Tag Archives: ketogenic diet

articles, insulin index, insulin resisatnce

the carbohydrate-insulin hypothesis vs the adipose centric model of diabetes and obesity

May 3, 2018 Marty Kendall 21 Comments

I recently shared Dr Ted Naiman’s latest “insulinographic” that attempts to explain the adipose centric theory of diabetesity.

It created some great discussion as well as some confusion, so I thought it would be worth an article to unpack the critical insights about how insulin really works in our body and what we can do to reduce body fat and avoid diabetes.

The first clarification is that this isn’t a meme or a graph. It’s more an infographic that attempts to explain how insulin is anti-catabolic and works like a dam to hold back the flood of stored energy in our body.

The dam analogy builds on the line of thought initially detailed in the Does insulin resistance really cause obesity? article.

Basal vs bolus insulin

I have spent a lot of time analysing the insulin index data which helps us to quantify our short-term insulin response to food.

This is helpful for people with diabetes (like my wife Monica) to choose foods that keep their blood sugars stable as well as help them more accurately calculate their insulin dose by accounting for carbohydrates, fibre, protein and fructose.

However, with all the focus on carbs, fat and protein, I fear we may have neglected the most important thing that influences our insulin response to the food we eat.

Majoring in the minors

Before we switched to a lower carb dietary approach, my wife Monica was taking about 50 units of insulin per day to manage her Type 1 diabetes. ABout half of that was for food (bolus) and half was her background insulin (basal).

These days, Monica takes about half the insulin that she used to. However, now about 80% of her daily insulin dose is basal insulin while only 20% of her insulin is taken to manage her blood sugars levels around meals.

	basal insulin	bolus insulin (for food)	total daily insulin
Higher carb diet	25 units	25 units	50 units
Low carb diet	20 units	5 units	25 units

Monica’s basal insulin demand has reduced a little due to some weight loss and improved insulin sensitivity.

The most interesting observation is that the vast majority of the insulin required by someone on a low carb diet is not related to the carbohydrates or even the protein in the food they eat.

While carbs and protein raise insulin in the short term, the fat on our body and the fat in our diet have the most significant influence on our insulin levels.

The grey area in the chart below shows the insulin released across the day by someone with a functioning pancreas. The pink line shows how someone with Type 1 diabetes tries to mimic this with an insulin pump.

A lower carb diet is a no-brainer for someone with diabetes to help them stabilise their blood sugars and appetite.^[1] However, we get to a point of diminishing returns when we only focus on the carbohydrate and protein in our diet while ignoring the fat in our diet and the fat on our body.

Elevated fasting (or basal) insulin is the elephant in the room for many people on a low carb or keto diet. Many people on a low carb or ketogenic stabilise their blood sugars and improve HbA1cs, but are still obese with high fasting insulin levels.

The harsh reality is that replacing the carbs and protein in your diet with fat will not reverse your hyperinsulinemia unless it also reduces the amount of fat stored on your body!

But what is going on?

But what can we do?

That’s where Ted Naiman’s “insulinographic” comes in.

Many people think that elevated insulin is the cause of obesity. But, I’m coming to realise that most of the time it’s actually the other way around.

It is actually obesity (or at least being overfat relative to our Personal Fat Threshold) that causes hyperinsulinemia.

Insulin is anti-catabolic

We typically think of insulin as an anabolic hormone that forces amino acids into muscles and glucose into our cells. But it can actually be more useful to think of insulin’s anti-catabolic properties.^[2] ^[3] ^[4] ^[5] ^[6] ^[7]

Rather than just building our muscles and fat stores or forcing glucose into the cells, insulin also works to keep fat and muscle in storage.

Insulin prevents entropy (or chaos) and ensures that we don’t melt into a puddle like Olaf the Snowman.

Someone with Type 1 diabetes does not have enough insulin to prevent catabolism. Their protein, fat and glucose stores in their body get released into their bloodstream in an uncontrolled manner and result in high glucose, high free fatty acids and high BHB ketones.

The good news though is that if your pancreas is working, you will produce insulin when you’re not eating to enable you to regulate the amount of fuel being released from storage into your bloodstream.

Healthy fasting insulin levels in hunter-gatherers range between 3 – 6 mIU/mL.^[8] In western populations, the average fasting insulin level is about 8.6 mIU/mL.^[9] People with insulin resistance or diabetes have much higher levels of fasting insulin.

Insulin is the hormonal signal that raises the dam wall to slow the flow from stored energy via our liver while the energy in our bloodstream is being used up.

The more fat you have to hold back in storage, the higher your insulin levels need to be.

This helps us to understand why many people low carbers who are obese have high fasting insulin levels. Even though they may be eating minimal amounts of carbs and protein in an effort to keep their insulin levels low, their body is keeping insulin high in an effort to hold their energy in storage until the energy in their bloodstream is used up.

To help elaborate on this I have fleshed out what various scenarios would look like in terms of body fat, insulin levels and energy in the blood (i.e. glucose, ketones and free fatty acids) in the table below.

note: TOFI = thin on the outside, fat on the inside and PFT = personal fat threshold

I can make you fat

Dr Jason Fung points out that people using exogenous (injected) insulin to manage their diabetes can develop obesity and insulin resistance because of their medications.

Dr Robert Lustig also explains how someone injected with a little bit of extra insulin at each meal will store more fat and not be able to mobilise their body fat (lipolysis).

To some extent, this is what happens when someone with diabetes injects insulin to cover a crappy nutrient-poor insulinogenic diet. With large doses of exogenous insulin to cover a high carb processed diet they never quite get the insulin dosing right. They end up overdosing with insulin and having to eat more to rescue themselves from low blood sugars. The great thing about a low carb more less processed foods for these people is that it helps stabilise blood sugar and insulin doses which is easier to manage with smaller doses of insulin.

To go back to our “dam” analogy, excessive exogenous insulin for someone who already has hyperinsulinemia is like building our dam wall higher than it needs to be. The higher dam wall will hold back more energy in storage than it needs to and less of the energy we eat will be released into the bloodstream.

We feel hungrier because the excessive exogenous (injected) insulin is not allowing energy to be released into circulation.

We will end up eating more, and this excess energy will be stored more easily. We will become more and more resistant to the insulin we are injecting as our fat stores become fuller, and we need more insulin to hold our fat in storage.

The solution here is a low carb diet to help stabilise blood sugars and hunger driven by excessive swings in insulin and blood sugar.

The fatal flaw in the insulin-centric view of obesity

Where this insulin-centric view of diabetes and obesity fails is that it doesn’t translate to someone who is not taking exogenous injected insulin or drugs that stimulate insulin release from their pancreas.

Our bodies optimise for efficiency. Unless you have an insulinoma (a tumour on your pancreas), your pancreas will not secrete more insulin than it needs to.

Our pancreas will not build the dam wall higher than it needs to be to hold back the energy coming into our system!

Irrespective of insulin levels, you cannot store energy we do not eat.

At the risk of doing your head in, we can look at the function of insulin as anabolic (building) and anti-catabolic (preventing breakdown) and get to the same conclusion:

Anabolic – Although dietary fat doesn’t raise insulin much in the short term, you will always have enough basal insulin on board to store the fat you eat on your body (note: this is the anabolic.
Anti-catabolic – Your pancreas will always produce enough insulin to slow the flow of energy out of the stores on your body while you use up the energy from the food coming in from your mouth.

Our fasting insulin is proportional to the amount of fat stuffed away in storage which is directly proportional to the amount of food that we have eaten.

We cannot really blame obesity on insulin resistance. It is our insulin sensitivity that enables our fat cells to grow. Once we become insulin resistant, we actually find it harder to store excess energy in our adipose tissue.

How to keep your basal insulin low

There a number of things that help us lower our dam wall, including:

exercise,
fasting,
a low energy diet, or
a high nutrient density diet.

Exercise

Exercise, particularly resistance excercise or HIIT, is a great way to build insulin sensitivity and helps us to burn off fat and sugar without the need for insulin.^[13] People with Type 1 diabetes find they need to reduce their insulin dose when they are active and increase their basal by about 25% when they don’t exercise.

Fasting

Not eating for a period of time is a great way to reduce your insulin.

Once you use up the glycogen in your liver, your body turns to the fat stores and lowers insulin levels to allow more stored body fat to flow over the dam into the system.

However, for some people, the problem with fasting is that it’s easy to overdo the refeed.

When I was fasting regularly to try to lose some extra fat, I found I would permit myself to eat more than I would otherwise have eaten. And the foods that I chose to eat were often less nutrient dense and more energy dense dense than usual.

In spite of the saint-like deprivation for days, I found I didn’t lose much weight over the long-term. In the end, I seemed to eat back my deficit. My wife Monica would say ‘I don’t think this fasting thing is working for you! Why don’t you try eating a little less each day?’

I have talked about using your bathroom scale or blood sugar readings to refine the frequency and quantity of your feeding to make sure you are moving towards your goal. Unfortunately, just like tracking calories, these approaches to fine tuning your food intake require self-discipline and deprivation which is not fun.

Even better than tracking blood glucose or your weight, another way to manage your fasting/feeding frequency and food intake would be to measure your blood insulin level to ensure it was going down to new lows before you ate, and then ensure that when you refeed that you didn’t drive insulin too high with too much food.

Unfortunately, there is no home test for insulin yet, so our blood glucose metre and the bathroom scale are the best we can do for now.

Many believe that they will keep insulin levels low if they focus on higher fat foods when they refeed. However, it is possible to drive higher levels of insulin with a high-fat intake in only a short amount of time.

A relevant example of this is Jimmy Moore’s recent high protein experiment where he reduced his fasting insulin from 14.2 to a very respectable 8.8 mIU/mL in five days on a high protein energy restricted diet.^[14] ^[15] ^[16]

Afterwards, he finished the fast on Sunday (8 April as per the date on the Instagram image below) he proceeded to boost his fasting insulin to 18 mIU/mL after a day of high fat refeeding before the laboratory was open to measure his post-experiment labs on Monday. This post refeed insulin was actually higher than his 14.2 mIU/mL insulin before the experiment began.

This also aligns with the study results shown below where participants lowered their insulin and triglycerides more higher protein lower carb diet.^[17]

Similarly, this twelve month randomised control low carb study found that people had better outcomes in terms of weight, body fat, insulin, HOMA-IR, HDL, hunger and emotional eating with higher levels protein.

It will be interesting to see how Jimmy’s upcoming high-fat bio hack goes. I hypothesise that Jimmy’s short-term insulin level may be lower after meals, but his longer-term fasting insulin will be higher on the high-fat approach.

Once we account for the Thermic Effect of Food (TEF), there is actually more available energy in the high-fat approach as shown in the calculations below.

	high protein (3:1)	80% fat
fat (g)	90	168
protein (g)	270	95
fat (cal)	810	1512
protein (cal)	1080	378
energy consumed (cal)	1890	1890
TEF (cal)	405	265
available energy (cal)	1485	1625
short-term insulin	higher	lower
long-term (fasting) insulin	lower	higher

With less energy actually available to the body in the high protein scenario, the pancreas will produce less insulin to allow more energy to be released from storage compared to the high-fat scenario.

Low energy diet

As noted in Ted’s insulinographic, a low energy density diet is another way to keep your basal insulin levels down.

You can achieve this by focusing on foods with a lower energy density which will make it harder to overeat. This will ensure your body fat stores are used. With less fat to hold back in storage, your insulin levels will decrease.

This is why we see some people who make the switch to a whole foods plant-based diet reduce their insulin requirements and reverse their diabetes. As long as they stick to whole foods, they will not be able to ingest enough energy to maintain their weight, so their insulin comes down. However, this does not hold for processed vegan junk food which can still be energy dense, highly processed, hyperpalatable and easy to overconsume.

What about trying to eat less food?

Another option is to try to simply eat less food. While this can be helpful, it shouldn’t be the only technique used as simply restricting the intake of nutrient-poor junk food is a recipe for nutrient cravings and rebound binge eating.

Nutrient-dense diet

Maximising nutrient density is my favourite hack because it addresses the following factors:

Adequate protein. If you eat foods that contain the vitamins, minerals and essential fatty acids you need you will obtain plenty of protein which, on a calorie for calorie basis, is the most satiating macronutrient. There is a lot of confusion around protein, but the reality is, if you are eating foods that contain adequate levels of vitamins, minerals and essential fatty acids you will be getting plenty of protein. Conversely, actively avoiding protein may lead to nutrient deficiencies. Whether you approach this in terms of higher nutrient densitym, targeting the most satiating macronutrients or the foods that will naturally provide you with greater satiety you arrive at pretty much the same point.

Energy density. A nutrient-dense diet typically has plenty of whole foods that have lower levels of refined carbs and processed fats which have a lower energy density and hence are hard to overeat.
Minimally processed. Quantifying nutrient density is a foolproof way to ensure that the food contains the micronutrients you need rather than hyperpalatable flavourings and colours from Frankenfoods that are designed to look like they are good for you (but they’re not). These minimally processed foods are also satiating without being hyperpalatable so are self-limiting.
Prevents cravings. Good nutrition, avoiding diabetes, weight control and lower insulin levels seems to boil down to getting the nutrients you need without too much energy. Focusing on nutrient-dense foods also gives the best chance of avoiding nutrient cravings that will unnecessarily drive your appetite.

Fat raises insulin too, it just takes longer

Most of the time we focus on carbs (and to a lesser extent protein) as being the culprit when it comes to raising insulin levels. But does this hold true when we look at the big picture?

The insulin index data suggests that higher fat foods have a lower insulin response. But is this simply because the insulin index testing only measured the insulin response over three hours?

The chart below on the left shows that insulin rises more slowly for a high-fat meal compared to glucose or a mixed meal.^[18] However, it still rises and looks like it will keep on going for a while after the 120-minute measurement.

If we were able to test the insulin response over 24 hours, I think we would see that insulin response is actually more closely related to the available energy in our food rather than a specific nutrient.

Is our long-term insulin response simply related to the amount of energy in our food and hence the amount of energy needs to be held back in storage by the liver?

Is it only because carbs and protein have a higher oxidative priority than fat that we see a greater short-term spike in insulin (i.e. the body needs to act more quickly with a sharper insulin response to hold back energy from carbs in storage compared to fat or protein)?

The adipose centric model of diabesity

The insulin-centric view of obesity, diabetes and insulin resistance focuses on reducing insulin by switching carbs out for fat to control our (short term) insulin response to food.

Meanwhile, the adipose-centric view of diabetes is a little bit more sophisticated and complete as it also considers the long-term insulin response to the food we consume.

Someone who is lean and insulin sensitive will have healthy levels of adipose tissue that can quickly swell to take on more energy and then release it. If you are insulin sensitive like these guys, you store precious energy very efficiently when it is available.

But our fat stores can only take in so much energy before they become full. There is a limit to how high you can build your dam wall.

When your fat cells become stuffed and can’t take on more energy, they are said to be “insulin resistant”. At this point, any excess energy spills out into the bloodstream as elevated glucose, free fatty acids or ketones. Excess energy is also pumped into our vital organs, and we develop fatty liver, fatty pancreas, heart disease and the other complications of western civilisation.

To be clear, it’s not being obese that causes diabetes. Instead, it’s a matter of being overfat relative to your Personal Fat Threshold. Some people are “blessed” to be able to store a lot more energy in their fat stores before they become insulin resistant and diabetic, while others find that can only store a little bit of energy in their adipose stores before it overflows and ends up being stored in their vital organs and bloodstream.

Disease progression and reversal

Listed below is the progression from health to disease, with hyperinsulinemia building progressively throughout.

Insulin-sensitive healthy fat levels that are able to easily absorb and release any excess energy for later use.
Expansion and filling of insulin-sensitive adipose tissue with sustained energy excess.
Fat cells become full and exceed your Personal Fat Threshold (largely influenced by genetics).
Fat cells become full and “insulin resistant” relative to other parts of the body.
Excess energy builds up as visceral fat in vital organs and spills over into the bloodstream (aka diabetes).
Excessive swings in blood sugar and insulin cause a dysregulated appetite driving further overeating.
Complications of western disease due to (i.e. obesity, diabetes, heart disease, Parkinsons, Alzheimers, dementia etc).

To reverse these steps and reduce insulin to normal levels we need to follow to:

Stabilise blood sugars and insulin swings by reducing processed carbohydrates to help improve appetite control and eliminate the need for exogenous insulin.
Focus on more nutrient dense, less energy dense foods to improve satiety and induce an energy deficit.
A sustained energy deficit causes a reduction in visceral fat which improves the function of the heart, liver, pancreas and brain.
Reduced pressure on the adipose fat allows to below the Personal Fat Threshold allows incoming energy to be buffered in fat stores without overflow into the bloodstream (i.e. reversal of diabetes).
Fat loss further reverses insulin levels and blood sugars to achieve optimal levels for longevity and performance.

So what’s the solution?

So, if insulin and carbs aren’t to blame for our obesity and diabetes then what can we do?

Is it back to just eat less, exercise more?

Well sort of, but not exactly.

There are a number of practical steps that we can take to avoid diabesity including:

Minimise cheap hyper-palatable processed food that overrides our satiety signals and tricks our taste buds.
Invest in quality food and learn to cook at home from fresh whole ingredients.
Monitor your nutrient intake by logging your food using Cronometer.
Eat your meals mindfully with other people rather than in front of a screen alone.
Don’t use food as a source of comfort.
Sleep and rest enough so you don’t need to use energy dense food as a pick me up.
Be active and build as much lean muscle as you can in order to efficiently burn the carbs and fat you consume.
Focus on nutrient-dense foods that are minimally processed that will minimize cravings. If you focus on maximising the good stuff in your diet, you will not have to worry as much about avoiding the processed food that are full of sugars, flavourings and seed oils.
Moderate carbs if you need to stabilise blood sugar and insulin swings which can help stabilise appetite. Diabetes and longevity expert, Dr Peter Attia, recommends that we eat foods that will keep our blood sugar low (i.e. less than 90 mg/dL) and with a relatively tight standard deviation of less than 10 mg/dL.^[19] ^[20]
Don’t demonise macronutrients, but instead prioritise nutrient-dense whole foods.

If all of the above still don’t get you to where you want to be then you may need to track your intake for a while and titrate down your calorie intake to recalibrate your version satiety. The good news is that many people find when focusing on maximising the nutrient density of their diet managing the quantity of food isn’t such a big deal.

References

^[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5792004/

^[2] https://www.ncbi.nlm.nih.gov/pubmed/16705065

^[3] https://www.ncbi.nlm.nih.gov/pubmed/3298320

^[4] https://www.t-nation.com/diet-fat-loss/insulin-advantage

^[5] https://www.ncbi.nlm.nih.gov/pubmed/16705065

^[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1804253/

^[7] https://academic.oup.com/bja/article/85/1/69/263650

^[8] http://wholehealthsource.blogspot.com.au/2009/12/whats-ideal-fasting-insulin-level.html

^[9] http://wholehealthsource.blogspot.com.au/2009/12/whats-ideal-fasting-insulin-level.html

^[10] https://www.ncbi.nlm.nih.gov/pubmed/7972417

^[11] http://www.diabetesincontrol.com/insulin-as-a-satiety-signal-in-postprandial-period/

^[12] https://weightology.net/insulin-an-undeserved-bad-reputation/

^[13] https://www.ncbi.nlm.nih.gov/pubmed/9435517

^[14] http://www.ketohackingmd.com/8-7-day-high-protein-hack-experiment-results-part-1/

^[15] http://www.ketohackingmd.com/9-7-day-high-protein-hack-experiment-results-part-2/

^[16] http://www.ketohackingmd.com/10-7-day-high-protein-hack-experiment-results-part-3/

^[17] https://www.ncbi.nlm.nih.gov/pubmed/15817850

^[18] https://chrismasterjohnphd.com/2017/07/26/insulin-really-response-carbohydrate-just-gauge-energy-status-mwm-2-23/

^[19] https://peterattiamd.com/2016-update/

^[20] https://www.youtube.com/watch?v=vDFxdkck354

articles, blood sugar, ketosis, therapeutic ketosis

keto… do you want some more?

January 27, 2018 Marty Kendall 4 Comments

key points

“Keto” is booming! But there is still a lot of confusion about what exactly constitutes “optimal ketosis”.
Most of the magic of ketosis occurs when you burn your own body fat rather than eat more dietary fat or consume exogenous ketones.
If your goal is weight loss or diabetes management, chase lower blood glucose levels, not higher ketone levels.
Our bodies switch to burning more fat via ketogenesis when we eat less digestible carbohydrates and protein available.
While many people get caught up chasing ‘optimal ketosis’, anything above 0.2 mmol/L with lower blood sugar levels is a sign that your insulin sensitivity and metabolic health is improving.
Eating ‘fat to satiety’ on a low carb or ketogenic diet can help you achieve ‘non-diabetic’ blood sugar levels. However, some degree of self-discipline may still be required to achieve optimal health and desirable body fat levels.

Keto is so hot right now!

Every woman and her cat seem to be getting on the keto bandwagon.

Whether it be cookbooks, Facebook groups or forums, keto is booming!

If everyone else is getting on the keto train then surely you need some?

And more must be better?

Right?

If you’re not doing it yet then maybe you’re missing out?

Or like every exponential trend, is there a crash just over the horizon?

Like tulip bulbs in the 1630s?

Or perhaps Bitcoin right now?

My keto journey

Personally, I’ve had a keen interest in ketosis for a while.

I was into keto before it was cool.

I followed Dave Asprey’s Bulletproof coffcoffeeze. I even bought a bunch of his expensive mycotoxin free beans.

I eagerly followed Jimmy Moore’s updates during his n=1 ketosis experiment during 2012.

I was so eager to follow in his footsteps as soon as I could!

I got hold of Keto Clarity as soon as it was released. I started adding butter and MCT oil to my coffee and eating liberal amounts of cheese, cream and coconut products in an effort to get my ketone values into what I understood to be the “optimal ketone zone”.^[1]

I spent a good chunk of money on strips to test my blood ketones regularly to see if I was achieving ‘optimal ketosis’.

Calories and energy balance didn’t matter.

I had faith.

But unfortunately, I wasn’t one of the blessed that could ‘eat fat to satiety’ and be as lean and healthy as I’d hoped.

The picture below is my work profile shot a year or so after chasing higher ketones with more refined dietary fat.

I was as heavy as I’d ever been, had early signs of fatty liver and prediabetes.

I realise now that I had been trying to drive exogenous ketosis with lots of extra dietary fat.

What I really needed was to learn how to achieve endogenous ketosis to burn off my unwanted body fat.

My quest to understand what went wrong has taken me on a fascinating journey in an effort to manage my own health as well as to understand how to assist my wife Monica better manage her type 1 diabetes.

In this post, I hope to share some of my learnings and insights to help people get what they really need from their keto journey and avoid the common pitfalls.

Virta Facebook Live Q&A

I recently had the opportunity to pose some of my most pressing questions about optimal ketone levels and protein intake to the Godfather of Keto, Dr Stephen Phinney in a recent Facebook live Q&A.

Dr Phinney addressed one of my questions in the live broadcast as well as responding in writing in writing on the Virta blog.

I have included my question on optimal ketone levels and Dr Phinney’s response below along with my own additional thoughts.

But first, I think it’s important to understand what ketosis actually is.

What is ketosis?

Ketosis occurs when there is a lack of Oxaloacetate from non-fibre digestible carbohydrates and protein to enable fat to be oxidised in the Krebs cycle. When Oxaloacetate availability reduces, the body produces Acetoacetyl CoA and Acetoacetate (AcAc) via ketosis.

You can also think of this in terms of insulin load. That is, when the net carbs and protein in the diet are reduced we switch to burn more of our fat via ketogenesis rather than in the Krebs cycle.

I used to think that we were only burning fat when via ketosis, but I now understand that’s not correct. Ketosis is just how we burn fat when the Kreb cycle can’t operate normally. Ketosis is an important biochemical process that allowed us to survive through times when food was scarce.

As described by Dr David Sinclair in this video, lots of good things happen during periods of low energy availability (e.g. increased autophagy, AND+ and SIRT1). Our bodies go into emergency repair mode to increase our chances of being around to procreate in future times of plenty.

Energy restriction is the only thing that has conclusively been proved to promote longevity in humans. But it’s hard, so it’s not very popular. When food is available, left to our own devices, our bodies tend to store up a little extra fat for the winter. Unfortunately, in our modern environment, winter never comes.

If your NAD+ levels are lower, more Acetoacetate (AcAc) will be converted to Beta-hydroxybutyrate (BHB) in the blood. If your NADH+:NADH ratio is high there will be more Acetoacetate in circulation. Acetone can be thought of as the vapour that is released from Acetoacetate. So, if less Acetoacetate is being converted to BHB, you will register higher breath ketones. Chris Masterjohn explains this in more detail in this video.

Reduced NAD+ levels are associated with ageing, and increased NADH levels are associated with over fueling and diabetes. Thus, high levels of BHB and low levels of breath acetone are not a good sign.

You may be interested to know that fat loss from the body is better correlated with higher breath acetone levels rather than ketones in the blood.^[2]

Personally, I find when I take Niacin supplements (vitamin B3 increases NAD+) my BHB plummets and my breath acetone skyrockets.

In summary, the amount of beta-hydroxybutyrate in your bloodstream at any point in time is influenced by the amount of fat ingested, your NAD+:NADH ratio as well as the rate at which they are using BHB.

What are normal ketone levels?

We all like to compare others to others to understand if we are normal.

I thought it would be interesting to crowdsource some data to understand what normal ketone levels are in people following a low carb or ketogenic diet. I wanted to understand if everyone was struggling to reach the ‘optimal ketone zone’ like I was.

The chart below shows the compilation of more than three thousand blood ketone and glucose data points crowdsourced from people following a low carb or ketogenic diet (with particular thanks to Michel from Ketonix for the anonymous data). Ketone values are shown in blue on the bottom and glucose is in orange on top.

Diabetic ketoacidosis

Someone with uncontrolled type 1 diabetes will have a very low NAD+:NADH ratio and hence very high levels of BHB (i.e. greater than 8 mmol/L). This is termed “ketoacidosis” and is accompanied by very high blood glucose levels. Someone with uncontrolled type 1 diabetes would be off the chart to the right.

High levels of BHB are dangerous because they are acidic. However, people who do not have Type 1 diabetes typically have blood ketone values less than 4.0mmol/L. People with a functioning pancreas do not need to fear acidic ketones, particularly if they are sitting to the left of this chart with lower levels of energy floating around in their blood.

The bloodstream, our metabolic highway

You can think of our bloodstream as our metabolic highway that helps get the energy to the cells that need it. We want enough energy in the blood to fuel the body, but not so much that a traffic jam occurs.

Really high levels of glucose in the bloodstream lead to glycation. Similarly, high levels of free fatty acids lead to oxidised LDL which increases your risk of heart disease.

If your bloodstream is full like syrup with excess glucose, ketones and fatty acids then the energy and nutrients can’t get where they need to go. Your kidneys will be working overtime clearing out the nutrients from the blood that your body does not require.

Your body raises insulin in an effort to stop energy flowing out of storage while you are still using up the energy in your blood.

When your bloodstream is clogged with energy there will be no opportunity for the body to cleanse and undertake autophagy. Detoxification won’t be able to occur as effectively, and your fat stores will continue to build up toxins.

Exogenous vs endogenous ketosis

I now realise where I went wrong in my early keto journey was that I didn’t understand the difference between exogenous and endogenous ketosis.

I now realise that I was trying to address my pre-diabetes and obesity with a classical or therapeutic ketogenic diet which is intended to be used for epilepsy, cancer, Alzheimer’s, Parkinson’s and dementia.

All this excess energy was just exacerbating the situation I was trying to solve.

Exogenous ketosis

The chart below shows the blood glucose and ketone levels during exogenous ketosis. While glucose may not be high, but we have high levels of ketones and likely higher levels of triglycerides in the bloodstream largely from external sources.

This may be helpful in a situation such as epilepsy, Alzheimer’s, Parkinson’s or dementia where glucose is not being processed efficiently by the brain. Excess glucose is thought to fuel the growth of some cancers, so reducing glucose and increasing ketones enables us to fuel the brain while not feeding the cancer cells.

Endogenous ketosis

The chart below shows what happens in endogenous ketosis. In fasting or energy restriction your blood sugar will decrease.

As you can see from this chart, your blood ketones may not be as high due to your high NAD+:NADH ratio and the fact that you are not pushing in large amounts of external fat. Ketones will also be used for energy rather than building up in the bloodstream.

In this lower energy state, your body will be pulling fat from your belly and bum to offset the deficit of energy from glucose and ketones in the bloodstream.

Your blood will no longer be a congested and the toxins will be able to flow out of your fat stores. Your kidneys will cleanse your bloodstream, and you will excrete the waste that was stored in your fat.

You will increase autophagy as you old proteins, and pre-cancerous cells are cleansed and eaten up by your body. Your insulin levels will also decrease, and your fat stores will become insulin sensitive again.

Without constant incoming energy, the fat in your pancreas, liver, heart, brain, eyes etc will then be used for energy. You will feel younger and lighter and start to think more clearly! You will effectively be slowing the aging process!

Ketosis vs diabetes and obesity

Someone managing diabetes and/or seeking weight loss should ideally target a lower overall level of energy in their bloodstream. Having less energy in the blood, whether in the form of glucose, ketones or free fatty acids, forces the body to supply more energy from body fat.

The chart below shows the levels of blood ketones that relate to higher and lower levels of glucose and ‘total energy’ from glucose and ketones.

The three thousand blood ketone and glucose levels have been divided into five ‘bins’ based on their total energy content. The smallest is shown on the left with the largest total energy shown on the right.

This data suggests that good metabolic health is characterised by not having excessive levels of energy floating around in the bloodstream. Lower glucose levels tend to correlate with lower blood ketones. The lowest blood glucose levels are associated with a blood ketone level of about 0.3 to 0.7mmol/L.

Virta ketone data

When I recently re-read the paper detailing the results of the first ten weeks of the Virta trial I was intrigued to see that, even though they were targeting ‘nutritional ketosis’ the average BHB level achieved was only just above the cut off for nutritional ketosis. The average BHB was 0.6mmol/L with a standard deviation of 0.6 mmol/L.

To better understand what this means, the chart below, many people had ketone levels below the cut off for nutritional ketosis of 0.5 mmol/L. The largest ‘bin’ of ketone values as 0.1 to 0.3 mmol/L.^[3] The second largest grouping was 0.3 to 0.5 mmol/L.

It struck me that these blood ketone levels aligned reasonably closely with the values shown in my crowdsourced data. My question to Virta and Dr Phinney’s response is shown below:

Dr Phinney’s comment that it was the people with the higher ketone levels that experienced better results in the long term made me think of the relationship between ketones and blood glucose which is also based on the crowdsourced data.

In fasting, people who are more insulin sensitive can more easily produce ketones when there is no food, while people with high levels of insulin have high blood sugar levels and tend to have lower levels of ketones as shown in the chart below.

So perhaps the people who did the best were the ones that were already more insulin sensitive and thus were able to go longer periods between food, especially once the insulin load of their diet was reduced and their blood sugar and insulin levels came down closer normal levels?

What does all this mean in practice?

At this point, you’re probably confused. Is it even worth testing ketones? And if I do, what values should I be targeting?

My conclusion, after doing a lot of self-testing as well as analysis of a lot of other people’s data is that, unless you require ketosis for therapeutic purposes your blood ketone levels probably don’t matter that much.

Some level of blood ketones is good to have (say 0.2 mmol/L or more), but more is not necessarily better.

And for goodness sake, don’t go chasing higher blood ketones with more dietary fat if your goal is fat loss from your body!

For people trying to manage obesity and/or diabetes, ketosis is a fascinating side effect of a lower energy state when you have less carbohydrate and protein to burn. But it is not the end goal. Ketosis is part of the process that occurs as we burn out own body fat.

So how do I optimise my blood sugars?

A diet with a lower insulin load (i.e. less non-fibre carbohydrates and less insulinogenic protein) will enable someone with diabetes to stabilise their blood glucose levels. They will require less insulin so their pancreas can more easily keep up to maintain healthy blood glucose levels.

Stable blood sugars and removal of processed carbohydrates often helps to normalise appetite and spontaneous weight loss.

As body fat stores become less full your adipose tissue will become more insulin sensitive and can then absorb the day to day energy flux without needing to spill excess energy into the bloodstream. Because your body fat is doing the job properly, you won’t see high levels of blood sugar in your blood.

Your body is always rebalancing your fuel system (i.e. glucose, ketones and free fatty acids) depending on your needs and dietary energy sources.

We can store a little bit of glucose in our bloodstream and liver, but the major fuel tank is our fat stores. When our adipose tissue is full and can’t take anymore everything else backs up and overflows.

How to stay below your “Personal Fat Threshold”

Fascinating recent work by Professor Roy Taylor at Newcastle University in the UK has shown that reducing fat from the vital organs like the pancreas can actually reverse diabetes.^[4]

Professor Taylor coined the term ‘Personal Fat Threshold’ which is the point at which your adipose tissue can no longer easily absorb the extra energy from the food we eat and starts to send more of it to other places in our body. It’s like our fat storage balloon is full.^[5]

Once we exceed our personal fat threshold any extra is energy shuttled off to the bloodstream in the form of high glucose, high free fatty acids and higher ketones) as well as the other parts of the body that are more insulin sensitive than our adipose tissue such as our liver, pancreas, heart, eyes, kidney, brain and heart).

The problem however with Professor Taylor’s approach was that it was an 800 calorie per day short-term intervention based on Optifast meal replacement shakes. The ideal approach would be to design a nutritious set of foods that would provide the nutrients you need without excessive energy.

Many people find that a low carb diet will help stabilise blood sugar levels. However, many, if not most, people find that they need to restrict energy intake and/or increase the nutrient:energy ratio of their diet in order to achieve the blood glucose control and body fat levels that are associated with optimal longevity. This can be achieved through intermittent fasting, time restricted feeding, meal skipping, ‘clean eating’, calorie counting or whatever works for you.

Regardless of how you feel about any of these concepts, you need to do whatever it takes to reduce the inputs to the point that you see the energy in your bloodstream decrease. How much discipline and deprivation you want to enforce on yourself depends on how close you want to get to optimal.

While it’s good to see your body fat levels reducing, measuring your blood sugar is probably the most effective way to get a cost-effective and immediate understanding of whether you actually need to eat (see How to use your glucose meter as a fuel gauge for more details on this concept).

The figures below show the relationship between HbA1c to various symptoms of metabolic disease such as diabetes, heart disease and stroke.^[6]

All-cause mortality is lowest with an HbA1c of somewhere between 4.5 and 5.0%.^[7]

Can we achieve optimal in our modern environment?

This Australian Aboriginal hunter from more than 100 years ago is my favourite example of optimal metabolic health.

Everything he could find to eat would have been filled with nutrients. He wouldn’t have overeaten because he had to hunt or gather everything, and that took a lot of effort.

Every year or so he would have had a period of externally enforced fasting when food wasn’t so plentiful. And if he was the fattest and slowest in his tribe he might have been prey to wild animals.

Today we like to reminisce about paleo and ancestral times. However, I don’t think we can ever go back to mimic how this guy lived, even if we wanted to.

While we can get unprocessed organic fairly nutrient dense foods, we will probably never achieve the food scarcity context that he had.

Today food is fairly cheap and easy to get hold of. And whenever when we eat ‘to satiety’ we are programmed by evolution to prepare for a famine on a long boat ride where only the people who could store energy survived.

Food is pleasure.

Food is entertainment.

Food is social connection.

Food is emotional.

People like to rail against the idea that we might need to limit our energy intake. However, in today’s context, I think we need to work out how to recreate the useful elements of ‘the good old days’ in a modern context.

Unless we’re prepared to live in the desert and leave our credit cards behind, perhaps things like periods of fasting to reduce our blood glucose levels, gyms to build strength, energy tracking apps like Cronometer to ensure we are eating nutritious food (and not too much of it) all play a role in our modern context?

It’s not going to be a popular concept, but some level of deprivation or self-control may be necessary if you want to achieve optimal health and delay the diseases of aging.

It’s OK if you don’t want to go all in and invest everything it takes to achieve optimal health, but it’s still useful to understand how to get even part of the way there.

Introducing, our new toy! The Nutrient Optimiser

It can be confusing to know how much of each macronutrient you should be eating. Everyone has different goals and circumstances.

Over the last few months, I’ve been working with a very talented programmer, Alex Zotov, to develop some handy software called the Nutrient Optimiser to help people navigate all this information and help people put it into practice.

The table below shows how we how we segregate people based on their different goals based on your blood sugar levels, HbA1c, waist:height ratio and trigliceride:HDL ratio. From there we can target the most nutrient dense foods and meals while also keeping your blood sugars stable, fueling your activity or help you to lose body fat.

If you do have diabetes, then a low carb/keto diet will help stabilise your blood sugars and will often help to stabilise your appetite. But then, as you improve your health you can continue to refine your food choices to and increase the nutrient density of your diet even more.

Meanwhile, if you’ve got great blood sugars but want to lose body fat there’s no reason to be eating a super high fat therapeutic ketogenic diet designed to control epileptic seizures.

The first instalment of the Nutrient Optmiser is a free calculator that will help you identify the ideal macronutrient ranges, energy intake and as well as a shortlist of optimal foods and meals to suit your goals. We’d love you to check it and let us know what you think. We hope it will help a lot of people avoid the confusion of keto and move forward towards optimal.

references

^[1]https://www.amazon.com.au/Keto-Clarity-Definitive-Benefits-Low-Carb/dp/1628600071

^[2]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737348/

^[3]http://assets.virtahealth.com/docs/Virta_Clinic_10-week_outcomes.pdf

^[4]http://www.ncl.ac.uk/press/articles/archive/2017/09/type2diabetesisreversible/

^[5] https://www.ncbi.nlm.nih.gov/pubmed/25515001

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

^[7]http://circoutcomes.ahajournals.org/content/3/6/661

^[8]https://www.perfectketo.com/how-too-much-protein-is-bad-for-ketosis/

^[9]https://nutritionfacts.org/video/the-great-protein-fiasco/

^[10]https://digitalcommons.wku.edu/ijes/vol10/iss8/16/

^[11]https://optimisingnutrition.com/2017/10/30/nutrition-how-to-get-the-minimum-effective-dose/

^[12]https://nutritionandmetabolism.biomedcentral.com/articles/10.1186/s12986-015-0009-2

articles, carbohydrates, diabetes, plant based, vegan

vegan vs keto for diabetes… which is one optimal?

July 25, 2017 Marty Kendall 21 Comments

I recently watched the Mastering Diabetes teleseminar on ketogenic diets with high hopes of picking up some gems of wisdom from the rising stars of the plant-based diabetes community.

Unfortunately, I was underwhelmed with what I heard.

I shared my frustration on Facebook.

Robb Wolf suggested I put together a response to some of the misinformation in the teleseminar. Hence this post. [Robb did an excellent breakdown on the claims in the What the Health Netflix doco, What the Health: A Wolf’s Eye View, which I highly recommend checking out if you haven’t already.]

What’s actually wrong with the keto diet for diabetes?

Cyrus Khambatta (aka Mangoman) and Robby Barbaro (The Mindful Diabetic) should be uniquely qualified, both academically and experientially having themselves lived with type 1 diabetes for decades.

If I were was going to attack keto for diabetes management, then there would have been a couple of ‘free kicks’ I think they could have taken. So, in fairness to both sides, I’ll touch on a few of what I see as legitimate issues with ‘popular keto’ before I dissect the Mastering Diabetes presentation.

Giving fat a free pass

Humans like things to be straightforward and binary.

Yes or No.

Black or white.

High fat or low fat.

Low carb or high fat.

High protein or low protein.

Plants only or animals only.

For the last four decades, we have been told that fat, particularly saturated fat, is bad because it causes heart diseases and should be avoided.

The tide is now turning. However, there will always be people who take things to the extreme.

Now fat is healthy. But is more is better?

Ketones are good. So more is better?

For many people, a higher fat diet will be more satiating, particularly compared to processed grains and sugars. However, not everyone can ‘eat fat to satiety’ without some level of restraint and self-discipline. We can’t all trust our appetite to kick in to effortlessly provide the lean and chiselled body that they dream of.

My personal experience is that you can overdo the fat and drive insulin resistance by pushing fat too hard. If you exceed your ‘personal fat threshold’^[1], your adipose tissues will become insulin resistant, and the body will start pushing excess energy to the vital organs.

While there is no need to fear fat, there is no reason to go hog wild to compensate for the butter and bacon deficiencies that we all developed over the past four decades.

When it comes to nutrition, you need to get your big rocks in place first (i.e. the nutrient dense foods). You can then fill up with fuel such as fattier foods if you do not want to burn any body fat. You could even add some starchy carbs if your blood sugars allow.

Having some level ketones is an indication that your insulin levels aren’t too high and your metabolism is working. However, if you are not yet metabolically healthy, chasing ‘fauxtosis’ by loading up on butter, coconut oil, cream and exogenous ketones to achieve high blood ketone levels can be a recipe for hypercaloric metabolic disaster that will drive insulin resistance.

People with type 1 diabetes (such as the Mastering Diabetes guys and my wife Monica) have a unique insight into the various factors that affect their insulin sensitivity. They can monitor their daily insulin dose.

I know some people with type 1 diabetes who have made an effort to chase higher ketones with more refined fat and less protein but found that they ended up needing more insulin. Retreating to a moderate to high protein approach with less added fat (as per Dr Bernstein’s recommended approach for Type 1 diabetes) enabled them to improve their insulin sensitivity (e.g. check out Allison’s Nutrient Optimiser analysis here).

This phenomenon is not unique to people with type 1 diabetes. There seem to be more and more people start out believing calories don’t count, only hormones. They then put their faith in the ‘magic ketone fairy’ and end up driving insulin resistance and obesity chasing ‘optimal ketone levels’ with more and more added fat.^[2]

I have a dream

Before we get into the nutritional analysis, permit me this indulgence to share my vision (with a hat tip to Martin Luther King) from Martin Laurence Kendall.

I have a dream that one-day nutrition will be defined by the nutrients that a food contains and the health benefits that it confers rather than religious and ethical beliefs or commercial interests.

I have a dream that all people, mothers and children, fathers and brothers, would be able to clearly understand the foods that are truly optimal for them.

I have a dream that one day all people afflicted with diabetes will be able to choose foods that will enable them to achieve normal blood sugars and restore the health and vitality that they deserve.

Further, that they will be able to choose optimal foods, with engineering precision, without being affiliated with the needless ridicule that they will needlessly die of a heart attack due to unnecessary fears about ‘artery-clogging saturated fat’ or ‘harmful animal proteins’.

I have a dream that one day people will have, freely in their grasp, quality nutritional information that enables them to make informed choices that will, in turn, bring about a new day in the commercial food environment.

I dream that one day all people, obese, diabetic, children and athletes alike, will be free from the corruption of Big Food and Big Pharma working through diabetes educators, diabetes associations, heart associations, medical institutions and animal welfare advocates.

Free at least. Free at last.

I hope that one day we will be free at last.

Indulgence over. On with the data.

On with the data.

Nutrient deficiencies in a high-fat diet

Another fact that I thought Cyrus and Robby would mention was that very high-fat foods tend to have a weak nutrient profile, especially compared to non-starchy vegetables.

The chart below shows the nutrients provided by the 800 highest fat foods out of the 8000 foods in the USDA database. If we prioritise fat, we will likely be lacking in around half of the essential nutrients.

A summary of some of the highest fat foods is shown below.

[For some real-life examples of the poor nutrient profiles achieved by people chasing high ketone levels in the misguided pursuit of weight loss check out the Nutrient Optimiser reports here, here, here here and here.]

Vitamins and minerals, in particularly electrolytes such as potassium, magnesium and calcium are critical to support our mitochondria, enabling them to produce energy and maximise insulin sensitivity.

People in the keto community are conscious that electrolytes are essential and go out of their way to supplement with magnesium, calcium, sodium and potassium as well as taking bone broth.

The kidneys let go of water and electrolytes when insulin levels drop. A ketogenic diet without attention to green leafy veggies is at risk of being very low in electrolytes. This will cause the pancreas to secrete more insulin to hold onto the scarce electrolytes. This increase in insulin levels may^[3] ironically drive insulin resistance.

Whether you call them electrolytes or alkaline foods^[5], our bodies need enough substrate to allow our kidneys to maintain a good acid/base balance without having to work too hard. Focusing on minerals can helps us maximise insulin sensitivity and ensure oxygen is efficiently be carried around our bloodstream.

There are plenty of foods available to provide the micronutrients that you need if you actually require therapeutic ketosis as an adjunct to cancer, epilepsy or dementia. We can achieve the Daily Recommended Intake (DRI) for most of the nutrients while still maintaining a low dietary insulin load.

The short list of foods that comprise a ‘well formulated ketogenic diet’ are shown below.

However, if you just need to manage diabetes with a low-carb diet (rather than therapeutic ketosis), you can achieve even higher levels of nutrition while maintaining stable blood sugars.

Given my family history of Type 2 and my wife Monica’s Type 1 diabetes, we generally focus on the foods listed below. Lots of people have found these lists useful. You can pin them to the fridge as a reminder of what you should focus on or print it out to take shopping next time when you need some inspiration. (There is a complete list of nutrient dense foods to suit different goals at the end of this article.)

Now my blood glucose levels are more stable, I’ve been trying to back off on the higher fat foods and focus on more nutrient-dense foods to build muscle and lose fat.

The ‘problem’ with the most nutrient-dense foods (as shown below) is that they typically have a very low energy density so it will be nearly impossible to get enough energy to prevent rapid weight loss.

Prioritising nutrient-dense foods is the secret to obtaining the nutrients you need with the lowest energy intake. If you don’t want to keep losing weight or want to run a marathon then adding some higher energy density foods will be useful.

High carbohydrate foods are not nutritious

After watching the Mastering Diabetes teleseminar, you will get the feeling that the Mastering Diabetes guys believe carbohydrate can do no wrong and we should only fear fat.

The reality, however, is that the foods with the least fat are generally even more nutritionally corrupt than the highest fat foods.

Not all of the low-fat foods are going to be beneficial.

Defining your nutritional approach as ‘high carbohydrate’ is not wise, especially if you are trying to manage diabetes. The foods with the most carbohydrates in our food system are typically very nutritionally deficient as well as highly insulinogenic.

If a ‘low carb diet’ leads you to avoid processed foods you may be better off. However, I don’t think defining nutrition in terms of macronutrient extremes is particularly useful. ^[6]

Plant-based versus animal-based foods

One area where vegans potentially have it over carnivores is vitamins and minerals. As shown in the chart below, a zero carb diet does not provide really high levels of many nutrients.

At the same time, there are plenty of people who appear to be thriving on a zero carb dietary approach. Many people with severe autoimmune related digestive issues succeed when they switch to a zero carb approach. Zero carb advocates will also tell you that they don’t need the recommended daily intake levels of the various micronutrients that are based on limited data or deficiency studies in people eating a standard high carb western diet.

A plant-based diet can provide a reasonably nutrient dense outcome. However, it will be hard to get adequate levels of omega 3, vitamin D and vitamin B-12. People following a strictly plant-based approach may need to supplement with these nutrients.

Achieving the minimum protein intake levels is possible. However, many people have concerns about the reduced bioavailability of plant based proteins and whether or not the minimum protein intake levels are actually optimal, particularly if you are active or older.

It’s also worth noting that other nutrients such as iron, vitamin A and omega 3 will be more bioavailable from animal-based sources. So it’s not as simple as comparing the nutrients in the food, what gets into your body is what really matters.

If you are going to follow a plant-based diet then prioritising the food listed below will give you the best chance of success. Most people are going to do best somewhere on the spectrum between exclusively plant-based and solely animal-based foods.

The real problem comes when we start to heavily process our food. Rather than prioritising the most nutrient dense and minimally processed vegetables, fruits and legumes, many vegans end up living on processed grains, cereal, sugar and soy products that have been treated with a host of fertilisers and pesticides. Meanwhile, many zero carbers or keto peeps end up living on nothing but bacon or processed meats from animals that were fed nutrient poor corn and grains with added antibiotics to make them grow quicker.

The vegan echo chamber

I have spent a good chunk of time hanging out in many vegan or plant-based groups trying to understand their position and gain insights about nutrient density. I have learned a lot from people like Professor Christopher Gardner, Ray Cronise and Dr Joel Fuhrman. Much of the analysis in this is based on the integration of my learnings their work with Dr Richard Bernstein and Dr Matt Lalonde.

Unfortunately, it seems that the vast majority of vegan/plant-based education comes from Dr Michael Greger through his sanitised, highly processed and hyper-palatable “Nutrition Facts” videos.

While Greger covers a lot of relevant research and raises some valid points, a lot of the time he seems to twist the science to ensure that the moral of the story is always ‘eat plants, not animals’. Plant-based is better. Eating animals will be bad for your health.

Without evolutionary context, we are asked again and again to believe that fat (particularly saturated fat) and ‘animal protein’ (whatever the hell that is!) is the primary cause of heart disease, the complications of diabetes and practically every other modern health ill.

There is no demonstrated biochemical mechanism provided as to how we suddenly became allergic to animal products. Meanwhile, vegans advocates generally give a free pass to sugar and processed grains.

With more than six million views and an estimated earnings of more than $100k per year from YouTube^[7] (not to mention donations^[8]), there appear to be a LOT of people eager to lap up the nutritional and medical justification of their ethical position.

Greger’s unique ‘interpretation’ of the scientific data all starts to make sense once you understand that he is the Director for Public Health and Human Agriculture for the Humane Society International.^[9]

The mission of the Humane Society is to celebrate animals, confront cruelty and shape public opinion.

I wonder if Greger does his researching, writing, filming and editing the Nutrition Facts videos as a hobby after he gets home after working 50 hours a week and commuting? Or perhaps he creates these videos as an employee of the Humane Society as part of their stated goal to shape public opinion on animal cruelty?

It seems Mangoman and Robby are pretty tight with Greger.^[10] Makes me wonder if Mastering Diabetes is a coordinated and strategic assault by the Humane Society on the low carb/keto/diabetes community who have become immune to Dr Greger.

I am by no means advocating animal cruelty. However, as a human, if you are looking for the best advice on human nutrition, is it wise to put your blind faith and unswerving trust in someone whose explicitly stated primary goal is animal welfare?

Do you really want to save the planet?

Worrying about whether we eat plants or animals exclusively is a modern luxury, an intellectual indulgence of sorts.

For the majority of human history, we have been opportunistic omnivores. When plants were the only thing that was available, we would eat them. When we could, we would chase down an animal to get the protein we need to thrive. We never had to worry about nutrient density because the foods we ate grew in fertile soil without pesticides. The animals we ate were eating their natural foods which were also nutritious for them.

Humans thrived and were able to populate the world because we learned to hunt, store, cook and process food. We became very good at getting the nutrients we needed with the minimum amount of effort.^[11]^[12]^[13]

Unfortunately, we have now become too good at processing food.

Many of us are now fantasising nostalgically about Paleo times.

It’s one thing to worry about saving animals, but ultimately we need to save the planet and our human race from accelerated extinction.

Our newfound ability to harvest fossil fuels enables us to move around in cars and grow a massive amount of food with chemical fertilisers. These foods grow quickly and give us plenty of energy, but few nutrients that we then process and feed to animals or humans.^[14]

Take a moment to think about how your life would be different if we had never discovered fossil fuels (e.g. coal or oil). For as long as it lasts we are gorging ourselves on stored energy that is making us lazy and obese and driving not just us, but life as we know it to an early grave. If you want to care about something it should be the sustainability of the global environment (including animals and humans).

If you want to care about something it should be the sustainability of the global environment (including animals and humans).

While humans are probably the biggest threat to the long-term sustainability of earth as we know it, most of us aren’t willing to volunteer ourselves or our family as the first ones to check out to save the planet.

[If you want some challenging thoughts on this topic you should check out Daniel Vitalis’ Why I Hunt podcast.]

The plural of anecdote is not data

So, finally, onto the Mastering Diabetes video.

Cyrus and Robbie look like genuinely nice guys.

They are both living with type 1 diabetes.

They look like they’re happy and thriving on a plant-based diet full of fruits and vegetables.

To be honest, they look a lot healthier than many recovering diabetics in the low-carb scene.

But at the same time, the zero carbers will hold up anecdotes of people who have not eaten a plant for decades and look as great as the Johnson Family.

Or Dr Shawn Baker who is setting world records as a masters athlete since cutting plants out of his diet.

Then the keto folks will point to Dr Dominic D’Agostino who thrives on high fat and exogenous ketones and is exceptionally smart and can lift very heavy stuff at the same time.

^[15]

While it’s useful to look at populations of people following a particular diet to look for trends, anecdote does not equal data.

It is more useful to look at underlying metrics (such as nutrient density and insulin load) that we can use to identify the optimal diet for humans.

I thought they would know better

Cyrus Khambatta is a smart guy. He was studying mechanical engineering at Stanford before he got type 1 and changed course to study nutritional biochemistry.

However, for all his ability in nutrition, engineering and mathematics (I took those classes, and I know how hard they are!), I thought he would have more to offer than what was presented!

People with diabetes get screwed around by the mainstream medical system and ‘diabetes education’ system. The system doesn’t really understand how it works, so they give them bad advice (e.g. “just eat like we tell everyone else to and cover it with insulin”)!

I remember clearly the anxiety and confusion we experienced after going to an appointment with the hospital endocrinologist when my wife Monica was pregnant with our daughter.

At her visits, she would routinely be told that she needed to reduce her blood sugars to avoid the many serious risks and complications and risks for her and the baby. Monica asked what else she could do to get the blood sugars down, but they had no advice. They just wanted to see them lower.

We now have two healthy and wonderful kids, but I if I can I would love to see other people spared the anxiety as well as minimise the genuine health risks related to diabetes. Hence my quest to understand how we can make intelligent food choices to optimise blood sugar and insulin levels.

What is the actual relationship between insulin and the food we eat?

The food insulin index data is a highly valuable resource that helps us to understand what causes us to secrete insulin and our blood sugars to rise. The chart below shows the results of the food insulin index testing on more than 100 different foods (click to enlarge).

The food insulin index testing demonstrates clearly that we have the lowest insulin response to fats and oils while we have the highest insulin response to high carbohydrate foods like jelly beans and rice bubbles. However, when we plot this data, we see that carbohydrate does not fully explain our insulin response.

We get a much better prediction of our insulin response when we account for protein (which requires insulin to metabolise) and non-digestible fibre.

Eating more fat will decrease the amount of insulin required to keep our blood sugars stable.

Eating more protein will reduce the amount of insulin your pancreas has to produce because it will push the more insulinogenic processed carbohydrates and sugar out of your diet.

How to improve your insulin sensitivity

If you reduce your intake of processed carbs and sugars, your insulin requirements will come down. Once your organs and muscles are no longer swimming in insulin, you will become more insulin sensitive (just like you become more sensitive to coffee or alcohol if you cut back your intake).

If you are injecting insulin, reducing the insulin load of your diet will enable you to significantly reduce your insulin dosage which will, in turn, allow you to more easily access your own body fat stores for fuel.^[16]

This data is an inconvenient truth for both high carb vegans or the nutritional recommendations such Food Pyramid / My Plate generated by the US Dept of Agriculture. But I think it could be beneficial for people who want to effectively manage their diabetes.

Granted, if you switch your processed grains and sugar for fruits and vegetables, you will do better. But is it really optimal?

If you can’t win, move the goalposts!!!!

So what do you do if you can’t win with science?

You change the rules! You move the goalposts.

It was Cyrus and Robby’s unique definition of insulin resistance that really frustrated me.

So you can understand my frustration, I need to explain the difference between basal and bolus insulin which is a daily reality for someone with type 1 diabetes.

Bolus insulin is taken with food and is proportional to the insulin load of the food they eat (i.e. carbs – fibre + half protein)^[17].
Basal insulin is the insulin that your pancreas would produce through the day and night whether or not you eat anything. It’s the basal insulin that keeps your fat in storage and your muscles from being used for fuel.

You need both, but their function is different.

For someone eating a standard western diet about one-third to a half of their insulin will be basal insulin with the majority being bolus insulin for the food you eat.

When you switch to a low carb or keto diet this ratio flips and the majority of your insulin is basal insulin. You only need a little bit of bolus insulin to cover the small amount of carbohydrates and protein that you eat. With less glucose to deal with, you don’t need as much insulin, and your blood sugars stabilise.^[18]

A significant portion of the Mastering Diabetes video was devoted to explaining their new creative definition of insulin sensitivity. The fundamental problem with this central piece of the Mastering Diabetes argument is that it conflates basal and bolus insulin. Your basal insulin is irrelevant if you are trying to do this sort of insulin sensitivity calculation!

It’s just the bolus insulin (i.e. for food) that matters when it comes to insulin sensitivity. The calculations in the table below demonstrate my point. If you take the denominator to your insulin sensitivity calculations to be the basal + bolus insulin, then the high carb approach has a better insulin sensitivity. If you only consider the bolus insulin (the only sensible approach in my view), then you declare the low-carb approach to be the winner.

	low carb	high carb	conclusion
ISF (g carb/unit insulin)	6	5
carbs (g)	50	500
bolus insulin (units)	8.3	100
basal insulin (units)	20	20
total daily insulin (per day)	28	120
24 carb / 24-hour insulin (basal + bolus)	1.8	4.2	High carb is better
24 carb / 24-hour insulin (bolus only)	6.0	5.0	Low carb is better

The chart below shows the difference in the daily blood sugar fluctuations of someone on a standard western diet and then after switching to a lower carb diet. The difference in the blood sugar levels is night and day! The difference in the quality of life between these two situations when it comes to energy levels, anxiety, depression, mood etc. is also immensely different.

I pinged Mastering Diabetes on their Facebook page to clarify if the cornerstone of their whole argument includes basal and bolus insulin. Unfortunately, my fears were confirmed (though they have since deleted their response and kicked me out of their Facebook Group).

Tight blood sugar control isn’t that important after all?

The next argument they try to run is that tight blood sugars really aren’t that necessary.

Cyrus (who is very active and practices intermittent fasting) has a Hba1c in the high 5s.

Robbie has a Hb1c in the low 6s.

Granted, this is good compared to the majority of the Type 1 population. They’ll have a better chance of thriving with good blood sugars if they are eating lots of vegetables and fruit compared to more processed grains and sugars that make up the typical diet. But it’s still a far cry from the blood sugar control of people following the type of low-carb approach advocated by Dr Richard Bernstein.

The problem I see with defining your diet as vegan or plant-based is that most people don’t have the self-discipline to stick with eating only vegetables and fruit and end up filling up on more processed (but still technically vegan) processed junk food.

Cyrus and Robbie argue that normal blood glucose fluctuations are between 70mg/dL to 145 mg/dL or 3.8 to 8.0mmol/L.

The problem with this argument is that what currently passes for ‘normal’ is far from optimal.^[19] Complications from diabetes start to kick in well below what is widely considered “normal”.

Just because it’s normal for most people to do Facebook on their phone while they drive doesn’t mean it’s ideal or optimal. Just because it’s normal to have poor blood sugar and most people are dying of metabolic diseases doesn’t sound like a persuasive argument for plant-based diet being optimal to me!

If you’re happy to settle for less than optimal blood sugar control because you have a strong ethical position, then that’s fine, but don’t construe it as optimal for everyone when it’s not.

The reality is that many people over at Type 1 Grit following Dr Bernstein’s approach are doing fabulously! Not everyone will achieve optimal, but it’s useful to know what to aim for and how to get there.

If you had a child or loved one with Type 1 diabetes would you want the opportunity to choose the approach that would yield the best results or would you prefer your advice to be tainted with ethical or commercial bias?

Check out the video the Type 1 Grit group put together for Dr B’s 83rd birthday to thank him for changing their lives.

Insulin resistance and metabolic syndrome are a big deal, so let’s not ruin more lives than we need to with bad advice that is based on bad math or putting ethical convictions or religious beliefs ahead of human health.

Understanding physiological insulin resistance

Cyrus and Robbie argue that someone on a low carb diet won’t deal with carbohydrate well when they are exposed to them. This phenomenon is real, but is typically due to what is termed ‘physiological insulin resistance’.

Someone who eats a lot of carbohydrates will have high levels of insulin floating around in their bloodstream. Then when they eat a carb bolus, their pancreas is primed to shoot out some more insulin to mop up the glucose and stop more glucose being released into the bloodstream via the liver. By contrast, someone who doesn’t eat a lot of carbohydrates will have low levels of insulin in their bloodstream and need to wind up their pancreas to produce insulin to bring down the glucose.

This phenomenon is also referred to the first phase versus second insulin response. Someone who is not eating a lot of carbs will have a slower first phase insulin response.

It’s like comparing someone’s time over 100m when they are starting from a standstill versus someone using a rolling start. It’s not a relevant comparison. This phenomenon will go away after a few days on a high carb diet.

At the same time though, micronutrients such as potassium, magnesium and calcium are critical to maintaining healthy insulin sensitivity and glucose uptake. Metabolic acidosis (caused by a lack of dietary electrolytes) appears to cause an upregulation in insulin by the pancreas to hold onto precious electrolytes. Over the long term, this could be another driver of insulin resistance, metabolic syndrome and diabetes. ^[20]

Getting adequate dietary electrolytes from green leafy vegetables will make it easier for our body to maintain acid/base balance. However, I don’t think we need to feed all diabetics a high carbohydrate exclusively plant-based diet to achieve this.

Eating fat makes you fat?

The vegan community seems to confuse eating fat and storing fat. The Ancel Keys / vegan story is that we store fat in our body because we overeat dietary fat. However, the reality is that we get fat because we eat more than we burn.

As shown in the graphic below from Ray Cronise’s Oxidative Priority paper, we will only burn fat (from our body or diet) once we’ve burned through the alcohol, ketones, protein and carbohydrate and fat that we eat (in that order).^[21]

When we eat our body prioritises the refilling of our glucose and glycogen stores in our blood stream and liver (which can hold about 1200 to 2000 calories) before we start to store the excess energy in our adipose tissue. Our body fat stores can hold a lot more energy, but not an unlimited amount. Once our fat stores are full and can hold no more, they become insulin resistant. We then start to store the excess energy in our vital organs such as our liver, kidney, brain, eyes, heart, etc.

The trick to weight loss is to keep your blood sugar levels low enough so that your liver glycogen is being replenished from your body fat rather than always having overfull glycogen stores, so we need to offload excess energy to our fat stores.^[22]

One of the many roles of insulin is to shut off the flow of stored energy from the liver into the bloodstream. If energy is coming in the pancreas will upregulate insulin to stop the flow of glucose from the liver back into the bloodstream (regardless of whether you’re eating carbs, fat or protein from animal or plant-based sources). The best way to reduce insulin is to stop eating and let your stored energy flow back into your bloodstream.

In a way, you can think of your liver as your fuel tank and you your blood glucose meter as the fuel gauge. If your blood sugars are high, you should think twice about whether you really need more fuel now.

If you are insulin sensitive, the bad news is that you can easily store excess energy as body fat very efficiently. Insulin is an anabolic hormone that will help you to grow. However, when you are insulin sensitive, you can lose fat relatively quickly when you reduce energy intake. If you are insulin sensitive your circulating insulin levels will be low, and fuel will more easily flow from storage. Hence you won’t be such a mindless slave to your uncontrollable appetite.

If you are insulin resistant and have high levels of circulating insulin, you may struggle to release your stored body fat. Your appetite will drive you to seek out food because you can’t efficiently access it from your body stores. You won’t be able to go very long between meals.

A low-carb diet can be helpful for someone who is insulin resistant because it can help lower insulin which in turn help them to normalise their appetite. Teaching that we get fat because we eat fat is just outdated science.

Even Dr Joel Fuhman will tell you that actively avoiding fat is stupid. He will also tell you that there is some value in eating fish on a regular basis to ensure you get adequate amounts of omega 3s and vitamin B-12.

Complications on a ketogenic diet

There are plenty of studies that show the shortcomings of a ketogenic diet. Sarah Ballantyne did a great job of summarising these on her Paleo Mom Blog here.

When you look in detail however you find that the adverse reactions the ketogenic diet are typically due to ‘keto in a can’ formula products.

While these food substitutes will help achieve therapeutic ketosis to help manage epilepsy or other chronic conditions, many of these keto formula products end up being very low in micronutrients.^[23]

Obtaining a significant amount of your energy intake from processed food-like products that have been separated from nutrients is not a good idea (e.g. whether it be sugar, processed grains, refined oils or exogenous ketones).

Is a low-carb diet actually good for diabetes?

Unfortunately, Cyrus and Robby didn’t mention the benefits of a low-carb diet for people with diabetes which are fairly well documented. The seminal paper that summarises much of the latest work in this area is documented in Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base.

Anyone who is on the fence about using a low-carb diet to manage diabetes should check out this paper which shows that a low-carb diet is better for weight, HbA1c, glucose, HDL and triglycerides compared to low GI or a grain-based diet.

Another well-known study is Christopher Gardener’s A to Z trial^[24] where they found that the Atkins diet did much better than the low-fat, particularly if you were already insulin resistant.^[25]

What should you eat if you are a vegan with diabetes?

So, after all this, what should we eat to maintain optimal blood sugar levels? Cyrus and Robby’s view is shown below. Unfortunately, it appears that their recommendations are driven more by their philosophical and ethical views rather than the nutrient content of the food or their ability to stabilise blood sugars.

In the green column, most people with diabetes aren’t going to do too well with a lot of fruits, starchy veggies, and beans. Intact whole grains do contain substantial nutrients but are very hard to find in our modern food system. Who actually eats wheat bran as a significant part of their diet? The vast majority of grains are processed with the nutrients discarded, so they are tasty and shelf stable.
In the red column, dairy eggs, meat, fish and poultry can be nutrient dense and keep your blood sugars stable (as long as you’re not afraid of fat in whole foods or ‘animal protein’).
In the orange column, higher fat foods like nuts, seeds, avocados, coconut and olives can be useful to help stabilise your blood sugars, but it is possible to overconsume them if your goal is to lose weight.

We want to maximise nutrient density as much as possible while keeping the insulin load of our diet down to the point that we keep blood sugars stable.

This does not end up being super high fat or super low fat. Fat just comes along with nutritious whole foods.

If you have diabetes, then a little more dietary fat initially may help to stabilise blood sugars. Once your blood glucose levels have stabilised, you can start to decrease the dietary fat and increase nutrient density as much as you can while still maintaining excellent blood sugar levels.

A low insulin load diabetes-friendly plant-based nutritional approach will be lacking omega 3 and vitamin B-12.

The shortlist of nutrient dense low insulin load plant-based foods is shown below. The foods at the top of each section should be reasonably safe for most people with diabetes. You should test your blood sugars to see how you respond to some of the foods further down the list.

Many people who are conscious of animal welfare will eat fish (i.e. pescetarian). Adding some fish will provide a much better nutritional profile than eating plants alone, with plenty of vitamin B12 and omega 3 available from the seafood.

I hope this is helpful for people who want to choose a plant-based approach to maximise nutrient density and maintain excellent blood sugar control.

If you’re still confused, I have designed the Nutrient Optimiser to identify what foods you should add or remove from your diet to ensure you are getting the nutrients you need while maintaining excellent blood sugar levels.

So which approach is optimal?

It depends.

The optimal approach for you will depend on your situation and goals.

Going plant based may be an improvement if your diet is currently full of sugar and processed grains, but it is not the singular solution to every ill. (For an excellent example of a very nutrient dense plant-based dietary approach check out David’s Nutrient Optimiser analysis here.)

To help you make more informed food choices, I have devised two different ways of measuring food quality:

Proportion of insulinogenic calories, and
Nutrient density.

The proportion of insulinogenic calories is the percentage of the food you eat that will require insulin to metabolise. The table below lists a range of nutritional approaches ranked by the percentage of insulinogenic calories (right-hand column).

If you’re interested in any of these approaches, you can download the list and save it to your phone or print it out to take shopping for some inspiration.

approach	pdf	foods	nutrient profile	% insulinogenic
well formulated ketogenic diet	pdf	foods	profile	21
low carb	pdf	foods	profile	34
plant based (diabetes friendly)	pdf	foods	profile	56
weight loss and insulin resistance	pdf	foods	profile	59
low carb pescitarian	pdf	foods	profile	61
the most nutrient dense foods	pdf	foods	profile	67
plant-based	pdf	foods	profile	68
plant based (without ND)			profile	73

Simply switching to a plant-based nutritional approach will leave you with 73% of your diet requiring insulin to metabolise. The diabetes-friendly plant-based approach will be an improvement, but a low-carb or ketogenic diet may be better if your goal is stable blood glucose levels.

Another way to look at things is nutrient density. You may have noticed the nutrient profiles shown above have a red dotted box. If a particular nutritional approach provides two times the Daily Recommended Intake for all essential nutrients, then you would get a perfect score of 100%. You can see below that the most nutritious foods below are pretty close to 100%.

By contrast, if we only focus on ‘plant-based foods’ nutritional outcome is not so flash. Thinking only in terms of plant-based is not automatically nutrient dense.

I have sorted the various food lists in the table below based on their nutrient score. My suggestion is to start at the top with the most nutrient dense foods and work your way down until you find an approach that suits your ethical framework or religious beliefs that will also enable you to stabilise your blood glucose levels (i.e. lower % insulinogenic calories).

approach	score	pdf	foods	nutrient profile	% insulinogenic
the most nutrient dense foods	99.7%	pdf	foods	profile	67
weight loss and insulin resistance	99.3%	pdf	foods	profile	59
low carb pescitarian	94.5%	pdf	foods	profile	61
low carbohydrate	81.0%	pdf	foods	profile	34
plant based	78.0%	pdf	foods	profile	68
plant based (diabetes friendly)	76.0%	pdf	foods	profile	56
well formulated ketogenic diet	74.0%	pdf	foods	profile	21
plant based (without ND)	57.0%			profile	73

Summary

While many people chose exclusively plant-based foods, they are not necessarily a better dietary choice compared to a more varied diet.
Someone following an exclusively plant-based approach will require supplementation with vitamin B-12, vitamin D and omega 3s.
Fat is not necessarily good or bad. Swinging to macronutrient extremes will not lead to an optimal outcome.
Reducing the insulin load of your diet will help to normalise your blood sugar and insulin levels.
Ideally, you should aim to achieve the blood sugars of a metabolically healthy person while maximising nutrient density at the same time.

references

^[1]https://www.ncbi.nlm.nih.gov/pubmed/25515001

^[2]https://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

^[3]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC301822/

^[4]https://www.quackwatch.org/01QuackeryRelatedTopics/DSH/coral2.html

^[5]https://authoritynutrition.com/the-alkaline-diet-myth/

^[6]https://optimisingnutrition.com/2017/03/19/micronutrients-at-macronutrient-extremes/

^[7]https://socialblade.com/youtube/user/nutritionfactsorg

^[8]https://nutritionfacts.org/donate/

^[9]http://www.hsi.org/about/who_we_are/leadership/subject_experts/michael_greger.html

^[10]https://www.facebook.com/mangomannutrition/videos/656469947843978/

^[11]https://optimisingnutrition.com/2016/10/23/energy-density-food-hyper-palatability-and-reverse-engineering-optimal-foraging-theory/

^[12]https://en.wikipedia.org/wiki/Optimal_foraging_theory

^[13]http://www.hoajonline.com/obesity/2052-5966/2/2

^[14]https://www.amazon.com/Dorito-Effect-Surprising-Truth-Flavor/dp/1476724237

^[15]https://fineartamerica.com/featured/8-muscleart-marius-poser-classic-jake-hartz.html

^[16]https://www.ncbi.nlm.nih.gov/pubmed/21241239

^[17]https://optimisingnutrition.com/2015/08/10/insulin-dosing-options-for-type-1-diabetes/

^[18]https://www.facebook.com/Type1Grit/

^[19]https://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

^[20]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC301822/

^[21]http://online.liebertpub.com/doi/full/10.1089/met.2016.0108

^[22]https://optimisingnutrition.com/2016/02/15/how-to-use-your-glucose-meter-as-a-fuel-gauge/

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

^[24]http://jamanetwork.com/journals/jama/fullarticle/205916

^[25]http://onlinelibrary.wiley.com/doi/10.1002/oby.21331/full

post udpated September 2017

articles, carbohydrates, fat, low protein foods list, nutrient density, protein

micronutrients at macronutrient extremes

March 19, 2017 Marty Kendall 7 Comments

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?

But protein is also insulinogenic, so less protein must be good. Right?

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 calories of the most nutrient-dense foods which will much more effectively provide you with your essential micronutrients.

But wee 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.

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

personalisation

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.

Check out the Nutrient Optimiser page for more details.

notes

^[1] There is a strong case for the idea that the DRI for vitamin C could be relaxed for a diet with lower glucose. See http://breaknutrition.com/ketogenic-diet-vitamin-c-101/ and http://orthomolecular.org/library/jom/2005/pdf/2005-v20n03-p179.pdf

^[2] Check out this video by Ron Rosedale for an overview of the topic of protein, mTOR signalling and longevity. https://www.youtube.com/watch?v=xtZ0LqUBySQ

articles, nutrient density, therapeutic ketosis, vegan, weight loss, zero carb

which nutrients is YOUR diet missing?

March 11, 2017 Marty Kendall 12 Comments

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.

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

Getting even more personal

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 operate 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.

referecnes

^[1] http://www.who.int/nutrition/publications/nutrient/en/

^[2] https://books.google.com.au/books?id=gtQyAgAAQBAJ&pg=PA185&lpg=PA185&dq=%22nutrient+hunger%22&source=bl&ots=VMRQ8EbvHx&sig=l_xJEksBS538UX3QwQNxVJBXTLw&hl=en&sa=X&ved=0ahUKEwjRj6mSs5DSAhWKyLwKHXBQAjEQ6AEIKDAC#v=onepage&q=%22nutrient%20hunger%22&f=false

^[3] https://www.amazon.com/Perfect-Health-Diet-Regain-Weight/dp/1451699158

^[4] https://www.amazon.com/Dorito-Effect-Surprising-Truth-Flavor/dp/1476724237

^[5] https://optimisingnutrition.com/2016/03/21/wanna-live-forever/

^[6] http://ajcn.nutrition.org/content/78/3/361.full

^[7] http://www.nature.com/articles/ncomms14063

^[8] https://www.amazon.com/Case-Against-Sugar-Gary-Taubes/dp/0307701646

^[9] https://www.youtube.com/watch?v=dBnniua6-oM

^[10] https://www.thepaleomom.com/adverse-reactions-to-ketogenic-diets-caution-advised/

^[11] http://ketotalk.com/2016/06/23-responding-to-the-paleo-mom-dr-sarah-ballantynes-claims-against-the-ketogenic-diet/

^[12] http://www.thelivinlowcarbshow.com/shownotes/10888/868-dr-sarah-ballantyne-challenges-the-wisdom-of-low-carb-diets-for-women-2/

^[13] In terms of macronutrients this high fat dietary approach comes out at 80% fat, 15% protein, 2% fibre and 3% net carbs.

^[14] http://www.who.int/nutrition/publications/nutrient/en/

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

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

October 23, 2016 Marty Kendall 4 Comments

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

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

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

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

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

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

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

OFT in the wild

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

… gone to extraordinary lengths to obtain energy dense honey …

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

OFT in captivity

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

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

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

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

sweet = good = energy to survive winter

But now we have entered a brave new world.

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

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

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

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

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

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

what happens when we go low fat?

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

Sounds logical, right?

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

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

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

Maybe a little too well.

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

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

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

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

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

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

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

what happens when we go low carb?

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

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

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

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

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

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

what happens when we go paleo?

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

Well, maybe. Maybe not.

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

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

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

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

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

enter nutrient density

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

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

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

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

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

optimal rehabilitation plan?

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

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

the solution

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

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

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

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

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

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

I hope this helps. Good luck out there!

post last updated OCtober 2017

references

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

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

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

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

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

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

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

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

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

articles, insulin index, weight loss

insulin load… the greatest thing since carb counting?

May 2, 2016 Marty Kendall 60 Comments

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!

Patricia said:

I use the insulin load concept.

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.

If you just want to know what you should eat these lists of optimal foods for different goals may be useful for you.

how to calculate your insulin load

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:

carbohydrates (70g),
fibre (63g), and
protein (104g)

So we start with the insulin load formula:

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.

As detailed in the how to use your glucose metre as a fuel gauge article, waiting until your blood glucose levels drop can be a useful way to increase the timing between meals and to understand whether your hunger is real. Once your blood glucose levels normalise you can even use your your bathroom scale to help time your fasting / feasting cycle to achieve your weight loss goals.

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.

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

post last updated: April 2017

references

^{^[1]} http://optimisingnutrition.com/2015/03/23/most-ketogenic-diet-foods/

^{^[2]} http://optimisingnutrition.com/2015/03/22/ketosis-the-cure-for-diabetes/

^{^[3]} https://en.wikipedia.org/wiki/Dietary_fiber

^{^[4]} https://optimisingnutrition.com/2015/07/06/insulin-index-v2/

^{^[5]} https://en.wikipedia.org/wiki/Glucogenic_amino_acid

^{^[6]} https://www.myfitnesspal.com/

articles, blood sugar, diabetes, fasting, weight loss

Antonio C. Martinez II’s type 2 diabetes reversal

February 29, 2016 Marty Kendall 15 Comments

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

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

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

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

type 2 diabetes diagnosis

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

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

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

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

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

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

heart attack!

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

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

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

reduced carbohydrate approach

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

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

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

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

tackling dawn phenomenon

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

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

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

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

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

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

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

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

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

HbA1c

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

ketones

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

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

glucose : ketone index

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

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

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

no turning back?

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

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

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

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

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

Antonio says:

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

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

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

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

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

… Brussell sprouts salad…

..some pate…

…and Le Côte de Beouf.

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

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

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

cured?

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

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

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

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

Congratulations Antonio and keep up the great work!

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

references

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

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

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

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

contact

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

articles, blood sugar, fibre

fibre on a ketogenic diet

October 5, 2015 Marty Kendall 47 Comments

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.

I recently heard an intriguing information-packed interview with Michael Ruscio on Episode 985 of Jimmy Moore’s Livin’ La Vida Low Carb Show where he said that:

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.

references

^{^[1]} https://microbewiki.kenyon.edu/index.php/Link_Between_Microbes_and_Obesity

^{^[2]} http://drruscio.com/probiotics-weight-loss-test-810/

^{^[3]} http://humanfoodproject.com/please-pass-microbes/

^{^[4]} http://www.marksdailyapple.com/prebiotics/#axzz3j5eI13iu

^{^[5]} http://www.marksdailyapple.com/prebiotics/#axzz3j5XIihW8

^{^[6]} https://proteinpower.com/drmike/2006/08/30/a-cautionary-tale-of-mucus-fore-and-aft/

^{^[7]} http://talkfeed.co.za/web-hold-lchf-diet-answers/

^{^[8]} http://authoritynutrition.com/10-myths-within-the-low-carb-community/

^{^[9]} http://www.webmd.com/diet/guide/fiber-how-much-do-you-need

^{^[10]} http://humanfoodproject.com/sorry-low-carbers-your-microbiome-is-just-not-that-into-you/

^{^[11]} http://www.humansarenotbroken.com/plant-paleo-part-2-grains-legumes-fiber-and-antinutrients/

^{^[12]} http://blog.primalblueprint.com/episode-70-dr-david-perlmutter/

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

^{^[14]} http://www.amazon.com/Brain-Maker-Power-Microbes-Protect/dp/0316380105

^{^[15]} http://www.drperlmutter.com/about/brain-maker-by-david-perlmutter-md/

^{^[16]} http://shepherdworks.com.au/disease-information/low-fodmap-diet

^{^[17]} http://www.thepaleomom.com/2012/09/reintroducing-foods-after-following-the-autoimmune-protocol.html

^{^[18]} http://www.bioscreenmedical.com/

^{^[19]} http://www.suppversity.com/2015/04/acute-l-carnitine-tartrate.html#vo2

^{^[20]} http://www.nourishbalancethrive.com/

^{^[21]} http://www.thelivinlowcarbshow.com/shownotes/12392/961-christopher-kelly-analyzes-latest-functional-health-tests-for-jimmy-moore/

^{^[22]} http://www.nourishbalancethrive.com/podcasts/nourish-balance-thrive/diet-consultation-jimmy-moore/

^{^[23]} http://thatpaleoguy.com/2012/01/05/dietary-fat-can-modulate-intestinal-tight-junction-integrity/

^{^[24]} http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1819381/

^{^[25]} http://fourhourworkweek.com/2015/03/18/mark-hart-raoul-pal-peter-attia/

^{^[26]} http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3978718/

^{^[27]} http://journals.cambridge.org/download.php?file=%2FBJN%2FBJN101_10%2FS0007114508094658a.pdf&code=b061b827201900699a5cdd4ecca8b84c

^{^[28]} http://www.slideshare.net/aeislas/the-role-of-the-gut-microbiota-in-nutrition-and-health

^{^[29]} https://chriskresser.com/are-vegetarian-diets-better-for-the-microbiome/

^{^[30]} http://robbwolf.com/wp-content/uploads/2015/07/Paleo-Solution-279.pdf

^{^[31]} http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402009/

^{^[32]} http://www.ncbi.nlm.nih.gov/pubmed/23249760

^{^[33]} https://en.wikipedia.org/wiki/Butyrate

^{^[34]} http://freetheanimal.com/

^{^[35]} http://vegetablepharm.blogspot.com.au/

^{^[36]} http://www.marksdailyapple.com/the-definitive-guide-to-resistant-starch/#axzz3iL8QNff1

^{^[37]} https://www.bulletproofexec.com/real-superfoods-that-destroy-inflammation-in-your-brain-the-body-response-that-may-change-your-mental-health-forever/

^{^[38]} http://perfecthealthdiet.com/

^{^[39]} https://iquitsugar.com/it-all-starts-in-your-gut/

^{^[40]} http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1379072/

^{^[41]} http://authoritynutrition.com/glucomannan/

articles, ketosis, nutrient density, protein

Fine tuning your diet to suit your goals – Darth Luiggi

September 21, 2015 Marty Kendall 8 Comments

It looks like Luis Villasenor is doing something right.

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.

Basal vs bolus insulin

Majoring in the minors

Insulin is anti-catabolic

I can make you fat

The fatal flaw in the insulin-centric view of obesity

How to keep your basal insulin low

Exercise

Fasting

Low energy diet

What about trying to eat less food?

Nutrient-dense diet

Fat raises insulin too, it just takes longer

The adipose centric model of diabesity

Disease progression and reversal

So what’s the solution?

References

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key points

Keto is so hot right now!

My keto journey

Virta Facebook Live Q&A

What is ketosis?

What are normal ketone levels?

Diabetic ketoacidosis

The bloodstream, our metabolic highway

Exogenous vs endogenous ketosis

Exogenous ketosis

Endogenous ketosis

Ketosis vs diabetes and obesity

Virta ketone data

What does all this mean in practice?

So how do I optimise my blood sugars?

How to stay below your “Personal Fat Threshold”

Can we achieve optimal in our modern environment?

Introducing, our new toy! The Nutrient Optimiser

references

Share this:

Like this:

What’s actually wrong with the keto diet for diabetes?

Giving fat a free pass

I have a dream

Nutrient deficiencies in a high-fat diet

High carbohydrate foods are not nutritious

Plant-based versus animal-based foods

The vegan echo chamber

Do you really want to save the planet?

The plural of anecdote is not data

I thought they would know better

What is the actual relationship between insulin and the food we eat?

How to improve your insulin sensitivity

If you can’t win, move the goalposts!!!!

Tight blood sugar control isn’t that important after all?

Understanding physiological insulin resistance

Eating fat makes you fat?

Complications on a ketogenic diet

Is a low-carb diet actually good for diabetes?

<img class="irc_mi" src="https://i2.wp.com/jamanetwork.com/data/Journals/JAMA/5118/joc70018f2.png?resize=407%2C333" alt="Image result for atkins at to z" width="407" height="333" data-recalc-dims="1" />

What should you eat if you are a vegan with diabetes?

So which approach is optimal?

Summary

references

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why bother with nutrient density?

macronutrient comparison

fat

saturated fat

protein

carbohydrates

nutrient density

comparison of nutrients adequate

application

personalisation

notes

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USDA foods database

Optimising nutrient density

Therapeutic ketogenic diet