In the previous article, Which Nutrients is YOUR Diet Missing?, we looked at the micronutrients that you might be lacking when following popular dietary strategies such as vegan, Paleo, keto, or zero carb.
As a follow-up, I thought it would be interesting to look at the effect on essential micronutrients if we define our dietary approach in terms of macronutrient extremes such as low carb, high fat, high protein, high carb, or low protein.
Humans tend to think in extreme terms. It’s easy to follow a binary approach to nutrition, but which, if any, of these are the most useful in terms of maximising the nutrition provided by our diet?
For most of my life, best practice nutrition has been defined by a fear of fat which spawned the low-fat processed food era.
And because protein is necessary for muscle growth, more must be better?
And then of course there is low carb, which has been popular since the appearance of the Atkins diet appeared in the early 1970s.
But then there are a good number of people who still define their diet as being high carb.
All of them seem to be similarly zealous about their all-or-nothing approach.
But are any of these macronutrient extreme approaches beneficial? And if so, which one leads us to the optimal selection of nutritious foods that will lead to health, happiness, optimal weight, and longevity?
why bother with nutrient density?
The premise of nutrient density is that we want to maximise the quantity of essential micronutrients that we need to support our bodily functions while not overdoing energy intake.
Micronutrient dense foods allow us to obtain adequate nutrition with fewer calories. Then, with our nutrients accounted for, higher micronutrient density might just lead to higher satiety levels, reduced appetite, reduced food intake and optimal body fat levels.
At the other extreme, if we consume fewer foods with a lower nutrient density, we will likely end up needing to consume more food to obtain the nutrients we need to survive and thrive. If our appetite drives us to keep on eating until we obtain the nutrients we need, we may end up having to consume too much energy and and end up storing unwanted energy as fat.
macronutrient comparison
In this post, we’ll look at the micronutrients provided by the highest-ranking foods when we sort the eight thousand foods in the USDA database by the most and least fat, protein, and carbs.
Approach
% protein
% fat
% net carbs
% fibre
high fat
14%
82%
3%
1%
low net carbs
33%
67%
0%
0%
most nutrient dense
49%
19%
20%
12%
high protein
77%
22%
1%
0%
least nutrient dense
7%
32%
59%
2%
low protein
1%
27%
68%
3%
low fat
8%
1%
84%
7%
high net carbs
3%
2%
92%
2%
This chart shows the macronutrient split for these extreme approaches.
fat
While low carb is still in the lead in terms of internet searches (as shown in the Google Trends data below), the ketogenic diet is becoming pretty popular these days.
The chart below shows the nutrients provided by 2000 calories of the fattiest foods. Nutrients are expressed in terms of the percentage of the daily recommended intake (DRI), for each nutrient, per 2000 calories (i.e. a typical daily intake).
While we achieve adequate amounts of about half of the essential micronutrients with a therapeutic ketogenic diet, we may need to consider supplementing some of the harder to obtain nutrients such as vitamin C[1], vitamin D, potassium, choline, vitamin K, and magnesium.
Looking at things from the other extreme, a low-fat diet will give you a ton of vitamin C, sodium, manganese, and iron. However, it will be harder to obtain adequate quantities of the twenty-one essential nutrients, particularly essential fatty acids.
saturated fat
These days, the US Dietary Guidelines have lifted their limit on fat and cholesterol but retained their limitation on saturated fat. Saturated fat and trans fats remain the two nutrients that we are advised to avoid.
The chart below shows the outcome when we avoid saturated fat. The top 10% of foods with the lowest saturated fat are lacking (i.e. < 100% DRI) in nineteen essential nutrients.
At the other extreme, foods with the most saturated fat are slightly better with seventeen essential micronutrients lacking.
As discussed in the ‘What about Saturated Fat?’ article, I think saturated fat is neither a concern nor a priority. Saturated fat a great clean-burning fuel, but there’s no need for us to make up for the last four decades of avoidance by suddenly binging on it.
The chart below shows a comparison of the nutrient density of the quartiles of saturated fat in terms of percentage of energy. It seems that the foods with moderate levels of saturated fat that are the most nutrient dense.
protein
Once you move past the fear of fat, the next hot topic is optimal protein levels.
The ‘high protein bros’ recommend more protein for muscle growth and satiety, while many in the low carb/keto community target lower protein levels for longevity and ketosis through minimising insulin and mTOR signalling.[2]
As shown in the chart below, when rank foods to minimise protein, we end up with only four essential nutrients meeting the recommended daily guidelines to prevent malnutrition.
At the other extreme, if we prioritise protein we end up with ten nutrients that we fall short of. The other twenty-six essential nutrients meet the minimum recommended levels.
Not only does protein contain essential amino acids, this analysis indicates that higher protein foods generally come bundled with high amounts of vitamins and minerals, such as vitamin B-12, selenium, vitamin B-6, riboflavin and copper.
It’s one thing to talk about targeting the minimum daily protein that you can get away with if you are looking to preserve muscle in fasting or extreme calorie deprivation during long term weight loss. It’s a whole different discussion if you’re looking to minimise protein while making up the rest of your daily energy intake with fats or carbs!
carbohydrates
The chart below shows the nutrients we obtain if we maximise energy from non-fibre digestible carbohydrates (i.e. net carbs). This high carb approach provides adequate amounts of twelve of the essential nutrients, while still being inadequate in twenty-four essential nutrients.
The chart below shows that low carb performs better than high carb, only falling short in sixteen essential micronutrients.
One of the benefits of a low carb approach, is that it often forces the elimination of many processed foods that fill the supermarket shelves to satisfy the demand for low fat foods driven by the admonition by the for the last four decades by the ruling dietary establishment to minimise fat.
A nutrient dense diet contains less non-fibre carb than the typical diet, but some people will do better, at least for a while, on a carb restricted diet. Another major benefit of low carb is for insulin resistant people when they can lower their blood glucose and insulin levels on a carb restricted diet. Many people find it easier to lose excess body fat once they have restored their insulin sensitivity.
nutrient density
You’re probably wondering where all these analyses are headed.
With all of these extreme approaches being so deficient in many micronutrients, you must be thinking “I hope there is a happy ending to this story, and soon.”
The good news is that we can manipulate our food selection to maximise micronutrients. But first, here’s something to scare you even more.
The chart below shows the outcome when we minimise the harder-to-find nutrients. This low nutrient density approach ends up being adequate in only three essential nutrients: sodium, vitamin C and iron.
The good news is shown in the chart below, which quantifies the nutrients provided by the most nutrient dense foods when we prioritise for the harder to find nutrients. Alpha linolenic acid (found mainly in nuts and seeds) is hard to come by in adequate quantities, however we can obtain the daily recommended intake of all the other nutrients when we prioritise the harder to find micronutrients.
comparison of nutrients adequate
It’s a little hard to present and digest this analysis clearly. There is no agreed protocol to compare the nutrient density foods. So I’ve tried to summarise it in a number of different ways to allow you to draw your own conclusions.
Firstly, the chart below shows the number of nutrients that each macronutrient extreme is adequate in, from the most nutrient dense at the top to the least nutrient dense at the bottom.
The chart below shows a stacked bar chart of the various nutrients in terms of % DRI. It’s like we have added up all the above charts for each nutrient and stacked them on top of each other. This chart demonstrates that there is a is a massive difference between the most nutrient dense and least nutrient dense approaches. If you’re foods that have a lower nutrient density you might just be hungrier compared to if you are eating the same number of calorie of the most nutrient dense foods which will much more effectively provide you with your essential micronutrients.
But we needn’t be too concerned about the micronutrients that are easy to obtain. What we really care about is the nutrients that are harder to obtain. The chart below shows the sum of the eighteen nutrients that are harder to obtain for each extreme approach.
application
It seems that thinking in terms of macronutrient extremes has some usefulness. However, focusing on micronutrient density seems to provide an order of magnitude improvement in the level of actual nutrients provided by our food.
Maybe it’s time for a new trend?
The ‘problem’ with nutrient dense foods is that that they are so lean and contain so much fibre that it can be hard to consume enough calories to maintain weight. You’ll just be too full!
If you are insulin sensitive and not looking to lose weight, then you could consider adding some more ‘Paleo friendly’ carbs such as beets, squash, yams, and sweet potatoes, and/or some fattier cuts of meat to fuel your activity. If you are insulin resistant, you may need to add some fattier (but still relatively nutrient dense) foods to maintain your weight while also keeping your blood glucose and insulin levels in check.
Perhaps micronutrient density is the most important parameter to pursue in our diet. Then with that cornerstone in place we can personalise our nutritional approach to suit our goals (e.g. weight loss, ketosis, athletic performance or healthy maintenance).
The various food lists in the table below are designed with micronutrient density as the main priority, but also consider insulin load and energy density to suit different goals.
In the end, no one sticks to an optimal list of foods that perfectly balances their diet 100% of the time.
I’ve been working on a system that will give you feedback on YOUR current diet, identify which nutrients you are currently lacking, and which supplements or real whole foods you may need to add or subtract to optimise your nutrition. Most people don’t eat perfectly all the time, but we could all use some help moving forward towards optimal.
I recently took a look at which nutrients might be missing from various popular dietary approaches in preparation for a recent on nutrient density. At a population level, the chart below shows the proportion of the US population that are deficient in various micronutrients. Many people are not getting enough vitamin D, vitamin E, magnesium, calcium, etc.
While your body hasn’t read the World Health Organisation’s reports on the Daily Recommended Intake of the various essential nutrients,[1] it’s likely that your appetite will drive you to seek out the nutrients that are lacking. If we are deficient in something that is required the body kicks in “nutrient hunger” and cravings that will make sure it gets what it needs.[2][3][4]
If you work hard to restrict your food intake to a certain dietary approach, but the body doesn’t receive the nutrients it needs, it may slow down and not function at full capacity. By contrast, adequate nutrition, without too much energy, slows many of the modern diseases of aging such as diabetes, Alzheimer’s and cancer and improves your chance of living healthfully to a ripe old age.[5]
USDA foods database
The chart below shows the nutrients that are both easiest and hardest to obtain from the eight thousand foods in the USDA foods database. At the bottom of this plot we have iron, various amino acids, and vitamin C, all of which are easy to obtain in adequate quantities.
However, at the top of the chart, we can see that it is much harder to obtain adequate quantities of six essential nutrients (omega 3 fatty acids, vitamin D, choline, vitamin E, and potassium). We would obtain sufficient quantities of all the other essential nutrients if we ate just a little of each of the foods in the USDA food database.
If we want to maximise nutrient density, it makes sense to prioritise foods that contain more of the harder-to-obtain nutrients. The chart below shows the nutrients for the top 10% of the 8000 foods in the USDA database (blue bars) when we prioritise for those. Not only do we get an increase in the more difficult to obtain nutrients, we also get a massive boost in all nutrients. Rather than being inadequate in six nutrients, we are now lacking only one (alpha-Linolenic acid, an Omega 3 fatty acid).
Limiting our food selection to the most nutrient dense foods makes it easier for us to consume the required nutrients without excessive energy, which is ideal if we are trying to lose fat or reduce calorie intake to slow the diseases of ageing.[6][7] Nutrient density becomes even more important if you’re fasting or restricting calories to achieve long term weight loss.
Optimising nutrient density
If you’re reading this, then you’re likely aware that there is a wide variety of dietary approaches that people follow to optimise their health depending on their preferences and beliefs.
I’ve tried to turn many of these beliefs about nutrition into a quantitative algorithm that we can use to evaluate and compare these approaches, and make sure we’re getting the outcome we want (e.g. low insulin, blood glucose control, nutrient density, or low/high energy density).
After testing a number of options, the three quantitative parameters that I have found the three parameters that are most useful are:
insulin load,
nutrient density, and
energy density.
My aim in this post is to show how considering nutrient density can improve various dietary approaches, from therapeutic ketogenic, vegan, paleo, and low fat. This post highlights which nutrients you will most likely be lacking with each of the different nutritional approaches, which foods you can use to fill these nutritional gaps, and perhaps which supplements you may need if you are still looking for some added nutritional insurance.
There’s been a lot of talk lately by Taubes[8] and Lustig[9] about how bad sugar and fructose are, but I think these nutritive sweeteners are just extreme examples of nutrient poor foods that are highly insulinogenic and energy dense. At the other end of the spectrum, we have foods like liver, broccoli, and spinach. Everything else is somewhere in the middle and will support or work against your goals, whatever they may be, to different degrees.
My aim here is to help you see where each of these foods sits on that continuum and use this information to help you refine your food choices to reach your personal goals.
Therapeutic ketogenic diet
Let’s start with the therapeutic ketogenic dietary approach. I have previously noted that a number of the issues and concerns with the ketogenic diet seem to relate to being able to obtain essential nutrients rather than consuming excessive levels of fat.[10][11][12] On one hand, I’m excited that the concepts of insulin load and percentage of insulinogenic calories have been helpful for people with chronic conditions such as epilepsy, cancer, dementia, Alzheimer’s etc. However, I think there is a risk their ultra-high fat diet will not contain the nutrients which are critically important for mitochondrial function and energy production.
The chart below shows the vitamins and minerals provided by a therapeutic ketogenic dietary approach if we simply prioritise for low insulin load (red bars)[13] in comparison to the average of all foods in the USDA database (orange bars). If you don’t pay attention to nutrient density a therapeutic ketogenic diet can provide lower levels of nutrition.
As shown in the chart below if we ate a little of all the foods in the USDA database, we would be deficient in six essential nutrients, whereas if we follow a therapeutic ketogenic diet, we will likely be lacking in ten essential nutrients.
The chart below shows the effect of how thinking in terms of nutrient density can improve the therapeutic ketogenic dietary approach (blue bars) compared to prioritising for insulin load only (red bars). All nutrients are boosted, particularly the harder to obtain ones.
While lots of people find that higher fat whole foods are hard to overeat, there are still some hyper palatable high fat foods that go down easily. We talk about eating “fat to satiety”, but what happens when nutrient hunger kicks in and your body is craving more potassium, magnesium, calcium, or one of the other nutrients that are harder to obtain in a very high fat dietary approach? If you keep on consuming large amounts of processed fats that don’t contain the nutrients you require, your appetite may not automatically turn off before you’ve consumed a lot of excess energy!
Low carb
The chart below shows the boost in nutrients when we consider nutrient density combined with a low carbohydrate approach. It appears that, based on this analysis, that without a focus on nutrient density, a low carbohydrate diet is likely to be deficient in folate, vitamin D, choline, potassium, magnesium, pantothenic acid, calcium, vitamin E and manganese. With a focus on nutrient dense foods, a low carb diet provides adequate amounts of the majority of nutrients.
Weight loss (insulin sensitive)
The weight loss approach is intended for people who are insulin sensitive but still have excess body fat to lose. Foods with a lower energy density (e.g. spinach, broccoli cucumber, celery, lettuce etc) typically are harder to overeat because they are bulky.
This approach doesn’t pay any attention to insulin load because it is assumed that people using this approach are not insulin resistant and are able to maintain good blood glucose levels. Practically, it’s also difficult to achieve a really high insulin load with these foods because they do not contain a large amount of processed carbs and are hard to overeat.
Without consideration of nutrient density, the essential fatty acids tend to be low along with vitamin B-12, choline, and tyrosine. However, once we factor in nutrient density all these nutrients dramatically improve.
This approach may not be viable for long term maintenance due to the extremely low energy density which would make it hard to get in enough energy. However, in the short term, it may be appropriate for a period of substantial energy restriction, and will provide maximum nutrition with a minimum amount of energy.
Zero carb
Getting adequate protein on a zero-carb approach is not a problem. However, unless there is a major focus on organ meats, there are a large number of vitamins and minerals, such as vitamin K, manganese, vitamin C, vitamin E, vitamin D, potassium, magnesium and calcium that may be worth supplementing.
Vegan
At the other extreme, the chart shows the nutritional analysis of the vegan diet. The main deficiencies in a vegan approach are omega 3s and vitamin B-12, which are hard to obtain without animal products. It may be prudent for vegans to consider fish oil supplementation and B-12 injections, or alternatively adding some seafood occasionally.
While it appears possible to obtain the recommended levels of protein, it’s hard to get very high levels of it. If you are insulin resistant, the fat levels can be increased using added coconut products and nuts.
Higher insulin load foods for bulking
The bulking approach is designed for people who are looking to gain strength and size by combining nutrient density with more calories and insulin load. Without consideration of nutrient density, a high insulin load means very low nutrient density foods. However, once we factor in nutrient density, we get a range of highly nutritious foods that may be helpful if you want to gain size and strength, while still maximising health and nutrition.
Paleo
The chart below shows the nutrients provided by the Paleo approach (i.e. no processed foods, dairy or grains) both with and without consideration of nutrient density. While ‘going Paleo’ eliminates many of the nutrient-poor processed food, it appears to be beneficial to also consider nutrient density as well in addition.
What does this all mean?
So, how do we decide which approach is best? Unfortunately, it’s not straightforward so I’ll look at this a number of ways.
What we ideally want is to identify the foods that will provide us with high amounts of all of the nutrients. The blue bars in the chart below represents the average of the % daily recommended intake of all the nutrients in the various approaches evaluated above, without considering nutrient density. The orange bars represent the average minus 0.5 x the standard deviation which is a measure of reliability. The higher the reliability the more consistent and high are the nutrients over all.
This chart shows that, in comparison to the other approaches, Paleo foods have a high and consistent level of nutrients; while the vegan and low energy density weight loss foods have high levels of some individual nutrients, but low levels of some others. Without consideration of nutrient density, the high insulin, low carb and zero carb approaches are a bit lacking in nutrients.
Things become a little more interesting once we factor in nutrient density. The vegan, therapeutic keto, low carb and zero carb approaches do poorly against the paleo, higher insulin load, most nutrient dense of all foods, and the lower energy density weight loss foods.
Many people will benefit on a high fat therapeutic ketogenic dietary approach, at least until their blood glucose and insulin levels normalise. However, in time, it may be beneficial to transition to more nutrient dense foods to continue their journey towards optimal health.
As detailed in the ‘how to optimise your diet for insulin resistance’ article, I think you should eat the most nutrient dense foods your pancreas can keep up with while maintaining good blood glucose levels. In time, someone who is highly insulin resistant may be able to progress to a more nutrient dense and more moderate fat approach if your ultimate goal is to normalise blood glucose levels and lose weight.
Food lists
If you identify with any of these goals, you may be interested in following these food lists. If blood glucose levels are sky high or you are managing a chronic condition such as epilepsy, cancer, Alzheimer’s or dementia, you may benefit from a higher fat therapeutic keto dietary approach, for a period. As your glucose levels come under control, you can transition to more nutrient dense foods that will also help you to achieve your weight goals.
As you can see, nutrients are provided at different levels depending on the approach. However, most people don’t follow any dietary approach strictly, so the nutrients in your diet will be different depending on your personal habits and preferences.
Rather than trying to pick up someone else’s nutrition plan, or live by a strict list, I think it’s better to refine your current habits, emphasising the good foods, minimising the bad, and progressively trying new foods that may be beneficial.
To this end, I’ve been developing a Nutrient Optimizer algorithm that can help you refine your food choices to suit your goals. By identifying the foods you are currently eating that align most with your current goals, which ones don’t, and which new foods perhaps you should consider.
Most current nutritional advice is driven by the avoidance of fat, particularly saturated fat, and therefore ends up being next to useless. Calorie counting apps like MyFitnessPal does nothing but count calories, which is also of limited use. Cron-o-meter tracks your micronutrients and can recommend foods to boost a single nutrient. However, there doesn’t seem to be anything available that will tell you which foods will help you actually correct multiple deficiencies and achieve a diet that is truly balanced in micronutrients.
The Nutrient Optimiser also allows you to tailor the approach to your goals, such as: therapeutic ketosis, diabetes management, weight loss or just nutrient dense maintenance. Food preferences like vegan, pescetarian, autoimmune, or paleo can be factored in to the recommended food lists.
At the moment, the process involves manually exporting food intake data from Cron-o-meter, then analysing it in a spreadsheet to manually generate a personalised report. I am eager to do this as a proof-of-concept for a range of people with various goals (particularly therapeutic ketosis, vegetarian, zero carb, fruitarian) to demonstrate how it works. So, if you’re happy to have your report shared publicly, and have a couple of weeks of Cron-o-meter data, feel free to send it to me and have your data analysed.
In time, the plan is to automate the process via an online interface and then ideally an independent mobile app. To keep up-to-date with progress, watch this space and check out the various analysed examples on the Marty Kendall’s Nutrient Optimiser Facebook page.
Epilogue… limitations
For completeness, I thought it would be worth mentioning a few limitations relating to calculating nutrient density…
Measuring foods in terms of calories has its own limitations as different macronutrients provide different amounts of energy (ATP) in different people. Some smart friends of mine are working on calculating ATP yield for different foods based on their macronutrient content. I’ll happily update this analysis in terms of nutrients per ATP as soon as that data is available. Initial indications are that people who are fat-adapted are able to use fat more efficiently (i.e. less entropy/losses in metabolism) and hence require less calories to yield the same amount of energy in the body (i.e. ATP). Hence, it appears that it is even more important for someone following a low carb or ketogenic approach to maximise nutrient density in terms of nutrients per calorie.
The official dietary reference values are based on limited research.[14] Typically, they relate to the minimum amount of a nutrient to avoid disease rather than the amount required for optimal function. They may also vary by person (e.g. someone who is more active may need more protein) and by their diet type (e.g. someone who is on a low carb diet may need less vitamin C to process the limited amount of glucose). Hence, I think the DRI values should be seen as a minimum. Ideally, we want to get more than the minimum while not having to ingest too much energy. I also don’t think nutrients are meant to come as individual vitamins and minerals in a bottle. The nutrients required to metabolise a certain food typically come packaged in whole foods, and often work synergistically. Taking supplements or fortifying foods will always be inferior to obtaining nutrients from whole foods.
Species-specific bioavailability and anti-nutrients are contentious topics. Zero carbers will tell you that nutrients in animal based foods are more bioavailable than plant based foods, while the vegans will tell you the opposite. To date, I haven’t been able to find useful data that would enable me to quantitatively refine the nutrient data in the USDA database regarding bioavailability. All we currently have is a measure of the nutrients contained in the food– rather than the nutrients that make it into your body after digestion. Again, if this data ever comes to hand, I’ll eagerly update the analysis.
Overall, I don’t think these limitations make a difference in the outcomes of the analysis. This is not an exact science and the body doesn’t operation like a rigid machine. Calculation of nutrient density is just a way to identify the foods that contain the most raw materials with the least amount of calories that your body can work with.
In Robb Wolf’s new book Wired to Eat he talks about the dilemma of optimal foraging theory (OFT) and how it’s a miracle in our modern environment that even more of us aren’t fat, sick and nearly dead.[1]
But what is optimal foraging theory[2]? In essence it is the concept that we’re programmed to hunt and gather and ingest as much energy us we can with the least amount of energy expenditure or order to maximise survival of the species.
In engineering or economics this is akin to a cost : benefit analysis. Essentially we want maximum benefit for minimum investment.
In a hunter gatherer / paleo / evolutionary context this would mean that we would make an investment (i.e. effort / time / hassle that we could have otherwise spent having fun, procreating or looking after our family) to travel to new places where food was plentiful and easier to obtain.
In these new areas we could spend as little time as possible hunting and gathering and more time relaxing. Once the food became scarce again we would move on to find another ‘land of plenty’.
The people who were good at obtaining the maximum amount of food with the minimum amount of effort survived and thrived and populated the world, and thus became our ancestors. Those that didnt’ didn’t.
You can see how the OFT paradigm would be well imprinted on our psyche.
OFT in the wild
In the wild, OFT means that native hunter gatherers would have gone bananas for bananas when they were available…
… gone to extraordinary lengths to obtain energy dense honey …
… and eaten the fattiest cuts of meat and offal, giving the muscle meat to the dogs.
OFT in captivity
But what happens when we translate OFT into a modern context?
Until recently we have never had the situation where nutrition and energy could be separated.
In nature, if something tastes good it is generally good for you.
Our ancestors, at least the ones that survived, grew to understand that as a general rule:
sweet = good = energy to survive winter
But now we have entered a brave new world.
We are now surrounded by energy dense hyperpalatable foods that are designed to taste good without providing substantial levels of nutrients.
Our primal programming is defenceless to these foods. Our willpower or our calorie counting apps are no match for engineered foods optimised for bliss point.
These days diabetes is becoming a bigger problem than starvation in the developing world due to a lack of nutritional value in the the foods they are eating.[3]
The recent industrialisation of the world food system has resulted in a nutritional transition in which developing nations are simultaneously experiencing undernutrition and obesity.
In addition, an abundance of inexpensive, high-density foods laden with sugar and fats is available to a population that expends little energy to obtain such large numbers of calories.
Furthermore, the abundant variety of ultra processed foods overrides the sensory-specific satiety mechanism, thus leading to overconsumption.”[4]
what happens when we go low fat?
So if the problem is simply that we eat too many calories, one solution is to reduce the energy density of our food by avoiding fat, which is the most energy dense of the macronutrients.
Sounds logical, right?
The satiety index demonstrates that there is some basis to the concept that we feel more full with lower energy density, high fibre, high protein foods.[5][6] The chart below shows how hungry people report being in the two hours after being fed 1000 kJ of different foods (see the low energy density high nutrient density foods for weight loss article for more on this complex and intriguing topic).
However the problem comes when we focus on reducing fat (along with perhaps reduced cost, increased shelf life and palatability combined with an attempt to reach that optimal bliss point[7]), we end up with cheap manufactured food like products that have little nutritional value.
Grain subsidies were brought in to establish and promote cheap ways to feed people to prevent starvation with cheap calories.[8] It seems now they’ve achieved that goal.[9]
Maybe a little too well.
The foods lowest in fat however are not necessarily the most nutrient dense. Nutritional excellence and macronutrients are are not necessarily related.
I am pretty burned out on the protein, carbs, fat shindig. I’m starting to think that framework creates more confusion than answers.
Thinking about optimum foraging theory, palate novelty and a few related topics will (hopefully) provide a much better framework for folks to affect positive change.
The chart below shows a comparison of the micronutrients provided by the least nutrient dense 10% of foods versus the most nutrient dense foods compared to the average of all foods available in the USDA foods database.
The quantity of essential nutrients you can get with the same amount of energy is massive! If eating is about obtaining adequate nutrients then the quality of our food, not just macronutrients or calories matters greatly!
Another problem with simply avoiding fat is that the foods lowest in fat are also the most insulinogenic, so we’re left with foods that don’t satiate us with nutrients and also raise our insulin levels. The chart below shows that the least nutrient dense food are also the most insulinogenic.
what happens when we go low carb?
So the obvious thing to do is eliminate all carbohydrates because low fat was such a failure. Right?
So we swing to the other extreme and avoid all carbohydrates and enjoy fat ad libitum to make up for lost time.
The problem again is that at the other extreme of the macronutrient pendulum we may find that we have limited nutrients.
The chart below shows a comparison of the nutrient density of different dietary approaches showing that a super high fat therapeutic ketogenic approach may not be ideal for everyone, at least in terms of nutrient density. High fat foods are not always the most nutrient dense and can also, just like low fat foods, be engineered to be hyperpalatable to help us to eat more of them.
The chart below shows the relationship (or lack thereof) between the percentage of fat in our food and the nutrient density. Simply avoiding or binging on fat does not ensure we are optimising our nutrition.
While many people find that their appetite is normalised whey they reduce the insulin load of their diet high fat foods are more energy dense so it can be easy to overdo the high fat dairy and nuts if you’re one of the unlucky people whose appetite doesn’t disappear.
what happens when we go paleo?
So if the ‘paleo diet’ worked so well for paleo peeps then maybe we should retreat back there? Back to the plantains, the honey and the fattiest cuts of meat?
Well, maybe. Maybe not.
For some people ‘going paleo’ works really well. Particularly if you’re really active.
Nutrient dense, energy dense whole foods work really well if you’re also going to the CrossFit Box to hang out with your best buds five times a week.
But for the rest of us that aren’t insanely active, then maybe simply ‘going paleo’ is not the best option…
… particularly if we start tucking into the energy dense ‘paleo comfort foods’.
If we’re not so active, then intentionally limiting our exposure to highly energy dense hyperpalatable foods can be a useful way to manage our OFT programming.
enter nutrient density
A lot of people find that nutrient dense non-starchy veggies, or even simply going “plant based”, works really well, particularly if you have some excess body fat (and maybe even stored protein) that you want to contribute to your daily energy expenditure.
Limiting ourselves to the most nutrient dense foods (in terms of nutrients per calorie) enables us to sidestep the trap of modern foods which have separated nutrients and energy. Nutrient dense foods also boost our mitochondrial function, and fuel the fat burning Krebs cycle so we can be less dependent on a regular sugar hit to make us feel good (Cori cycle).
Limiting yourself to nutrient dense foods (i.e. nutrients per calorie) is a great way to reverse engineer optimal foraging theory.
If your problem is that energy dense low nutrient density hyperpalatable foods are just too easy to overeat, then actively constraining your foods to those that have the highest nutrients per calorie could help manage the negative effects of OFT that are engrained in our system by imposing an external constraint.
But if you’re a lean Ironman triathlete these foods are probably not going to get you through. You will need more energy than you can easily obtain from nutrient dense spinach and broccoli.
optimal rehabilitation plan?
So while there is no one size fits all solution, it seems that we have some useful principles that we can use to shortlist our food selection.
We are hardwired to get the maximum amount of energy with the least amount of effort (i.e. optimal foraging theory).
Commercialised manufactured foods have separated nutrients from food and made it very easy to obtain a lot of energy with a small investment.
Eliminating fat can leave us with cheap hyperpalatable grain-based fat free highly insulinogenic foods that will leave us with spiralling insulin and blood glucose levels.
Eating nutrient dense whole foods is a great discipline, but we still need to tailor our energy density to our situation (i.e. weight loss vs athlete).
the solution
So I think we have three useful quantitative parameters with which to optimise our food choices to suit our current situation:
insulin load (which helps as to normalise our blood glucose levels),
nutrient density (which helps us make sure we are getting the most nutrients per calorie possible), and
energy density (helps us to manage the impulses of OFT in the modern world).
I have used a multi criteria analysis to rank the foods for each goal. The chart below shows the weightings used for each approach.
The lists of optimal foods below have been developed to help you manage your primal impulses. The table below contains links to seperate blog posts and printable .pdfs for a range of dietary approaches that may be of interest depending on your goals and situation.
If you’re not sure which approach is right for you and whether you are insulin resistant this survey may help you identify your optimal dietary approach.
In previous articles I have outlined the idea of the insulin load[1][2]which is similar to carbohydrate counting, but also accounts for the effect of protein, fibre ad fructose.
insulin load = total carbohydrates – fibre + 0.56 x protein
show me the data!
Most people understand that dietary carbohydrate is the primary nutrient that influences blood glucose and insulin as shown in the charts below. However, indigestible fibre[3] and glucogenic amino acids (protein)[4][5] also affect our blood glucose and our insulin response to food.
We can better predict the insulin and glucose response to our food if we also account for the effect of protein and indigestible carbohydrates (i.e. fibre). People aiming to follow ketogenic diet will want to eat foods towards the bottom left of these charts.
I was pleased to see Jason Fung even mention the food insulin index and the Optimising Nutrition blog at the recent low carb conference in Vail Colorado and it has been great to see a handful of people like Patricia and Mike put this theory into practice with great results as detailed in this article.
Patricia Berry Moore
This comment from Patricia Berry Moore made my day.
Marty! Are you the Low Carb Down Under Marty??!
You and Sarah Hallberg are why I started LCHF. And went from a very unhealthy type 2 diabetic at 156 lbs to a very healthy 113 lbs.
THANK YOU!
Patricia had seen my presentation on the food insulin index, applied the theory, and it worked!
I find it helps me refine my macros. A little less protein a bit more carbs and you can find that sweet spot. For me 50g per day is perfect.
My doctor threatened me with insulin and so I started went digging and found your lectures.
Over 10 months I lost 43 lbs (I’m 5’2″). I was pre-diabetic for ten years and then type 2 diabetic for ten years.
I am now off all my meds. I was on eight different ones for high blood pressure, high cholesterol, arthritis, re-flux, diabetes.
I’m never going back, so thank you!
This is Patricia’s “before photo.” You can see a ‘puffiness’ in her face characteristic of insulin resistance and hyperinsulinemia, which causes fluid retention. I showed this photo to my 12 year old daughter who said “that’s how you used to look.” Thanks dear… I think.
If you’ve hit a plateau it might be worth tracking the insulin load of your food for a while to fine tune your diet. Patricia says:
I use the app Lose it! which helps me track macros. So it’s pretty easy to keep a running total of my insulin load too.
I started at around 80g per day. As I decreased it, my blood sugars improved.
At this point my fasting blood glucose run at 65 – 75 mg/dL with an insulin load around 50g per day or so.
LCHF has really saved my life Marty.
This is Patricia now. Congratulations Patricia!
a little closer to home
As mentioned by my daughter, this is me before and after trying out my low insulin load, high nutrient density foods. I don’t think my hair moved in the 18 months between when these work profile photos were taken, but some inflammation and weight certainly did. My family assures me that at my worst I was bigger and unhealthier looking than the photo on the left!
The photo below on the left is my daughter’s “before photo” after spending 9 months in a high insulin environment. Children born to mothers who are type 1 diabetic and dosing with lots of insulin tend to be delivered early via C-section due to their excessive size caused by the high levels of insulin from the mother. The photo on the right is her twelve years later, all grown up!
The photos below are the same child, “JL,” who was one of the first type 1 diabetic children to receive insulin treatment in 1922. Without insulin he’s wasting away, literally eating his own fat and muscle, unable to metabolise carbohydrate. Two months later the photo on the right shows that he’s been able to make a full recovery with insulin injections.
The photo below is of another Type 1 sufferer before and after receiving exogenous insulin.
Hopefully from these photos you can see how there’s a “Goldilocks zone” for insulin. Not too little. Not too much. Just right. You can use the quantification of insulin load to find your sweet spot.
Mike Alward
I received similar feedback recently from Mike Alward who has also successfully applied the insulin load theory. Mike says:
I just wanted to say thanks for your work on insulin load, food insulin index and glucose : ketone index. It really helped me to understand what was holding me back from reaching and being able to maintain a state of optimal ketosis.
I manage my insulin load to ~75g per day. My BG has come down and my ketones are now in the optimal range. My GKI is now below 3.
I used to be pre-diabetic with blood glucose up around 6.5 mmol/L. Now, I am in the 4.5 – 4.7mmol/L range.
Being in optimal ketosis has helped to control my appetite and cravings (especially sugar), which has made intermittent fasting so much easier.
Keep up this important work!
With this reduced insulin approach Mike is able to accommodate a solid amount of protein into his diet while maintaining excellent blood glucose and ketone levels. Like anything, you can have too much of a good thing, including protein.
Many people find that as their insulin resistance improves they are able to handle a higher insulin load diet which may enable a higher nutrient density and less fat. If you are highly insulin resistant you may need to focus on a very low insulin load, high fat approach. As your blood glucose levels stabilise you will be able to transition to more nutrient dense foods that may have a higher insulin load.
Mike says:
My insulin load target is ~90g – 100g of protein / day. I am 6’0″.
Mike likes to track a range of different health makers.
I track my weight calories, macros, calculated insulin load, blood glucose, blood ketones and GKI.
Not everybody “geeks out” on this stuff. I am totally into “nerd safaris” to research non-conventional wisdom health.
I just got several folks to calculate their insulin load, and their heads almost exploded when I introduced them to GKI.
You can see in the chart below how Mike’s ketones have increased as he has reduced the insulin load of his diet.
The chart below shows how Mike’s glucose : ketone index (an approximation of insulin levels) has decreased as he lowered the insulin load of his diet.
Tracking the insulin load of your diet is a little more complex than just counting carbs, but not that much more work if you’re already tracking your food intake. Personally, I’m not a big fan of tracking everything you eat forever, but it can be useful to keep a food diary for a time to reflect and refine.
So how do you calculate the insulin load of your diet?
If you’re already tracking your food intake it’s a pretty simple thing to do. Below is an example output from MyFitnessPal[6] showing the food intake for the day comprising of:
insulin load = carbohydrates (g) – fibre (g) + 0.56 x protein (g)
Insert our values:
insulin load = 70g carbohydrates – 63g fibre + 0.56 x 104g protein
and calculate insulin load:
insulin load = 65g
It’s not that much different to tracking net carbs, but instead you also account for protein which also requires insulin.
I initially developed this calculation for people with Type 1 Diabetes (like my wife) who need to calculate their insulin dosage but it can work in a similar way for someone wanting to reduce the demand on their pancreas to the point that it can keep up and maintain normal blood glucose levels.
Reducing your insulin levels to normal healthy levels will allow your stored fat to be used for energy and manage your appetite. As you track your insulin load you can keep eliminating the foods that are driving it up until the point that you see the weight loss and blood glucose levels that you’re chasing. More recently I have incorporated this as a metric you can track in the Nutrient Optimiser to achieve your target glucose and ketone levels.
The appropriate insulin load will vary from person to person. A small woman aiming for weight loss using a lower protein ketogenic approach might have an insulin load as low as 40g per day while a larger man looking who is active and looking build muscle might have an insulin load as high as 300g per day.
A higher insulin load diet would allow more plant based foods, less fat and potentially a higher nutrient density (e.g. 40 to 50% of insulinogenic calories). The first priority will be to reduce the insulin load of your diet to the point where you can normalise your blood glucose levels and reduced insulin (e.g. 20 to 30% of insulinogenic calories).
The best idea is to start tracking where you’re currently at and look to reduce your daily insulin load until you achieve excellent blood glucose levels (i.e. average less than 5.6 mmol/L or 100 mg/dL). Once you normalise your blood glucose levels you could keep winding it down further until you achieve your desired level of ketones. As your body heals and you start to reduce the amount of fat around your organs you may be able to tolerate a higher insulin load diet and more nutrient dense diet in time.
a little more on the insulin load theory
So is it all about the insulin load? What about calories and conservation of energy?
In a metabolic ward context we typically find conservation of energy / CICO holds true. If anything someone on a high fat diet may be able to maintain their weight with less calories because fat is easier to digest and products less wasted energy (enthalpy). But in a free living environment how much we eat is influenced by our appetite which is influenced by the nutrient density of our food choices as well as our levels of insulin resistance.
This video gives a good overview of how insulin (either injected or from our own pancreas) affects whether we store fat on our body or release it to be used for fuel and how excess insulin can be problematic.
Most people think of macro nutrients in terms of carbohydrates, protein and fat as per the the picture below. They think that if we eat too much fat it will be stored as body fat. But the reality is a little bit more complex than that.
In the chart below the grey slices of the pie chart (i.e. the non-fibre carbohydrate and the glucogenic protein) are the components of your food that are glucogenic and will require insulin to metabolise.
The blue components are ketogenic (i.e. the dietary fat and the ketogenic protein) and do not require insulin to metabolise. If you’re lucky enough to be insulin sensitive you will burn the food you eat and your appetite will be well regulated with minimal change in body weight.
Indigestible fibre (black slice) doesn’t significantly affect our insulin response or even contribute to calories for us but rather is used to feed the bacteria in our gut. Fibre is a true ‘free food’.
If the insulin load of our diet is too high we are more likely to store a portion of the food. If we are insulin resistant our body will have to generate more insulin to deal with the non-fibre carbohydrate and glucogenic protein while increasing our chances that some of the food we eat will be stored on our body. We feel hungry and need to keep eating to obtain adequate energy. Calories still matter, but outside a controlled metabolic ward, body fat accumulation is more about managing fat storage and appetite than about counting calories.
Calories still matter, but outside a controlled metabolic laboratory, body fat accumulation is more about managing fat storage and appetite than consciously counting calories. Many people refer to insulin as the thermostat that controls our metabolism and our fat storage.
The good news here is that we can use our understanding of the storage properties of insulin to our advantage. If we are able to decrease the insulin load of our diet we are less likely to store fat and more likely to be able to use some of our stored body fat for energy. This will mean that we feel less compelled to eat because we are able to use up our own body fat rather than constantly eating. This reduced dietary insulin load scenario will lead to lower insulin levels, less storage, more use of body fat for fuel, a decreased appetite and a reduction in energy intake.
So, to reduce the insulin load of diet include you can:
eat more fibre,
eat less digestible carbohydrates, and
make sure your protein intake is not excessive.
can you eat too much fat?
Can you still eat too fat much while keeping the insulin load of your diet low?
The short answer is yes, especially if you’re chasing a certain macro nutrient value or high ketone values. Some people are able to stay very lean on a high fat ketogenic diet, but others need to also manage their dietary fat inputs to achieve their goal of body fat output.
The good news is that a low insulin load nutrient dense diet diet will typically lead to increased satiety and reduced energy intake.
The bad news is that excess energy, whatever the source, will lead to fat gain, inflammation and insulin resistance.
Many people recommend that you should eat ‘fat to satiety’. Unfortunately, high fat foods can be easy to overeat, at least for some individuals. There is no need to force yourself to eat extra fat if you are trying to lose weight. There’s no need to go out of your way to add extra fat and oils to your food. If your goal is weight loss, you can obtain more than enough fat from whole-food sources.
basal insulin and insulin resistance
The other unfortunate fact is that the insulin produced in response to food is less than half of the amount of insulin that your body produces. You pancreas is constantly producing basal insulin to manage the flow of energy out of your liver and to remove excess energy from your blood stream.
In addition to reducing the insulin load of your diet you may also need to increase the periods between your meals (intermittent fasting) and focus on building lean muscle mass to improve your insulin sensitivity. This will allow your insulin levels to decrease even more so that body fat can be accessed for fuel.
Implementing an intermittent fasting regimen can be useful for people who find that reducing the dietary insulin load doesn’t lead to enough reduction in appetite.
You can get a substantial decrease in insulin levels with a regular 18 to 24 hour fast. After this drop in insulin you may find your hunger levels actually decrease after a longer period of not eating.
summary
To regain control of your appetite you need to insulin load of your diet to the point that your pancreas can keep up and maintain normal blood glucose levels consistent with your personal metabolic health and level of insulin sensitivity.
If your blood glucose and insulin level are high then you should work to decrease the insulin load of your diet.
As the insulin load of your diet decreases you should see your blood glucose levels come down, your appetite reduce and your ketone levels come up.
If you’re still not seeing the results you want then the next step is to try intermittent fasting to further reduce your insulin and blood glucose as well as mitigate your overall food take.
As your blood glucose levels start to normalise you can start to focus on more nutrient dense foods with a lower energy density that may be helpful if weight loss is your goal.
The foods lists in the table below have been optimised to suit different levels of insulin resistance and tailored to your weight loss goals.
Can fasting improve blood glucose levels and reduce the need for diabetes medications? Antonio Martinez was eager to find out, so he set out on his own n = 1 experiment.
Antonio is an Attorney at Law (Martindale Hubbard Distinguished Rating and in The Legal Network Top Lawyers in New York) and businessman who worked for the late Dr Robert C. Atkins MD in government relations and appeared on his radio show in the 90s.
Antonio was one of the principal lobbyists and strategists involved in the passage of the Dietary Supplement Health and Education Act of 1994 (DSHEA) and has been involved in health care issues in law and policy throughout his career.
Back in the 90s Antonio adopted a low carb approach to lose weight for a time but says he then resumed a more moderate diet. It wasn’t until Antonio started to have his own health issues, including type 2 diabetes and a heart attack, that he realised he needed to intensify his efforts.
type 2 diabetes diagnosis
Antonio has a family history of Type 2 Diabetes, with both his mother and father suffering from the condition. Diagnosed with Type 2 Diabetes in 2002, Antonio was initially put on Metformin and eventually Janumet in 2008.
With the help of anti diabetic medications Antonio maintained a HbA1c in the 6s and was commended for his great blood glucose control. However even though he kept his blood glucose under the American Diabetes Association recommended maximum HbA1c of 7% Antonio was still at risk for cardiovascular disease.
As shown in the chart below, people with a HbA1c of less than 5.0% have the lowest risk of cardiovascular disease and stroke, however it doesn’t seem to count if you are using anti-diabetes medications to reduce blood glucose levels as they simply drive the excess energy back into storage as fat.
While anti-diabetic medications help to lower blood glucose levels (the symptom) these medications do not necessarily reduce your disease risk or allow the fat in your organs (the cause) to be released to restore insulin sensitivity (the solution).
Insulin is an anabolic hormone which means that it enables the body to build energy stores. If your problem is hyperinsulinemia, Type 2 Diabetes or fatty liver then your goal should be to lower your blood glucose and insulin levels to enable your stored body fat to be used for energy. Medicating high blood glucose without dietary changes will drive the energy back into storage as fat (including in your heart, liver and pancreas).
The diagram below from Dr Ted Naiman helps to explain how both high insulin levels (hyperinsulinemia) and high blood glucose levels (hyperglycemia) are interrelated and both bad news.
heart attack!
Sadly, on March 28, 2014, Antonio suffered a heart attack and had a stent placed in one artery.
Upon admission to the hospital he weighed 158 lbs and had a HbA1c of 7%. After the heart attack Antonio was prescribed aspirin, blood pressure medication, a statin, an anti-coagulant, and a beta blocker. Within a short time he began to experience side effects from the multiple medications.
Frustrated, he re-read a number of health and medical materials and told his doctors he would not be taking medications for the rest of his life. He also watched the documentary “Cereal Killers” which was a light bulb moment for him.
reduced carbohydrate approach
In July 2014, Antonio told his doctor and cardiologist that he was going on a high fat low carbohydrate diet. While his doctors did not advise against it, they were skeptical and warned him that he would have to have labs done frequently to monitor the impact of the diet.
Then in September 2014 Antonio received a call from his doctor who said
Congratulations. Whatever you are doing, keep doing it. You have a normal HbA1c! I’m taking you off Janumet. Take Metformin at the lowest dose as a control.
As shown below, Antonio’s HbA1c had come down from 6.6% to 4.9% with the low carbohydrate dietary approach. He had also dropped thirteen pounds to 145 lbs, his blood pressure had normalized, his HDL increased by 20 points and his triglycerides dropped below 100 mg/dL.
tackling dawn phenomenon
Despite eating only two low carb meals per day Antonio became concerned towards the end of 2015 that his morning blood sugar levels were starting to drift up.
Dawn Phenomenon is the process where the body secretes a range of hormones and glucose in preparation for the day, however if you are insulin resistant then the insulin response may not be adequate to maintain normal blood glucose levels. Having already experienced a heart attack he took this seriously and was eager to do whatever he could to reverse the situation.
So to kick off the new year Antonio adopted a regular fasting regime which involved going to bed without dinner on Sunday night and then not eating until Tuesday evening. This gives him a 44 to 48 hour fasting window each week.
The chart below shows Antonio’s blood glucose numbers through December before the fasting protocol and then through January and February with the fasting protocol in place.
Real life blood glucose numbers are always going to bounce around, however you can see that Antonio’s average blood glucose values have really improved.
I am getting the best numbers that I’ve ever had and no Dawn Phenomenon.
While the longer fasts are working well for Antonio he could also use shorter more regular fasting periods to keep his blood glucose down. Check out the Using your glucose meter as a fuel gaugearticle for some ideas on how you can make sure your average blood glucose is trending in the right direction.
One way of viewing high blood glucose levels and Dawn Phenomenon is the body’s way of releasing excess stored energy into the bloodstream to be used. If you are insulin resistant the body will use a process called gluconeogenesis to convert excess protein, and even fat to an extent, into glucose.
Once the excess fat decreases people will often become more insulin sensitive and the body will stop pumping out this extra glucose.
HbA1c
Starting out with an HbA1c of 5.1% Antonio was already doing pretty well due to his disciplined low carb approach. However the addition of the fasting protocol helped him break through the plateau and bring his blood glucose levels down even further towards optimal levels. Based on his blood glucose values he now has an HbA1c of around 4.6% which is pretty much optimal.
ketones
Antonio’s ketones are solid but actually trending down after introducing the fasting regime. The fact that Antonio has lower ketones values is not really a concern given that he’s likely using his ketones more effectively for energy rather than letting them build up in the blood as might be the case with a high fat diet without fasting.
I think many people get themselves into trouble chasing high ketone values by adding more dietary fat without improving their metabolism and insulin sensitivity to the point that they can actually use the ketones. Fasting forces your body to learn to use ketones for fuel.
glucose : ketone index
The ratio between glucose and ketones (GKI) can be a more useful measure when your blood glucose levels are reducing. A reducing GKI is an indication that your insulin levels are decreasing and your metabolic health is improving.
Antonio’s glucose : ketone ratio (GKI) improves each time he fasts and that it is trending down over time. These low GKI values indicate that he is achieving excellent metabolic health.
Thomas Seyfried’s GKI is a useful tool to track your metabolic health once your blood glucose values are approaching optimal levels. Seyfried aims for his cancer patients to have a GKI of 1.0, though a GKI below 10 is considered to be a fairly low insulin state and less than three is excellent metabolic health for someone not chasing therapeutic ketosis.
no turning back?
Antonio continues to enjoy the weekly fasts during which he focuses on drinking lots of different teas, coffee, and some bone broth. His weight has now dropped to 141 pounds and he is wearing the same size clothes as he wore in college.
When his friends ask him how he reversed his type 2 diabetes and got skinny. He replies,
By eating a high fat low carbohydrate diet based upon eating real food.
I work to keep my food macros in the range of 70 percent fat, 20 percent protein, 10 percent carbs as my ideal targets. I do watch my protein intake because excess will convert via gluconeogenesis.
I will likely maintain this approach for the rest of my life. I am loving my results!
Antonio says:
Another way to look at insulin resistance is your body telling you that you’re eating too much, eating too much of the wrong things or just eating too often. Our ancestors were hunter foragers whose eating habits were more like feast and famine, not three meals with snacks. Know and respect your insulin because it will command you to do so or otherwise wreak metabolic havoc on your health.
You can also think of your blood glucose meter as a fuel gauge. If your blood glucose levels are high then it might be time to stop filling the fuel tank for a while.
Intermittent fasting is like going to a metabolic gym and working out. Your body gets the opportunity to repair, recover, regenerate. Used intelligently, it will make the difference for your health and insulin sensitizing.
I am disappointed in the medical establishment because they should know better and they do not. Why isn’t clinical and therapeutic nutrition education mandatory in medical school and taught with the same emphasis as pharmacology?
And before go thinking Antonio is a saint that loves deprivation, he likes to feast too! Here he is with Ivor Cummins at Antonio’s favorite New York restaurant with some red wine..
… Brussell sprouts salad…
..some pate…
…and Le Côte de Beouf.
Lots of people would call this a ‘heart attack on a plate’, but for Antonio it seems to be working the other way. Here’s the blood glucose and ketone results the next morning.
And here’s Antonio recently on the job full of life and vitality.
Antonio with Former U.S. Senate Majority Leader Tom Daschle in Washington DC, February 2016
cured?
Is Antonio cured of his type 2 diabetes? The answer depends on your definition of “cured”.
Will Antonio be able to eat processed junk food five times a day? Probably not.
However if Antonio keeps up this fasting protocol along with his low carbohydrate approach then he just might be able to maintain optimal blood glucose levels without fear of another heart attack.
If that’s your definition of “cured” then the answer might be yes.
Congratulations Antonio and keep up the great work!
[This article has now been translated to Spanish. Check it out here.]
High fibre foods are often high in carbohydrates which can be problematic for people with diabetes or those trying to achieve ketosis.
People aiming for a low carbohydrate diet often avoid all carbohydrates, including fibre, however this may not be optimal for gut health or overall nutrition in the long term.
This article highlights nutrient dense, low carbohydrate sources of fibre that will have a minimal effect on blood glucose levels while helping to support gut health.
Dr Michael Ruscio
The human gut and the bacteria that inhabit it are still largely a mystery. However the latest research indicates that it is important.
Some people don’t do well with a very low carb approach in the long term;
Some studies indicate that a very high fat diet can lead to increased intestinal permeability (aka leaky gut) which can lead to insulin resistance;
In spite of the possible risk to optimal gut health, Dr Ruscio advises his patients to use a LCHF approach to manage blood glucose and weight, particularly for those who are insulin resistant;
His preferred approach is to start patients on a low carbohydrate autoimmune protocol and slowly increase carbohydrates to find their tolerance level for carbohydrates where they stop benefiting in terms of body weight or body fat; and
People on a low carb diet may benefit from a diet high in fibre / prebiotics / FODMAPs to promote microbial diversity and improve insulin sensitivity.
While some people believe that it is beneficial to try to manipulate the firmicutes : bacteroides ratio[1][2] or some other feature of gut microbiome,[3] Dr Ruscio says that this is far from settled science. What we do know is that a more diverse population of gut bacteria will reduce the probability that one strain of bacteria will take over our gut and become dominant (i.e. overgrowth).
Early exposure to a range of bacteria in a less sanitised environment helps to improve the ‘tone’ of our gut bacteria and reduces our chance of developing autoimmune issues.
While Dr Ruscio is cautious to highlight that we can’t just run a test and treat based on the results, he does a great job of teasing out what we can really know from the latest research on gut health in his AHS2014 talk.
total or net carbohydrates?
Prebiotics are, quite simply, indigestible food ingredients that stimulate the growth and maintenance of beneficial gut microbiota.[4]
While prebiotic fibre[5] appears to be beneficial for the gut microbiome, some people in the low carbohydrate scene will avoid fibre containing foods to eliminate the risk of these foods impacting on their blood glucose levels.[6][7][8]
In practice, however, this approach leaves people with a fibre intake well below the recommended minimum of 25g for women and 30g per day for men.[9]
In his article Sorry Low Carbers Your Microbiome is Just Not that Into You[10] Jeff Leach of the Human Food Project notes that (although he eats a high fat high fibre diet) people consuming a low carbohydrate diet aren’t necessarily slimmer. He suggests that this may be due to the lack of fermentable fibre.
The confusion around whether to count ‘total carbs’ or ‘net carbs’ is exacerbated by the fact that many people find that, despite claims of low net carbohydrates and high fibre, some manufactured ‘low carb’ products will often raise blood glucose levels.
At the same time, the food insulin index data suggests that there is no insulin response to fibre in foods. As detailed in this article, the correlation between insulin response and net carbs is much better than with total carbohydrates. This makes sense when we consider that fibre is not digested and absorbed by our intestinal tract but is instead metabolized by our gut bacteria.
The formula below for the calculation of insulin load is based on the observation that there is no insulin response to fibre and thus fibre should be negated from the calculation. To minimise the insulin load of our diet we need to prioritise foods that are high in fibre, low in digestible carbohydrates, and moderate in protein.
For most people this is largely a theoretical issue, but for people with type 1 diabetes who need to accurately calculate their insulin dose it becomes more important. The most prudent approach used by experienced type 1’s is to take a ‘net carbs’ approach to real whole foods, while assuming half or maybe all of the fibre in manufactured food products will be digestible (or ideally avoiding manufactured foods completely).
If you are particularly concerned about your blood glucose levels the ideal approach is to do your own n=1 experiment to test and track your own blood glucose levels to see if they rise after a particular food.
David Perlmutter
Dr David Perlmutter is a fascinating character on the cutting edge of the latest in health and wellness.
Perlmutter talks a lot about the benefits of prebiotics and probiotics for gut and brain health. Prebiotics are fibres that are not digestible by our stomach but rather feed the bacteria in our gut. Probiotics involve actually ingesting bacteria such as those found in yogurt, sauerkraut, Kombucha, Kefir, or other fermented foods.
Perlmutter notes that Americans typically get about five grams of fibre per day compared to the estimated one hundred and thirty grams of fibre that our Palaeolithic ancestors appear to have consumed.[11]
Dr Perlmutter spoke recently on Mark Sisson’s Primal Blueprint podcast[12] about how he believed that type 2 diabetes relates to changes in the gut bacteria and noted that this condition has been reversed through faecal transplants, which transfers healthy gut bacteria from one person into another.
Perlmutter promotes foods high in inulin[13] to feed the gut bacteria. Unfortunately, the issue for people with carbohydrate intolerance is that many of these foods are high in digestible carbohydrates that may also drive their blood glucose levels up.
I thought it would be useful to combine Perlmutter’s list of high inulin foods[14] with an evaluation of their proportion of insulinogenic calories and nutrient density.
As shown in the table below, the highest weighting used in the multi-criteria ranking is given to the insulinogenic properties of the foods (i.e. in order to prioritise foods that will not raise blood glucose levels), with some weighting given to fibre per calorie and fibre per weight, then to nutrient density per calorie and nutrient density per weight, and then calories per weight.
I find that it is important to consider the nutrient and fibre density in terms of both weight and calories. Considering calories alone will bias towards leafy veggies and herbs while considering weight will bias towards nuts and seeds. The best approach seems to be to consider both to get a balance.
ND / cal
ND / weight
fibre / cal
fibre / weight
calories / 100g
insulinogenic (%)
total
7.5%
7.5%
15%
15%
10%
45%
100%
Shown below are Perlmutter’s recommended probiotic foods from his Brain Maker book[15] sorted based on their insulinogenic properties, fibre content per calorie and nutrient density. The foods with the lowest percentage of insulinogenic calories will have the lowest effect on blood glucose levels. You can see more detail of the analysis here.
name
% insulinogenic
fibre (g) / kcal
fibre (g) / 100g
asparagus
47%
0.08
2.1
dandelion greens
47%
0.07
2.9
onion
56%
0.06
2.4
leek
81%
0.03
1.8
garlic
85%
0.01
2.1
Jerusalem-artichoke
87%
0.02
1.6
chicory root
87%
0.02
1.5
It’s worth noting that Perlmutter generally recommends eating these foods raw. As detailed in this article, cooking will change the fibre content of the foods, but perhaps not as much as you might think.
FODMAP foods
Limiting FODMAP foods (i.e. Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols) is a way of improving digestion in those with irritable bowel syndrome (IBS).[16] However, eliminating FODMAP foods may not be ideal in the long term. Once you have digestive issues under control it may be beneficial to slowly reintroduce FODMAP foods to promote a more diverse bacteria as well as increasing your nutrients.
After a period of avoiding FODMAP foods, the overgrowth of undesirable gut bacteria should diminish and you may be able to tolerate small amounts introduced slowly.[17]
In order to understand which FODMAP foods contain the most fibre and would be gentlest on blood glucose levels, I have run the FODMAP foods through the multi-criteria analysis with the weightings shown above. A shortlist of the highest ranking FODMAP foods is shown below. You can download the full detailed list here.
name
% insulinogenic
fibre(g) / kcal
fibre (g) / 100g
celery seed
34%
0.03
12
peanuts
14%
0.02
10
peanut butter
17%
0.01
6
pistachio nuts
19%
0.02
10
cashew nuts
23%
0.01
3
beans
57%
0.07
25
broad beans
55%
0.07
25
lentils
50%
0.09
31
our experience
Personally, I can eat pretty much anything and not have it bother me. However, I know that eating nutrient dense foods with a lower insulin load has helped me to feel brighter, less inflamed, and less fat.
On the other end of the spectrum, my wife Monica has type 1 diabetes and a host of digestive issues that seem to be part of the autoimmunity package deal. For her, feeling good, getting enough rest, having good gut health, and staying on top of her health is a constant battle.
I’ve been banging on about low carb diets for a while, but Monica’s ability to increase the amount of fat in her diet has been limited. Whenever she’d have a high fat meal she would end up with stomach distress with the same situation occurring with anything that was meant to be ‘helpful’ for the gut like resistant starch, MCT oil or glucomannan.
Late last year we found an excellent naturopath, Elizma Lambert from Realize Health, who was able to identify from her symptoms and testing that she had small intestinal bacterial overgrowth (SIBO) which was stopping her from being able to digest the fats that were critical to succeeding on a low carbohydrate diet.
Elizma was able to guide Moni through a process of cleansing the small intestine and then repopulating it with a diverse range of good bacteria. After testing her faecal microbiota through the Bioscreen lab in Melbourne[18] Elizma was able to identify areas where there was an overgrowth that needed to be treated followed by re-population with a diverse range of new good bacteria.
Individuals suffering from diabetes often struggle to metabolise fats and she also helped her, through supplementation of L-carnitine, to get her fat metabolism moving which has also enabled her to better clear the LDL cholesterol in her blood.[19] Once the digestion and blood glucose levels improved, her depression also lifted and she was able to decrease medications.
More recently however Moni had to have antibiotics for an infection. Unfortunately, the antibiotics also blew away the newly established good gut bacteria for a while, and a lot of the gut distress and depression issues regressed and she has had to work again to rebuild the good gut bacteria.
We’re blessed to have Elizma just around the corner from us in Brisbane Australia, however if you’re dealing with autoimmune or digestive issues then I encourage you to find someone who can guide you through the process, or even contact Elizma directly as she is now able to do consults via Skype. Similarly, Chris Kelly of Nourish Balance Thrive in California, United States, will be able to guide you through the minefield back to metabolic health.
Jimmy Moore’s n=1
I’ve got a lot of time for prolific podcaster Jimmy Moore. I have learned a great deal from his eager pursuit of information from all the experts that he interviews on his show. After a life of morbid obesity, his brother dying at 41, and both grandfathers dying in their early 50s, Jimmy is on a quest to improve his own health and share his journey and learnings with the world in the process.
Jimmy did a very public n=1 ketosis experiment where he lost 78 pounds (35kg) over a year of eating to optimise his blood glucose and maintain nutritional ketosis. Launching from this he wrote the books Cholesterol Clarity and Keto Clarity which has done a lot to increase the profile of the ketogenic diet in the public consciousness.
More recently however Jimmy has struggled to keep the weight off and blood glucose levels down in spite of continuing with a high fat ketogenic diet and keeping his calories reasonably low. Jimmy has been quite up-front about this, even sharing all his test data and two podcast interviews with Chris Kelly of Nourish Balance Thrive.[20]
In the first interview[21] Chris recommended that Jimmy get into a regular exercise routine, eat more veggies, and stop donating blood due to his low iron levels.
After his interview with Chris, Jimmy’s Facebook and Instagram accounts started showing a lot of great looking plates of food piled with heaps of colourful veggies under the hashtag #howIreallyeat.
It seemed that Jimmy has moved on from his position of minimising total carbohydrates to maintain ketosis in favour of maximising veggies and nutrient density.
In their second interview[22] Chris discussed Jimmy’s gut bacteria and possible overuse of dairy, and noted that Jimmy had a particularly limited population of gut bacteria.
Chris: And it’s very unusual for me to see what I saw on your test result, Jimmy, which is really low levels of all of the markers that come from bacteria. I wouldn’t like to say for sure that this means that there’s no bacteria there or undergrowth or anything like that. Again, I think it’s definitely — Once you seen this, it’s worth doing the experiment especially since I’ve seen on the CHRON-O-Meter results that your fibre was only a third of what the RDA is.
Jimmy: It’s higher now.
It seems that after finding that he was not keeping the weight off with the very high fat ketogenic approach that had helped him initially, he was eager to listen to Chris and try more nutrient dense veggies and fibre. Chris Kelly himself eats a very high fat ketogenic diet, but at the same time manages to get very high levels of fibre and nutrient density as detailed in this article.
It’s hard to know if Jimmy’s limited diversity of gut bacteria is the reason for his lifelong struggle with obesity or if it has more recently been exacerbated by his restricted palette of high fat foods low in prebiotic fibre. Jimmy is not the first person I have seen struggle to balance their blood glucose levels in spite of following a disciplined high fat ketogenic diet.
Is Jimmy’s apparent limited microbial diversity due to years of poor nutrition before he found low carb, something weird in the water in North Carolina, or his prolonged extreme high fat diet? Whatever the case, I think Jimmy would do well to take Chris’ advice and continue with his diet heavy in non-starchy veggies that look very tasty, nutrient dense and full of fibre.
Diabetes is a complex disease; however, it seems that gut health and fibre are part of the puzzle.
what does the research say?
I went looking for studies that support the idea that, as suggested by Dr Ruscio, a high fat diet can cause leaky gut and insulin resistance and found a handful of moderately useful references.
An article by Jamie Scott referenced a study where they found that people on a diet high in omega-6 rich seed oils developed leaky gut, however people on saturated fats fared much better.[23]
A rodent study from Thomas Seyfried suggested that a diet with excess calories and ketogenic macros can lead to weight gain and poor blood glucose outcomes.[24] However it’s worth noting that the food being tested in the experiment was a high fat powdered formula medical food. It’s hard to know if you would get the same results whole foods.
In Episode 65 of Tim Ferris’s podcast Peter Attia talks about how he sees some people not thriving on a ketogenic diet, particularly if there is not an energy deficit.[25]
The study A High-Fat Diet Is Associated With Endotoxemia That Originates From the Gut[26]compares a ‘prudent diet’ (20% fat, 60% carbs, 31g fibre) with the ‘western diet’ (40% fat, 40% carbs and 12.5g fibre) for a month and finds that plasma endotoxin activity increases on the ‘western diet’ compared to the ‘prudent diet’. There are no further details of the diets, however given the difference in fiber it is likely that the ‘prudent diet’ was loaded with veggies while the ‘western diet’ was processed carbs. I think it’s hard to draw any meaningful conclusions from this other than more fiber is better than less fiber, particularly given that 40% fat is not really a high fat low carbohydrate diet.
The study Comparative effects of very low-carbohydrate, high-fat and high carbohydrate, low-fat weight-loss diets on bowel habit and faecal short-chain fatty acids and bacterial populations[27]compares a low carbohydrate high fat diet (5% carbs, 13g fibre) with a high carbohydrate high fibre diet (including high fibre bran cereal and lentils) (46.4% carbs, 31.5g fibre) and found that the low carb diet group had less butyrate and bifidobacteria than the higher carbohydrate group.
A range of papers suggest high fat foods lead to metabolic disorders via the mechanism described graphically below.[28] I’m far from an expert in this emerging field of research, however it appears to me that the mechanism is more likely to relate to the lack of fibre and nutrients rather than necessarily the presence of fat in the diet.
Overall, I would say that research in this area is interesting but not clear cut and subject to prejudice (i.e. people just ‘know’ that high fat diets are bad for you) and bias (e.g. an experiment where the ‘prudent diet’ is full of nutrient dense veggies and fibre while the high fat approach is nutritionally limp by comparison).
Paleo ambassadors such as Chris Kresser,[29] and Robb Wolf[30] have been getting excited lately about a paper by Ian Spreadbury Comparison with ancestral diets suggests dense acellular carbohydrates promote an inflammatory microbiota, and may be the primary dietary cause of leptin resistance and obesity.[31] ‘Acellular carbohydrates’ refers to carbohydrates that are not contained within cellular storage vacules. This includes cereal grains and flours, whereas roots and tubers contain starch within cells (cellular). The title of the paper pretty much says it all.
The paper makes a lot of sense, however what is missing is the ability to quantify ‘acellular carbohydrate’. If we were to try to tie this back to something quantifiable I would say fibre is good, while processed non-fibrous carbohydrates are bad.
My takeaway learnings from the research is that:
For whatever reason, some people don’t do well long term on an extreme high fat approach.
Omega-3 fats are better when it comes to gut and metabolic health compared to omega-6 polyunsaturated fats.[32]
A hypocaloric ketogenic diet is better than a hypercaloric ketogenic diet.
More fibre is better than less fibre unless you are recovering from digestive issues such as SIBO or IBS. Reducing fermentable fibre is a temporary solution until the yeasts or bacteria are cleared from the small intestine, and in no way a long-term approach to a healthy diet and biochemistry.
From an evolutionary point of view I cannot see a mechanism that demonstrates how naturally occurring fats that we have been eating for many generations (e.g. olive oil, butter, coconut oil, cream, etc.) have suddenly become the cause of the gut distress and autoimmunity that we have seen flourish in recent decades when the use of sugar and highly processed grains have also exploded.
butyrate
According to Wikipedia:
Butyrates are important as food for cells lining the mammalian colon (colonocytes). Without butyrates for energy, colon cells undergo autophagy (self-digestion) and die.
Short-chain fatty acids, which include butyrate, are produced by beneficial colonic bacteria (probiotics) that feed on, or ferment prebiotics, which are plant products that contain adequate amounts of dietary fibre.
These short-chain fatty acids benefit the colonocytes by increasing energy production and cell proliferation and may protect against colon cancer.[33]
There have been two recent health fads which attempt to increase butyrate:
resistant starch, and
Bulletproof coffee.
Increasing the amount of resistant starch in the diet, as promoted by Richard Nikoley[34] and Tim ‘Tater Tot’ Steele,[35] aims to actively feed the good gut bacteria and increase butyrate in the gut from the bacterial fermentation of the resistant starch. Robb Wolf’s sensitive digestion seems to have benefited from adding resistant starch. Mark Sisson also came out with a definitive guide to resistant starch that was overall in favour of it.[36]
Personally I’ve tried resistant starch. It definitely does something in your gut. I can’t say that my life was changed markedly for the better, but it may be a useful supplement. Though as with all supplements, it’s probably not ideal to be taking them for the rest of your life but rather find the required nutrients in real whole food if possible.
One of the claimed benefits of Bulletproof coffee is that high butyrate content of the grass-fed butter is beneficial for the gut.[37] What is not clear though is whether the ingested butyrate actually gets to the lower intestine, as it is a small molecule which would likely be absorbed before it reaches the large intestine. Using butyrate as a suppository or part of an enema is an option, but it seems a better idea to have the colonic bacteria present to produce butyrate and other short chain fatty acids for gut health.
safe starches
Paul Jaminet is a proponent of safe starches to improve gut health. In his Perfect Health Diet he recommends eating some carbohydrate foods such as white rice, white potato, and sweet potato.[38]
These minimally processed whole foods are better than processed carbohydrate and I can understand how these safe starches could be beneficial to feed gut bacteria, which may lead to an overall improvement in health. However, for a diabetic these high GI and high carbohydrate foods likely do not provide an acceptable solution when it comes to blood glucose levels.
sugar, processed carbohydrates and gut health
It seems most people agree that that cutting out sugar and processed foods is a good thing.
Dropping sugar and processed carbohydrates will reduce your chance of feeding an overgrowth of ‘bad bacteria’ (especially Streptococcus, Enterococcus and yeasts such as Candida albicans).
Enter the low carb paleo approach with plenty of nutrient dense fibre.[39][40]
fibre and satiety
Fibre makes us feel full. While high fat foods are calorie dense (at nine calories per gram), high fibre foods increase the bulk of our food without necessarily increasing calories.
Glucomannan is a water soluble dietary fibre with some clear research findings behind it, showing that it absorbs water and swells in your stomach to promote a feeling of fullness, as well as working as a prebiotic to increase the diversity of bacteria in the gut.[41]
The other good thing about high fibre foods is that they often come packaged with plenty of nutrients.
Real whole foods will be more likely to contain the essential nutrients, as well as other beneficial nutrients that we have not yet identified. Isn’t the ideal food something that will give us plenty of fibre to feed our gut, keep us full, give us nutrients and keep us regular?
While there are lots of fibre supplements out there (e.g. glucomannnan, potato starch, and psyllium husk) I think the ideal way is to maximise the nutrient dense high fibre foods.
In line with the idea that we want to promote a good range of healthy gut bacteria, we also want to eat a wide range of fibre in our food (soluble, insoluble and mucilaginous) to promote a wide range of gut bacteria.
so how do we get fibre without raising blood sugars?
Again, we seem to have a balancing act between maximising fibre and nutrition on one hand and managing blood glucose levels on the other.
So what foods can we eat that will give us all the good stuff without negatively impacting our blood glucose levels?
Rather than just looking at high inulin foods or FODMAP foods as discussed above, I have analysed all of the USDA foods database to find the foods that have the highest amount of fibre that will provide us with plenty of nutrients and be gentle on our blood glucose levels.
The highest ranking foods are shown below while a more extensive list can be downloaded here (note: this list is sorted based using a multi criteria analysis that considers fibre, nutrient density and insulinogenic properties). Foods with a lower percentage of insulinogenic calories will be gentler on your blood glucose levels while the foods with more fibre will be great for your gut.
As you look down this list you will see that most of these foods are nutrient dense seeds, herbs or leafy vegetables. Rice and wheat feature in the mix, but only in their natural unprocessed form.
food
% insulinogenic
fibre (g) / kcal
fibre (g) / 100g
flaxseed
8%
0.05
27
sesame seeds
12%
0.03
17
caraway seed
22%
0.09
38
chili powder
24%
0.09
35
rosemary
23%
0.10
43
basil
29%
0.12
38
sage
26%
0.10
40
sunflower seeds
11%
0.02
12
sesame seeds
14%
0.02
12
hazelnuts
8%
0.02
11
paprika
28%
0.09
35
savory
30%
0.13
46
marjoram
31%
0.11
40
parsley
32%
0.10
33
curry powder
31%
0.08
33
almonds
14%
0.02
12
mustard seed
22%
0.02
12
pine nuts
9%
0.08
43
almond butter
12%
0.02
10
Kellogg’s all-bran w/ ex fibre
35%
0.13
50
oregano
36%
0.12
43
thyme
36%
0.10
37
cloves
35%
0.08
34
spearmint
39%
0.09
30
sesame butter (tahini)
18%
0.02
9
peanuts
14%
0.02
10
pepper, red or cayenne
34%
0.06
27
pistachio nuts
19%
0.02
10
cumin seed
39%
0.02
11
turmeric
51%
0.06
21
celery flakes
53%
0.09
28
avocados
7%
0.04
7
pepper, black
54%
0.08
25
chives
54%
0.07
26
peanut flour
39%
0.03
13
radishes
60%
0.08
24
peppers
45%
0.07
22
coconut meat
6%
0.02
16
chia seeds
13%
0.07
34
As shown in the formula below the percentage of insulinogenic calories is lower the more fibre we have.
If you are concerned about your blood sugar then try to choose foods with a lower percentage of insulinogenic calories, keeping in mind that a whole egg is about 25%.
summary
In summary, I think a ‘well formulated ketogenic diet’ that will be beneficial for both blood glucose and overall health looks less like this…
… and more like this.
A high fibre nutrient dense diet will give you a better chance of achieving health without messing up your blood glucose levels.
acknowledgements
Thanks to Alex Leaf and Elizma Lambert of Realize Health for reviewing this article and providing some of the more technical detail. If you feel like you’ve tried everything and still need some help I highly recommend contacting Elizma who can arrange some additional testing and get to the bottom of the issue.
Thanks to Jimmy Moore for chasing Dr Ruscio for some more references on the subject and Michael Ruscio for providing references.
Luis (aka Darth Luiggi who runs the Ketogains Facebook Group) has been on a ketogenic diet for more than 14 years!
Here are a couple of video interviews where Luis explains his approach.
He is also very active in coaching the more than 7000 Ketogains members on his Facebook group and Reddit.
Recently I was able to get a look at a few days of Luis’s food diary on My Fitness Pal so I thought it would be interesting to run some numbers on his diet.
My focus of the blog has been on optimising diet for diabetes management, however I wanted to also demonstrate that a nutritious low insulin load diet is also great for health and fitness.
The analysis below shows the combination of three meals. Along with plenty of protein (beef, chicken, egg, pork) he also has a solid amount of vegetables (broccoli, lettuce and spinach) as well as a good amount of added fats (butter, olive oil and coconut oil) to maintain ketosis.
The nutritional analysis of these three meals is shown below. As you would expect from the dude who runs Ketogains, the carbs are low at 5% with the protein being fairly substantial at 29% of daily calories.
The protein score is excellent with 145% of the RDI being met with 1000 calories and 58% of the RDI for vitamins and minerals being met with 1000 calories.
A score of 100 means that you will meet the recommended daily intake (RDI) for all the nutrients with 1000 calories, as discussed in the previous ‘the most nutrient dense food for different goals’ article.
The table below shows how Luis’s diet stacks up based on the nutritional ketosis weighting.
At 26g of fibre per day his fibre score is solid but not high compared to the other meals analysed. His calorie density is high but that isn’t a big issue given that he is already fairly lean.
The insulin score is not extremely high as there is a solid amount of protein and he’s not worried about diabetes or achieving therapeutic ketosis.
The vitamin and mineral score is the one area that could be improved, though it is better than average.
As you will hear on the videos, Luis is already a big advocate for leafy greens as an integral part of a ketogenic diet.
If we did want to improve the vitamin and mineral score we could simply add extra spinach and broccoli (or any of the nutrient dense veggies from this list).
I’ve dropped the lettuce (which is not as nutrient dense) and increased the broccoli and spinach so we have 400g of each across the three meals.
The resultant nutritional analysis for the revised food diary is shown below. The nutrient balance score has increased from 58 to 70 and we’d only have 8g of net carbohydrates per meal in spite of the significant increase in vitamins and minerals.
With the increase in non-starchy veggies we increase the fibre intake from 26g to 40g across the three meals which would mean that he would now meet the recommended daily fibre intake of 30g per day for men.
The other advantage of this approach is that it would be more filling which may lead to a decreased overall calorie intake. While Luis knows the power of a ketogenic diet for weight loss he also knows that to get such a low percentage body fat you also need to run in a calorie deficit and this approach may assist in naturally controlling appetite and satiety.
He is currently in a ‘cutting phase’ which is why he is tracking his food intake in My Fitness Pal, so reducing his calorie density and increasing fibre might help him to spontaneously achieve a reduction in overall energy intake.
If you’re interested in using the ketogenic diet as part of a bodybuilding routine I would definitely recommend checking out Ketogains. Even though he looks tough with all those muscles he’s really polite, gracious and only too willing to help other people on the journey. And regardless of your goals, Luis’s Ketogains calculator is an excellent tool if you want to calculate your macros or target grams of protein, fat and carbs.
A low carb helps reduce blood sugars and insulin levels and help with many common metabolic diseases (e.g. diabetes, heart disease, stroke, cancer, Parkinson’s and Alzheimer’s).
We become insulin resistant when our adipose tissue becomes full and can’t store any more energy. Excess energy is then stored in the liver, pancreas, heart, brain and other organs that are more insulin sensitive.
Endogenous ketosis occurs when we don’t eat and we burn our own body fat (e.g. fasting). While insulin and blood sugar levels are low we may have lower blood ketones flowing from our fat stores.
Exogenous ketosis occurs when we eat lots of fat (e.g. butter, MCT oil) or take exogenous ketones. Our blood ketones may be higher, but our insulin levels will rise to remove excess energy from the blood.
Most of the good things associated with ketosis occur due to endogenous ketosis.
Most people following a ketogenic diet have lower blood ketone values than Phinney’s ‘optimal ketosis’ chart, especially once they become fat adapted.
If your goal is blood sugar control, longevity or weight loss then tending towards endogenous ketosis with lower blood sugars and lower ketones is likely a better place to be than targeting higher blood ketones.
Introduction
I have seen a lot of interest and confusion recently from people following a ketogenic about ideal ketone and blood sugar levels.
This article reviews blood ketone (BHB), breath ketone (acetone) and blood sugar data from a large number of people who are following a low carb or ketogenic diet to understand what “normal” and “optimal” really look like.
This understanding, based on real life data from people following a ketogenic dietary approach, will to help us fine tune our diet and lifestyle to suit our goals whether they be:
Many people initiate a low carb diet to manage their blood glucose levels, insulin resistance or diabetes.
As shown in the chart below, foods with less carbohydrate do in fact have a a smaller impact on our blood sugar.[1][2][3]
While not typically recommended by dieticians and diabetes associations, it would appear that, if you are insulin resistant, have prediabetes, or diabetes (Type 1 or Type 2) it make sense to reduce the carbohydrates in your diet to the point where you can achieve the blood glucose levels of a metabolically healthy person.
what are optimal blood sugar levels?
“Normal” blood sugar regulation is defined as having a HbA1c of less than 6.0%.
“Prediabetes” is diagnosed when you have a HbA1c between 6.0 and 6.4%.
Type 2 diabetes is diagnosed when you have a HbA1c of greater than 6.4%.
However, as you can see from the charts below, this definition of “normal” is far from optimal.
By the time you have “prediabetes” with a HbA1c of greater than 6.0% you are at risk of many of the most common western diseases of aging and causes of death (i.e. heart disease, stroke, Parkinson’s, Alzheimer’s and cancer).[4][5]
If you’re interested in optimal rather than that what currently passes for “normal” health, the table below shows some suggested HbA1c and average blood sugar targets for optimal health and longevity.
risk level
HbA1c
average blood sugar
(%)
(mmol/L)
(mg/dL)
optimal
4.5
4.6
83
excellent
< 5.0
< 5.4
< 97
good
< 5.4
< 6.0
< 108
danger
> 6.5
> 7.8
> 140
ketosis vs hyperinsulinemia
While high glucose levels are bad news in and of themselves (glucose toxicity and excessive glycation), high blood sugars typically go hand in hand with high insulin levels which are also bad news.[6][7][8]
A metabolically healthy person will store excess energy in their fat cells for easy access when required later. But if we continue to fill our fat cells with excess energy, you will get to the point where they cannot expand to accept any more energy. It is at this point that our adipose tissue becomes insulin resistant.
The good news is that insulin resistance will slow the expansion of our fat cells (the excess energy can’t get in as easily).
The bad news is that once our fat cells become insulin resistant the excess energy will be re-directed to the parts of our body that are more insulin sensitive such as our liver, pancreas, heart, brain and other vital organs.
Our pancreas will work overtime secreting more insulin to try to keep the energy in the liver as well as put it back into storage.
High insulin levels mean that we will find it harder to release energy from our fat stores when we go without food.[9] Without easy access to our body fat stores, we will be driven by our appetite to eat again sooner.
Someone who is insulin resistant is more likely to become obese because their chronically elevated insulin levels will drive them to eat more often because, without easy access to their fat stores, they feel bad without a constant flow of glucose for energy.
Fasting insulin levels in healthy populations range between 2 to 6 mIU/L.[10][11][12] The average insulin levels in western populations are 8.6 mIU/L. Meanwhile, the official reference range for “normal” fasting insulin is less than 25 mIU/L.[13][14]Given that the western world is going through a crisis of metabolic health, it is probably safe to say that, similar to the “normal” blood glucose levels, this cut off for insulin levels is also far from optimal.
how to manage your dietary insulin load
To help manage your insulin levels and blood sugar you can tailor the insulin load of your diet to suit your current level of insulin resistance. As shown in the chart below, our insulin response to the food we eat is proportional the net carbs plus about half the protein it contains.
Reducing the insulin load of your diet can help to reduce your insulin and blood sugar levels to the point where your pancreas and current insulin resistance levels can keep up. When our insulin levels are low, we can access our body fat for fuel, either from our body or our food. We then see the ketone levels in our blood rise. At this point we are deemed to be “in ketosis”.
A person with type 1 diabetes (like my wife Monica) is not able to produce enough insulin. Without exogenous insulin injections they will see both their blood glucose and blood ketones rise to very high levels. This is called ketoacidosis which is a dangerous state that requires exogenous insulin as soon as possible to prevent their body from falling apart.
Without insulin people with type 1 diabetes are unable to metabolise glucose and turn to their muscles for energy. As shown in the image below of JL, one of the first children with type 1 diabetes to receive insulin, they quickly regain weight.
It’s important to find the optimal amount of insulin. Lowish blood ketones with healthy blood glucose levels is a normal healthy state where your body fat can more easily be accessed for fuel.
People who switch to a low carb dietary approach often find that their blood glucose and insulin levels plummet and they are not hungry because excess excessive amounts of energy can now flow out of storage (a little bit like someone with uncontrolled type 1 diabetes.
However the problem with a very low insulin load dietary approach (e.g. very high fat therapeutic ketogenic diet), is that it may not contain enough of the vitamins and minerals that you need for optimal function and avoid nutrient cravings in the long term.
High fat foods also have a high energy density which can make it hard for some people to control portion sizes if their goal is weight loss. Very high fat foods also tend to be less nutrient dense.
blood glucose and ketones in fasting
When we go without food, our blood glucose levels will decrease as the glucose in our bloodstream and liver (glycogen) are used up. The body then turns to our fat stores and our liver converts them into ketones for use. This is termed “endogenous ketosis” (endogenous = originating from within an organism).
As explained by Dr David Sinclair in the video below, there are a ton of beneficial things that occur during endogenous ketosis such as autophagy, mitogenesis, mitophagy, upregulation of SIRT1 and increase of NAD+).
Ketones also increase during this low energy state to keep the brain and muscles well fuelled. However, while ketones are present, they are not necessarily the cause of these benefits that are often associated with ketosis.
The chart below shows my blood sugar and blood ketone (BHB) during a recent seven day fast. You can see that as glucose levels decrease, ketone levels rise.
You can see that the sum of glucose and ketones continues to increase during fasting. I have termed the sum of glucose and ketone as “total energy” (i.e. glucose + ketones).
Often in fasting it seems that the body will let the total energy in the blood go quite high. This enables you to be on a state of very high alert ready to find food to survive. It feels great and I typically feel at my sharpest after not eating for a few days.
exogenous ketosis vs endogenous ketosis
I think it’s important to understand the difference between exogenous ketosis and endogenous ketosis.
Endogenous ketosisis when we eat less than the body needs to maintain energy balance and we are forced to use some of our body fat to make up the difference.
Exogenous ketosis occurs when we eat lots of fat (or take exogenous ketones) and we see blood ketones (beta hydroxybutyrate) build up in the blood.
Ketones in the blood occur when you are eating more fat than you are burning. Lower blood ketones are not a cause for concern as long as your blood glucose levels are also low (i.e. low total energy).
The reality is that we will all be somewhere on the spectrum between exogenous and endogenous ketosis. We need enough energy to get through the day and not fade away.
But keep in mind that most of the really good stuff that we attribute to ketosis and the ketogenic diet occurs due to endogenous ketosis when fat is coming from our body.
We may not have high blood ketone levels in exogenous ketosis, but that’s OK because that’s where the good stuff.
what should your blood sugars and ketone levels be in ketosis?
The ketogenic diet is still evolving and fertile area of research. Even Keto Clarity co-author Eric Westman recently admitted that there is still a lack of clarity around what constitutes ideal ketone levels.[15]
The chart below shows the ‘optimal ketone zone’ from Volek and Phinney’s Art and Science of Low Carb Living which is typically referred to as the ultimate guide to optimal ketone values. The problem, however, 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 if you’re trying to lose weight).
Recently, I had the privilege of having Steve Phinney (pictured below in our kitchen making his famous blue cheese dressing) stay at our place for a night when he spoke at a Low Carb Down Under event in Brisbane.
I quizzed Steve about the background to this optimal ketosis chart. He said it was based on the blood ketone levels of participants in two studies. One was with cyclists who had 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 had recently transitioned into a state of nutritional ketosis.
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 athletes in the FASTER study) actually show lower levels of ketones than might be expected.
Over time, many people, particularly metabolically healthy athletes, move beyond the ‘keto adaption’ phase and are able to utilise fat as fuel even more efficiently and their ketone levels reduce further.
Urine ketone strips are often considered to be of limited usefulness due to the fact that the body stops excreting ketones as it learns to use them. Could it be a similar situation with blood ketones (BHB), albeit over a longer period of time?
As our blood glucose levels decrease, our ketones increase to balance out the fuel deficit. When we have less glucose available our insulin levels go down, more fat is burned and blood ketone levels rise. The chart below shows the sum of the blood glucose and ketones (i.e. total energy) from nearly three thousand data points from a broad range of people following a low carb or ketogenic dietary approach.
[note: In late 2015 I pooled a range of data from myself and a number of people on the Optimal Ketogenic Living (OKL) Facebook group. After sharing this data initially a number of other people sent me their data. Later, Michel Lundell from Ketonix agreed to share a very large set of anonymised data for me to analyse.]
On the left hand side of the chart, we have a low energy situation where insulin levels are also low. The body will be drawing on stored body fat for fuel to meet the shortfall and weight loss will occur.
On the right hand end of the chart, we have a high energy situation from both glucose and ketones. This high energy situation causes the pancreas to secrete insulin to control lipolysis (i.e. the release of fat from storage) because there is more than enough energy floating around in the blood.
It’s a slight oversimplification to say that the left hand side of the chart is endogenous ketosis (which is good) and the right is exogenous ketosis (which is bad).
We may or may not see high blood ketone levels when we go without food for a long period. However replicating high ketone levels with high levels of exogenous ketones or an oversupply of dietary fat is not the same, even though both situation are called “ketosis”.
Based on this data it seems the body tries to maintain a blood glucose level of around 4.9mmol/L and a blood ketone level (BHB) of around 1.5mmol/L. The table below shows this data in terms of average as well as the 25th percentile and 75th percentile points (i.e. 50% of the values fit between the 25th and 75th percentiles).
ketones (mmol/L)
BG (mmol/L)
BG (mg/dL)
HbA1c
GKI
BrAc
total energy (mmol/L)
25th
0.6
4.2
76
4.3
1.8
46
3.4
average
1.5
4.9
89
4.7
7.3
56
6.4
75th
2.1
5.6
101
5.1
14
66
12.9
blood glucose and ketone levels during exogenous ketosis
Most people however do not require this degree of therapeutic ketosis, particularly if managing insulin resistance or obesity is the priority. People using low carb to manage diabetes or weight loss goals may end up driving excess energy consumption and a lower than necessary nutrient density, both of which may be counter productive.
People following a therapeutic ketogenic diet may be fuelling up with MCT oils to achieve high ketone levels and low glucose : ketone index values (GKI) value for therapeutic purposes. Others will target high levels of ketones for brain performance. Others will load up on exogenous ketones and glucose to ‘dual fuel’ the system for athletic performance.
One of the benefits of a low carb or keto diet is that it tends to eliminate a lot of hyperpalatable processed foods, and lowers insulin levels which help many people normalise their appetite and eat less.
The danger, however, with trying to drive exogenous ketosis is that it will lead to an energy excess situation which will drive insulin to remove excess energy from your bloodstream, which can worsen insulin resistance.
Even though we are getting most of our energy from fat rather than carbs, the body will still work to bring the total energy back towards optimal levels using insulin, and stop the release of stored glycogen and body fat until you have used up the energy in your blood from your food. This is why Thomas Seyfried and Dominic D’Agostino talk about the benefits of a calorie restricted ketogenic diet. [16][17][18]
blood glucose and ketone levels for weight loss and endogenous ketosis
Many people embark on a ketogenic dietary approach to manage their diabetes and achieve long term weight loss. They want lower insulin levels to enable them to burn more body fat for long term insulin sensitivity and health.
On the left hand side of the total energy chart below we have a situation where we are generating endogenous ketosis, meaning that our own body fat is being burned for fuel. With a lower total energy level in our blood, our body needs to pull fat from our body fat stores as well as use up the excess stored fat and old proteins in our liver, pancreas, brain and other vital organs (i.e. autophagy).
In order to understand what all this means I have divided the three thousand data points into five quintiles, from lowest to highest total energy. For each quintile I have calculated the average, 25th percentile and 75th percentile blood ketone (BHB) value. Half of the ketone values will fit between the 25th and 75th percentile values.
The key takeaway from all this analysis is that the lowest blood sugar levels are associated with lower ketone levels and a lower total energy.
quintile
average BG (mmol/L)
BG (mg/dL)
ketones (mmol/L)
total energy (mmol/L)
25th
average
75th
1
4.5
80
0.3
0.6
0.7
5.0
2
4.9
88
0.4
0.8
1.1
5.7
3
5.1
92
0.6
1.1
1.5
6.2
4
5.1
92
1.2
1.8
2.3
6.9
5
5.1
91
2.2
3.2
4.0
8.3
In the discussion above we see that the lowest risk of the modern diseases of aging and metabolic health occurs when we have a HbA1c of less than 5%. Dr Richard Bernstein recommends a blood glucose of 83 mg/dL or 4.6 mmol/L as optimal. It seems that as a general rule (maybe other than when we are fasting or aiming for therapeutic ketosis) being somewhere to the left of this chart is optimal.
You may not always be able to live at a very low total energy level, but as you fast or increase the spacing between your meals your total energy levels will decrease and you will get all the positive benefits of fasting. (See How to Use Your Blood Sugar Meter as a Fuel Gauge and How to Use Your Bathroom Scale as a Fuel Gauge for objective measures to refine your balance between feasting and fasting to achieve your goals).
You don’t achieve optimal ketone levels by adding fat with super high ketone levels, but rather by managing your energy balance, carbohydrate intake, and meal timing so you can dip into endogenous ketosis on a regular basis through fasting.
When you do eat, you should try to maximise nutrient density to ensure you get the nutrients you need without needing to overeat. Your blood ketone levels will decrease when you are using insulin to build and repair your muscles. When you stop eating for a while you will see them rise again as fat flows out of storage.
Anecdotally it seems that people who are very physically fit may find they have lower blood ketone levels. Lower blood ketone levels (say greater than or equal to 0.2mmol/L) with low blood glucose levels seems to be a healthy place to be.
In fact, you could even save your money on testing ketones and just focus on making sure your blood sugars are closer to optimal.
is it the ketones or NAD+ that is really doing the good stuff?
A smart friend of mine, Robert Miller, has been influencing my thinking recently around ketones.
Robert’s theory is that the benefits that people attribute to ketones are actually largely due to an increase in nicotinamide adenine dinucleotide (NAD+).[19][20]
Adequate levels of NAD are critical to moving energy around our body, from our food to our mitochondria.[21]
NAD+ declines with age, increases in fasting, during a ketogenic diet or in response to exercise.
When NAD+ rises, SIRT1 helps our body to repair and improve our insulin resistance.[22]
Our NAD+/NADH balance is critical to controlling our appetite and telling the body whether we need more fuel, or if it’s time to tap into our body fat stores.
We can increase our circulating levels of NAD+ by eating a nutrient dense diet, particularly with adequate niacin (vitamin B3).[23]
There are also a range of NAD+ supplements that seem to have positive benefits for a lot of people.
Nicotinamide Riboside is a close precursor to NAD+ which can be helpful for people who struggle to make NAD+ directly from food.
NAD+ metabolism is a fascinating rabbit hole if you want to do some research, but for now let’s say that it’s important to have adequate NAD+ to enable your mitochondria to convert the food you eat to energy rather than having it back up in your body.
what about breath ketones (acetone)?
You will likely be aware that three separate types of ketone bodies:
acetone (breath ketones),
acetoacetic acid, and
beta-hydroxybutyric acid (BHB in the blood).
Fatty acids come to the liver either from our food or lipolysis (mobilisation of fat from our body) and converted to acetoacetate. Unfortunately, we have no way to directly measure acetoacetate, only BHB in the blood and acetone in the breath.
The Ketonix is a device that you blow into that measures the acetone which is akin to an exhaust that is released when you burn acetoacetate.
“Endogenous acetone production is a by-product of the fat metabolism process… Breath acetone concentration (BrAc) has been shown to correlate with the rate of fat loss in healthy individuals… A strong correlation exists between increased BrAce and the rate of fat loss.”
The Ketonix data shows a similar relationship but with a lot of scatter!
Most people at this point throw in the towel and go back to blood ketones (BHB) which appear to be more reliable, but it’s important to note that breath acetone is a stronger marker of burning ketones for fuel, not just buffering energy in the blood.
What I’m trying to illustrate with the dodgy clipart in the chart above is that having high blood ketones and low levels of breath acetone appears to be a sign that you are not burning the fat you’re eating.
By contrast, a high level of breath acetone with a low level of blood ketones (BHB) and low blood glucose may be a sign that you are very effectively burning the fat you eat.
If you had a choice, I think it’s better to have high breath acetone (BrAce) and lower blood ketones (BHB) (which would indicate that you were efficient at burning fat) than high BHB and low BrAc (which would indicate that you were good at eating fat but not necessarily burning fat).
The figure below shows BHB vs BrAc for the different purposes that people nominate for using the Ketonix. What we see is that people with diabetes (red trend line) have both higher blood glucose and higher blood ketone (BHB) levels (i.e. higher total energy). Fuelling the mitochondria with the right nutrients that increase NAD+ will both help to burn off the excess energy and manage appetite through the NAD+/NADH ratio.
The second law of thermodynamics states that the total entropy (chaos) of an isolated system can only increase over time. The total energy concept is novel, but it seems that an organism that is aging will decay and not be able it’s energy packed in storage but rather we will see increasing levels of energy floating around in the blood stream.
summary
Metabolic related diseases such as heart disease, cancer, stroke, diabetes, Alzheimer’s disease, kidney disease are the major causes of death.
People with the best metabolic health (i.e. low HbA1c, insulin and blood sugar levels) have the lowest risk of dying from these common western diseases of aging.
Keeping your processed and starchy carbohydrates low will help to keep your blood glucose and insulin levels and reduce your risk of obesity.
When we fast, our glucose levels decrease and ketones increase to maintain our energy levels.
People who are metabolically healthy and insulin sensitive typically have a lower level of total energy (i.e. glucose + ketones) in their bloodstream.
We can mimic the rise in ketones with added fats or exogenous ketones that we see in fasting, however the real benefits occur when the body is forced to draw on its own stored energy and we experience autophagy, upregulation of SIRT1, and a rise in NAD+.
The benefits that we generally attribute to ketones may also be due to increased NAD+ levels which occur in fasting and / or with a nutrient dense diet.
We can only measure beta hydroxybutyrate (in the blood) and acetone (in the breath). We can think the BHB as a buffer ready for use, and acetone as the exhaust showing that the ketones have been burned for fuel. Higher levels of fat burning with a lower need for buffering is a better place to be than a high buffer in the blood and minimal fat burning.
A therapeutic ketogenic diet has a very low insulin load from non-fibre carbohydrates and a higher amount of dietary fat to achieve higher ketone to manage chronic conditions such as cancer, epilepsy, alzheimer’s, dementia etc.
The chart below shows our insulin response versus insulin load which considered fibre and protein as well as carbohydrates. People wanting to following a ketogenic diet should eat foods towards to the bottom left of this chart.
We can quantify the insulin load using the following formula:
insulin load = total carbohydrates – fibre + 0.56 x protein
The chart below shows the nutrition provided by this high fat approach. The therapeutic ketogenic dietary approach does not provide the DRI levels of:
tyrosine,
phosphorus,
alpha linolenic acid,
threonine,
vitamin A,
copper,
vitamin K,
riboflavin,
selenium, and
lysine.
Hence this style of therapeutic approach is idea for a shorter term intervention with a higher nutrient density approach being adopted when possible.
other dietary approaches
The table below contains links to separate blog posts and printable .pdfs detailing optimal foods for a range of dietary approaches (sorted from most to least nutrient dense) that may be of interest depending on your situation and goals. You can print them out to stick to your fridge or take on your next shopping expedition for some inspiration.
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.
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.
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.
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.
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:
ketosis occurs when your blood sugars are close to optimal,
blood sugars can be optimised by reducing the insulin load of your diet, and
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.
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