Tag Archives: jason fung

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

the carbohydrate debate

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

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

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

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

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

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

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

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

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

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

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

mainstream recommendations

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

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

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

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

the middle ground?

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

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

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

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

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

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

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the big picture

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

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

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

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

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

so just tell me what to do!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

the latest food insulin index data

Understanding the factors that our requirement for insulin is critical to good managing and avoiding diabetes and maintaining good metabolic health.

Living with someone who has Type 1 Diabetes for fifteen years I’ve gained an intimate understanding of how different foods will take your blood glucose levels on a wild ride.

In this article, I will share my insights from the latest food insulin index data and how we can apply it to optimise our insulin and blood glucose response to the food we eat.

How to get off the blood glucose roller coaster

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

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High blood glucose levels make her feel “yucky”.  Plummeting blood glucose levels due to the mega doses of insulin don’t feel good either.  Low blood glucose levels drive you to eat until you feel good again.  This wild blood glucose roller coaster ride leaves you exhausted.  If you have diabetes, you are likely familiar with this feeling.

Young female injecting insulin in her abdomen

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

When we decided we wanted to have kids, we found a great doctor who helped us to understand how to match insulin with carbs, but moderating the input of carbohydrate that necessitates insulin was never mentioned by physicians, endocrinologists or diabetes educators.

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We eventually stumbled across low carb, and she was above to significantly improve her blood glucose control.

The latest food insulin index data

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

I hoped that by gaining a better understanding how different foods affect our requirement for insulin, I might be able to further refine our food choices to further reduce the amplitude of Monica’s blood glucose swings.

The initial research into the food insulin index was detailed in a 1997 paper An insulin index of foods: the insulin demand generated by 1000-kJ portions of common foods by Susanne Holt, Jennie Brand Miller and Peter Petocz who tested the insulin response to thirty-eight different foods.

insulinindex

The food insulin index score of various foods was determined by feeding 1000kJ (or 239 kcal) of a range of foods to non-diabetic participants and measuring their insulin response over three hours.   This was then compared to the insulin response to pure glucose, which is assigned a value of 100%, to arrive at a “food insulin index” value for each food.

FII versus time chart

Considering how significant this information could be for people trying to manage their insulin levels (e.g. people with diabetes, “low carbers” or “ketonians”) I was surprised that there hadn’t been much further research or discussion on the topic.  I found a few references and mentions in podcasts, but no one was quite sure what to do with the information, mainly because only a small number of foods been tested.

After some searching, I came across a PhD thesis Clinical Application of the Food Insulin Index to Diabetes Mellitus (Kirstine Bell, September 2014).   Appendix 3 of the thesis contained an extensive food insulin index database of foods that had now been tested.  I plotted the relationship between carbohydrates and the food insulin index data.

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As you can see, the relationship between carbohydrates and insulin is not straightforward.  Some high protein and low-fat foods are sitting quite high up on the vertical axis while there are some high fibre foods with a lower insulin response than you might expect.  However, once we account for the effect of protein, fibre and fructose we get are able to more accurately predict our body’s response insulin response to food.  The foods in the bottom left corner of this chart are the least insulinogenic (or insulinemic).

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If you want to dig into this data a bit more, you can check out the interactive Tableau version here.

As detailed in the most ketogenic diet foods article, this improved ability to quantify our insulin response to food enables us to identify foods that require less insulin and reduce the amplitude of our blood sugar swings in response to food.  This understanding could also prove invaluable for who need a therapeutic ketogenic dietary approach as an adjunct to cancer treatment, epilepsy or dementia.

Calculating the proportion of insulinogenic calories is useful for people who require a very low insulin therapeutic ketogenic diet while insulin load is useful for people managing hyperinsulinemia, insulin resistance or diabetes.

Monica’s daily insulin dose has dropped from more than fifty units a day to closer to 20 units of insulin per day, and the amplitude of her blood glucose swings is much smaller.

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While living with Type 1 will never be fun, the journey towards normal blood glucose levels has been more than worth it, with Moni’s energy levels improving to the point she can go back to work and look forward to a long, healthy and happy life.

The problem with the food insulin index

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

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

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

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optimal foods for different goals

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

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

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

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the Nutrient Optimiser

Building on the ability to quantify insulin load, nutrient density and energy density, more recently I have been developing a novel tool.  The Nutrient Optimiser reviews your food log diet and helps you to initially normalise your blood glucose and insulin levels by gradually retraining your eating habits by eliminating foods that boost your insulin level and blood glucose levels.

Once your glucose levels are normalised the Nutrient Optimiser focusses on your micro nutrient fingerprint to identify foods that will fill in your micro nutrient deficiencies with real food.

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If you still have weight to lose, the Nutrient Optimiser will focus on the energy density of your diet until you have achieved your desired level of weight loss.  Alternatively, the Nutrient Optimiser can help you if you were looking to increase your insulin levels for bulking or identify higher energy density foods for athletes.

It’s early days for the Nutrient Optimiser, but the initial results are very promising.

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Post last updated July 2017