blood glucose values he now has an HbA1c of around 4.6% which is pretty much optimal.

ketones

Antonio’s ketones are solid but actually trending down after introducing the fasting regime. The fact that Antonio has lower ketones values is not really a concern given that he’s likely using his ketones more effectively for energy rather than letting them build up in the blood as might be the case with a high fat diet without fasting.

I think many people get themselves into trouble chasing high ketone values by adding more dietary fat without improving their metabolism and insulin sensitivity to the point that they can actually use the ketones. Fasting forces your body to learn to use ketones for fuel.

glucose : ketone index

The ratio between glucose and ketones (GKI) can be a more useful measure when your blood glucose levels are reducing. A reducing GKI is an indication that your insulin levels are decreasing and your metabolic health is improving.

Antonio’s glucose : ketone ratio (GKI) improves each time he fasts and that it is trending down over time. These low GKI values indicate that he is achieving excellent metabolic health.

Thomas Seyfried’s GKI is a useful tool to track your metabolic health once your blood glucose values are approaching optimal levels. Seyfried aims for his cancer patients to have a GKI of 1.0, though a GKI below 10 is considered to be a fairly low insulin state and less than three is excellent metabolic health for someone not chasing therapeutic ketosis.

no turning back?

Antonio continues to enjoy the weekly fasts during which he focuses on drinking lots of different teas, coffee, and some bone broth. His weight has now dropped to 141 pounds and he is wearing the same size clothes as he wore in college.

When his friends ask him how he reversed his type 2 diabetes and got skinny. He replies,

By eating a high fat low carbohydrate diet based upon eating real food.

I work to keep my food macros in the range of 70 percent fat, 20 percent protein, 10 percent carbs as my ideal targets. I do watch my protein intake because excess will convert via gluconeogenesis.

I will likely maintain this approach for the rest of my life. I am loving my results!

Antonio says:

Another way to look at insulin resistance is your body telling you that you’re eating too much, eating too much of the wrong things or just eating too often. Our ancestors were hunter foragers whose eating habits were more like feast and famine, not three meals with snacks. Know and respect your insulin because it will command you to do so or otherwise wreak metabolic havoc on your health.

You can also think of your blood glucose meter as a fuel gauge. If your blood glucose levels are high then it might be time to stop filling the fuel tank for a while.

Intermittent fasting is like going to a metabolic gym and working out. Your body gets the opportunity to repair, recover, regenerate. Used intelligently, it will make the difference for your health and insulin sensitizing.

I am disappointed in the medical establishment because they should know better and they do not. Why isn’t clinical and therapeutic nutrition education mandatory in medical school and taught with the same emphasis as pharmacology?

And before go thinking Antonio is a saint that loves deprivation, he likes to feast too! Here he is with Ivor Cummins at Antonio’s favorite New York restaurant with some red wine..

… Brussell sprouts salad…

..some pate…

…and Le Côte de Beouf.

Lots of people would call this a ‘heart attack on a plate’, but for Antonio it seems to be working the other way. Here’s the blood glucose and ketone results the next morning.

And here’s Antonio recently on the job full of life and vitality.

Antonio with Former U.S. Senate Majority Leader Tom Daschle in Washington DC, February 2016

cured?

Is Antonio cured of his type 2 diabetes? The answer depends on your definition of “cured”.

Will Antonio be able to eat processed junk food five times a day? Probably not.

However if Antonio keeps up this fasting protocol along with his low carbohydrate approach then he just might be able to maintain optimal blood glucose levels without fear of another heart attack.

If that’s your definition of “cured” then the answer might be yes.

Congratulations Antonio and keep up the great work!

[This article has now been translated to Spanish. Check it out here.]

references

^{^[1]} http://www.thelivinlowcarbshow.com/shownotes/12960/997-attorney-Antonio-martinez-pushing-lchf-through-public-policy-and-the-law/

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

^{^[3]} http://www.fitnessunderoath.com/the-44-hour-diet/

^{^[4]} http://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

contact

If you’re going through a similar experience Antonio would love to hear from you via his website at www.acmartinez2.com

articles, blood sugar, diabetes

balancing diet and diabetes medications

August 17, 2015 Marty Kendall 16 Comments

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

when do you need insulin?

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

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

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

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

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

Fasting and improving insulin sensitivity

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

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

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

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

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

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

the balance between diet and medication

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

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

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

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

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

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

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

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

the dangers of glucose toxicity

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

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

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

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

the dangers of insulin toxicity

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

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

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

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

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

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

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

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

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

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

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

two sides of the same coin?

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

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

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

refining insulin levels for type 1 diabetics

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

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

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

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

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

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

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

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

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

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

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

the law of small numbers

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

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

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

adjusting insulin doses for type 2 diabetics

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

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

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

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

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

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

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

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

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

references

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

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

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

[4] https://intensivedietarymanagement.com/

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

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

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

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

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

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

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

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

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

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

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

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

articles, blood sugar, diabetes, insulin index, nutrient density, protein

how to calculate insulin dosing for type 1 diabetes (including protein and fibre)

August 10, 2015 Marty Kendall 9 Comments

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

introduction

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

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

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

carbohydrate counting

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

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

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

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

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

Bernstein’s own approach

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

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

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

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

sugar surfing

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

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

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

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

food Insulin Index

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

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

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

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

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

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

Total Available Glucose (TAG)

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

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

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

separate boluses for carbohydrates and protein

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

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

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

insulin calculator

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

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

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

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

inputs

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

outputs

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

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

meals

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

our experience

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

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

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

meal	carbs (g)	protein (g)	insulin load (g)
bacon, eggs, avocado and spinach	4	15	19
spinach and cheddar scrambled eggs	6	18	24
steak, broccoli, spinach, haloumi	6	20	26
coffee with cream and stevia	1	1	2
chia seed pudding – no fruit	7	4	11
broccoli, bacon, cream and mozzarella	3	17	20
sausages, avocado, sour cream, tomato	7	13	20
bacon, eggs, spinach and pesto	4	16	20
bacon and eggs	3	18	21
bacon, eggs, avocado and sauerkraut	5	21	26
fathead pizza with anchovies and pesto	4	13	17
bacon asparagus and eggs	3	18	21

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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