Tag Archives: ketogenic amino acids

how optimize your diet for your insulin resistance

Lately I’ve seen a number of common themes come up at low carb conferences and online.  The contentious questions tend to run along the lines of:

  1. I did really well on a low carb diet initially, but my fat loss seems to have stalled. What gives?  What should I do now?
  2. If protein is insulinogenic should I actively avoid protein as well as carbs if my goal is to reduce insulin because low insulin = weight loss?
  3. If eating more fat helped kick start my weight loss journey, then why does eating more fat seem to make me gain weight now?

This article outlines some quantitative parameters around these contentious questions and helps you chose the most appropriate nutritional approach.

the importance of monitoring blood glucose levels

Coming from a diabetes headspace, I’ve seen firsthand the power of a low carb diet in reducing blood glucose and insulin levels.  As a Type 1 Diabetic, my wife Moni has been above to halve her insulin dose with a massive improvement in energy levels, body composition and mood.

If your blood glucose levels are high, then chances are your insulin levels are also high.  Insulin is the hormonal “switch” that causes us to store excess energy as body fat in times of plenty.[1]  Lower levels of insulin in times of food scarcity then enable us to access to the stored energy on our body.[2]

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You can actively manage the fat storing potential of your diet by managing the insulin load of the food you eat.

The chart below shows that our glucose response is fairly well predicted by the carbohydrates we eat.  (note: The “glucose score” is the area under the curve of glucose response to various foods tested over the three hours relative to glucose which gets a score of 100%.) [3] [4]

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Having high blood glucose levels is bad news.[5]  The chart below shows the correlation between HbA1c (a measure of your average glucose levels over three months) and the diseases that will kill most of us, cardiovascular disease, coronary heart disease and stroke.[6]  It makes a lot of sense to do whatever it takes to reduce our blood glucose to the levels of a metabolically healthy person to postpone the major diseases of aging.

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optimal ketone levels

Ketones in our blood rise when our insulin levels are low.[7]  As shown in the chart below, even better than carbohydrates, insulin levels are better predicted by the net carbohydrates plus about half the protein we eat.[8] [9]

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

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The problem however with this chart is that it is difficult for most people to achieve “optimal ketone levels” (i.e. 1.5 to 3.0mmol/L) without fasting for a number of days or making a special effort to eat a lot of additional dietary fat (which may be counterproductive in the long run if you’re trying to lose weight).

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Recently I had the privilege of having Steve Phinney stay at our house when he spoke at a Low Carb Down Under event in Brisbane (btw, he’s also a passionate cook if you let him lose in the kitchen).  I quizzed Steve about the background to his optimal ketosis chart.  He said it was based on two studies, one with cyclists who the adapted to ketosis over a period of six weeks and another ketogenic weight loss study.  In both cases these ‘optimal ketone levels’ (i.e. between 1.5 to 3.0mmol/L) were observed in people who were transitioning into a state of nutritional ketosis.

2016-11-15-10-58-17

Since the publication of this chart in the Art and Science books, Phinney has noted that well trained athletes who are long term fat adapted (e.g. the low carb athletes in the FASTER study[10]) actually show lower levels of ketones than might be expected.  It appears that over time many people, particularly athletes, move beyond simple keto adaption and are able to utilise fat as fuel even more efficiently and their ketone levels reduce further.

Metabolically flexible people are able to access and burn fat efficiently and hence only release free fatty acids or ketones into the bloodstream when they need the energy.  If you’re metabolically healthy and can call on your fat stores as required there’s no need to be walking around with super high levels of glucose or ketones.

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If you’ve been following a ketogenic diet for a while and / or are metabolically healthy then your ketone levels may not be as high as you might expect from looking at Volek and Phinney’s “optimal ketone zone” chart.

And as discussed in my Alkaline Diet vs Acidic Ketones article, higher ketone levels could even be an indication that you have some level of metabolic acidosis.  People with untreated Type 1 Diabetes have very high ketone as well as blood glucose levels at the same time (i.e. ketoacidosis).

Phinney says he does not condone the “adolescent behaviour” of competing to see how high you can get your ketone levels and warns that you can risk loss of lean body mass by chasing high ketone levels with an inappropriately low insulin load approach (i.e. very low carb and very low protein).[11]

People with higher NAD+ levels (an important coenzyme which declines with aging[12]) and lower NADH levels are more likely to produce more breath acetone (which can be measured with the Ketonix) and less BHB ketones in the blood.   Hence, higher consistent levels of breath acetone may be a more useful indication than blood ketones that you are burning fat rather than just eating fat.[13]

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“The ratio of β-OHB to AcAc depends on the NADH/NAD+ ratio inside mitochondria; if NADH concentration is high, the liver releases a higher proportion of β-OHB.”[14]

While I think it’s good to have some ketones in the blood as an indication that your insulin levels aren’t too high, it can be hard to interpret what high or low level of blood ketones mean.

As noted in Peter Attia’s Fat Flux article, the BHB ketones you measure in your blood is a function of:

  • the dietary fat that you’re eating,
  • plus the fat being liberated from your body fat (lipolysis),
  • minus the BHB being used by your muscles, heart and brain.

High blood ketones could mean that your insulin levels are low and your level of lipolysis is high (i.e. lots of fat is being released from your body).  In this case, high ketones are an indicator of metabolic health and may facilitate healthy appetite regulation and enable you to burn your stored body fat.

However, high blood ketone levels could also mean that you are eating a lot of dietary fat (or consuming a lot exogenous ketones) and your body isn’t well adapted to using ketones for fuel and hence unused ketones are building up in your blood stream.  If this is the case, then loading up with more dietary fat in the pursuit of higher ketone levels may cause you to become more insulin resistant and inflamed as your ketone levels rise but the fat is not yet able to be efficiently oxidised for fuel.

The plot below shows a compilation of glucose and ketone values from a range of people following a low carb or “ketogenic” diet.  It seems that the most metabolically healthy people have low blood glucose levels and moderate ketones at rest, however they can easily access plenty of glucose and fat from the body when required.

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It makes sense to me from an evolutionary perspective that someone who is healthy would be able to conserve energy when not active (i.e. hiding in a cave) but then be able to quickly access stored energy when required (i.e. when being chased by a sabre-toothed tiger).  The body doesn’t always need super high blood ketone levels and hence we secrete insulin to remove both glucose and ketones back into storage.

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The exception to this seems to be in periods of extended fasting when the body is on high alert and we are in a super-fuelled state ready to chase down some food at a moment’s notice.

So, unless you’re fasting or exercising intensely, it seems that having a lower total energy (i.e. blood glucose plus blood ketones) might be a better place to be rather than having super high ketone levels.

There is also interesting emerging research suggesting that as we become more fat adapted we can obtain more fuel from fat and hence do not need to rely on ketones which are more of an emergency fuel source during starvation.  It’s as if, just like in time we no longer measure high ketones in the urine as we utilise them better, we also start to show less ketones in the blood.  Quoting my friend Mike Julian:

I think we become less ketogenic with further adaptation simply because as we improve our ability to utilize the fat we create spin off glucose from both glycerol and acetone that goes to restore beta oxidation of fatty acids.

The spin of glucose provides oxaloacetate and restores Krebs function in the liver and reduces ketogenesis in favour of complete oxidation of acetyl-CoA. In short, ketogenesis is a transitional state, not the end goal.

Ketones will be lower if you’re fit.  Even Phinney has said that very adapted individuals are in ketosis starting at 0.3mmol.  Look at how robust the GNG is in the low carb guys in the FASTER study. It is a direct result of the nearly doubled rate of fat oxidation.

All of the glycerol when fat is oxidised has to go somewhere and it is used to make glucose. This glucose is then used to restore the Krebs cycle which means that the can make even better use of fat etc, but reduces GNG via traditional means and in turn reduces ketogenesis.

It’s a system that feeds into itself.  The better fat burner you are, the more glucose you make from fat, the better you are at fat burning and so on.

As we get better at fat utilisation we also get better at deriving glucose from fat metabolism. This source of glucose reduces the need for ketogenesis.[15] [16]

So overall, measuring blood ketones is intriguing, but not always the most reliable measure of where your metabolic health status.  Moreover, eating more dietary fat in an effort to raise your blood ketone levels is no guarantee that you’re going to lose body fat.[17]

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You may be “ketogenic” in that you are able to generate ketones, though they may not necessarily show up in high levels in the blood if you are also athletic and able to use your blood glucose and ketones effectively for energy.

the relationship between ketones and glucose

The chart below shows the generalised relationship between blood glucose and blood ketones for different people with:

  • Type 2 Diabetes,
  • Pre-diabetes,
  • Mild insulin resistance, and
  • someone who is metabolically healthy.

(note: Someone with uncontrolled Type 1 Diabetes would be literally ‘off the chart’ with high blood glucose and high blood ketones.)

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The table below shows the HbA1c incident rates for cardiovascular disease, stroke and coronary heart disease from the chart above to average blood glucose levels and the corresponding ketone levels and glucose : ketone index values.   This gives us a useful understanding of what different HbA1c risk levels look like in terms of average blood glucose levels, ketones and the glucose : ketone index.

metabolic health level HbA1c average blood glucose ketones GKI
 (%)  (mmol/L)  (mg/dL)  (mmol/L)
low normal 4.1 3.9 70 2.1 1.9
optimal 4.5 4.6 83 1.3 3.5
excellent < 5.0 < 5.4 < 97 > 0.5 11
good < 5.4 < 6 < 108 < 0.3 30
danger zone > 6.5 7.8 > 140 < 0.3 39

While it can be interesting to measure ketones, as a general rule, if you have consistently high blood glucose levels you are likely to be insulin resistant and hence will benefit from a higher fat dietary approach.

If you have high insulin and glucose levels, when transitioning to a high fat diet your glucose and insulin levels will likely plummet to be closer to the levels of a metabolically healthy person and suddenly you will be able to access your body fat stores for fuel.  You might quickly find yourself losing weight like it was magic and you’ll think the keto diet is the best thing ever!  Amazingly, lots of people find that they can “eat fat to satiety” and still lose weight (at least during this initial stage).

For the last four decades we’ve been told to avoid fat, particularly saturated fat.  Imagine the excitement, enthusiasm, and maybe even anger, when someone who has been avoiding fat finds that they suddenly start losing weight when the do the opposite to what they’ve been told to do!

it works until it doesn’t

The problem with adding more dietary fat is that it works until it doesn’t.

Let’s say (based on the levels of metabolic health in the table above) you are able to successfully “level up” from the “danger zone” though “good” blood glucose control to “excellent” blood glucose levels with a high fat dietary approach, but then your weight loss slows and then stops well short of your optimal body fat levels.

What gives?

What do you do now?

Do you listen to the people who say you should eat more fat or the people who say you should eat less fat?

It can be confusing on the interwebs!

I think the answer depends largely on whether you are insulin resistant or insulin sensitive.  You should ‘level up’ to the most nutrient dense nutritional approach that your current level of insulin sensitivity allows.

It’s worth noting that while many people can achieve ‘excellent’ blood glucose levels through dietary manipulation, the people that I’ve seen get to truly optimal blood glucose control tend to be working hard with both their nutrition and training to maximise their lean body mass.

what is insulin resistance anyway?

In order to understand what we need to do when we stop losing weight on keto I think it’s important to understand what causes insulin resistance.

Many people think that people who are fat are simply insulin resistant.  This is partly true.   However, while insulin resistance and obesity are related, it’s not quite that simple.  It’s useful to understand the difference.

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A metabolically flexible insulin sensitive person stores excess energy eaten for later use in the fat stores on the body (i.e. adipose tissue).  When they stop eating, someone who is insulin sensitive will experience a drop in blood glucose and insulin levels and stored body fat will be released.   For the lucky people who are insulin sensitive, calories in calories out (CICO) largely works as advertised.  They find it difficult to depart far from a healthy set point weight without a change in diet quality or insulin load.

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However, as we keep eating more and more low nutrient density foods to obtain the micronutrients we need, we get to a point where the adipose tissue can no longer hold all that excess energy and starts to channel it into the organs because the fat stores are full.

The body knows that this isn’t such a great idea though because our vital organs are, well, vital, so the body becomes insulin resistant as a defence mechanism to avoid damage to vital organs, and hence the levels of sugar in our blood rise to avoid storing the extra energy in the organs.   The body even starts dumping the excess sugar into the urine to avoid having to pump it into the liver, pancreas, eyes and brain.

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The a of the major problems with insulin resistance is appetite dysregulation.  That is, when you are insulin resistant your insulin levels stay higher for longer which then makes it harder for you to access your body fat for fuel between meals.   As shown in this chart, if your blood glucose levels are high the release of fat from your body (ketones) will be low, ghrelin will kick in[18], and it will be hard to go very long without food.  Your appetite will be more likely to win out over your willpower and thus make it hard to lose weight if your insulin levels are high.

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Eating “low carb” or “keto” enables us to lower insulin levels to the point that our appetite works more in line with the way it’s meant to when we were metabolically healthy / insulin sensitive / metabolically flexible.  Our appetite drives us to seek out nutrients and energy when required and stop when we have had enough.   (note: keep in mind though that lower insulin levels are due to eating a lower dietary insulin load, not necessarily due to more dietary fat.)

Once our appetite is restored and we can more easily access our own body fat I think we need to change focus, especially if adding more fat isn’t moving you toward your weight loss goals.

be a nutrient chaser

Once your blood glucose levels are normalised but you’re stuck on a plateau and not sure where to turn I think it’s a good idea to turn your focus to chasing nutrients rather than ketones or even worrying about blood glucose levels quite so much.

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As your blood glucose and insulin levels decrease, you should be able to release more body fat stores and hence have less need for dietary fat.  When we focus on balancing micronutrients macronutrients largely look after themselves.

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As well as adequate energy, the body works hard to make sure it gets the nutrients it needs to thrive.  The vitamins and minerals that come with whole foods are like the spark that ignites the fuel they contain.[19]  We always get ourselves into trouble when we separate nutrients from energy.  While refined sugars and grains are particularly problematic because they spike insulin, neither refined sugars or purified fats contain the same level of nutrients necessary to power our mitochondria that whole foods do.

The problem comes when we eat nutrient poor foods.  We are left with a residual need for nutrients that are required to convert our food into energy (ATP).  Our appetite will drive us to seek out more food to obtain the required nutrients.

“Added sugars displace nutritionally superior foods from the diet and at the same time increase nutritional requirements. Specifically, vitamins such as thiamine, riboflavin and niacin are necessary for the oxidation of glucose, and phosphates are stripped from ATP in order to metabolise fructose, which leads to cellular ATP depletion. The metabolism of fructose also leads to oxidative stress, inflammation and damage to the mitochondria, causing a state of ATP depletion. Hence, the liberation of calories from added sugars requires nutrients, and increases nutritional demands, but these sugars provide no additional nutrients. Thus, the more added sugars one consumes, the more nutritionally depleted one may become. This may be particularly extreme in individuals whose habitual diet is already lacking in key micronutrients.”[20]

“A nourishing, balanced diet that provides all the required nutrients in the right proportions is the key to minimising appetite and eliminating hunger at minimal caloric intake.”[21]

“To produce ATP efficiently, the mitochondria need particular things.  Glucose or ketone bodies from fat and oxygen are primary.   Your mitochondria can limp along, producing a few ATP on only these three things, but to really do the job right and produce the most ATP, your mitochondria also need thiamine, riboflavin, niacin, pantothenic acid, minerals (especially sulfur, zinc, magnesium, iron and manganese) and antioxidants.   Mitochondria also need plenty of L-carnitine, alpha-lipoic acid, creatine, and ubiquinone (also called coenzyme Q) for peak efficiency.”[22]

If we don’t get enough amino acids to prevent loss of lean muscle mass the body will also up-regulate appetite (i.e. protein leverage hypothesis).[23] [24]   While we can track our food intake to try to actively manage our energy intake, in the end, appetite, driven by the body’s need for nutrients, tends to win out.

Even if we are successful in limiting our intake, our body senses an energy crisis and slows down to make sure it has enough energy and stored fat to run our inefficient metabolism.  However, when we consume whole foods with a higher nutrient density our appetite tends to be satisfied with less energy because it can run more efficiently with an optimal balance of the nutrients it needs.[25]

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If we want to lose weight we need to find a way to provide the body with the nutrients it needs to function optimally with the minimum amount of energy intake while still maintaining low enough blood glucose and insulin levels to allow energy to flow out of our fat stores. 

ask the experts

There was an interesting panel discussion in Episode 1161 of Jimmy Moore’s Livin La Vida Low Carb Show “Q&A Medical Panel – 2016 Low Carb Cruise” where someone asked:

LCHF says calories don’t matter.  But I still gain weight even when in ketosis.  What’s up with that?

There was a range of responses from the panel of medical doctors, not all in agreement, but my favourite answer was from Dr Ted Naiman (pictured below on the cruise) who said:

I have tons of patients who absolutely plateau out on this diet.   Everyone who goes on LCHF loses a ton of weight, and then hits a plateau.  This is extremely common.  Almost universal.  

If you eat enough fat, the flow of fat into your adipose sites will equal the flow of fat out of your adipose sites and you’re just going to plateau. 

My number one priority is nutrient density.  Eat less fat bombs and instead eat the highest nutrient density foods you possibly can and then more of the fat that you’re burning comes from your internal body stores. 

I recommend really high fat diets for people who are really glucose dependent to help them get fat adapted.  Then, once you have reached your ideal body weight you have to eat a high fat diet then as well because you’re burning fat.  But there is a period in the middle when you’re plateaued when you do want to eat less fat because you want your fat to come off stored body fat.  

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are you really insulin resistant?

I think the critical question here is whether you are really insulin resistant.  The most useful measure is simply to test your blood glucose levels.

If you have been diagnosed with diabetes, then you will have a glucose meter and you’ll be able to easily test your blood glucose levels to know where you’re at.  Glucometers are fairly cheap to purchase and often come with a rebate.

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There are many people who are fatter than they want to be but still have reasonable insulin sensitivity and normal blood glucose.  For these people, eating more fat doesn’t always get them where they want to be.[26] [27]

At the same time, many skinny people are actually insulin resistant (TOFI).  It of depends on how much energy your belly is willing to store before it starts pumping the excess fat into your vital organs.

The irony here is that you may look healthier if you are skinny, but it may mean that your adipose tissue is able to store less energy before it transitions to start storing excess energy in your vital organs.

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For those of you that don’t like testing your blood glucose level I have outlined a number of other ways to determine whether you are actually insulin resistant.  This understanding can then be used to understand whether you may need more or less dietary fat.

oral glucose tolerance test

An Oral Glucose Tolerance Test (OGTT) is the generally accepted medical test for insulin resistance and diabetes.  An OGTT measures someone’s rise in blood glucose in response to a large amount of ingested glucose.   If it goes up too much after a standard amount of glucose then you are deemed to be insulin resistant.

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The problem is most people following a low carb approach will likely fail an OGTT because of physiological insulin resistance.  Someone following a low carb diet won’t have a lot of insulin circulating in their body, so when they ingest a large amount of fast acting glucose their pancreas will respond from a “standing start” and has to pump out a lot of insulin to respond to the glucose.  The glucose levels of someone following a low carb dietary approach may rise quite a lot before the pancreas can catch up.

By comparison, someone eating more carbohydrates would have higher levels of insulin circulating that will act on the glucose as soon as it was ingested with only a little bit of extra insulin needing to be secreted in response to the food and hence the glucose response would be lower.

kraft test

A Kraft Insulin Assay, which measures insulin response over time to a certain amount of glucose, will give you an accurate idea of whether you’re insulin resistant, however these tests are expensive and fairly hard to obtain.  A Kraft Test might be a useful way to see if your are becoming insulin resistant even if your glucose levels are keeping up, for now.

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oral protein tolerance test

Whether or not your blood glucose levels rise or decrease in response to a high protein meal with no carbohydrate is also a useful way to understand if you are insulin resistant.

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Someone who is metabolically healthy will release glucagon and insulin in response to protein as it is metabolised to maintain a stable glucose level.[28]  Someone who is insulin resistant may not produce adequate insulin to counteract the glucagon released by the liver and hence they may see their blood glucose levels rise.

If you find your glucose levels do rise significantly response to protein, it may be a sign that you need to slow down a little on the protein (or at least limit processed protein powders and opt for whole food sources of protein which are harder to overeat).

Realistically though, unless you’re severely insulin resistant, have Type 1 Diabetes or are using therapeutic ketosis to manage a chronic health condition such as cancer, epilepsy, alzheimers or dementia, most people don’t need to micromanage their protein intake if they are eating a range of unprocessed whole foods.

Your ability to handle protein may improve with time as your insulin resistance improves or you build a bit more muscle mass.  Actively avoiding protein to minimise insulin may be counterproductive in the long term if it leads to loss of lean body mass.

optimal dietary approach survey

While testing blood glucose is a pretty good indicator of your insulin resistance status, there are a number of reasons that you may not want to test, including:

  • you don’t yet own a blood glucose meter,
  • you don’t like the sight of your own blood, or
  • test strips can be expensive, especially if not covered by insurance.

Beyond testing your blood glucose and / or ketone levels, there are a wide range of other indicators that you may be insulin resistant and may need a higher fat dietary approach.   I have prepared this multiple choice survey to help people better understand which dietary approach might be ideal for them based on their situation and goals.

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You may be insulin resistant and / or benefit from a higher fat diet if you answer yes to most of these of these questions.[29]   If you answer no to most of these questions then you may do better if you focus on nutrient dense foods rather than more fat.

  1. Do you have a chronic health condition such as cancer, epilepsy, dementia, Alzheimer’s, Parkinson’s, severe insulin resistance or traumatic brain injury?
  2. Have you been diagnosed with diabetes?
  3. Is your HbA1c greater than 6.4%?
  4. Is your fasting glucose greater than 7.0 mmol/L?
  5. Is your post meal glucose level greater than 11.0mmol/L or 200 mg/dL?
  6. Is your triglyceride : HDL ratio greater than 3.0?
  7. Are your triglycerides greater than 1.1mmol/L or 100mg/dL?
  8. Are your blood ketone levels less than 0.3mmol/L?
  9. Is your fasting insulin greater than 20 uIU/mL or 120 pmol/L?
  10. Is your C-reactive protein greater than 1.0 mg/dL?
  11. Does your blood glucose level rise significant after eating a large protein only meal?
  12. Do you have a big hard belly (fat stored around the organs not on the surface)?

can I take my insulin levels to zero?

You cannot eliminate your need for insulin by eating a 100% fat diet, or even not eating at all.

Back in the 70s Dr Richard Bernstein worked out by self experimentation that people with Type 1 Diabetes require both basal and bolus insulin.  Basal insulin is required, regardless of food intake, to stop the body from breaking down its own lean body mass.  Bolus insulin is required to metabolise the food eaten.[30]

Someone on a typical western diet has about a 50:50 ratio of basal to bolus insulin.  Someone on a low carb diet will require less insulin, however 80% of their insulin dose required as basal insulin and the remaining 20% for their food.  While the body typically doesn’t secrete insulin in response to fat, and appetite is often reduced on a high fat diet, if we force an energy excess with high levels of processed fats there will always be enough basal insulin circulating in the blood to remove the excess energy to our fat stores.

Someone with Type 1 will modify their insulin sensitivity factor in their insulin pump to match their insulin sensitivity to optimise their blood glucose control.  People without Type 1 Diabetes can change their insulin sensitivity (and hence require less insulin) by, amongst other things, being exposed to less insulin[31] and improving our level of lean body mass (muscle) and mitochondrial function.  It is important to ensure your diet has adequate protein to build muscle as well as exercising that muscle to make sure our body is well trained and efficient at using that energy.

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Having well trained lean muscle mass is critical to glucose disposal and insulin action and thus reducing overall insulin levels.[32]  In addition to avoiding foods that quickly raise our blood glucose levels, we need to train our body to dispose of the glucose effectively and efficiently with less reliance on large amounts of insulin through building lean body mass.  This is achieved by (amongst other things like sleep, sunlight, reduced stress etc) eating nutrient dense foods that power up the mitochondria to enable us to burn the energy efficiently.

so just tell me what to eat!

I have prepared the table below to guide people to the most optimal foods based on their blood glucose levels and current level of insulin resistance and whether you need to lose weight (based on your waist to height ratio[33]).

approach average glucose waist : height
(mg/dL) (mmol/L)
therapeutic ketosis > 140 > 7.8
diabetes and nutritional ketosis 108 to 140 6.0 to 7.8
weight loss (insulin resistant) 100 to 108 5.4 to 6.0 > 0.5
weight loss (insulin sensitive) < 97 < 5.4 > 0.5
nutrient dense maintenance < 97 < 5.4 < 0.5

There’s no nutrient poor processed grains or added sugars in any of these lists.

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The therapeutic ketosis foods have higher levels of added fat.  The nutrient dense weight loss foods contain more lean proteins and non-starchy veggies and less added fat.

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Someone with poorly controlled Type 2 Diabetes may start out on a high fat ketogenic approach (say 2:1 fat to protein by weight), in time they should be able to progressively ‘level up’ to more nutrient dense foods as their insulin sensitivity improves and they find their blood glucose levels can tolerate it.

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Someone who has long standing diabetes or who has Type 1 Diabetes may settle on a 1:1 for maintenance.  Someone who becomes more insulin sensitive may be able to cut their dietary fat down even more as they are more easily able to release fat from their body fat stores.  Even if someone wanting to lose weight got down to a 1:0.5 protein to fat ratio by weight the majority of their energy is still coming from fat, they’re just given their body a better chance of needing to use dietary fat.

I hope this helps you find the optimal approach for you.  I would love to hear how it goes.

post last updated May 2017

references

[1] https://optimisingnutrition.com/2015/06/22/why-we-get-fat-and-what-to-do-about-it-v2/

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

[3] https://optimisingnutrition.com/2015/06/29/trends-outliers-insulin-and-protein/

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

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

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

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

[8] https://optimisingnutrition.com/2015/06/29/trends-outliers-insulin-and-protein/

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

[10] http://www.sciencedirect.com/science/article/pii/S0026049515003340

[11] https://youtu.be/r8uSv6OgHJE?t=2080

[12] https://en.wikipedia.org/wiki/Nicotinamide_adenine_dinucleotide

[13] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737348/pdf/OBY-23-2327.pdf

[14] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4102118/

[15] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140964/

[16] https://www.facebook.com/groups/198981013851366/permalink/261051057644361/?comment_id=261276760955124&comment_tracking=%7B%22tn%22%3A%22R4%22%7D

[17] https://www.youtube.com/watch?v=r8uSv6OgHJE&feature=youtu.be

[18] http://www.nature.com/ejcn/journal/v67/n7/abs/ejcn201390a.html

[19] https://www.amazon.com/Nutritional-Approach-Revised-Model-Medicine-ebook/dp/B00CXECDI8/ref=tmm_kin_swatch_0?_encoding=UTF8&qid=&sr=

[20] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975866/

[21] http://perfecthealthdiet.com/

[22] http://terrywahls.com/about-the-wahls-protocol/

[23] http://sydney.edu.au/science/outreach/inspiring/news/cpc.shtml

[24] http://www.nature.com/ejcn/journal/vaop/ncurrent/full/ejcn2016256a.html

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

[26] https://optimisingnutrition.com/2016/06/13/low-energy-density-high-nutrient-density-foods-for-weight-loss/

[27] https://www.dropbox.com/s/n8tzuiixb1n1cxi/Weight%20Loss%20on%20Low-Fat%20vs.%20Low-Carbohydrate%20Diets%20by%20Insulin%20Resistance%20Status%20Among%20Overweight%20Adults%20and%20Adults%20With%20Obesity-%20A%20Randomized%20Pilot%20Trial%20(1).pdf?dl=0

[28] https://optimisingnutrition.com/2015/06/15/the-blood-glucose-glucagon-and-insulin-response-to-protein/

[29] http://www.thebloodcode.com/

[30] https://www.youtube.com/watch?v=6lrbxITXAVA

[31] https://www.ncbi.nlm.nih.gov/pubmed/21241239

[32] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2343294/

[33] https://en.wikipedia.org/wiki/Waist-to-height_ratio

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optimising protein and insulin load

  • “Low carb”, “ketogenic” or “nutrient dense” mean different things to different people. Defining these terms numerically can help us to choose the right tool for the right application.
  • Decreasing the insulin load of your diet can help normalise blood glucose levels and enable your pancreas to keep up. However, at the same time a high fat therapeutic ketogenic approach is not necessarily the most nutrient dense option, and may not be optimal in the long term, particularly if your goal is weight loss.
  • Balancing insulin load and nutrient density will enable you to identify the right approach for you at any given point in time.
  • This article suggests ideal macro nutrient, protein and insulin load, and carbohydrate levels for different people with different goals to use as a starting point as they work to optimise their weight and / or blood glucose levels.

context matters

Since I started blogging about the concepts of insulin load and proportion of insulinogenic calories many people have asked:

“What insulin load should I be aiming for?” 

Unfortunately, it’s hard to give a simple answer without some context.

The answer to this question depends on a person’s current metabolic health, age, activity level, weight, height and goals etc.

This post is my attempt to provide an answer with some context.

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disclaimers

Full disclosure…  I don’t like to measure the food I eat.  I have developed the optimal foods lists to highlight what I think are the best foods to suit different goals and levels of metabolic health.

I think food should be nutritious and satiating.  If you goal is to lose weight it will be hard to overeat if you limit your food choices to things like broccoli (which contains sulforaphane), celery, salmon and tuna.

At the same time, some people like to track their food.  Tracking food with apps like MyFitnessPal or Cron-O-Meter can be useful for a time to reflect and use as a tool to help you refine your food choices.  If you’re preparing for a bodybuilding competition you’re probably going to need to track your food to temporarily override your body’s survival to force it to shed additional weight.

Ideal macronutrient balance is a contentious issue and a lot has already been said on the topic.  I’ll try to focus on what I think I have to add to the discussion around the topics of insulin load and nutrient density.

If you want to and skip the detail in the rest of this article, this graphic from Dr Ted Naiman does a good job of summarising optimal foods and ideal macronutrient ranges.   If you’re interested in more detail on the topic, then read on.

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insulin is not the bad guy

The insulin load formula was designed to help us more accurately understand the insulin response to the food we eat, including protein and fibre.

insulin load = total carbohydrates – fibre + 0.56 * protein

The first thing to understand is that insulin per se is not bad.  Insulin is required for energy metabolism and growth.  People who can’t produce enough insulin are called Type 1 Diabetics and typically don’t last long without insulin injections after they catabolise their muscle and body fat.

Insulin only really becomes problematic when we have too much of it (i.e. hyperinsulinemia[1]) due to excess processed carbohydrates (i.e. processed grains, added sugar and soft drinks) and/or a lack of activity which leads to insulin resistance.

The concepts of insulin load and proportion of insulinogenic calories can provide us with a better understanding of how different foods trigger an insulin response and how to quantitatively optimise the insulin load of our diet to suit our unique situation and goals.

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different degrees of the ketogenic diet

Words like “ketogenic”, “low carb” or “nutrient dense” mean different things to different people.   This is where using numbers can be useful to better define what we’re talking about and tailor a dietary approach.  For clarity, I have numerically defined a number of terms that you might hear.

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ketogenic ratio

The therapeutic ketosis community talk about a “ketogenic ratio” such as 3:1 or 4:1 which means that there are three or four parts fat (by weight) for every part protein plus carbohydrate.[2]

For example, a 3:1 ketogenic diet may contain 300g of fat plus 95g of protein with 5g of carbs.  This ends up being 87% fat.  A 4:1 ketogenic ratio is an even more aggressive ketogenic approach that is used in the treatment of epilepsy,[3] cancer or dementia and ends up being 90% fat.

These levels of ketosis is hard to achieve with real food and is hard to sustain in the long term.  Hence, it is typically used as a short term therapeutic treatment.

ratio of fat to protein

People in the ketogenic bodybuilding scene (e.g. Keto Gains) or weight loss might talk about a 1:1 ratio of fat to protein (by weight) for weight loss.    A diet with a 1:1 ratio of fat to protein could be 120g of fat plus 120g of protein.  If we threw in 20g of carbs this would come out at 66% fat (which is still pretty high by mainstream standards).   A 1:2 protein:fat ratio would end up being around 80% fat.

protein grams per kilogram of lean body weight

Some people prefer to talk in terms of terms of percentages or grams of protein per kilo of lean body mass.  For example:

  • The generally accepted minimum level of protein is 0.8g/kg/day of lean body mass to prevent malnutrition.[4] This is based on a minimum requirement of 0.6kg to maintain nitrogen balance and prevent diseases of malnutrition plus a 25% or two standard deviations safety factor.[5]
  • In the Art and Science of Low Carb Performance Volek and Phinney talk recommend consuming between 1.5 and 2.0g/kg of reference body weight (i.e. RW). Reference weight is basically your ideal body weight say at a BMI of 25kg/m2.  So, 1.5 to 2.0kg RW equates to around 1.7 to 2.2g/kg lean body mass (LBM).
  • There is also a practical maximum level where people just can’t eat more lean protein (i.e. rabbit starvation[6]) which kicks in at around 35% of energy from protein.

The table below shows a list of rule of thumb protein quantities for different goals in terms of grams per kilogram of lean body mass and as a percentage of calories assuming weight maintenance.[7]

scenario % calories g/kg LBM
minimum (starvation) 6% 0.4
RDI/sedentary 11% 0.8
typical 16% 1.2
strength athlete 24% 1.8
maximum 35% 2.7

gluconeogenesis

You may have heard that body will convert ‘excess protein’ to glucose via gluconeogenesis, particularly if there is minimal carbohydrates in the diet and/or we can’t yet use fat for fuel.

For some people this is a concern due to elevated blood glucose levels, but it may also mean that more protein is required because so much is being converted to glucose that you need more to maintain muscles growing your muscles.  As we become more insulin sensitive we may be able to get away with less protein because we are using it better (i.e. we are growing muscles rather than making glucose).

Most people eat more than the minimum level of protein to prevent malnutrition.  People looking to gain muscle mass will require higher levels.  Although keep in mind you do need to be exercising to gain muscle, not just eating protein.

Ensuring adequate protein and exercise is especially important as people age.  Sarcopenia is the process of age related muscle decline which is exacerbated in people with diabetes.

Sadly, many old people fall and break their bones and never get up again.   When it comes to longevity there is a balance between being too big (high IGF-1) and too frail (too little IGF-1).

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carbohydrate counting

Then there is carb counting.

  • People on a ketogenic approach tend to limit themselves to around 20g (net?) carbohydrates.
  • Low carbers might limit themselves to 50g carbs per day.
  • A metabolically healthy low carb athlete might try to stay under 100g of carbs per day.

Limiting non-fibre carbohydrates typically eradicates most processed foods (e.g. sugar, processed grains, sodas etc).   Nutrient density increases as we decrease the amount of non-fibre carbohydrates in our diet.

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protein, insulin load and nutrient density

In the milieu of discussion about protein I think it’s important to keep in mind that minimum protein levels to prevent the diseases of malnutrition may not necessarily optimal for health and vitality.

Protein is the one macronutrient that correlates well with nutrient density.  Foods with a higher percentage of protein are typically more nutrient dense overall.

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Considering minimum protein levels may be useful if you are looking to drop your energy intake to the bare minimum and while still providing enough protein to prevent loss of lean muscle mass (e.g. a protein sparing modified fast).   However, if you are looking to fill up the rest of your energy intake with fat for weight maintenance then you should be aware that simply eating foods with a higher proportion of fat will not help you maximise nutrient density.

Practically though very high levels of protein will be difficult to achieve because they are very filling, thus it is practically difficult to eat more than around 35% of your energy from protein.  Protein is also an inefficient fuel source meaning that you will lose around 25% of the calories just digesting and converting it to glucose via digestion and gluconeogenesis.

If you are incorporating fasting then I think you will need to make sure you are getting at least the minimum as an average across the week, not just on feasting days to maintain nitrogen balance.  That is,  you might need to try to eat more protein on days you are eating.

what is ketosis?

“Ketogenic” simply means “generates ketones”.

An increase in ketosis occurs when there is a lack of glucogenic substrates (i.e. non-fibre carbohydrates and glucogenic protein).  It’s not primarily about eating an abundance of dietary fat

I think reducing insulin load (i.e. the amount of food that we eat that requires insulin to metabolise), rather than adding dietary fat, is really where it’s at if you’re trying to ‘get into ketosis’.   We can simply wind down the insulin load of our diet to the point that out blood glucose and insulin levels decrease and we can more easily access our stored body fat.

insulin load = total carbohydrates – fibre + 0.56 * protein

Whether a particular approach is ketogenic (i.e. generates ketones) will depend on your metabolic health, activity levels and insulin resistance etc.

Whether you want to be generating ketones from the fat on your excess belly fat rather than your plate (or coffee cup) is also an important consideration if weight loss is one of your goals.

While people aiming for therapeutic ketosis might want to achieve elevated ketone levels by consuming more dietary fat, most people out there are just looking to lose weight for heath and aesthetic reasons.  For most people, I think the first step is to reduce dietary insulin load until they achieve normalised blood glucose levels (i.e.  average BG less than 5.6mmol/L or 100mg/dL, blood ketones greater than 0.2 mmol/L).   People with diabetes often call this “eating to your meter”.

Once you’ve achieved normal blood glucose levels and some ketones the next step towards weight loss is to increase nutrient density while still maintaining ketosis.  Deeper levels of ketosis do not necessarily mean more fat loss, particularly if if you have to eat gobs of eating processed fat to get there.

Ray Cronise and David Sinclair recently published an article “Oxidative Priority, Meal Frequency, and the Energy Economy of Food and ACtivity:  Implications for Longevity, Obesity and Cardiometabolic Disease”  which does an interesting job of looking at the ‘oxidative priority’ of various nutrient and demonstrate that the body will burn through nutrients in the following order:

  1. alcohol,
  2. protein (not used for muscle protein synthesis),
  3. non fibre carbohydrate, and then
  4. fat.

What this suggests to me is that if you want to burn your own body fat you need to minimise the alcohol, protein and carbohydrate which will burn first.  To me this is another angle on the idea that insulin levels are the signal that stops our body from using our own body fat in times of plenty.   And if we want to access our own body fat we need to reduce the insulin load of our diet to the point we can release our own body fat.

insulin load versus nutrient density

The risk however with the insulin load concept is that people can take things to extremes.  If our only objective is to minimise insulin load we’ll end up just eating bacon, lard, MCT, olive oil… and not much else.

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In his “Perfect Health Diet” book Paul Jaminet talks about “nutrient hunger”, meaning that we are more likely to have an increased appetite if we are missing out on a particular nutrients.  He says

“A nourishing, balanced diet that provides all the nutrients in the right proportions is the key to eliminating hunger and minimising appetite.“

In the chart below shows nutrient density versus proportion of insulinogenic calories.  The first thing to note is that there is a lot of scatter!  However, on the right-hand side of the chart there are high carb soft drinks, breakfast cereals and processed grains that are nutrient poor.  But if we plot a trendline we see that nutrient density peaks somewhere around 40% insulinogenic calories.

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If you are metabolically challenged, you will want to reduce the insulin load of your diet to normalise blood glucose levels.  But if you reduce your insulin load too much you end up living on purified fats that aren’t necessarily nutrient dense.

If we are trying to avoid both carbohydrates and protein we end up limiting our food choices to macadamia nuts, pine nuts and a bunch of isolated fats that aren’t found in nature in that form.  Rather than living on copious amounts of refined oils I think we’re in much safer territory if we maximise nutrient density with whole foods while still maintaining optimal blood glucose levels.

The chart below shows the proportion of insulinogenic calories for the highest-ranking basket of foods (i.e. top 10% of the foods in the USDA foods database) for a range of approaches, from the low insulin therapeutic ketosis, through to the weight loss foods for someone who is insulin sensitive and a lot of fat is coming from their body.  At one end of the scale a therapeutic ketogenic may only contain 14% insulinogenic calories while a more nutrient dense approach might have more than half of the food requires insulin to metabolise.

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macronutrient splits

It’s one thing to set theoretical macronutrient targets, but real foods don’t come in neat little packages of protein, fat and carbohydrates.  The chart below shows the macronutrient split of the most nutrient dense 10% of foods for each of the four nutritional approaches.  The protein level for the weight loss approach might seem high but then once we factor in an energy deficit from our body fat it comes back down.

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In reality you’re probably not going to be able to achieve weight maintenance if you just stick to the nutrient dense weight loss foods.  You’ll either become full and will end up using your stored body fat to meet the energy deficit or you will reach for some more energy dense foods to make up the calorie deficit.  If you look at the macronutrient split of the most nutrient dense meals for the different approach you find they are lower in protein and higher in fat as shown in the chart below.

2016-12-03-3

nutrient density

The chart below shows the percentage of the daily recommended intake of essential vitamins, minerals, amino acids and fatty acids you can get from 2000 calories for each of the approaches.

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You can meet most of your nutritional requirements with a therapeutic ketogenic diet, however you’ll have to eat enough calories to maintain your weight to prevent nutritional deficiencies.

As you progress to the more nutrient dense approaches you can meet your nutrient requirements with less energy intake.   The beauty of limiting yourself to nutrient dense whole foods is that you can obtain the required nutrition with less energy and you’ll likely be too full to overeat.

As far as I can see the holy grail of nutrition,  health and longevity is adequate energy without malnutrition.

If we look in more detail we can see that the weight loss (blue) and nutrient dense approaches (green) provide more of the essential micronutrients across the board, not just amino acids.

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While the protein levels in the “weight loss” and “most nutrient dense” approaches are quite high, keep in mind that the food ranking system only prioritises the nutrients that are harder to obtain.

The table below shows the various nutrients that are switched on in the food ranking system for each approach.

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This table shows the number of vitamins, minerals, amino acids and fatty acids counted for each approach.

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In the weight loss and nutrient dense approach, of the twelve essential amino acids, only Tyrosine and Phenylalanine has been counted in the density ranking system.

It just so happens that protein levels are high in whole foods that contain essential vitamins, minerals and fatty acids. 

It appears that if you set out to actively avoid protein it may be harder to get other essential nutrients.  The risk here is that you may be setting yourself up for nutrient hunger, and rebound/stall inducing cravings in the long term as your body becomes depleted of the harder to obtain nutrients.

choosing the right approach for you

I believe one of the key factors in determining which nutritional approach is right for you is your blood glucose levels which gives you an insight into your insulin levels and insulin sensitivity.

As shown in the chart below, if your blood glucose levels are high then it’s likely your insulin levels are also high which means you will not be able to easily to access your fat stores.  I have also created this survey which may help you identify whether you are insulin resistant and which foods might be ideal for you right now.

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While you may need to start out with a higher fat approach, as your glucose levels decrease and ketone levels rise a little you will be able to transition to more nutrient dense foods.

The table below shows the relationship between HbA1c, glucose, ketones and GKI.   Once you are getting good blood glucose levels you can start to focus more on nutrient density and weight loss.

 Risk level HbA1c average blood glucose ketones GKI
 (%)  (mmol/L)  (mg/dL)  (mmol/L)
low normal 4.1 4.0 70 5.5 0.7
optimal 4.5 4.6 83 2.5 1.8
excellent < 5.0 < 5.3 < 95 > 0.2 < 30
good < 5.4 < 6.0 < 108 < 0.2
danger > 6.5 7.8 > 140 < 0.2

more numbers

The table below shows what the different nutritional approaches look like in terms of:

  • ketogenic ratio
  • ratio of fat to protein
  • protein (g)/kg LBM
  • insulin load (g/kg LBM)
approach keto ratio fat : protein protein g/LBM insulin load (g/LBM)
therapeutic ketosis 1.8 2.2 1.0 0.9
diabetes 0.9 1.0 1.8 1.5
weight loss (incl. body fat) 0.5 0.6 2.5 2.4
nutrient dense 0.3 0.3 3.0 2.8

The 1.0g/kg LBM for therapeutic ketosis is greater than the RDA minimum of 0.8g/kg LBM so will still provide the minimum amount while still being ketogenic.  It’s hard to find a lot of foods that have less than 1.0g/kg LBM protein in weight maintenance without focussing on processed fats.

At the other extreme most nutrient dense foods are very high in protein but this might also be self-limiting meaning that people won’t be able to eat that much food.  As mentioned earlier, it will be hard to eat enough of the nutrient dense foods to maintain your current weight.  Either you will end up losing weight because you can’t fit as much of these foods in or reaching more energy dense lower nutrient density foods.  Also, if you found you were not achieving great blood glucose levels and some low-level ketones with mean and non-starchy veggies you might want to retreat to a higher fat approach.

The table below lists optimal foods for different goals from most nutrient dense to most ketogenic.    Hopefully over time you should be able to work towards the more nutrient dense foods as your metabolism heals.

dietary approach printable .pdf
weight loss (insulin sensitive) download
nutrient dense (maintenance) download
weight loss (insulin resistant) download
diabetes and nutritional ketosis download
therapeutic ketosis download

what about mTOR?

Many people are concerned about excess protein causing cancer or inhibiting mTOR (Mammalian Target of Rapamycin).[8]  [9]

From what I can see though, the story with mTOR is similar to insulin.  That is, constantly elevated insulin or constantly stimulated mTOR are problematic and cause excess growth without being interspersed with periods of breakdown and repair.

Our ancestors would have had times when insulin and mTOR were low during winter or between successful hunts.  But during summer (when fruits were plentiful) or after a successful hunt, insulin would be elevated and mTOR suppressed as they gorged on the nutrient dense bounty.

These days we’re more like the futuristic humans from Wall-E than our hunter gather ancestors.   We live in a temperature controlled environment with artificial lighting and tend to put food in our mouths from the moment we wake up to the time we fall asleep.[10]

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Rather than chronic monotony (e.g. eating five or six small meals per day every day), it seems that periods of growth (anabolism) and breakdown and cleaning (catabolism) are optimal to thrive in the long term.  We need periods of both.  One or the other chronically are bad news.

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As my wise friend Raymund Edwards from Optimal Ketogenic Living says

“FAST WELL, FEED WELL.” 

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how much protein?

Optimal protein levels are a contentious topic.  There is research out there that says that excess protein can be problematic from a longevity perspective.  Protein promotes growth, IGF-1, insulin and cell turnover which can theoretically compromise longevity.  At the same time, there are plenty of studies that indicate that we need much more protein than the minimum RDI levels.[11]

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In the end, you need to eat enough protein to prevent loss of lean muscle and maintain strength.  If you’re trying to build lean muscle and working out, then higher levels of protein may be helpful to support muscle growth.  If you are trying to lose weight, then higher levels of protein can be useful to increase satiety and prevent loss of lean muscle mass.  Maintaining muscle mass is critical to keeping your metabolic rate high and avoiding the reduction that can come with chronic restriction.[12] [13]

In addition to building our muscles, protein is critical for building our bones, heart, organs and providing many of the neurotransmitters required for mental health.  So protein from real whole foods is generally nothing to be afraid of.  It’s typically the processed high carb foods that make the detrimental impact on  insulin and blood glucose levels.

The table below shows a starting point for protein in grams depending on your height.  This assumes that someone with a lean body mass (LBM) of 80 kg is burning 2000 calories per day and your lean body mass equates to a BMI of 20 kg/m2.  LBM is current weight minus fat mass minus skeletal mass which again is hard to estimate without a DEXA.

There are a lot of assumptions here so you will need to take as a rule of thumb starting point and track your weight and blood glucose levels and refine accordingly.  It’s unlikely that you will get to the high protein levels of the most nutrient dense approach because either you would feel too full or your glucose levels may rise and ketones disappear, so most people, unless your name is Duane Johnson, will need to moderate back from that level.

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Example:  Let’s say for example you were 180cm and were managing diabetes and elevated blood glucose levels.  You would start with around 117g of protein per day as an initial target and test how that worked with your blood glucose levels.  If your blood glucose levels on average were less than say 5.6mmol/L or 100mg/dL and your ketones were above 0.2mmol/L you could consider increasing transitioning to more nutrient dense foods. 

If you want to see what this looks like in terms of real foods and real meal meals check out the optimal food list and the optimal meals for the different approaches.

insulin load

Using a similar approach, we can calculate the daily insulin load (in grams) depending on your height and goals.  The values in this table can be used as a rule of thumb for the insulin load of your diet.

If you are not achieving your blood glucose or weight loss goals, then you can consider winding the insulin load back down.  If you are achieving great blood glucose levels, then you might consider choosing more nutrient dense food which might involve more whole protein and more nutrient dense green leafy veggies.

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Example:  Let’s say for example you are a 180cm person with good glucose control but still wanting to lose weight, your initial target insulin load would be 156g from the superfoods from fat lost list.  If you were not losing weight at this level, you could look to wind it back a little until you started losing weight.  If you are consistently achieving blood glucose levels less than 5.6mmol/L or 100mg/dL and ketones greater than 0.2mmol/L you could consider transitioning to more nutrient dense foods. 

summary

In summary, reducing the insulin load of your diet is an important initial step.  However, as your blood glucose and insulin levels normalise there are a number of other steps that you can take towards optimising nutrient density on your journey towards optimal health and body fat.

  1. Reduce the insulin load of your diet (i.e. eliminate processed carbage and maybe consider moderating protein if still necessary) to normalise blood glucose levels and reduce insulin levels to facilitate access to stored body fat.
  2. If your blood glucose levels are less than say 5.6 mmol/L or 100mg/dL and your ketone levels are greater than say 0.2 mmol/L then you could consider transitioning to more nutrient dense foods.
  3. If further weight loss is required, maximise nutrient density and reduce added fats to continue weight loss.
  4. Consider also adding an intermittent fasting routine with periods of nutrient dense feasting. Modify the feasting/fasting cycles to make sure you are getting the results you are after over the long term.
  5. Once optimal/goal weight is achieved, enjoy nutrient dense fattier foods as long as optimal weight and blood glucose levels are maintained.
  6. If blood glucose levels are greater than optimal blood glucose levels, return to step 1.
  7. If current weight is greater goal weight return to step 3.

references

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

[2] http://www.epilepsy.com/learn/treating-seizures-and-epilepsy/dietary-therapies/ketogenic-diet

[3] http://www.epilepsy.com/learn/treating-seizures-and-epilepsy/dietary-therapies/ketogenic-diet

[4] http://www.health.harvard.edu/blog/how-much-protein-do-you-need-every-day-201506188096

[5] https://intensivedietarymanagement.com/how-much-protein-is-excessive/

[6] https://en.wikipedia.org/wiki/Protein_poisoning

[7] https://optimisingnutrition.com/2015/08/31/optimal-protein-intake/

[8] https://www.youtube.com/watch?v=Yv-M-5-s9B0

[9] http://nutritionfacts.org/video/prevent-cancer-from-going-on-tor/

[10] https://www.youtube.com/watch?v=qPpAvvPG0nc

[11] https://www.ncbi.nlm.nih.gov/pubmed/27109436

[12] http://ajcn.nutrition.org/content/87/5/1558S.long

[13] https://en.wikipedia.org/wiki/Protein-sparing_modified_fast

a fresh perspective on nutrition

Warning: This post is a celebration of how data analysis can help us understand how to optimise our nutrition to suit different goals.  It may contain novel ideas based on large amounts of data.   

I was flattered when Chris Green (@heuristics) recently posted a graphical presentation of the food insulin index and my nutrient density data analysis using Tableau.

If you click on the image below you can see where the different foods sit on the plot of nutrient density versus proportion of insulinogenic calories or click on individual data points to learn more about a particular food and find out why it ranks well or poorly.

I think presenting the data in an interactive format using Tableau makes large amounts of data more accessible compared to a static chart or spreadsheet that can be produced in Excel.

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Inspired by Chris’s chart, I uploaded the Food Insulin Index data for 147 foods from Kirstine Bell’s thesis Clinical Application of the Food Insulin Index to Diabetes Mellitus.

Click on the chart below to see a larger version or, better yet, open the interactive Tableau version here.   Click on the different tabs to see how your insulin response relates to different parameters such as carbohydrates, fat, protein, glycemic index, glycemic load and sugar.

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I think the food insulin index data is exciting because it helps us better understand what drives blood glucose, insulin, Hyperinsulinemia, metabolic syndrome, and the diseases of western civilisation that are sending us to an early grave and bankrupting our western economy.

I’ve included some brief notes on the interactive charts in order to unpack what I think the data is telling us, but if you want a more detailed discussion of the data I encourage you to check out the articles:

investing your insulin budget wisely

I think being able to better understand our insulin response to food is exciting for people with Type 1 diabetes (like my wife) to more accurately calculate their insulin dose or people trying to achieve therapeutic ketosis for the treatment of epilepsy or cancer.

Understanding exactly how fibre and protein affect insulin and glucose demonstrates quantitatively why a low carbohydrate moderate protein approach works so well for people who are insulin resistant.

While lots of people have found the food insulin index data useful, I want to highlight in this article that insulin load is only one factor that should be considered.

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If we only consider insulinogenic properties of food there is a risk that we unnecessarily demonise nutrient dense foods that happen to elicit an insulin response.  Rather than avoiding insulin, I think it’s better to think in terms of investing a limited insulin budget.  And just like different people have different levels of income, different people have a different (but still finite) “insulin budget”.  For example…

  • Someone using therapeutic ketogenic approach to battle epilepsy or cancer will want to minimise the insulin load of their diet by eating very high amounts of fat, fasting, and perhaps supplementing with MCTs or exogenous ketones. Someone pursuing therapeutic ketosis will need to pay particular attention to making sure they obtain adequate nutrition within their very small insulin budget.
  • If you have Type 1 Diabetes large doses of insulin will send you on a blood glucose roller coaster that might take a day or two to get under control. Eating a Bernstein-esque low carb diet with moderate to high protein levels and lots of non-starchy veggies will make it possible to manage blood glucose levels with physiologic (normal) amounts of insulin without excessive blood glucose and insulin swings.[1] [2]
  • For a type 2 diabetic who struggles to produce enough insulin to maintain their blood glucose in normal ranges, a lower carb moderate insulin load diet will help their pancreas to keep up and achieve normal blood glucose levels while minimising fat storage.
  • People using a ketogenic approach for weight loss need to keep in mind that reduced insulin levels and ketosis occurs due to a lack of glucose and not higher levels of dietary fat. If your primary goal is weight loss, fat on the plate (or in the coffee cup) should be just enough to stop you from going insane with hunger.  Too much dietary fat will mean that there will be no need to mobilise fat from the body.
  • Athletes and people who are metabolically healthy can be more flexible in their choice of energy source and perhaps focus more on more nutrient dense foods as well as energy dense foods.

insulin is not the bad guy

Humans are great at thinking in absolutes (good/bad; black/white) while ignoring context.  We all like to grab hold of our favourite bit of the elephant of metabolic health and hold on tight.

image02

While many people suffer from hyperinsulinemia and its vast array of associated health consequences we need to remember that insulin is critical to life and growth and is required to metabolise protein for muscle growth/repair as well as all the other important functions of amino acids (neurotransmitters etc).[3]

Ideally we should make every bite count if we want to maximise health and longevity.  Every calorie should contain the maximum amount of nutrients possible.  In a similar way, every unit of insulin that we “invest” should be associated with the maximum amount of nutrition (think of the nutrient density of spinach or liver liver versus than nutrient a soft drink or white bread).

So let’s look at how we can “leverage” our “insulin investment” to maximise our health outcome.

show me the data

In this article I’m going to risk overloading, overwhelming, and confusing you, the reader, with too much data.  But at the same time, with all the data available you won’t have to take my word for it.  You can make your own conclusions.

If the idea is far out, you need to see the data. All the data. Not the hazard ratio, not just the conclusions from the computer.

My new grand principle of doing science: habeas corpus datorum, let’s see the body of the data. If the conclusion is non-intuitive and goes against previous work or common sense, then the data must be strong and all of it must be clearly presented.

So, how should you read a scientific paper? I usually want to see the pictures first.[4]

Richard David Feinman, The World Turned Upside Down

I am trying to draw conclusions from more than 6000 foods in the USDA foods database.  These are hard to present accurately in single charts, so I’ve used a few.  If something that you see doesn’t make sense at first you can drill down into the data to check out the detailed description.  I have also included as much micronutrient and macronutrient as I can.  Just ‘mouse over’ a data point that you’re interested in to see how it compares to another data point.

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In the sections below I have given an overview of different ways to look at nutrient density with a more detailed discussion in the appendices at the end of this article.   Unfortunately this post is probably not going to work well on your phone.

You’ll need to view it on big screen for best effect.

Sorry.

My 2c on nutrient density

Lots of people talk about nutrient density, however most of the time this is in relation to a few favourite nutrient(s) rather than a broad range spectrum of essential vitamins, minerals, amino acids and fatty acids.

We hear that butter is high in Vitamin K2 and Vitamin D and hence we should eat more of it[5] or that whey protein is high in essential amino acids (e.g. leucine and lysine) and therefore everyone should be buying tubs of it.[6]

A lot of time these claims are used to advertise a product or to argue a particular philosophical position (e.g. zero carb, vegan, plant based, paleo etc).  The problem here is that many of these so call ‘nutrient dense superfoods’ do not contain a well rounded range of the nutrients that are required for health, but rather a narrow slice of nutrients.

Paleo, Just Eat Real Foods[7] or ‘plant based’ is a good start, however I think there are some foods that are more useful than others.  As detailed in the Building a Better Nutrient Density Index article there are also  some nutrients that are harder to obtain in adequate quantities.

Once we identify the nutrients that are harder to obtain we can focus on the foods that contain the highest amounts of these nutrients.   At the same time it is also useful to think about nutrient density in the context of specific goals, whether that be therapeutic ketosis, weight loss, diabetes or optimal athletic performance.

The more I try to get my head around what it means to optimise nutrition, the more important nutrient density seems to be.  The irony is that many people retreat from insulin to the safe haven of high fat diets that don’t actually have the micronutrients required to optimally power mitochondria, the power plants of our bodies.  Like most things, we need to find the right balance.

Most people now seem to understand that hammering high blood glucose with more insulin is dumb because the problem is insulin resistance and poor glucose disposal, not high blood glucose.

But then the next question is what causes insulin resistance?

It seems to me that part of the answer is sluggish mitochondria that aren’t running at optimal efficiency to burn off the energy we throw at them.  Part of the reason for this is that we’re not powering them with the right nutrients.

To produce ATP efficiently, the mitochondria need particular things.  Glucose or ketone bodies from fat and oxygen are primary.

Your mitochondria can limp along, producing a few ATP on only these three things, but to really do the job right and produce the most ATP, your mitochondria also need thiamine, riboflavin, niacin, pantothenic acid, minerals (especially sulfur, zinc, magnesium, iron and manganese) and antioxidants.

Mitochondria also need plenty of L-carnitine, alpha-lipoic acid, creatine, and ubiquinone (also called coenzyme Q) for peak efficiency.

Dr Terry Wahls

The Wahls Protocol

Terry%20Wahls,%20M.D.%20Photo%20and%20Book%2003272014[1]

This video gives an excellent overview of the role that nutrients play to drive the krebs cycle to enable our mitochondria to produce ATP, the energy currency of our cells.

We can then moderate that using insulin load to  work within the limits of your current metabolic health (i.e. insulin resistance, muscle mass, activity levels, pancreatic function etc).

You need to eat to maintain the blood glucose levels of a metabolically healthy person.

Robb Wolf

robbwolf-468x468[1]

Nutrient density vs proportion of insulinogenic calories

The plot below shows nutrient density versus proportion of insulinogenic calories.   The size of the data points are proportional to the energy density of the foods they represent (e.g. the size of the markers for celery with a low energy density are smaller than for butter which has a high energy density).

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There is a lot of data here!  You can click on the image below to see a larger version of the chart or better yet look at the interactive online Tableau version (which I think is pretty cool!).  If you ‘mouse over’ the foods that you’re interested in you can see more details of the foods from the USDA food nutrient database.  Click through the various tabs to see how things look for specific food groups.

The x-axis on these charts is nutrient density / calorie.  You can find out more about how this is calculated in the Building a better nutrient density index article.  Essentially zero is average (or zero standard deviations from the mean) while greater than zero is better than average and less than zero is worse than the average of the 6000 foods analysed.

The nutrient density calculations are based on the USDA database which provides the nutrient content of more than 6000 foods.  It does not account for species specific bioavailability or issues such as fat soluble vitamins.  

I don’t think we can use this to say that plant foods are better or worse than animal foods, but rather it shows us which foods to avoid due and which foods are the best choices within particular categories.  

Personally I think optimal involves getting a balanced range of the most nutrient dense plant and animal based foods. 

So what does this data mean and how could it be practically useful?

  • If you’re metabolically healthy then I think you’d do well eating from the most nutrient dense foods on the right hand side of the chart (i.e. celery, spinach, mushrooms, onions, oranges etc). While many of these nutrient dense foods may have higher proportion of insulinogenic calories I think it’s hard for most people to overeat them.
  • The foods most people should avoid are the highly insulinogenic low nutrient density foods on the top left of this plot (i.e. soft drinks, fruit juice, sport drinks etc).
  • If you’re insulin resistant or aiming for therapeutic ketosis (e.g. as an adjunct treatment for cancer or epilepsy or dementia) you will want to move down the chart to the higher fat low insulinogenic foods while keeping to the right as much as possible.
  • It’s important to note that the high fat foods typically have a lower nutrient density because they do not contain as broad a range of nutrients.

Energy density versus nutrient density

While 60 to 70% of the western population seem to be suffering some level of metabolic syndrome and are insulin resistant[8] some people who are metabolically healthy are still obese.[9]  For these people simply reducing the energy density without consideration of carbs or insulin load (i.e. lowering their fat intake with higher amounts of water and fibre) will help them to consume less calories.

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Someone who is metabolically healthy (i.e. excellent blood glucose levels etc) yet still obese would do well to focus on the nutrient dense low energy density vegetables, fruits, seafood and meat in the top right of this chart.

This is basically where I’m at after normalising my glucose and HbA1c but I’d still like to drop some more weight.  I now need to take my own advice and focus on more nutrient dense proteins and vegetables and indulge less on the yummy high fat foods.

The typical problem with a low fat approach typically comes not from eating too much vegetables or fruit (top right of this chart) but rather when your energy comes from highly insulinogenic, energy dense low nutrient density foods (e.g.  processed grains and softdrinks) which end up on the top left of all of these charts.

The only real ‘problem’ with a high nutrient density low energy density approach is that it is physically difficult to get enough food down to achieve an energy surplus.  The benefit is that it typically leads to weight loss while still maintaining very high levels of nutrition.

A high nutrient density low energy density approach could still be ketogenic due to the low level of processed carbohydrates and low insulin load.

Click here to view the interactive Tableau version of nutrient density versus energy density.

Net carbs versus nutrient density

Lots of people like to count carbohydrates or net carbohydrates (i.e. carbohydrates minus the indigestible fibre).  In my view I think it’s better to think in terms of net carbohydrates when eating real foods to make sure you don’t miss out on nutrient dense vegetables.

The chart below shows nutrient density versus net carbohydrates.  Focusing on the foods on the top right and avoiding the soft drinks, cereals and breads at the bottom will be a pretty good strategy.

The limitation of net carbs is that it doesn’t account for the impact of protein which is an important consideration for people with type 1 diabetes or advanced type 2 diabetes.

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Click here to view an interactive Tableau version of nutrient density versus net carbs.

Insulin load versus nutrient density

This brings us to my favourite way to look at nutrient density… insulin load.

Thinking in terms of insulin load involves consideration of net carbs plus about half the protein as requiring insulin.  Insulin load per 100g of food is neat because it means that we also end up with lower energy density foods as well which is not a bad thing for most people who often wouldn’t mind losing some weight (note: low energy density foods like celery may not be so great if you’re trying to fuel for a marathon).

I think it’s good to also consider the insulin effect of protein because insulin is a finite resource.   While people who are metabolically healthy will be able to eat high protein foods without seeing a substantial rise in their blood glucose levels, people who are very insulin resistant or have type 1 diabetes will see their  glucose levels rise with protein and may need to inject insulin to cover the protein they eat.  This doesn’t mean though that people who are insulin resistant should avoid high protein foods, because they are typically very nutrient dense.

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Again, we can see that it’s the soft drinks, breakfast cereals and breads at the bottom of this chart that we really need to be avoiding!

This thinking seems to align with common sense wisdom.  Tick.

Click here to view an interactive version of insulin load versus nutrient density.

Summary

Hopefully you can see how thinking about nutrient density graphically in combination with other parameters can be useful to refine your food selection for different goals.

The appendices to this article below show more charts for different food groups with a little more discussion of my observations.

Or better yet, why not dive into the interactive data in Tableau and see what you can make of it yourself.

  • Appendix A – Nutrient density vs proportion of insulinogenic calories for therapeutic ketosis
  • Appendix B – Nutrient density vs energy density for weight loss and / or the metabolically healthy
  • Appendix C – Nutrient density vs net carbohydrates for people on a low carb diet
  • Appendix D – Nutrient density vs insulin load for diabetes and therapeutic ketosis

Appendix A – Nutrient density vs proportion of insulinogenic calories for therapeutic ketosis

Foods with a lower proportion of insulinogenic calories can be useful for people trying to achieve therapeutic ketosis, however at the same time we can see at the bottom of this plot that high fat / low insulin load foods are not necessarily the most nutrient dense.

People should ideally choose foods with the highest nutrient density (right hand side) while keeping the proportion of insulinogenic calories in their diet low enough to achieve their goals (e.g. blood glucose, insulin, tumour growth or seizure control).

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Click here to view the interactive Tableau version of nutrient density proportion of insulinogenic calories.

Vegetables

Vegetables are typically have high levels of vitamins and minerals as well as some protein but not much fat.

Most people, particularly those who are not severely insulin resistant, will do well to focus on the most nutrient dense vegetables on the right hand side of this chart (i.e. celery, spinach, squash, cabbage, broccoli, mushrooms, artichokes, kale) as their energy density, insulin load and net carbs are also low.

Celery is an example of a food with high amounts of vitamins and minerals with a very low energy density, hence it does really well on the nutrients / calorie scale.

The foods in the chart below with the lowest proportion of insulinogenic calories typically have added fat (e.g. french fries, onion rings which are not ideal) or are very high in fibre (e.g. asparagus, spinach and soybeans which is better).

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Seafood

Seafood is really the only substantial source of essential omega 3 fatty acids (i.e. DPA, DHA, EPA, ALA) and hence is an important part of a balanced diet.

The highest nutrient density seafoods are cod, anchovy, salmon, caviar and tuna.  The lowest insulin load fish are mackerel, herring, salmon and caviar.

Again, we should ideally focus on the most nutrient dense foods on the right hand side of the chart, but move down the chart to the least insulinogenic foods depending on our level of metabolic health.

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Animal products

Liver is the most nutrient dense of the animal products (right hand side) while processed meats are less nutrient dense (left hand side).  High fat meats are also typically less nutrient dense (bottom of chart).

Non-processed meats are typically well worth the investment of your limited insulin budget.

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Nuts seeds

Many nuts and seeds are high fat while also being fairly nutrient dense (i.e. pine nuts, coconut and pecans).  Nuts have a low proportion of insulinogenic calories and hence help to normalise blood glucose levels, but possible to overdo if weight loss is your primary goal.

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Dairy and egg

Some dairy products are both high fat and nutritious (e.g. parmesan cheese, egg yolk).

Cream and butter are high fat and energy dense so are useful for managing blood glucose levels but are possible to overdo if weight loss is your primary goal.

Low fat dairy products such as skim milk and whey are typically very nutrient poor overall.

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Fruit

Some fruits are nutrient dense, but are typically highly insulinogenic (tangerines, cherries, grapes, apricots, oranges and figs).  Only olives and avocados have a low proportion of insulinogenic calories, however they are not particularly nutrient dense.

image08

Cereals and grains

Unprocessed grains such as oatmeal, teff, spelt, brown rice and quinoa can be nutrient dense but are highly insulinogenic.  Unprocessed grains may be fine if you are metabolically healthy, but choose carefully and don’t go adding sugar, honey or molasses.

However breakfast cereals and most breads are typically highly insulinogenic while also having a poor nutrient density and hence are a poor investment of your limited insulin budget.

This analysis supports the idea that dropping processed grains, packaged breakfast cereals and soft drinks would be a pretty good place to start for most people!

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Legumes

Navy beans, lima beans and lentils are nutrient dense but highly insulinogenic.

Peanuts, peanut butter and tofu do OK in terms of both being low insulinogenic as well as nutrient dense.

Processed soy products and meat replacement products are typically highly insulinogenic and have poor nutrient density.

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Fats and oils

Fish oil is the most nutritious of the fats.  However as a general rule pure fats are not particularly nutrient dense.  Margarines and salad dressings are very nutrient poor.

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Beverages

Soft drinks, sports drinks and sweetened iced teas are bad news and are an extremely bad investment of your limited insulin budget.  Fruit juices are not also not particularly nutrient dense.  Better to eat your fruit whole.

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Appendix B – Nutrient density vs energy density

Low energy density, high nutrient density foods are a great way to lose weight, particularly for those who are insulin sensitive.  As we avoid processed carbs as well as high levels of dietary fat while maintaining high levels of nutrition we can allow the fat to come from our belly rather than our plate.

image03

Click here to view the interactive Tableau version of nutrient density versus energy density.

Vegetables

It’s hard to go wrong with the low energy density high nutrient density foods in the top right of this chart (i.e. celery, mushrooms, spinach, onions, broccoli, seaweed, kale etc).

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Seafood

Some seafood is nutrient dense and lower in fat (e.g. oysters, tuna, lobster).

Seafood is important because it provides the essential omega 3 fatty acids that are hard to obtain in significant amounts from vegetables and it provides higher levels of protein.

If you are serious about losing weight you’d do pretty well if you limited yourself to the vegetables in the top right of the chart above and the seafood in the top right of the chart below.

Animal products

There are many nutrient dense low energy density animal foods as shown in the chart below.  Liver does pretty well followed by game meat.  Processed meats are not so good.

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Nuts seeds

Nut are low insulin but not necessarily low energy density or spectacularly great in terms of nutrients per calories.  Consider limiting your nuts and seeds if your primary goal is weight loss.

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Dairy and egg

Whole egg (top right corner) is probably your best option from the dairy and egg category.

Butter and full fat cheese have a high energy density (bottom).

Low fat dairy is nutrient poor (top left corner)!

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Fruit

If your goal is weight loss then low energy density fruits such as tangerines / mandarins, cherries, apricots and pears will be more helpful than energy dense fruits such as bananas, prunes, raisins and dried fruits.

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Cereals and grains

Some unprocessed grains are nutritious and have a low energy density (top right), however as a general rule, breakfast cereals and processed grains are a poor investment of your limited insulin budget (bottom of chart).

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Legumes

Lima beans, navy beans, tofu, mung beans and hummus are nutrient dense and low energy density (top right).   Peanuts have a  low insulin load and solid nutrient density but a high energy density (bottom).

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Appendix C – Nutrient density vs net carbohydrates for diabetes

Most people keeping track of their carbohydrate intake think in terms of net carbs or total carbohydrates, however this does not consider the insulin demand from protein which is a real consideration if you have diabetes.

Thinking in terms of net carbs will be the best approach for most people; however, if you are highly insulin resistant or have type 1 diabetes you may be better to consider insulin load which considers the effect of protein on insulin.

Choosing foods to the top right of these charts will help you keep nutrition high and net carbohydrates low.

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Click here to view an interactive Tableau version of nutrient density versus net carbs.

vegetables

There are plenty of vegetables on the top right of this plot that have minimal net carbs while being very nutrient dense (e.g. celery, spinach, broccoli, asparagus, mushrooms).

Low water foods such as mushrooms, leeks, shallots (at the bottom of the plot) will be hard to eat large quantities of although they have a higher amount of net carbs per 100g.

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seafood

Most seafood has minimal levels of net carbs, though it’s interesting to note that some seafoods such as oysters have a glycogen pouch depending on what time in the season they are harvested.

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animal products

Similar to seafood, most animal products have negligible amounts of net carbs.  The amount that is contained in muscle glycogen is not significant.

Liver and game meats are consistently the most nutrient dense of the animal products.

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nuts seeds

Nuts and seeds have some non-fibre carbohydrates.  Pine nuts, macadamias and almonds are low in carbs with moderate nutrient density.

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dairy and egg

Many dairy and egg products have a high nutrient density as well as being low in net carbs which is why they are popular with low carbers.  Fat free cheeses have more carbohydrates.

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fruit

There are some lower carb fruits however, it may be wise for people with insulin resistance to avoid many of the higher carbohydrate fruits at the bottom of this chart.

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cereals and grains

This chart demonstrates why many breakfast cereals and processed grains (at the bottom of this chart with high levels of carbohydrates and minimal nutrition) are a bad investment of your limited insulin budget.  This style of analysis demonstrates why the common wisdom that soft drinks and breakfast cereals are bad news.

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legumes

Not all legumes are created equal.  Choose wisely.  Navy beans, legumes, lima beans and peanuts are probably your safest bet.

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beverages

Soft drinks and sports drinks are a very poor investment of your limited insulin budget as they are very low in nutrients.

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Appendix D – Nutrient density vs insulin load

Thinking in terms of nutrient density versus insulin load enables us to more intelligently consider how we invest our insulin budget.  Again, it’s not that insulin is bad, but rather we should use it wisely for the most nutrient dense foods.

Soft drinks, breakfast cereals and bread at the bottom of this chart are a poor way to invest the limited capacity of your pancreas.

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Click here to view an interactive version of insulin load versus nutrient density.

vegetables

Don’t be afraid of vegetables.  Most of them have a very low insulin load.  They should take up a large amount of your plate.  But choose wisely from the top corner (e.g. celery, spinach, squash cabbage, broccoli).

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seafood

There are lots of good investments to be made in the top right of this chart of seafood (oyster, salmon, lobster, mackerel).

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animal products

Animal products require insulin but they are rich in amino acids which play an important role in the body.   The amount you need will be dependent on your situation and your goals (e.g.  someone aiming for therapeutic ketosis will want less while someone looking to build muscle or retain muscle while dieting will want more protein).

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nuts seeds

Looking at nuts in terms of insulin load rather than net carbs enables better differentiation based on how much insulin these foods will demand from your system.   Pine nuts, macadamia nuts and coconut have the lowest insulin load while being nutrient dense.

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dairy and egg

Dairy can be insulinogenic, however the higher fat butter, cream and egg still have a fairly low insulin load.

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fruit

Grapefruits, cherries, apples, grapes and oranges have a large amount of nutrition with a low insulin load versus more concentrated or dried fruit options.

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cereals and grains

The breakfast cereals at the bottom of this chart with high amounts of insulin demand and lower levels of nutrients are bad news people who are insulin resistant.

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legumes

Lima beans, navy beans, and lentils have a fairly low insulin load and high nutrient density.  However if you are insulin resistant you will need to eat to your metre and make sure your blood glucose levels don’t rise too much if you eat legumes.

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fats and oils

Just because it is low insulin doesn’t mean that it is good for you.  Not many very high fat foods have substantial nutrient density.  When it comes to nutrient density, fats in whole foods are a better than trying to consume refined oils.

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Beverages

Soft drinks are bad news as they will stimulate large amounts of insulin while providing minimal amounts of nutrition and satiety.

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references

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

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

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

[4] Feinman, Richard David (2014-12-12). The World Turned Upside Down: The Second Low-Carbohydrate Revolution

[5] http://chriskresser.com/vitamin-k2-the-missing-nutrient/

[6] http://www.whfoods.com/genpage.php?tname=foodspice&dbid=38

[7] https://iquitsugar.com/jerf-just-eat-real-food/

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

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

the food insulin index v2

It’s generally difficult for healthy people to eat too much protein.  However the fact that protein requires some insulin to metabolise is an important consideration for people who need to inject extra to keep their blood glucose levels stable.

A better understanding of the insulin response to various foods would be useful for diabetics calculating their insulin dose or even to help refine food choices to manage insulin load.

Since launching the optimising nutrition blog I have had many interesting discussions and learned a lot about protein and how it affects insulin and blood glucose.

The Most Ketogenic Diet Foods article which reviews the food insulin index data and what we can learn about our food choices has received almost 200,000 view.  Given the level of interest, I thought it would be useful to review this topic in more detail.

the food insulin index… a quick refresher

If you’ve been reading Optimising Nutrition blog you would have come across discussion of the recent food insulin index testing undertaken at the University of Sydney as detailed in Kirstine Bell’s PhD thesis Clinical Application of the Food Insulin Index to Diabetes Mellitus [1] (Sept 2014).

The primary learning from the recently expanded food insulin index data is that the carbohydrate content of a food only partially explains the insulin response.  The protein, fibre and fructose also affect our insulin response to our food.

The cluster of data points on the left-hand side of the figure below shows that:

  1. low carbohydrate, high fat foods trigger a negligible insulin response, while
  2. low carbohydrate high protein foods cause a significant insulin response.

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When we assume that fibre is indigestible and protein has about half the insulinogenic effect of carbohydrates we get a much better prediction of insulin response.

image002

The insulin requirement of a particular food is described better by the following formula:

insulin load = total carbohydrates – fibre + 0.56 * protein

digestion time for protein versus carbohydrates

One of the limitations of the food insulin index data is that the insulin area under the curve was measured over only three hours.  This is not a big deal for foods that are high in carbohydrates as they are generally fully digested within three hours.

However protein can take much longer to digest.  In the article The Blood Glucose, Glucagon and Insulin Response to Protein we saw that the insulin response to protein in diabetics can be even greater and over a longer period than for people who do not have diabetes.

If we were to repeat the food insulin index testing over a longer period it is likely that the measured insulin response would be significantly greater and even more-so in people with diabetes.  That is, the insulin response to protein may be greater than the 56% of the insulin response to carbohydrate indicated by the analysis of the food insulin index data if we were to measure the insulin response over a longer period.

Wilder’s ketogenic formula

Dr Russell Wilder of the Mayo Clinic was the first to coin the term ‘ketogenic diet’. [2]  Wilder developed the diet as an alternative to fasting in the treatment of epilepsy in the 1920s.

Image result for dr russell wilder

Wilder also developed the formula shown below to determine whether a diet would be ketogenic.  If the number from this calculation was greater than 1.5 (ideally greater than 2.0) then the diet would be considered to be ketogenic and appropriate for the treatment of epileptics. [3]

image003

This formula is based on the understanding that:

  • 100% of carbohydrate is glucogenic (i.e. converts to glucose),
  • 54% of protein is glucogenic,
  • 46% of protein is ketogenic, and
  • 10% of fat is glucogenic.

I had previously searched for detail of how Wilder had arrived at the 56% / 46% split for protein and only found references suggesting that the 56% glucogenic potential of protein comes from the analysis of nitrogen in the urine of dogs. [4]  However I recently came across this paper which details Wilder’s thinking in more detail.

Wilder’s conclusion that a diet needs to have more than two times the ketogenic precursors compared to glucogenic precursors is still the basis of the formulation of diets used to treat epilepsy.

According to George Cahill, Krebs also found that 57g of glucose may be derived from 100g of protein. [5]   Again, this is similar to the insulin demand for protein observed in the food insulin index tests.

carbohydrate counting

The most straight forward approach is to assume that protein has no impact on insulin or blood sugars.

Dr Richard Berstein and Dr Robert Atkins pioneered the concept of carbohydrate counting for weight loss and diabetes management in the 70s and 80s.  There have been various waves of popularity of low carbohydrate diets with many people finding success.

Carbohydrate counting alone is a reasonable approach that is likely to work for most people, particularly if they are not highly insulin resistant.

However, there are some people that reducing carbohydrates alone doesn’t work for.   The fact that protein also generates insulin suggests that managing protein as well as carbohydrates may be necessary to manage insulin levels.

thermic effect of food

You may have heard of the concept of the thermic effect of food where different foods require different amounts of energy for the digestion process.  For example, a mushroom, which has a very low calorie density and a lot of fibre and protein, may require more energy to digest than is obtained from the digestion of the mushroom.

The maximum and minimum thermic effect (also known as the specific dynamic action) for each macronutrient is shown below. [6]

Microsoft Word Document 3072015 40140 PM.bmp

Compared to carbohydrates and fat, protein only yields between 76% and 84% of the energy per calorie ingested because of losses in digestion.  This is useful to know if you’re trying to minimise calorie intake.

As discussed in the Why We Get Fat V2 article, part of this thermic effect of food is also likely to be due to the fact that there is a significant loss of energy when we convert protein to glucose to be used as energy.  The body doesn’t like to do this other than in an emergency.

Steve Phinney’s “well formulated ketogenic diet”

One of the key observations from Steve Phinney’s well formulated ketogenic diet (WKFD) chart is that we need to strike a balance between carbohydrates and protein in order to maximise the ketogenic potential of our diet.

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You can have 30% protein and 5% carbs or 20% carbs and 10% protein and still be within the bounds of a ketogenic diet.  However if you have 30% protein and 20% carbs you will be outside the realms of a ketogenic diet because you will be producing too much glucose.

According to Nuttall and Gannon [7] the body requires between 32 and 46g per day of high quality dietary protein to maintain protein balance.  This equates to around 6 to 7% of calories in a 2000 to 2500 calorie diet being taken ‘off the top’ for growth and maintenance, with everything else potentially available as ‘excess’ protein for gluconeogenesis.  This should not be considered optimal, but simply a minimum reference point for the absolute minimum amount of protein.

Interestingly, the slope of the line along the face of Phinney’s WFKD triangle corresponds with the assumption that 7% of protein goes to muscle growth and repair (protein synthesis) with 75% of the remaining ‘excess’ protein being glucogenic.  This 75% value is in the “ball park” (although a little higher) of our previous estimate of the glucogenic potential of protein based on the analysis of the food insulin index data.

amino acid potential

We also have an understanding of which amino acids are glucogenic, which are ketogenic and which are a bit of both. [8] [9] [10]  The table below shows the various amino acids divided up on the basis of their ketogenic versus glucogenic potential and also which are essential versus non-essential. [11]

Microsoft Word Document 3072015 34915 PM.bmp

Only two amino acids are exclusively ketogenic.  There is a handful that are both glucogenic and ketogenic.  However most of the amino acids are glycogenic, meaning that they will most likely turn into glucose if not required for protein synthesis.

According to David Bender “In  fasting  and  on  a  low  carbohydrate diet  as  much  of  the  amino  acid  carbon  as  possible  will  be  used  for gluconeogenesis, an ATP-expensive, and hence thermogenic process.” 

Hence it appears likely that in a low carbohydrate diet situation excess amino acids that fit under the “both” classification will be turned to glucose rather than ketones because the body needs the extra glucose which it is not getting from ingested carbohydrates.

Conversely, if someone is consuming a high carbohydrate diet the excess amino acids that fit into the “both” category will be converted to ketones rather than glucose because the body is getting more than enough glucose from the diet.

So, to some extent, protein is versatile depending on the body’s need. But at the same time, it is only a small portion of the amino acids that are able to do this. The fate of the majority of the amino acids is pre-destined.

the krebs cycle

The figure below shows the process of catabolism of amino acids. [12]

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I am not an organic chemist, but from what I understand this means that:

  • The amino acids Leucine and Lysine cannot be converted back to glucose as they are ketogenic;
  • Isoleucine, Tyrosine, Phenylalanine, Tryptophan, Threonine all enter into the amino acid catabolism cycle and can be used for various functions, such as muscle repair and growth, but can also be converted back into glucose if required (glucogenic) or turned into fatty acids (ketogenic); and
  • The remaining amino acids enter the cycle and can be used for a variety of functions in the body, but cannot be converted into fatty acids.  If they are not required they can be turned into glucose and potentially stored as body fat.

The majority of the amino acids obtained from the digestion of protein have the potential to be turned into glucose through gluconeogenesis.

The reason that we don’t see a sharp rise in blood glucose is partly because amino acids from digestion circulate in the blood until they are required.  Gluconeogenesis is a demand driven process.  Glucose is pulled from amino acids when there is no other source rather than pushed into the bloodstream due to ingestion of excess protein.

By contrast, glucose from carbohydrates will be used to refill glycogen stores (liver and muscle) and then find their way quickly into the bloodstream.  In most people, the amino acid stores in the blood are not saturated and hence there is plenty of capacity to store amino acids until they are required, at least if you have good insulin sensitivity and are not diabetic.

The body does need glucose, and it is fine to get it from carbohydrates or protein via gluconeogenesis.  However many people struggle to produce enough insulin and / or are insulin resistant and hence struggle to keep their blood sugars in normal range.  For these people it makes sense to reduce the insulin load their diet (the portion that requires insulin) to a point that they can maintain normal blood glucose levels.

tallying up the amino acids

I figured I could use this knowledge of the categorisations of the various amino acids to better understand how much of the proteins in the 8000 foods listed in the USDA food database are glucogenic versus ketogenic.

For each food in the USDA database I tallied up the weight of the glucogenic and ketogenic amino acids and the amino acids that fell onto the ‘both’ category and found that:

  • ketogenic amino acids make up only 12% by weight of the total protein across the 8000 foods in the database,
  • glucogenic amino acids comprise 74% of the foods, and
  • amino acids that fit in the “both” comprise 14% of the total weight of amino acids.

This means that somewhere between 78% and 89.5% of protein has the potential to turn into glucose, depending on whether you considered the amino acids in the ‘both’ column to be glucogenic or ketogenic, or somewhere in between.

For someone eating a low carbohydrate diet nearly 90% of ‘excess’ protein could be turned to glucose in the blood stream.

Why is this different to the observation from the food insulin index testing that approximately 56% of protein raises insulin?  Perhaps the following factors come into play:

  1. When we consider the glucogenic potential of the individual amino acids we are considering the maximum potential of protein if it is not first used for protein synthesis.  The amount of protein synthesis will be greater for say an athlete or a body builder, with less protein remaining for gluconeogenesis.
  2. Converting protein to glucose requires energy and hence some of the energy from ingested protein is lost in the process and hence is not converted to glucose.
  3. The insulin index testing is undertaken over only three hours. Protein takes much longer to digest and be metabolised into glucose hence the insulin index testing may underestimate the full glucogenic potential of protein.

which foods have the most ketogenic protein?

So I bet you are wondering which forms of protein have the highest amount of ketogenic protein.  Maybe not?  Well, I was, and I am going to share it with you.

The table below shows the foods from the USDA database that have the most ketogenic protein (assuming the ‘both’ amino acids are split 50/50 glucogenic / ketogenic) in terms of grams of ketogenic amino acids per 100 grams of the food.

Food ketogenic aminos ( per 100g) % ketogenic protein % insulinogenic
Seal, Bearded Alaskan 19.4g 23% 72%
Whale, Beluga 17.6g 25% 64%
Cod 16.3g 26% 68%
Seaweed, spirulina 14.2g 25% 64%
White fish 13.6g 22% 53%
Parmesan cheese 12.3g 32% 28%
Beef, sirloin 10.0g 33% 50%
Beef, ribeye 9.7g 33% 44%
Bacon 9.3g 25% 22%
Egg yolk 9.2g 27% 18%
Lamb 9.0g 25% 39%
Chicken, breast with skin 7.8g 24% 48%
Salmon 7.0g 28% 45%
Egg, whole 3.3g 26% 29%
Milk 0.9g 29% 43%

It is hard to know what to make of this list other than noting that the seal, whale and cod have the highest amounts of ketogenic protein.  Perhaps there is something about cold water animals that cause them to store more ketogenic amino acids?  This seems to align with what we see in the traditional diets of humans who may eat more fat if they are living further away from the equator but eat more carbohydrates from fruits if they live closer to the equator.

Although seal, whale and cod have high amounts of ketogenic amino acids, overall they are still quite insulinogenic.  In view of the high proportion of insulinogenic properties of some meats it is not surprising that people can thrive on a 100% meat zero carb diet because the body can get as much glucose they need from the meat.[13]  At the same time though, I’m not sure that an all meat diet can provide an optimal array of vitamins and minerals unless you are emphasising organ meats.

In view of the fact that a large amount of protein can be converted to glucose through gluconeogenesis, it seems better to focus on foods that have a lower percentage of insulinogenic calories if you are insulin resistant or do not have a fully functioning pancreas.

Rather than worrying about whether you’re eating too much protein, most people will do fine if they limit their processed grains and sugars and eating as much protein as their appetite directs them to.  If you are aiming for a therapeutic ketogenic diet to manage chronic conditions such as cancer, epilepsy or dementia, then you may want to consider moderating your protein intake to drive ketosis.

While there is no such thing as a glycemic index for protein, it also makes sense to avoid processed foods if you are after stable blood glucose levels and lasting satiety.  Unless you are a bodybuilder who is looking for a quick insulin spike it would be prudent to prioritise protein from whole foods.

summary

The table below shows a comparison of a range of glucogenic factors for protein relative to carbohydrate, summarising the discussion above.  Most of the approaches to understanding the insulinogenic portion of protein give an even higher value than suggested by the analysis of the food insulin index data.

Basis % insulinogenic Comment
Carbohydrates only 0% A lower end sensitivity assuming that no protein is converted to glucose (i.e. as per standard carbohydrate counting).
Food insulin index 56% Based on testing of > 100 foods in healthy individuals
Thermic effect of food 77% Average of additional in digestion losses minus 7%.
Wilder’s formula 54% Used in initial ketogenic formula
Krebs  / Janney 57% Based on nitrogen excretion in dogs
Glucogenic potential (min) 78% Based on summing amino acids in USDA foods database, excluding “both” aminos.
Glucogenic potential (max) 89.5% Based on summing amino acids in USDA foods database, including “both” aminos.
Steve Phinney WFKD 75% Assuming that the first 7% of calories goes to growth and repair with 75% of the remaining amino acids being glucogenic.

the most ketogenic foods… updated

I have calculated the insulinogenic potential of the foods shown in this previous article (The Most Ketogenic Diet Foods) using the following approaches:

  • carbohydrates only;
  • food insulin index data (i.e. protein is 56% insulinogenic);
  • thermic effect (i.e. protein is 77% insulinogenic); and
  • maximum glucogenic potential of the amino acids for each food (varies for each food based on data in USDA foods database).

This updated data illustrates the difference in standard carbohydrate counting and the full insulinogenic potential of the food.  While there is a range of values due to the varying amounts and types of protein overall, there is a reasonable alignment between the food insulin index (56%), thermic effect of food (77%) and maximum glucogenic potential values, particularly when we compare it to the carbohydrate only approach for the lowest carbohydrate foods.

least insulinogenic foods

food carb only (0%) FII (56%) thermic (77%) glucogenic (max)
olives 1% 4% 4% 4%
cream 3% 4% 6% 4%
pecans 2% 5% 8% 6%
Macadamia nuts 3% 5% 7% 6%
duck 0% 7% 4% 9%
pork sausage 2% 10% 19% 9%
sesame seeds 7% 7% 10% 11%
sausage 0% 9% 12% 14%
frankfurter 2% 11% 14% 14%
pepperoni 0% 10% 14% 15%
bacon 1% 16% 21% 21%
mackerel 0% 20% 28% 28%

Eggs

egg  carb only (0%) FII 56%) thermic (77%) glucogenic (max)
egg yolk 16% 15% 20% 19%
whole egg 17% 21% 23% 25%
egg white 6% 53% 71% 72%

Dairy products

Cheese

cheese carbs only (0%) FII (56%) thermic (77%) glucogenic (max)
cream cheese 5% 9% 10% 9%
brie 1% 14% 20% 18%
limburger 1% 14% 19% 18%
camembert 1% 15% 21% 19%
Monterey 1% 15% 20% 19%
cheddar 1% 15% 20% 19%
gruyere 0% 17% 23% 20%
Colby 3% 16% 21% 20%
blue 3% 16% 21% 20%
edam 2% 17% 23% 21%
gouda 2% 18% 24% 22%
feta 6% 18% 23% 22%
ricotta, whole milk 7% 21% 27% 24%
mozzarella 3% 20% 26% 26%
cream cheese, low fat 16% 25% 28% 27%
parmesan 3% 21% 27% 28%
mozzarella, skim milk 4% 26% 34% 31%
Swiss 6% 22% 27% 34%
ricotta, part skim milk 15% 33% 40% 37%
cream cheese, fat free 29% 62% 75% 72%
Swiss, low fat 8% 45% 48% 73%
cottage cheese, low fat 17% 55% 69% 86%
mozzarella, non-fat 10% 60% 79% 95%

Milk

milk carb only (0%) FII (56%) thermic (77%) % insulinogenic (max)
Full cream milk, 3.7% fat 29% 41% 41% 43%
Human milk 40% 43% 44% 43%
Skim milk, 1% fat 47% 65% 72% 69%
Chocolate milk, low fat 63% 72% 76% 70%

Yogurt

yogurt carb only (0%) FII (56%) thermic (77%) % insulinogenic (max)
plain, whole milk 30% 42% 48% 46%
Plain, low fat 44% 63% 70% 68%
fruit, low fat 71% 81% 85% 83%
plain, skim milk 55% 78% 87% 85%
fruit, non-fat 70% 90% 97% 96%

Fruits

fruit carb only (0%) FII (56%) thermic (77%) % insulinogenic (max)
olives 1% 3% 4% 4%
avocados 4% 8% 9% 7%
raspberries 42% 42% 51% 45%
blackberries 40% 42% 53% 47%
strawberries 70% 75% 76% 69%
oranges 77% 81% 83% 76%
apples 88% 89% 89% 81%
bananas 91% 91% 95% 86%

Vegetables

vegetable carb only (0%) FII (56%) thermic (77%) % insulinogenic (max)
endive 6% 22% 29% 24%
dock 5% 27% 33% 27%
mustard greens 7% 61% 43% 34%
asparagus 36% 60% 69% 34%
artichoke 22% 35% 39% 38%
sauerkraut 30% 41% 45% 40%
broccoli 3% 35% 47% 42%
lettuce 28% 44% 50% 42%
coriander 15% 36% 44% 43%
chrysanthemum leaves 0% 32% 43% 44%
alfalfa 3% 42% 57% 47%
parsley 34% 52% 59% 48%
cauliflower 32% 50% 56% 48%
spinach 24% 53% 63% 50%
bamboo shoots 19% 50% 62% 51%
mushroom 31% 56% 66% 55%
turnip 17% 30% 34% 62%
onions 78% 85% 88% 82%

Nuts, seeds and legumes

nuts, seeds legumes carbs only (0%) FII (56%) thermic (77%) % insulinogenic (max)
pecans  2% 5%  10% 5%
Macadamia  3% 5%  6% 6%
coconut meat  7% 6%  10% 7%
coconut cream  6% 7% 9% 8%
coconut milk  6% 7% 9% 8%
Brazil nuts  3% 7% 10% 9%
flax seed  1% 8% 12% 11%
walnuts  4% 9%  11% 11%
pine nuts  5% 9%  11% 11%
sesame butter (tahini)  6% 11% 15% 14%
sesame seeds  0% 12% 10% 15%
chia seeds  6% 13% 17% 16%
peanuts  4% 13%  19% 18%
sunflower seeds  9% 14% 19% 18%
pumpkin seeds  6% 14% 22% 19%
pistachio nuts  12% 19%  23% 22%
cashew butter  21% 22% 29% 25%
almonds  7% 13% 18% 17&

Fish

fish carbs only (0%) FII (56%) thermic (77%) % insulinogenic (max)
Tuna 0% 32% 44% 44%
Mackerel 0% 33% 46% 25%
Herring 0% 19% 26% 25%
Salmon 0% 24% 33% 34%
Sardine 0% 26% 36% 36%
Anchovy 0% 31% 42% 42%
Swordfish 0% 31% 42% 42%
Trout 0% 31% 44% 43%
Carp 0% 32% 43% 43%
Yellowtail 0% 36% 49% 49%
Bass 0% 37% 51% 51%
Mullet 0% 37% 51% 51%
Squid 18% 41% 49% 51%
Abalone 23% 47% 55% 57%
Monkfish 0% 44% 59% 60%
Halibut 0% 47% 24% 61%
Mussel 17% 49% 60% 62%
Oyster 21% 46% 56% 63%
Crab 0% 48% 66% 65%
Shrimp 5% 48% 64% 65%
Hadock 0% 51% 68% 66%
Perch 0% 49% 65% 67%
Clam 14% 56% 67% 71%
Scallop 19% 59% 76% 80%

Meat

meat carbs only (0%) FII (56%) thermic (77%) % insulinogenic (max)
Bologna 6% 12% 17% 14%
Frankfurter 2% 11% 14% 14%
Duck 0% 14% 17% 17%
Chorizo 2% 15% 18% 17%
Beef, ribeye 0% 15% 26% 21%
Bacon 1% 15% 21% 21%
Pork, ham 6% 17% 38% 22%
Pork, blade, hocks & shoulder 31% 23% 42% 31%
Turkey 0% 23% 29% 32%
Lamb mince 0% 24% 27% 34%
Chicken 0% 24% 34% 34%

post last updated May 2017

references

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

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

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

[4] https://books.google.com.au/books?id=SqzMBQAAQBAJ&pg=PA245&dq=Krebs+1964+The+metabolic+fate+of+amino+acids.&source=gbs_toc_r&cad=4#v=onepage&q&f=false

[5] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC292907/pdf/jcinvest00272-0077.pdf – Cahill references a 1964 paper by Krebs in this paper but I can’t find the original paper.

[6] http://en.wikipedia.org/wiki/Specific_dynamic_action

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

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

[9] http://en.wikipedia.org/wiki/Ketogenic_amino_acid

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

[11] http://www.medschool.lsuhsc.edu/biochemistry/Courses/Biochemistry201/Desai/Amino%20Acid%20Metabolism%20I%2010-14-08.pdf

[12] http://en.wikipedia.org/wiki/Gluconeogenesis

[13] http://zerocarbzen.com/2015/03/09/zero-carb-interview-the-andersen-family/

what is a ‘well formulated ketogenic diet’?

While everyone uses fat for fuel to some degree, a ketogenic diet aims to reduce insulin levels to a point where ketone levels are high enough to be measured in the blood, breath or urine. [1]

In starvation, insulin levels plummet with glucose levels coming down and ketone levels increase progressively.

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According to Dr Steve Phinney’s chart below, a “well formulated ketogenic diet” contains between 3 and 20% carbohydrates and between 10 and 30% protein.

image016

Other dietary templates such as the Mediterranean or Paleo diets typically contain more carbohydrates and less fat.

The concern typically expressed about restricted carbohydrate diets is that they will not provide adequate nutrition (i.e. vitamins, minerals and amino acids).

Diabetics, along with the general population, are advised to eat in line with the USDA Food Pyramid / My Plate guidelines which emphasise “healthy whole grains” while discouraging saturated fat and cholesterol.

Diabetics are told that they should not deprive themselves of any foods or not to risk getting inadequate nutrition, but rather to “cover” any carbohydrates they eat with insulin (or treat with medications such as Metformin for type 2 diabetics).

Even in health circles ketosis is sometimes considered to be extreme and not worth the effort for most people, but is it really that hard to achieve?

When we look at the relationship between ketones, blood sugar and HbA1c we see that someone with excellent blood glucose levels will have a moderate amount of blood ketones.

The chart and table below are based on my tracking of blood sugars and ketone values.  Optimal blood (i.e. 4.6mmol/L) glucose corresponds to a ketone value of about 1.3mmol/L.

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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 > 0.4
good < 5.4 < 6.0 < 108 < 0.3
danger > 6.5 > 7.8 > 140 < 0.3

In view of this it’s hard to see why ketosis is extreme.  It’s just what happens when someone has reduced their dietary insulin load to a point where they are achieving excellent blood sugars!

Ketosis is a sliding scale.  Some people will want to push their ketone levels to therapeutic levels though fasting and a higher fat diet, but this may not be necessary for general health.

Most people would benefit from reducing their dietary insulin load to a point where their blood sugars are close to excellent.

See Diabetes 102 for more info on what your blood sugars should be and the Goldilocks Glucose Zone for more thoughts on how to manipulate your diet to get excellent blood glucose levels.

I am a big fan of Steve Phinney (I attended a masterclass with him when he was in Brisbane last year), but I think he potentially alienates people when he starts off talking about the Inuit and Steffanson living off all meat diets.

I also understand why the people generally might baulk at the idea of mainlining butter and MCT oil to drive up ketones.  “How can eating all that extra fat really be healthy?” they ask.

I propose an alternative sales pitch for ketosis:

  1. ketosis occurs when your blood sugars are close to optimal,
  2. blood sugars can be optimised by reducing the insulin load of your diet, and
  3. once you optimise your blood sugars you will reduce your hunger, access your body fat for fuel and a whole host of other health markers will improve.

What’s not to like?

What do you think?

[this post is part of the insulin index series]

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

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

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

why we get fat and what to do about it v2

  • Although protein does not raise blood sugars as much as carbohydrate, it still requires insulin.
  • Dietary fat does not raise your blood glucose and is not insulinogenic.
  • Optimal nutrition is about maximising micronutrients while managing your glucose load so your pancreas can keep up.
  • In addition to managing carbohydrates, moderating protein, increasing fibre and maximising nutrition, are important to optimise body fat and normalise blood glucose.

background

Gary Taubes [1] has moved the needle in terms of the wider acceptance of the hormonal theory of obesity with his books Good Calories Bad Calories and Why We Get Fat and What to Do About It. 

The hormonal theory of obesity revolves around the idea that the food we eat affects our insulin levels which in turn governs how much fat is stored or used for fuel. [2] [3]

image001

With his focus primarily on carbohydrate, Taubes has not directly address the fact that protein also requires insulin, stating:

“the assumption has always been that the effect of protein has is small compared to that of carbohydrates, and that it is muted because protein takes considerably longer to digest.” [4]

This may be true to an extent, but could a better understanding of the insulinogenic effect of protein help us further refine the hormonal theory of obesity and our ability to improve blood glucose control, particularly for those who are not able to achieve their goals by simply reducing carbohydrates?

Recently people such as Steve Phinney [5] and Jimmy Moore [6] have brought increased attention to the ketogenic diet which takes the low carbohydrate dietary approach to the next level.  One of the observations from those measuring blood ketones and trying to achieve nutritional ketosis is that, in addition to limiting carbohydrates, protein needs to be moderated in order to register meaningful blood ketone levels.  Too much protein raises insulin and reduces fat burning.

So, using Gary Taubes analogy [7], what does the food insulin index data [8] tell us that would help us ‘push the rock a bit further up the hill’?

do calories count?

The antagonists to the hormonal theory of obesity point to numerous studies that show that if you put people in a metabolic ward and feed them a set number of calories and make them exercise the same amount they will lose or gain roughly the same amount of weight regardless of the macronutrient composition of the diet. [9]

This may be largely true, other than some exceptions as discussed below.  However in the real world most people eat when they are hungry and stop when full.  Most people do not count every morsel that goes into their mouth.

It should not be necessary to consciously control our appetite.  As the Paleo community point out, somehow we seemed to have done pretty well regulating our own appetite before recent times.  Something seems to have changed for the worse. [10]

image002

Most low carbohydrate diet studies allow the low carbohydrate group to eat to satiety while the low fat group has to count calories so they do not exceed their target intake.  Even under these conditions though, the low carbohydrate typically usually wins out. [11] [12]

image003

Isn’t finding a way of eating that will make us satisfied with fewer calories the dietary Holy Grail?  When a ‘diet’ becomes enjoyable and self-regulating it is no longer a ‘diet’, it’s just a way of eating!

So what is it about higher fat dietary approaches that leave people naturally satisfied on fewer calories?

what does insulin do?

The hormone insulin is a tangible reality in our family.  We have vials of it sitting in the fridge!

My wife has had type 1 diabetes for nearly three decades and wears a pump to deliver insulin through the day with extra doses at meals.

Helping her to refine her insulin doses has become a regular pastime for me, especially through our two pregnancies to try to give our kids the best chance of success.

I think it is helpful to look at diabetics to see what happens when we have too much or too little insulin.

Type 1 diabetics, before they start on insulin, are typically wasting away because their pancreas has stopped making enough insulin. Extremely low levels of insulin cause them to use body fat and muscle for fuel to a point where they waste away.

At the other extreme, diabetics often find that they gain weight quickly when they start injecting insulin.  Insulin is an anabolic hormone that regulates how we grow muscle and store fat.

The picture below shows “JL” one of the first type 1 diabetics to receive insulin in 1922.  The photo on the left is after diagnosis but before insulin.  The photo on the right is the same child two months after starting insulin injections.

image004

Check out this post to see photos of my kids when they were born after spending nine months in a high insulin environment.  It’s hard to argue that they were born big due to gluttony and sloth in utero!

I found this explanation from Robert Lustig helpful to understand how insulin affects our appetite, energy levels and fat storage.

If we are consuming highly insulinogenic meals a little bit extra energy gets stored away each time we eat.  Unfortunately this extra food does not help us feel full or provide more energy, it just gets stored as fat and we just have to eat more at the next meal.  If we also try to restrict calories to lose weight we feel sluggish and have low energy and our metabolism down-regulates to compensate!

This chart from Richard Feinman’s The World Turned Upside Down illustrates the process of cumulative fat storage in a high insulin environment.

image005

The Atkins approach recommends that you reduce your carbohydrates to less than 20g per day during the two week ‘induction phase’ and then allows you to wind them back up slowly to the point that you stop losing weight. [13]

With Atkins however there is no consideration of the insulinogenic effect of protein.  Unlimited fat and protein are allowed as long as you are limiting carbohydrates.  The problem is if you just increase protein and still fear fat you may not get enough reduction in insulin to allow your body to properly access fat for fuel.

Richard Feinman uses the analogy that insulin is like a tap that controls fat storage.  Without high levels of insulin we can not store as much fat, and thus we have more calories available for energy and therefore do not feel the need to eat as much.

Conversely, if we eat meals that generate less insulin we will be more likely to be able to access our body fat stores for fuel (i.e. ketosis).

This net flow of energy from (rather than into) our fat cells leaves us a little less hungry at each meal because we are getting calories from our fat stores, and hence we are less like likely to overeat without consciously trying.

meal timing

In the past, the nutritional community has looked to the ‘healthy’ body building community as the model to follow.  Bodybuilders often eat five or six meals a day to make sure they gain muscle and ‘keep their metabolism high’.  Food manufacturers have been only too willing to design foods for every occasion, with a burgeoning protein and supplement industry.

The problem is, unless you’re a body builder aiming for ‘mad gainz’, working out intensely, meticulously planning your meals and tracking every calorie, increased meal frequency  is probably not going to end well for you.

The figure below demonstrates how obese people generally have elevated insulin levels throughout the day.  By contrast, lean people tend to have more punctuated bursts of insulin, with the bursts balanced by  with periods of lower circulating insulin when the body is able to access stored body fat for fuel.

image006

Like me with my caffeine addiction, constant use of anything will lead to tolerance and insensitivity. [14]  Many find they become insulin resistant due to a diet of fsat digesting highly processed carbohydrate based foods.

One option that has become more popular in recent times is the concept of intermittent fasting. [15]  [16] [17] Going for period without food (or at least carbohydrates) enables your body to decrease insulin levels and allows it to access body fat for fuel.

The increased use of body fat for fuel during the fasting period typically results in a reduction of total food intake across the day.

Some people who have tried low carbohydrate diets with limited success find that intermittent fasting is what allows them to achieve the improved blood glucose and / or weight loss they are after.

I know for me it was intermittent fasting that helped me to improve my blood sugars, raise ketone levels and kick-start fat loss that I had been striving for but not achieving, even on a low carbohydrate Paleo approach.

when a calorie is not a calorie

You may be aware that gluconeogenesis is the process where the body can produce glucose from protein.  I only realised recently that protein is made up of glucogenic amino acids (approx. 78%), ketogenic amino acids (approx. 12%) and amino acids that can be either glucogenic or ketogenic (approx. 14%). [18]

Digestion breaks protein down into amino acids which circulate in our bloodstream until they are required for muscle growth and repair (i.e. protein synthesis) or to balance blood sugars (i.e. via gluconeogenesis).

When we do not eat protein or carbohydrate for a long period the body can obtain glucose from muscle via gluconeogenesis.  This is how we can survive long periods of starvation and still supply adequate glucose to the brain.

“In fasting and on a low carbohydrate diet as much of the amino acid carbon as possible will be used for gluconeogenesis.” [19]

For someone on a low carbohydrate diet this means that nearly 90% of protein not used for muscle growth and repair can be converted to glucose!

The fact that protein can turn to glucose just like carbohydrate at first sounds absurd, then scary.  However it is possible to use the glucogenic properties of protein as a ‘hack’ to help you achieve weight loss and / or normal blood glucose levels.

The first benefit is that glucose from protein is accessed as required from the amino acids circulating in the blood stream rather than raising blood sugar immediately, as is typically the case for carbohydrate, particularly if our liver and muscle glycogen is already full.

The second benefit is that it takes extra energy to convert protein to glucose before it can be used for energy.  This is sometimes known as the ‘thermic effect of food’. [20]

You are likely aware that one gram of carbohydrate will digest into on gram of glucose that will provide four calories to be used by the body for energy.  If you burn one gram of protein in a calorimeter you’ll get four calories of heat.

However to convert one gram of protein to glucose takes approximately one calorie, so you only get three calories for energy or body fat storage.  [21]  Viola!  A calorie is not a calorie when it comes to protein being converted to glucose via gluconeogenesis.

Sam Feltham did an interesting n=1 experiment where he compared the effect of 21 days of excess calories on a high carb diet versus the same number of calories on a LCHF approach.  The results are summarised in this chart.  The weight gain on the LCHF approach was minimal, with waist measurements coming down.  However on the high carbohydrate approach the weight gain was basically as per the calories in calories out formula.  Interestingly, the vegan approach was only slightly better than the high carbohydrate approach.

Day21Results

fat and insulin

When it comes to insulin demand and fat storage, dietary fat is unique.

The major theme that reappears throughout Richard Feinman’s The World Turned Upside down is that

“carbohydrate and protein can be turned to fat but, while glucose can be made from protein, with a few exceptions, you can not make glucose from fat.”

Excess glucose from carbohydrate and protein enters our blood stream and is removed, with the help of insulin, to be stored as fat (i.e. lipogenesis).

The chart below shows that the body secretes less insulin in response to higher fat foods. [22]

image007

If you turn things around to look at insulin demand in terms of non-fat calories (i.e. carbohydrates plus protein) we see that there is effectively no insulin response to fat!

image008

What this means is that the low fat foods we have all been eating to avoid getting fat and getting heart disease are the number one way to increase insulin, which facilitates fat storage as well as increasing insulin resistance which is the primary thing that drives heart disease! [23] [24]

If we eat fewer calories overall the body will use our body fat for energy, but only if insulin levels are low enough to allow the fat to be released for fuel.

If we are trying to lose weight the highest priority is to reduce the insulin load of our diet.  We can then eat fat to satiety while maximising nutrition.

can you eat too much fat?

So can eating too much fat make you fat?  Yes and no.

If we eat a high fat diet that is also high in carbohydrates and protein we will have high insulin levels and most likely a calorie excess.  This will lead us to store the glucose from the carbohydrates and protein as fat. [25]

However if our diet is low in carbohydrate and moderate in protein such that our insulin levels are reduced, we will be able to access our body fat for fuel, and therefore be less hungry.

In the absence of significant amounts of insulin we typically do not overeat fat.  A low carbohydrate, moderate protein, high fat diet will typically lead to reduced hunger, reduced calorie intake and typically lead to weight loss.

If you are struggling to drop weight on a high fat diet, then a period of intermittent fasting and/or tracking your food in a food diary (e.g. MyFitnessPal or Cronometre) might help establish your target macronutrient ratios and avoid overdoing the calories.  After this period of ‘retraining’ you should ideally be able to just eat when you’re hungry and stop when you are full.

The figure below shows the macronutrient ratio of four phases of a ketogenic diet according to Steve Phinney. [26]   Note how in the early phases of the ketogenic approach the dietary fat percentage does not necessarily have to be high.  Carbohydrates are low enough to reduce insulin levels to the point that body fat can be used for fuel.

image009

Once the desired weight loss is achieved carbohydrate levels can come up a little with fat increasing significantly to supply adequate calories for weight maintenance.

carbohydrate

The food insulin index data below shows us that carbohydrates are the primary macronutrient that generates insulin. [27]

image010

Carbohydrate is typically the body’s primary source of glucose.  We need some glucose for the brain to function (about 40g to 160 calories per day minimum), however the body can obtain this from protein via glycogenesis if there is no carbohydrate available.

You may have heard that the body has no need for carbohydrates and that there is no such thing as an essential carbohydrate.  This is true, however you should keep in mind that many important vitamins come packaged with carbohydrates (e.g. vegetables).

The optimal approach is to obtain high levels of nutrients while avoiding excessive insulin and normalising blood sugar.   We can do this by selecting high nutrient density, low insulin, and high fibre vegetables such as those contained in the food lists here.

fibre

While the low carbohydrate diet crowd tend to prioritise avoidance of carbohydrate-containing foods to improve blood glucose levels and achieve weight loss, many people also do well using a high fibre high vegetable approach. [28]

Most agree that eating lots of vegetables is a good idea.  As discussed in this article there is a strong basis for a low calorie density, high nutrient density diet for weight loss and health.

The insulin index data also supports this approach.  As detailed this article, the insulin demand of foods is better predicted by net carbohydrates (i.e. total carbohydrates minus indigestible fibre) than by only considering carbohydrates.

The insulin index data also supports this approach.  As detailed in this article, the insulin demand of foods is better predicted by net carbohydrates (i.e. total carbohydrates minus indigestible fibre) than by only considering carbohydrates.

Indigestible fibre effectively neutralises the insulinogenic effect of carbohydrates. Fibre also adds to the bulk of our food which helps with satiety and also feeds our gut bacteria, which is highly beneficial. [29]  [30]

Rather than taking fibre supplements, the ideal approach is to select high fibre foods that also have a low insulin load.  Some examples of these are spinach, mushroom, broccoli, and Brussels sprouts.  More options are detailed in these optimal food lists.

High fibre foods also often have a high nutrient density and a low calorie density.   By eating this type of food we ensure we are getting excellent nutrition, tend to be satisfied on fewer calories and also keep our insulin load down.

We are now learning the importance of fibre for our gut bacteria which influences the rest of our health.  Reducing the sugar and process carbohydrates will help to avoid manage any overgrowth in ‘bad bacteria’.

People who do not have blood sugar issues may do well on things like sweet potato, rice, lentils and tomatoes (these foods are included in this list of foods for the metabolically healthy).  However if you’re struggling to control your blood sugars you should be mindful that these foods will add to your insulin load and should be minimised (these lists of optimal foods for weight loss or optimal foods diabetes and nutritional ketosis are more ideal if you are struggling with high blood glucose levels).

In summary, maximising fibre is another tool that we can use, in addition to minimising carbohydrates, moderating protein and eating fat to satiety, to manage blood sugars and obesity.

protein

High protein foods do not generate a sharp rise in blood sugar compared to high carbohydrate foods because the digested amino acids circulate in the blood for use as required to raise blood sugar, rather than directly spilling into the blood stream in the same way that simple carbohydrates would raise your blood sugar if your glycogen stores were already full.

image011

Protein is also satiating and typically leads to a reduction in overall calories.  Your body will continue to search out food until it obtains adequate protein.  Once you obtain adequate protein you will be more likely to stop eating. [31]

Protein also contains a range of essential and non-essential amino acids that are required for muscle growth and repair as well as mental function.  Maximising the amount and variety of amino acids that come from our diet is the ideal approach rather than trying to supplement.

As noted above, increasing your protein intake is a possible ‘hack’ for diabetics to obtain glucose without spiking blood sugars.

Diabetics and ‘low carbers’ will often limit carbohydrates but compensate by increasing protein.  This is generally not a problem because protein is slower to digest than carbohydrate and hence the blood sugar rise from protein is slower and more manageable in comparison to carbs.  The body also releases glucagon to offset the protein used in protein synthesis which also helps to stabilise blood sugars.

However, just because protein does not spike blood sugars as aggressively as carbohydrate does not mean that it does not require insulin.    The food insulin index data indicates that while the blood sugar response is less than carbohydrates, the insulin demand of protein is still significant.

image012

According to Nuttall and Gannon between 32 and 46g of high quality dietary protein is required to maintain protein balance.  This represents around 6 to 7% of the calories in a 2000 to 2500 calorie diet being taken off the top for growth and maintenance.  Protein in excess of this level is available for gluconeogenesis.

This should not be taken to mean that extremely low amounts of protein are optimal for health or obtaining glucose from protein via gluconeogenesis is necessarily bad thing.   As noted in Phinney’s WFKD below protein levels can range between 10% and 30% while still being ketogenic.  The optimal approach revolves around maximising the amount of amino acids from protein and vitamins and minerals from generally carbohydrate based foods while at the same time keeping the glucose load low enough for your pancreas to keep up to optimise your blood sugars.

Ingested protein not used for growth and repair of the body does not magically disappear.  A small amount (approx. 12%) will be converted to ketones and used as it if were fat.  About 14% can be used either as glucose or fat.  But around 80% of protein can only be used as glucose.

This glucogenic protein in excess of the body’s requirements will also require insulin to be used for energy in the mitochondria or to be stored in the fat cells.

High levels of protein will generate insulin which will reduce fat metabolism (i.e. lower levels of ketones).  If your pancreas is struggling to supply enough insulin to maintain blood sugars then the insulin load from protein will make it harder for your pancreas to keep up and achieve optimal blood sugars.

If you are trying to lose weight then excess insulin (over and above the amount used for protein synthesis that receives glycogen) will also promote fat storage.

nutrient hunger

Similar to the concept of protein hunger, if you are not giving your body the vitamins and minerals it needs it will keep on seeking out more food.

In his Perfect Health Diet, Paul Jaminet notes that

“a nourishing, balanced diet that provides all the required nutrients in the right proportions is the key to eliminating hunger and minimising appetite and eliminating hunger at minimal caloric intake.”

It makes sense that eating a nutrient dense diet would help our body to heal and recover from anything else that might be causing insulin resistance and obesity.

Many people talk about the benefits of various supplements for different ailments and performance enhancement, but surely the best approach is to maximise the quality and range of nutrition from the food you eat every day before investing in supplements?

liver storage and insulin sensitivity

A healthy insulin sensitive person will store glucose in their liver as glycogen with minimal rise in blood sugars after eating, regardless of the macronutrients.

A person with type 2 diabetes however will often spill excess glucose into the blood stream which will cause the blood glucose levels to rise and thus additional insulin will be necessary to clear excess glucose from the blood.  Excess protein not used for protein synthesis will contribute to refilling the glucose stores in the liver and muscles. [32]

It makes sense in this situation that you would want to limit the insulin load (i.e. carbs and excess protein) to starve the liver (or ‘dry up the root’ to quote Bob Briggs) such that it is not over full in order to reduce spilling of excess glucose into the blood.

practical application

Steve Phinney is probably the most well respected authority on the ketogenic diet.  His ‘well formulated ketogenic diet’ versus other dietary approaches shown in the chart below is quite useful.

image007

You will notice that the WFKD space is a triangle indicating that you need to balance your carbohydrates and protein levels in order to manage your insulin load and achieve nutritional ketosis.

You can have 30% protein and 5% carbs, or 20% carbs and 10% protein and still be within the bounds of the WFKD triangle.

However if you run with 30% protein and 20% carbs you will be well outside the realms of a ketogenic diet because you will be producing too much insulin, meaning that you will be ‘kicked out of ketosis’ (i.e. your fat burning will be slowed).

Understanding your insulin load may be the difference between achieving your desired goals from a low carbohydrate diet and not quite getting there.

For a more detailed discussion of how to tweak your glucose load to achieve your goals check out the article the Goldilocks glucose zone.

summary

  • Although protein does not raise blood sugars as much as carbohydrate, it still requires insulin.
  • Dietary fat does not raise your blood glucose and is not insulinogenic.
  • Optimal nutrition is about maximising micronutrients while managing your glucose load so your pancreas can keep up.
  • In addition to managing carbohydrates, moderating protein, increasing fibre and maximising nutrition, are important to optimise body fat and normalise blood glucose.

[1] http://garytaubes.com/

[2] https://intensivedietarymanagement.com/tag/hormonal-obesity-theory/

[3] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC329588/pdf/jcinvest00481-0161.pdf

[4] http://www.healthcentral.com/diabetes/c/36758/20088/gary-round-3/

[5] http://www.amazon.com/Keto-Clarity-Definitive-Benefits-Low-Carb/dp/1628600071

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

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

[8] https://www.bulletproofexec.com/gary-taubes-bad-science-gut-health-nusi-223/

[9] https://www.youtube.com/watch?v=aRCv5RWXWx8

[10] http://nchstats.com/2010/01/14/obesity-americans-still-growing-but-not-as-fast/

[11] http://www.sciencedirect.com/science/article/pii/S0899900714003323

[12] http://jama.jamanetwork.com/article.aspx?articleid=205916

[13] http://www.atkins.com/how-it-works/atkins-20/phase-1

[14] My 23andMe genetic testing tells me that I am likely to be able to metabolise caffeine quickly however I am prone to type 2 diabetes and obesity!

[15] https://intensivedietarymanagement.com/category/fasting/

[16] http://www.eatstopeat.com/

[17] http://thefastdiet.co.uk/

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

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

[20] http://en.wikipedia.org/wiki/Specific_dynamic_action

[21] If you want to dive into the detail on this I recommend you check out Chapter 14 of Richard Feinman’s The World Turned Upside Down.

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

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

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

[25] http://www.sciencedirect.com/science/article/pii/S0026049514001115

[26] https://www.youtube.com/watch?v=8NvFyGGXYiI&index=1&list=PLrVWtWmYRR2BlAsGG9tr6T-B4xSum8SCc

[27] Data from http://ses.library.usyd.edu.au/handle/2123/11945

[28] http://www.mangomannutrition.com/

[29] http://www.drperlmutter.com/health-depends-gut-bacteria/

[30] http://www.drperlmutter.com/tag/type-2-diabetes/

[31] http://jn.nutrition.org/content/137/6/1478.full

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

the Goldilocks glucose zone

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

background

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

the Goldilocks glucose zone

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

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

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

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

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

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

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

Not too hot.  Not too cold.

Not too hard.  Not too soft.

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

the safe starches debate

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

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

the case for limiting carbohydrates

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

1. Non-fibre carbohydrates are:

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

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

natural glucose utilisation level

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

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

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

image001

some perspective

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

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

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

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

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

minimum carbohydrate requirement

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

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

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

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

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

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

image005

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

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

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

what is the minimum protein requirement?

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

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

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

three macros or two fuel sources?

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

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

  glycogenic ketogenic both
non-essential Alanine

Arginine

Asparagine

Aspartate

Cysteine

Glutamate

Glutamine

Glycine

Proline

Serine

Tyrosine
essential Histidine

Methionine

Valine

Leucine

Lysine

Isoleucine

Phenylalanine

Tryptophan

Threonine

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

the “well formulated ketogenic diet”

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

image007

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

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

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

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

the Goldilocks glucose zone

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

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

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

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

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

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

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

what about the Kitavans?

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

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

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

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

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

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

comparison of dietary approaches

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

image011

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

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

image014

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

what is our light on the horizon?

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

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

image016

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

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

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

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

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

what gauges do we use to steer the boat?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[18] http://thenoakesfoundation.org

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

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

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

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

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

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

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

how much insulin is required to cover protein?

Given that protein appears to contribute to insulin demand I ran a number of scenarios with the food insulin index data to see if insulin requirement is better predicted by carbohydrate in a food plus some proportion of the protein.

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The analysis indicates that insulin demand is related to carbohydrate about 60% of the protein.

There’s not a lot of information on the split between glucogenic amino acids and ketogenic amino acids out there, however it seems that only leucine and lysine are exclusively ketogenic and cannot be converted into sugar, while isolucine, threonine, phenylaline, tyrosine and tryptophan are both ketogenic and glucgoenic.  The remaining thirteen of the twenty one amino acids are exclusively glucogenic, meaning that they can be converted to sugar.

The proportion of protein that can turn to glucose relates to the amount of excess protein to the body’s needs, so it will be affected by a number of factors including a person’s activity levels, how much protein and carbohydrates they eat.

The correlation of food insulin index with carbohydrate about half the protein is better than carbohydrate alone (R2 = 0.435 compared to R2 = 0.461) and we no longer have the issue of high protein foods sitting on the vertical axis as shown below.

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Accounting for protein in addition to carbohydrate seems to better predict insulin demand.

So in summary, while protein doesn’t spike blood sugar as much as carbohydrates, protein does still require a significant amount of insulin.  People not achieving the desired results from carbohydrate restriction alone may benefit from moderating their protein intake.

[next article…  fibre… net carbs or total carbs?]

[this post is part of the insulin index series]

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

the top 100 most ketogenic diet foods

Ketosis occurs when our insulin levels drop and and our body switches to fat for fuel.

Managing our insulin response to the food we eat is critical to ensuring that we are able to burn fat.

The food insulin index data indicates that our insulin response to food is best predicted, not just by carbohydrate, but also the protein and fibre content of our food.

This improved understanding can help us prioritise foods with a lower insulin load that will help us improve our blood glucose control.

But before we get to the list of the most ketogenic foods, let’s look at the research and the theory that enables us to identify foods that will cause the least insulin response.

food insulin index

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 different foods to non-diabetic participants and measuring their insulin response over three hours.   This was then compared to the insulin response of pure glucose (which is assigned a value of 100%) to arrive at a “food insulin index” value for each food.

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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 due to the fact that only a small small number of foods been tested.

more food insulin index data

Digging a bit further I came across a recent PhD thesis from the University Of Sydney titled Clinical Application of the Food Insulin Index to Diabetes Mellitus (Kirstine Bell, September 2014) which contained a more extensive list of foods that had been tested since the original study.

With this additional data perhaps we can make more sense of the various factors that affect insulin, the master regulating hormone of our metabolism?

In the chart below I have plotted the carbohydrates versus the insulin response of foods for more than one hundred foods.  Although insulin is loosely correlated with the carbohydrate content of our food, we can see that high protein foods such as steak, tuna and fish still require a significant amount of insulin.

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I ran some analysis on the data and found that we secrete about half as much insulin in response to protein compared to carbohydrate.  And we get the best correlation when we assume that indigestible fibre does not raise insulin.  Interestingly, fructose only requires about a quarter of the insulin as carbohydrate.

Once we account for protein and fibre we get a much better prediction of the insulin response to food compared carbohydrate alone.  People wanting to follow a low carb or ketogenic diet will want to eat foods that lie towards the bottom left of this chart.

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[Check out this cool interactive visualisation of all the FII test data here.]

Using this understanding we can calculate insulin load of our food using the following formula:

insulin load = total carbohydrate – fibre + 0.56 x protein – 0.725 x fructose

We can also calculate the proportion of the energy in our food that requires insulin to metabolise (i.e. “the percentage of insulinogenic calories”).

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If you have the macronutrient details of food or a meal you can calculate the percentage  of insulinogenic calories using this calculator created by Dr Ted Naiman.

possible applications

Insulin is not bad at normal levels, but we are understanding more and more that excess insulin (e.g. hyperinsulinemia, insulin resistance, Type 2 diabetes) is highly problematic, perhaps as much or more than high blood glucose levels.

Understanding how to calculate our insulin response to food could enable us to better manage our diet to avoid elevated blood glucose and hyperinsulinemia.

The biggest challenge for someone with Type 1 Diabetes (like my wife) occurs when you require a large dose of insulin to address a high blood glucose level that is caused by eating non-fibre carbohydrates and large amounts of protein.  It’s much easier to manage your blood glucose levels when the insulin load of your diet is lower (i.e. less non-fibre carbohydrates and moderate protein).

A more accurate understanding of insulin load can also help people with diabetes more accurately calculate their insulin dose or people trying to manage conditions like cancer or epilepsy through a therapeutic ketogenic diet.

For the rest of us who are somewhere on the insulin resistance scale, being able to calculate the insulin load of our diet will enable us to enable our pancreas to keep with our diet and maintain normal blood glucose levels.

the most ketogenic foods

Listed below are the most ketogenic foods.  I have included a number of other parameters that may be of interest:

  • energy density – foods that contain high levels of fibre and water have a low energy density (i.e. calories per 100g) and will tend to make us full with fewer calories.
  • percentage of insulinogenic calories – this is the proportion of the energy in the food that will require insulin to metabolise.
  • insulin load – foods such as non-starchy vegetables have a higher proportion of insulinogenic calories, but because of their low energy density will have a very low insulin load per 100g of food, meaning that you will need to eat a lot of that particular food for it to affect your blood glucose or insulin significantly.
  • net carbohydrates – these are the digestible carbohydrates that will affect your blood glucose levels and insulin that remain after you account for the indigestible fibre.

The amount you need to prioritise each of these parameters depends on a range of considerations including your blood glucose control and your weight loss goals.   Along with the insulin response to different foods, nutrient density and energy density are other important parameters we can use to optimise our food choices.

2016-07-06 (11)

The chart below shows the nutrients provided by the most ketogenic foods in comparison to the USDA foods database.  We can see that there are quite a number of nutrients that are less available in the most ketogenic foods compared to the average of the foods that commonly available.   While it is valuable to manage the insulin load of our diet it is also important to maximise the nutrient density of our diet as much as we can while still maintaining excellent blood glucose levels.

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different 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 add to your list for your next shopping expedition.

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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I have sorted the foods below by insulin load which will be useful if you are looking for foods to help you manage the insulin load of your diet.  If you’re interested, the most ketogenic foods article has these foods sorted by their proportion of insulinogenic calories.

Focusing on foods with a low percentage of insulinogenic calories will be useful if you are aiming for a high fat therapeutic ketogenic diet.  Focusing on foods with a low insulin load may be more useful if you want to lose weight and use some of your body fat for fuel.

the most ketogenic diet foods

eggs

Eggs are a staple for low carbers, ketogenic dieters and diabetics.  Not only are they nutritious they are also low in carbohydrates.

 Fried-Egg-Wallpaper-5

food % insulinogenic insulin load (g/100g) calories/100g
egg yolk 18% 12 275
whole egg 30% 10 143
egg white 74% 9 52

The egg white is higher in protein and hence more insulinogenic.  At the same time the energy density (calories/100g) of the egg white is lower and hence the insulin load per 100g for the egg white is lower.

dairy

Some people believe that red meat and dairy are uniquely insulinogenic, however my reading of the food insulin index data is that there is nothing special about these foods that isn’t explained by their carbohydrate, protein and fibre content.

Dairy foods typically have a high energy density.  This is great if you’re a growing baby, an athlete trying to replenish energy or a bodybuilder trying to spike insulin for hypertrophy.  High palatability and high energy density are not a good combination if you’re trying to lose weight.

cheese

food % insulinogenic net carbs/100g insulin load  (g/100g) calories/100g
cream cheese 10% 4 8 348
cottage cheese 38% 3 9 93
ricotta cheese 25% 3 11 174
feta cheese 22% 4 14 265
Limburger cheese 18% 0 15 327
Camembert cheese 20% 0 15 299
brie cheese 19% 0 16 334
Muenster cheese 20% 1 18 368
blue cheese 20% 2 18 354
mozzarella 23% 2 18 318
Monterey 20% 1 19 373
cheddar cheese 20% 1 20 403
Colby 20% 3 20 394
Edam cheese 22% 1 20 356
Gouda cheese 23% 2 20 356
provolone 24% 2 21 350
Gruyère cheese 21% 0 22 412
goat cheese 22% 2 25 451
Swiss cheese 26% 5 25 379
parmesan cheese 30% 3 31 411

milk and cream

Milk has a higher proportion of insulin calories compared to cheese.  Butter and cream have a lower insulin load and proportion of insulinogenic calories.

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food % insulinogenic net carbs/100g insulin load  (g/100g) calories/100g
butter 0% 0 1 734
cream 5% 4 5 431
goat milk 40% 4 7 69
full cream milk 44% 5 7 65
low fat milk 58% 5 7 50
human milk 43% 7 8 71
reduced fat milk 59% 5 8 51

yoghurt

Full fat plain Greek yoghurt has the lowest percentage of insulinogenic calories while the sweetened and low fat options are extremely insulinogenic.

greek-yogurt

food % insulinogenic net carbs/100g insulin load  (g/100g) calories/100g
Greek Yoghurt 27% 6 9 130
plain low fat yoghurt 69% 7 11 63
skim milk yoghurt 86% 8 12 55
low fat fruit yoghurt 93% 19 22 95

fruit

It’s interesting to note that there are only a handful of fruits with a low percentage of insulinogenic calories (i.e. olives and avocados).  However some fruits like oranges have a lower insulin load because of their low energy density and therefore may not spike your blood sugar as much as dates or raisins which have a high proportion of insulinogenic calories as well as a high insulin load.  If in doubt, get a blood glucose metre and compare how much your favourite foods raise your blood glucose levels.

spanish-olives

food % insulinogenic insulin load (g/100g) calories/100g
olives 3% 1 145
avocado 8% 3 160
blackberries 27% 3 43
raspberries 30% 4 52
strawberries 49% 4 32
apples 50% 7 52
gooseberries 52% 6 44
passionfruit 52% 14 97
apples 54% 7 48
pears 54% 7 50
boysenberries 54% 8 50
kiwifruit 55% 9 61
carambola 56% 5 31
blueberries 56% 9 57
blueberries 58% 14 88
watermelon 60% 5 30
jackfruit 61% 16 95
cherries 61% 9 50
mango 63% 11 60
pears 64% 7 42
cranberries 65% 8 46

vegetables

There aren’t many dietary approaches that don’t advise you to eat more vegetables.  It’s also hard to overeat non-starchy veggies because they have a very low calorie density and are high in fibre.  Again, due to the low energy density the net carbohydrates are low in a lot of the non-starchy veggies and hence won’t significant raise your blood glucose levels.

vegetable-03

food % insulinogenic insulin load (g/100g) calories/100g
alfalfa 19% 1 23
chicory greens 23% 2 23
endive 23% 1 17
escarole 24% 1 19
coriander 30% 2 23
beet greens 35% 2 22
banana pepper 36% 3 27
mustard greens 36% 3 27
collards 37% 4 33
jalapeno peppers 37% 3 27
sauerkraut 39% 2 19
pickles 39% 1 12
cucumber 39% 1 12
zucchini 40% 2 17
red peppers 40% 3 31
chayote 40% 3 24
edamame 41% 13 121
radishes 43% 2 16
turnip greens 44% 4 29
summer squash 45% 2 19
arugula 45% 3 25
carrots 47% 5 37
parsley 48% 5 36
chives 48% 4 30
spinach 49% 4 23
artichokes 49% 7 47
soybeans (sprouted) 49% 12 81
Brussel sprouts 50% 6 42
lettuce 50% 2 15
asparagus 50% 3 22
celery 50% 3 18
bamboo shoots 50% 2 11
okra 50% 3 22
cauliflower 50% 4 25
broccoli 50% 5 35
turnips 51% 3 21
chard 51% 3 19
celery flakes 53% 42 319
dandelion greens 54% 7 45
Chinese cabbage 54% 2 12
red cabbage 55% 5 29
portabella mushrooms 55% 5 29
rhubarb 55% 3 21
cabbage 55% 4 23
shiitake mushroom 58% 7 39
snap beans 58% 3 15
yeast extract spread 59% 27 185
kale 60% 5 28
bamboo shoots 60% 5 27
turnips 61% 4 22
carrots 61% 4 23
potatoes 64% 26 158

nuts and seeds

Most nuts and seeds have a low percentage of insulinogenic calories though they have a higher energy density are possible to overeat.

food % insulinogenic insulin load (g/100g) calories/100g
macadamia nuts 6% 12 718
pecans 6% 12 691
coconut cream 8% 7 330
coconut milk 8% 5 230
brazil nuts 9% 16 659
coconut meat 10% 9 354
sesame seeds 10% 17 631
hazelnuts 10% 17 629
pine nuts 11% 21 673
flax seed 11% 16 534
walnuts 13% 22 619
sunflower seeds 15% 22 546
almonds 15% 25 607
almond butter 16% 26 614
butternuts 17% 28 612
pumpkin seeds 19% 29 559
sesame butter 21% 33 586
pistachio nuts 22% 34 569
cashews 26% 40 580
coconut 34% 39 443
gingko nuts 52% 15 111
coconut water 66% 3 19

seafood

Seafood is a great source of essential fatty acids which are heard to find in plant based foods.

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food % insulinogenic insulin load (g/100g) calories/100g
mackerel 14% 10 305
cisco 29% 13 177
caviar 33% 23 264
herring 36% 19 217
sardine 37% 19 208
anchovy 44% 22 210
trout 45% 18 168
fish roe 47% 18 143
sturgeon 49% 16 135
salmon 52% 20 156
tuna 52% 23 184
flounder 57% 12 86
oyster 59% 14 102
perch 62% 14 96
rockfish 66% 17 109
whiting 66% 18 116
halibut 66% 17 111
crayfish 67% 13 82
shrimp 69% 19 119
pollock 69% 18 111
white fish 70% 18 108
orange roughy 70% 17 105
haddock 71% 19 116
cod 71% 48 290
octopus 71% 28 164
lobster 71% 15 89
crab 71% 14 83
clam 73% 25 142
scallop 77% 22 111

animal products

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food % insulinogenic insulin load (g/100g) calories/100g
bacon 11% 11 417
bologna 11% 9 310
sweetbread 12% 9 318
liver sausage 13% 10 331
pepperoni 13% 16 504
blood sausage 14% 13 379
kielbasa 15% 12 325
knackwurst 16% 12 307
liver pate 16% 13 319
bratwurst 16% 13 333
frankfurter 17% 12 290
chorizo 17% 19 455
pork ribs 18% 16 361
beef sausage 18% 15 332
duck 18% 15 337
salami 18% 17 378
meatballs 19% 14 286
lamb rib 19% 17 361
turkey bacon 19% 11 226
pork sausage 20% 16 325
headcheese 20% 8 157
turkey 20% 21 414
beef brains 22% 8 151
pork sausage 25% 13 217
bologna 26% 11 172
T-bone steak 26% 19 294
lamb brains 27% 10 154

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 micronutrient fingerprint to identify foods that will fill in your micronutrient 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.

2017-03-082

Post last updated: April 2017