Tag Archives: intermittant fasting results

how to use your bathroom scale as a fuel gauge

“Complete abstinence is easier than perfect moderation.”

St Augustine

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This article is a follow up to the “How to use your glucose metre as a fuel gauge” article, which has been quite popular, with lots of people reporting success in lowering their blood glucose and recalibrating their hunger signals by using the numbers they see on their glucose metre.

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To recap, the process revolves around the idea that, perhaps even better than calorie counting or carbohydrate counting, the numbers you see on your blood glucose metre are a good indication of whether you are running low on fuel and need to eat or whether you are just eating out of habit, routine, social boredom or for entertainment.

While eating for pleasure occasionally or as part of a celebration is fine and part of enjoying life, in the long run, most of us need to find a way to obtain the nutrients we need with less energy if we want to avoid obesity, diabetes and all the associated negative consequences.

If we eat highly insulinogenic low nutrient density foods regularly our insulin levels stay high and our fat stays locked in storage and hunger drives us to eat more frequently.  However, if we reverse this cycle to lower our glucose and insulin to normal levels we start to eat less frequently and we allow our stored energy to flow out of our fat cells, our appetite decrease and there is a good chance we will lose weight and gain health.

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The table below shows the simple process whereby someone could decide if they really need to eat.  Using this process would ensure that their blood glucose levels continue to trend down as their excess energy in their bloodstream and vital organs (pancreas, liver etc) flows out of storage.

blood glucose action
>  7-day average, well slept and low-stress delay eating and/or exercise and wait for blood glucose to come down
< 7 day average if hungry, enjoy nutrient dense foods that align with your insulin sensitivity
< 73mg/dL or 4.0 mmol/L if hungry, eat higher insulin load foods and delay exercise

Using numerical outputs to guide our decision making

There is no end of debate as to whether a calorie is a calorie or whether calories matter.   Rather than tracking estimates of inputs like calories eaten or calories burned in exercise, there is nothing like tracking outputs such as your blood glucose levels, waist or weight to understand what your body is doing with the food you are eating and whether you are eating too much or too little.

If your glucose levels, insulin, waist or weight are increasing then chances are you’re eating too much, too often or the wrong type of food.

The plot below is a stark reminder that our chances of living longer improve if we have lower body fat levels or a waist to height ratio close to 0.5.

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The problem with tracking glucose levels

The ‘problem’ with tracking blood glucose levels is that, in time, with regular fasting, our glucose levels will normalise to healthy levels but we may still be left with excess weight.  So where do we turn once our blood glucose levels are optimal but our body fat levels are still above optimal?

This brings us to the star of this article, Rebecca Latham, who is a great example of how you can use your body measurements to guide your feast / fast cycle to achieve your long-term goals.

Rebecca has been following a low carb diet since the start of February 2009.  She was featured in the 2010 New Atkins for a New You[1]  as well as on the Atkins site as an example success story.[2]  She was a guest on Episode 404 of Jimmy Moore’s Livin’ La Vida Low Carb podcast.

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After a stressful time towards the end of 2015 Rebecca Latham decided she needed to make a focused effort to her lose some extra weight that had crept on.  Rebecca is also particularly motivated by her family history of ALS, Parkinson’s Disease, dementia and cancer and her own ongoing battle with Type 2 Diabetes.

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Rebecca’s Protocol

On 1 January 2016, Rebecca set an initial goal to lose 0.2 pounds per day over three months.      Rebecca was also eager to reduce her fasting blood glucose levels from the 100mg/dL back to the 70mg/dL that they had been at before she regained her weight.

Part of Rebecca’s inspiration comes from her uncle, Buell Carlton Cole.

He was general surgeon to the President of the United States, who would control his weight by simply not eating until he returned to his goal weight.  I initially thought this was an unhealthy approach until I read up a more about intermittent fasting.

Rather than simply not eating until she achieved her goal weight, Rebecca’s system involved not eating on days when her weight in the morning was above her target weight.  Her only exception was to be special occasions and celebrations.

Here are Rebecca’s weight loss results during her initial 90-day challenge.  Initial weight loss can be quite quick as the insulin levels drop and the body releases water.  However, it gets a bit harder to continue with straight line weight loss as time goes on as you can see towards the end.

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After the reached her initial goal, Rebecca had some issues that she needed to look after and ended up regaining some of the weight as you can see in the plot below of her weight over the past year.  However, once these challenges were behind her she got back on her program.  For the final part leading up to the end of the year she has dropped her goal weight loss back to 0.06lbs per day to hit her goal on 31 December 2016.   See if you can spot the few ‘blips’ around Thanksgiving and Christmas.

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This chart shows that she needed to fast for about one day in three through the year to lose nearly a quarter of her body weight over the year!

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Reflecting on her journey, Rebecca says:

I reached my highest lifetime weight in February 2009, when I weighed in at 158 pounds, with a body fat percentage of 43.7%. This is my scale weight chart for this past almost eight years since I started eating low carb high fat (LCHF) and nutritional ketosis.

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Each time I lost weight and stopped tracking and weighing myself, I gradually put most of the weight back on again. As you can see by the chart, this happened several times, and the last few times it happened, my weight was going up a little higher each time.

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On January 1, 2016, I developed and started using my Protocol. Since starting the Protocol, I took two breaks, once in May 2016 when my husband had a heart attack and I was too concerned with his health to care about my own, but I got back on the Protocol within a couple of weeks and started seeing success again.

The next time I took a break was in July 2016, when I had to eat high carb and not fast for a week in preparation for some metabolic testing. As soon as the testing was over, I was back on the Protocol and started losing again. I have been going strong ever since, with small gains here and there brought on by restaurant meals and Thanksgiving.

I have now I reached my ultimate goal for scale weight, weighing in at 122.4 pounds with a body fat percentage of 25.7%, which means that I have lost approximately 37.5 pounds of body fat. The Protocol is the only thing that has brought me sustained weight loss, and I plan to follow it for the rest of my life!

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Many people have a love/hate or even just a hate/hate relationship with their bathroom scale.  It would be nice if low carb or nutrient dense achieved optimal health outcomes without any restriction for everyone.  However, unfortunately, sustaining weight loss in the long term often takes discipline, some form of accountability and some level of restriction for most of us.

While weighing yourself every day isn’t much fun, the national weight control registry data indicates that people who have successfully lost weight and kept it off weigh themselves regularly.[3] [4]  [5] Rebecca’s intended long term maintenance plan will likely be to weigh herself regularly and fast again once her weight goes outside her target range.

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Better than calorie counting?

Some people who first try low carb or keto find that they initially lose a lot of weight eating to satiety as their blood glucose and insulin levels drop to healthier levels.  However, in the long term, many people find that they need to be more disciplined and mindful of how much and/or how often they are eating to reach their optimal level of body composition.

The great thing about combining fasting with working to a goal like this is that it makes sure you don’t overdo the feasting days.  I’ve found personally that it can be hard to know how much to eat after a fast.  A quantitative system like this helps to manage and calibrate your appetite when you’re feasting.

If you eat to satiety, and not beyond, then you won’t have to fast again as soon as compared to if you binge after your fast.  Eating to satiety on a regular basis means that your body’s metabolism doesn’t slow and adjust in the same way that it would if you maintained a constant caloric restriction.[6]

Life extension benefits

There are a number of benefits to fasting:

  • You can reduce your insulin levels more than if eating small but regular meals which keeps your insulin levels consistently elevated.
  • Fasting gives your body a chance to repair through a process called autophagy which is where the old cells are cleaned up which allow space for the fresh new cells to grow.
  • Fasting trains your body to become ‘metabolically flexible’ so you can use your body fat stores for and your food for fuel.
  • There is less need to focus on the quantity of food eaten at every single meal.
  • It’s not ideal to always be in growth mode with mTOR switched on. Alternating periods of growth and repair appear to be more beneficial in the long term.[7]
  • Fasting makes sense from an ancestral point of view when we wouldn’t have had constant access to plentiful food the way we do now. Periods of intentional restriction mimic what we have become adapted to and follow the seasons of the past.

Fasting also seems to have some special anti-aging effects.  When food is scarce 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 to a time when food is more plentiful and you can reproduce and pass on your genes.  Unfortunately, this emergency repair function doesn’t happen when food is plentiful.

Fasting and blood glucose levels

During the first three months following her protocol, Rebecca added a blood glucose target to also bring her blood sugar down by 0.25 mg/dL per day.  As you can see in the chart below her blood glucose levels have dropped pretty much in parallel with her weight loss during this time.

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More recently, she tested her blood glucose levels and found that they were consistently great so she ended up discontinuing the testing because it was becoming monotonous and not helping her make useful decisions.

While it’s useful to track a few things, it can be overwhelming and time-consuming to keep track of too many things at once and lead to analysis paralysis.  It’s good to find a handful of things to track that will help you make useful decisions.

Do we lose fat or muscle during fasting?

One hot topic of discussion is the amount of lean mass (i.e. or muscle) that one may lose in long term fasting.

The reality is that any weight loss is going to consist of a combination of water, fat and muscle (or lean muscle mass).  The chart below from Kevin Hall’s model shows that we initially lose a lot of carbohydrate (glycogen) and with it a lot of water.

Protein / muscle loss is the smallest component of loss from the body and this decreases as we adapt more to using fat and ketones rather than relying on glucose.  It takes a few days to adapt to using fat and ketones, but in the long run they are by far the greatest proportion of energy used during fasting.

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Rebecca’s experience aligns with this.  She didn’t get a DEXA scan, but she does take regular body measurements which she uses to calculate her body fat percentage (see US Navy Circumference Method).  Based on these measurements she lost 28.6 lbs of fat and 3.0 lbs of lean mass.   So, more than 90% of her weight loss over the past year was fat.

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“Problems” with fasting

Jason Fung has recently popularised the concept of fasting in the low carb community via his blog and videos and published The Complete Guide to Fasting.  There is a ton of convincing evidence on the benefits of fasting which is an age old practice for a variety of reasons.

However, Dr Steve Phinney has come out highlighting his concerns with long term fasting with respect to loss of lean tissues as well as vitamins and minerals.    A number of others have expressed concerns that fasting without due care and attention to refeeding will not be beneficial in the long term.

One way to reconcile the differences is to see these concerns as two ends of the spectrum.  Jason’s focus is very sick people who come to him with major kidney issues due to their advanced Type 2 Diabetes, while Steve’s focus is more around maximising athletic performance for those whom maintaining muscle mass is critical to performance.

As you can see in the chart below from Differences in fat, carbohydrate, and protein metabolism between lean and obese subjects undergoing total starvation the proportion of energy from lean body mass increases as our level of available level of body fat decreases.

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Also, if you are more fat adapted your body will be able to more easily draw energy from stored body fat rather than requiring glucose which can be drawn from the protein in your body via gluconeogenesis.

Most people don’t fit neatly into either of the extremes, so how do you refine the approach to suit your current situation?   That is where optimising your food choices to suit your current situation comes in.

How much to eat after your fast?

Personally, one challenge I find with fasting is that it’s easy to overdo it when you get to eat again.  I think some people experience this more than others.  Dr Phinney made the analogy that telling someone not to binge at the end of a fast is like telling someone to hold their breath but then not to take too big a breath when they come up for air.

While some people can eat normally the next day after a fast, personally I find that it’s easy to reach for the energy dense lower nutrient dense foods or to give yourself liberty to eat foods that you may not normally eat if you were being disciplined all the time.   By doing this, I’ve found it’s still possible to maintain or gain weight when fasting more days that you eat if you’re not disciplined with what you eat on your feasting days.

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If you find yourself reaching for energy dense low nutrient density foods like processed carbs, a block of chocolate or litre of cream after your fast then you could take that as a sign that you need to revert to shorter fasting periods until you’re more fat adapted.

Another challenge with fasting is that it will deplete your system of vital nutrients in the long term meaning that you may be more inclined to binge when you do eat unless you’ve focusing on maximising nutrient density in your feasting periods.[8]

What to eat after you fast

One of the unique things about fasting is that it forces your body into the cleansing process of autophagy and primes the body to rebuild.  Hence, it’s especially important to feed the parts of the body you want to grow (lean muscle mass is critical for long term health[9]) and maximise the nutrient density during the initial refeed.

In some ways, a fast is only as good as the feast afterwards that your body is highly primed to absorb.  For me that means trying to plan some nutrient dense greens and a solid amount of protein for my first meal so I don’t end up reaching for the energy dense cream, butter or peanut butter or indulge in some junk carbage because I feel like I’ve earned it.

If your goal is to lose fat during the fast then it’s important to build back the essential vitamins, minerals and amino acids during the feeding period.   The body will fight to get what it needs in the long run and I think you’ll have a better chance of avoiding cravings and involuntary binging if you maximise the essential nutrients of your food when you do this.  And if you are using fasting to achieve long term weight loss I think it makes sense to try to get the maximum number of nutrients with the least amount of energy (a.k.a.  avoiding empty calories and maximising nutrient density).

People looking to use fasting for long term weight loss may benefit from starting out with a higher fat dietary approach if they are very insulin resistant.  However, as blood glucose levels progressively improve you should be able to transition to a more nutrient dense nutritional approach which will allow you to get your required nutrients with less energy.

I see a lot of arguments online regarding whether high fat keto or high protein is optimal. I think these arguments come down to context.  The table below gives some guidance as to which approach might be right for you initially based on:

  1. your blood glucose levels (if your glucose levels are high you will likely benefit from a higher fat keto approach, at least initially until your glucose levels start to normalise),
  2. ketones (some is better than none, but there’s no need to chase high ketones with heaps of extra dietary fat, especially if you are trying to lose body fat), and
  3. waist to height ratio (this is going to be more useful than the BMI chart to tell you if you still need to lose a bit of weight).
approach average glucose ketones (mmol/L) waist : height
(mg/dL) (mmol/L)
therapeutic ketosis > 140 > 7.8 < 0.3
diabetes and nutritional ketosis 108 to 140 6.0 to 7.8 < 0.3
weight loss (insulin resistant) 97 to 108 5.4 to 6.0 < 0.3 > 0.5
weight loss (insulin sensitive) < 97 < 5.4 > 0.2 > 0.5
nutrient dense maintenance < 97 < 5.4 > 0.2 < 0.5

This graphic from Dr Ted Naiman demonstrates how foods are all somewhere on the sliding scale between maximum energy density and maximum nutrient density.  If we are aiming for long term weight loss, we want to maximise nutrient density as much as we can while keeping blood glucose levels and insulin levels low. Then as we improve blood glucose levels and insulin sensitivity we will be able continue to move towards the right to more nutrient dense approaches which will help to provide satiety and adequate nutrition with less energy.[10]

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If / when we reach our ideal weight or level of body fat, we can afford to add back in some more energy dense foods because we are no longer trying to use the glucose in our liver (glycogen) and body fat from our belly.[11] [12]

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Rebecca says:

I originally started eating ketogenically a few years ago by eating very high fat, lower protein, and very low (sometimes zero) carbs. That worked for a while, and I lost weight, but as time went on, I found that I was eating so much fat and so little protein that I was getting hungry all the time.

I now get plenty of protein on my eating days. I am 5’3″ and eat 125g on the days that I feast.  I find with this approach I am less hungry and my Protocol requires me to fast less often.[13] [14]

Losing lean muscle mass is bad news whether you’re a bodybuilder, a diabetic or an older person battling sarcopenia.[15]   Not only will losing muscle decrease your metabolic health, glucose disposal and metabolic rate, your body will also increase appetite to regain the muscle, making it harder to keep on losing the fat.[16]

It’s not just about looking buff and building muscles, amino acids are critical to fueling mitochondrial function and creating neurotransmitters that assist in staying happy and sleeping well.  For example, the amino acid tryptophan produces serotonin which makes us happy and melatonin which helps us sleep.[17]

For reference, Rebecca’s 125g of protein per day ends up being 3g/kg LMB.  This equates to 2g/kg LBM per day on average if you factor in the fact that she fasts every third day.   This aligns with Volek and Phinney’s recommendations in the Art and Science of Low Carb Living (i.e. 1.5 – 2g/kg reference body weight) which equates to 1.7 to 2.2g/kg LBM .  In Lyle McDondald’s Rapid Fat Loss Handbook he recommends between 1.8 to 4.4g/kg LBM protein, with a higher level of protein if you are lean and more active, and less if you are obese and inactive, to prevent muscle loss during a protein sparing modified fast.

The optimal food lists have been designed to help maximise nutrient density (including ensuring adequate amino acids) ideally without needing to rely on tracking calories.  Rebecca does track what she eats, but mainly to make sure she is getting adequate protein on her feasting days.

The Protocol does not *require* tracking food intake, but I strongly recommend it. I found, for myself, that if I did not track on feast days, I ate too much fat and not enough protein, and I was having to fast a lot more to make my daily goals. Starting in April, I did start using the OKL macros and recommending the same to others.[18]

Rebecca also practices early time restricted feeding (eTRF) which means she eats earlier in the day due to better insulin sensitivity which seems to be producing good results for a lot of people.  I have heard a lot of reports from people that have found that eating earlier rather than later helps with sleep, appetite and blood sugar.

Variations

I encourage you to check out Rebecca’s Facebook group where she has documented her daily progress and learnings and supports others using the Protocol.  You can download a spreadsheet and start tracking and sharing your own progress.  Public accountability and a supportive community are always going to be helpful in achieving such a long-term goal.

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Rebecca has ‘stacked’ several different techniques from her learnings to ensure her long term success this time around to fight her genetics and tendency to regain her weight.

Before launching in, there are several considerations to tailor Rebecca’s approach to suit your situation and goals such as:

  • Target rate of weight loss. Rebecca recommends that people aim for a maximum weight loss of 0.2lbs or 0.1kg per day.  Anything more is typically hard to sustain in the long term.  You might be feeling ambitious and this level might be easy to achieve when things are going well but it may be hard to sustain in the longer term, especially if you have a few social gatherings or parties that leave you with some catching up to do.  As you approach your goal weight you may be glad you chose a less aggressive goal as the weight loss becomes a little harder to achieve.

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  • Social context. This type of approach can be hard to work around family or social commitments.  I like to enjoy good food with my family on the weekends and save my fasting for work days when it’s easier to skip food.  When I’ve followed this protocol, it leaves me fasting Monday and Tuesday and eating dinner Tuesday night with the family or ideally a hearty breakfast Wednesday morning.  Based on my scale weight I may end up fasting another day or two on Thursday and / or Friday.
  • What’s your maximum fasting tolerance? Fasting gets easier with practice.  You might want to start with just skipping a couple of meals, then going for 36 hours, then a couple of days.  If you find your cravings are leading you to binge or sacrifice food quality, then you may want to stick with shorter fasting periods or aim for a less aggressive target rate of weight loss.
  • What else do you want to measure? The good thing about measuring weight is that it’s easy.  It can however be problematic in that there are a ton of things that influence your weight other than fat gain or loss (e.g. muscle, water, how full is your gut, when did you go to the toilet etc); it’s an easy way to measure your progress day to day.  In the long term, you want to see a trend in the right direction.  If you have diabetes, then you may also want to track your glucose and even your ketone levels.  It will also be useful to track your waist measurement periodically to see whether you’re getting closer to your optimum waist to height ratio of 0.5, particularly if you are building muscle and hence the BMI chart categories won’t mean much for you.  For reference, during 2016 Rebecca’s waist to height ratio went from 0.54 to 0.44.

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How full is your stress bucket?

A word of warning, again from personal experience, is that this approach is simple, but it’s not necessarily easy.  Wondering what number you will see on the scale each day can be exciting but a bit stressful.  It can be frustrating when you see the number going in the wrong direction or not keeping up with your target rate of weight loss.

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Chris Masterjohn recently did an excellent podcast How I Lost 30 Pounds in Four Months and How I Knew It Was Time which I highly recommend if you’re hoping to lose some serious weight.

A regular fasting routine is another thing that you will add to your “stress bucket” and if you don’t already have your sleep, nutrition, relationships, stress, circadian rhythm and regular activity in check then the cortisol and related insulin spikes may make achieving long term success with this approach harder than it would otherwise be.

If you do have these things ticked off and you’re feeling relaxed after a Christmas holidays but may have overdone the celebratory food then you can download a copy of the spreadsheet from My Low Carb Road – Fasting Support and give it a go.

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references

[1] http://www.why-low-carb-diets-work.com/atkins-forum.html

[2] https://www.carbsmart.com/low-carb-success-story-rebecca-latham.html

[3] https://www.ncbi.nlm.nih.gov/pubmed/24355667

[4] https://www.ncbi.nlm.nih.gov/pubmed/18198319

[5] https://www.ncbi.nlm.nih.gov/pubmed/14668267

[6] https://www.ncbi.nlm.nih.gov/pubmed/20921964

[7] https://optimisingnutrition.com/2016/10/29/the-complete-guide-to-fasting-book-review/

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

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

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

[11] http://livinlavidalowcarb.com/blog/the-llvlc-show-episode-1161-qa-medical-panel-2016-low-carb-cruise/26797

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

[13] http://www.artandscienceoflowcarb.com/

[14] http://www.ketoisland.com/blog/is-keto-high-fat-or-low-fat/

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

[16] http://www.nature.com/ejcn/journal/vaop/ncurrent/full/ejcn2016256a.html?platform=hootsuite

[17]  https://optimisingnutrition.com/2016/12/03/finding-your-optimal-insulin-load/

[18] https://www.facebook.com/groups/MyLowCarbRoadFastingSupport/permalink/147072942381538/

 

 

post last updated July 2017

the complete guide to fasting (review)

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.

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

image17Michael 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:

  1. Fasting is not that hard. Give it a try.
  2. You can build up slowly.
  3. 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).

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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.

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Desperate times call for desperate measures!

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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.

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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.

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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.

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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.

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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).

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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.

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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.

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fasting to optimise blood glucose levels

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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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).

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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.

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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.

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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.

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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.

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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.

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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.

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summary

  1. 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.
  2. Fasting can help optimise blood glucose and weight in the long term, with a disciplined regimen.
  3. 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.
  4. 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

Antonio C. Martinez II’s type 2 diabetes reversal

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.

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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.  

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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).

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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.

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heart attack!  

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

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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.  

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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.   

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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.  

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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.   

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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.   

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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.  

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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..

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… Brussell sprouts salad…

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..some pate…

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…and Le Côte de Beouf.

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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.

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

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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

optimising blood sugars with RD Dikeman

It has been a transformational journey for RD Dikeman since his son Dave was diagnosed with Type 1 Diabetes, both as a parent and for himself as he has implemented a regimen of what he likes to call “meal skipping” (a.k.a. intermittent fasting) guided by his own blood glucose levels.

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I came across Dave Dikeman, a young man with Type 1 Diabetes, in Episode 831 of Jimmy Moore’s LLVLC Show.  I still remember ten year old Dave saying “finger pricks now or amputations later, the choice is pretty simple”.   Dave’s pragmatic attitude to his condition was another light bulb moment in our family’s journey to learning to manage diabetes.

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It has also been quite a journey for RD Dikeman, Dave’s dad, who recently posted a few comments on the Optimising Nutrition Facebook Group that I thought were worth capturing.

I’ll tell you a quick story about how this whole low carb thing started.

Dave is near death, in the hospital, diagnosed with T1. The doctor rolls in to meet us. A kindly doctor – no Bernstein – but a very kindly man (he took an injection of insulin to show Dave not to be afraid).

So the doctor is talking to Dave and finds out they both went to the same school. So there’s some kinship.  And the doctor recognizes that Dave is a pretty sharp guy and Dave starts asking questions ‘will I die young?’ And Doc is brutally honest ‘you have to control your blood sugars – amputations, blindness and those things are on the table’.  And doc starts to give us a lecture on how to do that.

He has an easel and a sharpie. Anyway, he draws a rollercoaster blood sugar graph and he says ‘carbo makes blood sugar go up and insulin go down and you want to be between 80 and 180 (sigh) mg/dL.’

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And Dave goes ‘I just won’t eat carbo’.  TRUE STORY.!

And ME!! I interrupt and say (throw me down and kerb stomp me everyone) ‘You need carbo for… ENERGY’. LOL!

So I spent the next month force feeding Dave oatmeal. I am heckled daily for this. Every time there is oatmeal. Oatmeal on a TV commercial.  Oatmeal at restaurant.  Heckled!

About a month later guess who discovered ‘The Bernstein Book‘!!! NOT ME!! It was Roxanne (my wife).  So that is two fails for me.

I will say the happiest moment of my life was reading Bernstein’s ‘law of small numbers’. I knew then that we had a way out of this mess.

Being 100% wrong never felt so good.  I have a good leader. The whole thing was his idea.

Since then, RD has become passionate about the low carb way of eating and helping other people learn more about diabetes.  He is an admin on the Type One Grit Facebook Page which is a great source of support and inspiration for people with Type One Diabetes.  He and Dave also produce Dr Bernstein’s Diabetes University which captures nuggets from Dr B on YouTube.

RD lives low carb theory…

I don’t eat any carbohydrate-glucose foods. No sugar, manipulated sugar fruits, grains or starch. Ever. Carbs are only from fibrous veggies and nuts.

and it seems to be working.

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Dr Bernstein’s recommended target blood glucose is 83mg/dL (or 4.6mmol/L) with a recommendation that people with Type 1 Diabetes actively work to keep within a ten point range of this target number (i.e. 73 to 93mg/dL or 4.0 to 5.2mmol/L).

Dr B tells the story of how, back in the day, blood glucose meter sales reps would come to his office.  He would get them to demonstrate how it worked by testing it on themselves so he could see their blood glucose number.  Sure enough, the blood glucose levels of these healthy young non-diabetic sales reps was always around 83mg/dL.

Since then there has been  plenty of research that showing the benefits of having an average blood glucose level of around 83mg/dL including reducing your risk of cancer, obesity, heart disease and a range of other metabolic issues.

Some people operate happily at the lower end of this range, particularly if they are younger and / or insulin sensitive and producing ketones.  Generally though, the body of someone with a healthy metabolism will bring them back to a blood sugar of around 83mg/dL (or 4.6mmol/L).

Not too high.  Not too low.  Just right.

The table below shows a generalised relationship between blood glucose, ketones, HbA1c and the glucose : ketone ratio (GKI).  There’s no perfect number for everyone, however typically the lower your HbA1c, without using blood glucose lowering medications, the lower your risk of metabolic syndrome and related diseases (see the Diabetes 102 article for more details).

ketone BG (mmol/L) BG (mg/dL) GKI HbA1c Comment
0.20 5.9 106 29.5 5.32 good
0.50 5.3 95 10.6 4.93 high normal
0.60 5.2 93 8.6 4.85 high normal
0.70 5.1 91 7.2 4.79 high normal
0.80 5.0 90 6.2 4.74 high normal
0.90 4.9 88 5.5 4.69 high normal
1.00 4.8 87 4.8 4.66 high normal
1.50 4.6 83 3.1 4.51 optimal
2.00 4.5 80 2.2 4.41 low normal
2.50 4.3 78 1.7 4.33 low normal
3.00 4.2 76 1.4 4.27 low normal
3.50 4.2 75 1.2 4.22 low normal
4.00 4.1 74 1.0 4.18 low normal

RD is not technically diabetic himself however he understands the dangers of high blood glucose levels.  RD found that the low carb way of eating helped him lower his own blood glucose, however he still wasn’t consistently achieving Dr Bernstein’s target blood glucose level of 83mg/dL.

What he did find was that when he waited to eat his blood glucose would come down as the body used up the glucose in his blood.  Over time RD developed a practice of meal timing guided by his glucose meter that finally enabled him to optimize his own blood glucose levels.

My blood sugar tells me when it’s time to get some insulin sensitizing exercise at the gym also.

I would say if blood sugar is above normal (83 mg/dL) then beta cells are ‘on’ and insulin is a fat storage hormone (obviously other functions).

It’s your table exactly Marty Kendall!

This is the table that RD is excited about (from the using your glucose meter as a fuel gauge article).

blood glucose action
>  7 day average, well slept and low stress consider delaying eating and / or exercising
< 7 day average if hungry, enjoy nutrient dense foods that align with your insulin sensitivity
< 73mg/dL (4.0 mmol/L) if hungry, eat higher insulin load foods and delay exercise

If your glucose is higher than YOUR average then you may not need to eat right now.

If you are insulin resistant, when you do eat, you should focus on foods that won’t spike your blood glucose levels.

Eating when your blood glucose is less than YOUR current average will allow you to progressively lower your blood glucose.

Decreasing average blood glucose = winning!

For most people it will take some time before they can get their blood glucose down to Dr B’s target of 83mg/dL.  Using this method RD has been able to decrease his HbA1c from 5.3% to 4.8%.

If your blood glucose is below 73mg/dL (4.0mmol/L) then you may benefit from foods with a higher insulin load to replenish glycogen stores.

The continuous glucose meter plot below shows RD’s blood glucose levels after a few years of implementing Dr Bernstein’s advice in his family.  Not bad!

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I am able to lower my HbAc1 about 0.1% every six months. It’s not easy.

If you aren’t at mid 4s, look to belly fat and/or treating your body like an amusement park in younger days (guilty!)

One big takeaway from the journey has been how long it takes to heal the metabolism…. not a surprise if you’ve been sabotaging it for decades, I guess.

RD says it’s more than just the exercise.  It’s the food and the fasting too.

I worked out plenty in 2006.  Same gym.

RD understands that it is important for his long term health to do whatever he can to strip the fat from his body, particularly from his organs.

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As we reverse fatty liver and fatty pancreas  normal insulin sensitivity can be restored which in turn leads to normal blood glucose levels and normal body weight.

RD doesn’t use the scale to track his health, but rather his blood glucose meter.

I know if I eat too much food or if I stop working out, my blood sugar starts rising and I start to put on weight.  This happens even with a low carb diet.

If I fast and work out, my blood sugar returns to normal.  I feel better.

So really, I don’t use the (weight) scale, I can use my blood sugar meter instead.

Fixing your metabolism by learning how to eat and losing weight after years of eating the standard…  well it takes some time…  a few years in my case.

I’m still seeing improvement and motivated.  I’m definitely not going back.

Congrats RD!

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For more details on how to use your blood glucose meter as a fuel gauge check out this article.

how to use your blood sugar meter as a fuel gauge

  • Chronically elevated blood sugar levels can be a sign that you are eating too much and/or too often.
  • You can use your blood sugar to help you refine your meal timing to optimise your weight and blood sugar levels.
  • Delaying your next meal allows your body to use up the stored energy in your bloodstream, liver and body fat stores.

Over the long term, a decreasing weight on the scale can be a good indicator that you are not overeating.  However, in the short term, blood glucose levels can be a more useful indicator of whether you really need to eat now or if you are just eating because out of habit, boredom, entertainment or comfort.

The below table outlines a protocol that will help you to use your blood sugar meter as a fuel gauge to reach your diabetes and fat loss goals.

blood sugar action
greater than average, well slept and low-stress delay eating and/or exercise to reduce glucose
 less than average if hungry, enjoy nutrient-dense foods that align with your insulin sensitivity
< 73mg/dL (4.0 mmol/L) if hungry, eat higher insulin load foods and delay exercise

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This approach is not intended for people who do not produce enough insulin (i.e. type 1 diabetes, type 1.5, LADA and MODY) but rather for people who are insulin resistant and produce large amounts of insulin but still have high blood sugar levels (i.e. pre-diabetes and type 2 diabetes).

Reducing insulin

Eating frequently will keep your insulin and blood sugar levels consistently high, particularly if you tend to consume foods with a high insulin load.

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By contrast, reducing meal frequency enables blood sugar and insulin levels to decrease.

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High levels of insulin keep fat stores from being used glycogen trapped in the liver while the energy in the bloodstream is used up.

When our adipose tissue can’t absorb any more energy, it becomes insulin resistant.  This makes it harder for insulin to get into our major fat stores on the body.  But your pancreas continues to ramp up insulin production in order to reduce high blood glucose levels in the blood and to keep the glucagon stores in the liver.  With elevated insulin levels and more insulin resistant adipose tissue the excess energy now starts to get stored in more sensitive parts of the body such as our liver, pancreas, heart, brain and eyes.

Delayed eating allows the energy in the bloodstream to reduce.  Once the liver glycogen stores start to be depleted, then the body finally turns to body fat for fuel.[1]

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Decreasing body fat, particularly from the liver, pancreas and kidneys leads to improved insulin sensitivity and eventually leads to normal blood sugar levels.[2] [3]

Eating larger meals with more carbohydrate causes your blood sugar to stay higher for longer.  Conversely, consuming smaller meals with a lower insulin load allows your blood sugar to return to baseline faster.

When to eat

Your blood sugar metre can be a useful tool to understand whether you really need extra energy or whether you could skip a meal or two or not eat for the day.

If you have some level of insulin resistance, then chances are your blood sugar levels will be higher in the morning due to liver glycogen being released as your body prepares for the day.  This is sometimes referred to as Dawn Phenomenon.

If you are insulin resistant the insulin secreted by your pancreas doesn’t keep up with the release of glucose into the bloodstream, and hence your blood sugar will be high.

If you test your blood sugar in the morning and it’s higher than your current average, then you might want to delay eating until your blood sugar comes back down.  This may mean eating your first meal early afternoon followed by an early dinner (i.e. 16:8 intermittent fasting).   Alternatively, if you consistently find your blood sugars are high in the morning you could skip dinner avoid eating later in the evening, which would help to lower morning blood sugar.

There is no perfect fasting routine for everyone.  Over time you’ll find one that suits you, and you will be able to calibrate your feeling of hunger with your actual need for food based on your blood sugar levels and reduce the frequency of testing.  Once you’ve established new habits you will no longer need to rely on the glucose metre.

Some people find that they can ‘eat to satiety’.  However, others find that they tend to overeat and ‘binge’ after a long period between meals, particularly on energy dense and nutrient poor hyper-palatable foods.  Using a metric like your blood sugars is useful to make sure fasting is providing the outcomes you want.  Tracking your glucose levels can help you ensure that your blood sugar levels are decreasing but not so much that you will lose control of food quality or quantity when you eat next.

Tailored just for you

Many people agree that intermittent fasting is a good idea, but many people get confused about what frequency is best for them.

How do you know whether you should be doing:

There are so many options!

How do you know which one is right for you?

How can you tell if it’s working?

How can you refine and tweak to reach your goals?

What if you just really feel hungry but it’s not “time to eat” yet!?!?

The advantage of using your blood sugar level as a guide versus a regimented intermittent fasting protocol or a fixed calorie intake is that it accounts for the energy your burn as well as what you’re eating.

You could argue that tracking your blood sugars could be more useful than calorie counting.  Ensuring that your blood sugars are decreasing by delaying eating will ensure that you are running at an energy deficit and pulling fuel from the energy stores on your body.

The body is a complex adaptive system, and our energy expenditure will vary based on many factors beyond our ability to measure and manage.

Eating is not bad.  You need to balance your intake with your energy expenditure while getting the nutrients you need to thrive.  This can be a challenge when we are surrounded by cheap hyper-palatable nutrient-poor foods.

Refining your feasting/fasting route around your blood sugars will help you to fine-tune when and how much you eat to your actual requirements.

Your blood sugar meter can help you understand whether your hunger is real and help you to refine your eating regimen.

If your blood glucose levels are lower than your average, then your insulin levels will be decreasing, and you’ll be using up your stored body fat and liver glycogen.

If your blood sugar levels are increasing, then it’s likely you’re overeating and/or too often which means you’ll be storing energy as fat on your body.

When using this approach, you can eat to eat to satiety.  But if you overdo your intake at this meal it will mean that you will be delaying your next meal a little longer.

You could even use this approach to make sure you don’t overdo the refuelling and keep the insulin load of your meals such that your blood sugar doesn’t go over say 120 mg/dL (or 6.7 mmol/L).  A blood sugar level above this is a sign that your liver glycogen stores are full and spilling over into your bloodstream.

Some people find that they tend to eat less overall when intermittent fasting compared to trying to eat numerous ‘small’ meals.  Saint Augustine wisely said:

“Complete abstinence is easier than perfect moderation.”

I think this also applies to our meal timing and portion sizing.

By choosing to eat only when your blood sugar is below YOUR target blood sugar level, you can tailor the approach to your current situation and metabolic health.

Waiting until your blood sugar reaches optimal levels (i.e. 83mg/dL or 4.6mmol/L) is not realistic for most people.  It’s best to start from where you are now and work towards optimal.

In the study Adherence to hunger training using blood sugar monitoring: a feasibility study[5], the researchers found that participants did much better when they set their own personalised blood sugar target rather than waiting until their blood sugar levels reached some optimal target before eating.

The other noteworthy observation from this study was that people who were obese lost a significant amount of weight!

Overweight participants achieved significant weight loss over the two-week period, with an average loss of 1.5 kg (95 % CI 2.2, 0.9) and a corresponding reduction in BMI of 0.6 kg/m2 (95 % CI 0.3, 0.8), p < 0.001).  By contrast, lean participants maintained their weight.

The end game

The long-term goal is to achieve an optimal HbA1c of 4.5% which equates to an average blood sugar level of 83 mg/dL (or 4.6 mmol/L).

There are plenty of excellent reasons to keep your blood glucose and insulin levels in check such as reducing your risk for cancer…[6]

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…heart attack, stroke[7] and a whole range of western diseases.[8]

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People with Type 1 Diabetes following Dr Bernstein’s protocol try to keep their blood glucose within ten points of the optimal target level of 83 mg/dL (4.6 mmol/l).  This means that they will dose with insulin when their blood glucose rises above 93 mg/dL (or 5.2 mmol/l) and then eat to bring their glucose levels back up when they drop below 73mg/dL (or 4.0 mmol/L).

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Someone who has a functioning pancreas but is struggling with insulin resistance, hyperinsulinemia and/or obesity can use a similar process to manage their blood glucose and insulin levels.  However, rather than dosing with insulin to bring their blood glucose down they simply delay eating until they burn through the excess glucose in their bloodstream.

Waiting to eat until your blood glucose levels are below your recent average will ensure that they are decreasing over time.  Most glucose meters will display the average glucose level for the last seven, fourteen and thirty days, so it is easy to tell what your current target is.

On the Freestyle Lite metre (our family favourite) you can show your 4, 14 and 21-day average blood sugar by pressing the ‘m’ button on the left-hand side of the metre.

If you’re eager, you could go to the trouble of graphing your blood sugar numbers, However, in the end, if your seven-day average is less than your fourteen-day average then you’re moving in the right direction.

Over time you want to see your average blood glucose levels coming down.  If you find your blood glucose levels drifting up, it’s a sign that you need to intensify your fasting regimen.

If working out your average blood sugar level is a bit complex you can just set an arbitrary target of say 10 mmol/L on waking.  If after a while you find you are mostly under waking under 10mmol/L you can change your target to 9.0 mmol/L, then 8.0 mmol/L, then 7.5 mmol/L, then 7mmol/L and so on.

Normalising blood sugar and insulin will often help people to lose weight, particularly if you’re insulin resistant.  However, some people will still need to pay attention to continuing to lose weight once their blood sugar and insulin is normalised.

Will optimal blood glucose levels guarantee weight loss?

While normalising blood sugars and insulin sensitivity will usually help you improve your body weight, it is possible to have excellent blood sugars and still be overweight (e.g. by eating a lot of fat that doesn’t raise blood sugar but doesn’t allow body fat to be burned).

The chart below shows Rebecca Latham’s blood sugar levels decreasing over a period of three months.  Once your average blood glucose level drops below 83mg/dL or 4.6mmol/L, then you may do better switching to using a weight target rather than a glucose target to drive your eating frequency.

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If you have achieved excellent blood sugar and still want to lose weight, you can transition to using your target body weight as a trigger to decide whether to eat that day as detailed in the article How to use your bathroom scales as a fuel gauge.

Weight Gurus Bluetooth Smart Connected Body Fat Scale w/ Large Digital Backlit LCD, Precision/Accurate Measurements include: BMI, Body Fat, Muscle Mass, Water Weight, and Bone Mass

The chart below shows Rebecca’s weight loss to achieve her goal over twelve months and then transitioning to a maintenance regimen during 2017.

No automatic alt text available.

When not to use this approach

Exercise may raise your blood sugar in the short-term due to the body dumping glycogen from your liver into the bloodstream to fuel your activity.  If you don’t eat before or after exercise, your body will have to replenish the glycogen stores from the energy stores on your body.

There will be times when you’re hungry, or it will be appropriate to eat for social reasons such as a party, family gathering, etc.  Periodic fasting and then feasting is a regular part of our culture.  Tracking your blood glucose levels will help you get back on track after these indulgences.  Personally, I tend to employ this approach after feasting periods such as Christmas to recalibrate my appetite.

You should also keep in mind that other things affect blood sugar including stress, sleep, sickness, hormones and exercise that you will need to be mindful of when deciding whether to delay a meal due to your blood sugar being high.

Fasting may not be ideal if you’re stressed, sick, not sleeping well and/or are pushing the exercise envelope.  During these times, it may be better to focus on life maintenance and listen to your appetite and leave your fasting until the rest of your life is under control.

If you are taking insulin or other blood sugar lowering medications, you will need to make sure they are reduced to make sure your blood sugars don’t drop too low. Otherwise, you may have to eat to raise your blood sugar due to the excess medication.

The problem with injected insulin or many other diabetes medications is that, while it may help to reduce blood sugar levels, it also drives the energy back into the cells rather than allowing the stored energy to flow out of storage.

The more you reduce insulin (injected or produced from your own pancreas) to normal healthy levels the quicker the healing can occur.  However, at the same time, it would be prudent to reduce medications progressively to prevent your blood glucose levels from going too low.[10]

High blood sugar levels can be a sign that you’re stressed, exhausted or your hormones are out of whack (including time of the month for females), all of which will lead to insulin resistance.  You can use Heart Rate Variability to track your stress and exhaustion with an app such as Elite HRV which enables you to see when you’re exhausted and need to back off and rest.

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If you just don’t feel like fasting and your blood sugar levels are high it’s probably a sign that you need to rest, relax, sleep, meditate, see some real sunlight during the day and stop gazing into the artificial sun on your devices before you go to bed.   Using f.lux on your computer or blue blocking glasses after sunset is worth considering.

Image result for f.lux

While longer therapeutic fasts can be beneficial, a shorter duration feast / fast cycle that brings your blood sugar levels down to below your average is likely to be more useful to improve your metabolism while reducing the extreme swings in water weight or any concerns that you’re not getting adequate protein to support lean body mass.

Will monitoring my blood sugars help me enter ketosis?

The most straightforward approach is just to measure your blood sugar levels when you feel hungry and not eat until they drop below your target level.  You could still use this method even once you have improved your insulin sensitivity to losing weight by targeting even lower blood glucose levels before eating.

The chart below shows the sum of blood glucose and blood ketone levels for people on a low carb or ketogenic diet.  While a low carb diet helps to stabilise blood sugar and removes hyperpalatable foods when benefits a many people in terms of weight loss and energy levels, some of the major benefits are reserved for the periods when we are in a low energy stage (e.g. reduced insulin levels, autophagy, mitochondrial biogenesis, increase in NAD+ and increase in SIRT1).  It is in these periods of low energy that our body goes into cleansing and repair mode so it can survive through the famine to be able to reproduce in the next time of plenty.

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Zooming in on the left hand side of the chart, we can see that it’s the periods when we drive the energy in our blood down through delaying eating or restricting energy intake that we get the major benefits often associated with a low carb or ketogenic diet.

You will likely have some blood ketones in your bloodstream when your blood glucose levels are low, but they may not be at the levels that many consider to be ‘optimal ketosis’.  As shown in the chart below, if your blood glucose levels are at 4.5mmol/L or 80 mg/dL then you you might expect blood ketone levels to be somewhere between 0.3 and 0.7mmol/L.  If your blood sugars are at 4.9mmol/L or 88 mg/dL your ketones might be somewhere between 0.4 and 1.1 mmol/L.

While measuring ketones can be interesting, they tend to be a much noisier measurement.  As the glucose in your blood reduced your body will be forced to turn to your body fat stores, so you will increase your fat burning.  Part of the reason that you may not see high levels of ketones in your blood though is that they are being used efficiently for fuel and not backing up in your bloodstream.  So if you have limited funds for test strips and don’t want to be pricking yourself too often then I would focus on blood glucose levels.

Ketones and the glucose: ketone index

Monitoring your blood sugar will work whether you are insulin sensitive or insulin resistant, obese or healthy weight.

The body does a fantastic job of replenishing your glycogen stores and stabilising your blood glucose whether it be from carbohydrates, gluconeogenesis from amino acids or even gluconeogenesis of fat once you are highly insulin sensitive.

If you require therapeutic levels of ketosis, once you are starting to get your blood sugar levels under control, you could begin to track your ketones or the glucose: ketone index (GKI).  Decreasing glucose along with rising ketones is a sign that your glycogen stores are being depleted, your insulin levels are reducing and you your hunger is a signal that you really need food.[11]

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Tracking the ratio between your glucose and ketones (GKI)[12] and delay eating until your GKI is under a certain level could be a useful strategy if you are aiming for therapeutic ketosis for the management of chronic conditions such as cancer, Alzheimer’s, Parkinson’s or dementia.

Alternatively, you could simply not eat until your ketone levels were higher than a certain threshold.  You could start with a target ketone level of 0.4 mmol/L and keep winding that up till you achieve your desired results.

However, testing blood ketones every time you feel hungry could be expensive.  Many people also find that their blood ketone levels tend to decrease as they adapt to a low carb diet.

While all these things are relevant and useful, make sure to use them as tools to help you live life rather than taking over your life and stressing you out.  Your goals need to be realistic and tailored to your situation.  Hopefully, in time this ‘hunger training’ approach will help you build new habits around eating which will mean you won’t need to rely on the testing.

Fast well.  Feed well

Keep in mind if you are eating less food less often you will need to maximise nutrient density when you do eat, including ensuring that you are getting adequate nutrients to maintain lean muscle mass over the long term.

Some people advise refeeding with high-fat ketogenic foods after a fast.  While they may help keep insulin levels lower, it may not enable you to replenish the micronutrients that you lost during your fasting (particularly the minerals such as potassium, magnesium and sodium and the amino acids).  It also may not be optimal to refeed on very high-fat foods if you are trying to lose body fat.  Foods with adequate protein and high levels of nutrients will also be more satiating and enable you to be ready to fast again sooner.

I know personally, I tend to reach for the energy dense nutrient poor foods after a period of fasting.  That’s why I developed that Nutrient Optimiser to help you fine-tune your diet based on your current level of insulin resistance.

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The chart below shows a comparison of the nutrients / 2000 calories in all the foods in the USDA foods database versus the most nutrient dense foods identified by the Nutrient Optimiser algorithm.  If our goal is weight loss, then these foods can be beneficial to ensure we get the nutrients we need with the minimum amount of energy.

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I think what we really want when we refeed is to maximise the nutrients : energy ratio of the food we eat so we can maximise our fat loss goals and be able to fast again soon without risking nutrient deficiencies.  After a period of fasting and autophagy, we want to refeed on nutritious food that will help us build back a strong, healthy body.

Best of luck if you chose to try this approach.  I look forward to hearing how you go.

 

 

references

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

[2] https://intensivedietarymanagement.com/fatty-pancreas-t2d-9/

[3] http://care.diabetesjournals.org/content/early/2015/11/29/dc15-0750?patientinform-links=yes&legid=diacare;dc15-0750v1

[4] https://intensivedietarymanagement.com/dawn-phenomenon-t2d-8/

[5] http://nutritionandmetabolism.biomedcentral.com/articles/10.1186/s12986-015-0017-2

[6] http://onlinelibrary.wiley.com/doi/10.1002/ijc.29917/epdf

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

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

[9] http://lowcarbbetterhealth.blogspot.com.au/2016/02/day-37-2016-weight-loss-and-blood.html

[10] http://optimisingnutrition.com/2015/08/17/balancing-diet-and-diabetes-medications/

[11] http://www.nature.com/articles/ncomms10580.epdf?shared_access_token=MUKioJXu6KVY753YIDoPVNRgN0jAjWel9jnR3ZoTv0NZFUsLxRRWAKMsrNHEbSj2q0khGxVdwhqgBvlELqp6rtnjRj5ppdqpqF9VFYO_6UzYPSf3Z5ZW4kFdG4GQIZ71IGlh7tQHXrGHJ2Nz7rN5iw-9csWuhb9uHxuz_-28FyOP6Tcmjd1H9Uxq9OwlIQTy

[12] http://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

 

post last updated January 2018