Tag Archives: Ketosis

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how much protein do I need on keto?

February 3, 2018 Marty Kendall 5 Comments

There is a lot of confusion about ‘excess protein’ and whether you can have too much protein on keto.
Insulin and protein are used to build and repair your muscles, organs and the other important parts of your body. This is an important and beneficial use of protein and insulin.
Foods that contain the harder to find nutrients (e.g. potassium, magnesium, choline, vitamin D) typically contain plenty of protein.
Actively avoiding protein and can lead to a less nutritious diet.
Unless you require therapeutic ketosis for the treatment of cancer, epilepsy, Alzheimers, Parkinson or dementia, you should be chasing vitality, health and nutrition along with stable blood sugar levels rather than some arbitrary ketone level.
There are a range of different ways to quantify protein intake. Thinking in terms of percentages can be more confusing than helpful.
It’s hard to over-consume protein because it is highly satiating. However, if you avoid protein your body may drive you to consume more calories until you get the protein it needs.
If you follow your appetite and focus on foods that contain the vitamins and minerals you need you will probably get enough protein.

Virta Facebook Live Q&A

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

Dr Phinney’s response to my question is shown below, including his recommended protein intake levels of 1.2 to 1.75 g per kg reference body weight of protein.

While I largely agree with Dr Phinney’s response, I think it’s worth elaborating on some of the issues that are causing so much confusion at the moment.

Will too much protein kick me out of ketosis?

If you’ve read previous posts on Optimising Nutrition you’ve probably seen my analysis of the food insulin index data that shows that our carbohydrate intake alone doesn’t explain our insulin response to food.

The food insulin index data shows that our insulin response to food is more accurately predicted when we consider the fibre and protein content of our food, not just the carbohydrate.

However, I fear that many people have used the insulin load concept as a reason to avoid protein. I now understand that this is far from optimal within the broader context of good nutrition for health, weight loss and vitality.

If you are interested in learning more the implications of the insulin index data I recommend you check out the following articles:

Effect on blood sugar and insulin

While trading your calories from butter for steak will increase your requirement for insulin, the food insulin index data suggests that as a general rule, getting more of your energy from protein will reduce your insulin requirements as it forces out processed carbohydrates as shown in the chart below.

Getting more energy from protein tends to decrease our glucose response as it forces out nutrient-poor refined high carb foods. Your body can convert protein to glucose (i.e. gluconeogenesis) if it really needs to but it’s a lot of work, so it would much rather get energy from carbs or fat.

Protein is also very satiating. Once we have enough protein, our body tends to crave more fatty and carby foods for energy.^[10]

While it is both financially and metabolically expensive, protein is the most important component of your diet. Different people will need different amounts of protein depending on their life stage and activity levels.

While you probably don’t need to be going out of your way to binge on more protein than you can comfortably consume, actively avoiding protein containing foods is a recipe for nutritional disaster. If you are exercising or lifting heavy then you will naturally crave more protein.

If you actually need higher levels of blood ketones for therapeutic ketosis, it may be a good strategy to consciously restrict protein. However, I don’t’ think the vast majority of people chasing ketones are looking for therapeutic keto for the management of cancer, Alzheimer’s, epilepsy, dementia or Parkinson’s but rather fat loss or diabetes control.

Protein number crunching

The numbers around protein can be confusing due to the units used.

Dr Phinney uses ‘reference body weight’ (RW) (which he says is ‘the weight you were when you were in college’).
The mainstream nutrition world talks in terms of total body weight (BW).
Meanwhile, the sports nutrition community talk in terms of lean body mass (LBM).

In order to understand what this means in practice, let’s look at an example of a woman who is currently 40% body fat but was 25% in college (i.e. her reference weight). For argument’s sake let’s say she was 70 kg in college but she is currently 87 kg or 193 lb. The images below will give you an idea of what these level of body fat levels look like.

In the table below I have calculated what Dr Phinney’s recommended protein intake looks like for this person in terms of:

reference body weight (RW),
lean body mass (LBM), and
body weight (BW).

Based on Dr Phinney’s guidance, this person should be eating between 84 and 123 g of protein per day.

	body fat	weight (kg)	weight (lbs)	lower limit	upper limit
reference weight	25%	70	154	1.2 g/kg RW	1.75 g/kg RW
lean body mass	0%	52.5	116	1.6 g/kg LBM	2.3 g/kg LBM
body weight	40%	87.5	193	1.0 g/kg BW	1.4 g/kg BW
protein (g/day)				84	123

On a practical note, there is nothing low about 2.3 g/kg LBM protein. While I do track my intake I find it hard to get above 2.2 g/kg LBM even when trying to maximise protein. At the same time, the lower limit is well above the official Recommended Daily Intake of 0.84 g/kg for men and 0.75 g/kg for women which are set to maintain nitrogen balance and prevent disease (i.e. not achieve optimal health and vitality).

What about percentages?

Talking about protein in terms of percentages of energy intake can be confusing as it depends on your activity levels or whether you are dieting. Theoretical energy intake requirements are based on your lean body mass and activity levels.

The table below shows what Dr Phinney’s protein recommendation of 1.2 to 1.75 g/kg RW (or 1.6 to 2.3 g/kg LBM) look like for our hypothetical woman above in terms of percentage of energy intake for different energy intakes depending if she was trying to lose weight, maintain weight or was more active.

scenario	calories	lower	upper
30% deficit	1158	29%	42%
sedentary	1654	20%	30%
lightly active	1852	18%	27%
moderately active	2084	16%	24%
vigorously active	2431	14%	20%
protein (g)		84	123

Protein intake in terms of percentage energy intake can vary widely to the point that it’s practically useless. It’s generally much more useful to talk in terms of protein intake in grams per weight lean body mass rather than percentages.

Protein and nutrient density

Since stumbling across the insulin index, one thing I have found consistently is that nutrient-dense foods are not low in protein.

If you are focusing on the foods that contain the harder to find nutrients (e.g. magnesium, magnesium, choline, vitamin D etc) you will be getting plenty of protein.

Conversely, the only way to really get the ultra-low protein intakes being recommended by many people without an energy deficit is to avoid most solid foods and prioritise macadamia nuts, butter and oils. It should not be a surprise that it will be hard to get a broad spectrum of essential nutrients with this sort of dietary approach.

As shown in the chart below, nutrient density tends to increase up to about 50% of energy intake. If you’re eating more than 50% protein you’re likely relying on processed foods and supplements.^[11]

The chart below shows the nutrient profile of the most nutritious foods in the USDA database. If you could stick to these foods you would easily be getting a lot of the essential nutrients without having to consume too much energy.

The problem with these foods is that they can be very satiating which makes it hard to get enough energy in if you are active. However, if you are trying to lose weight these foods may help to ensure that you are getting the nutrients you need with less energy without being hungry.

It’s interesting to see many people who have been experimenting with the Nutrient Optimiser have commented on how little food they can get away with while experiencing minimal levels of hunger. Nutrient dense foods tend to be hard to overeat and also provide you with the nutrients to prevent cravings and hence reduce appetite.

For comparison, the chart below shows the nutrient profile of the ketogenic diet foods. That is, the foods that have the lowest percentage insulinogenic calories. These foods are 80% fat, 15% protein and 3% net carbs). Ironically, an individual consuming these foods will be meeting the minimum levels of protein but they will be missing out on a large number of other vitamins and minerals.

I find that it’s often the people who are trying to actively avoid protein that find themselves at the bottom of the Nutrient Optimiser Leaderboard with a very poor nutrient profile.

The chart below shows the nutrient profile that we get when we actively avoid protein. The only nturients that we get enough of in this scenarios is sodium and vitamin C!

Unless you are chasing therapeutic ketosis for the treatment of cancer, epilepsy, Alzheimers or dementia I think your focus should be on building health and maximising nutrition rather than higher ketone values.

If you are getting the micronutrients you need to thrive you will be getting plenty of protein and won’t need to worry too much about getting adequate protein intake. Conversely, if you are actively avoiding protein you will be unnecessarily sacrificing your other micronutrients (especially if you are replacing your calories from protein and carbs with refined fat).

But will too much protein kick me out of ketosis?

As I write this I have been experimenting with adequate protein with less fat and carbs and maximal nutrients on the Ketogains Bootcamp. A typical daily Cronometer summary is shown below.

My protein is sitting at about 2.2g/kg LBM for me given that I’ve been spending a lot of time in the gym lifting heavy during this time. I’ve also been able to hit many of the nutrients targets while maintaining a significant calorie deficit.

Leading up to this period my blood glucose levels were sitting in the mid 5s (approx 100 mg/dL). However, once I introduced the energy deficit my glucose levels plummet to the mid 4s (approx 80 mg/dL).

And although I don’t worry much about ketones, they seem to be sitting at around 0.7 mmol/L, which I’m pretty happy with.

I know if I keep my blood glucose around this level I will continue to lose weight and continue to improve my glucose control and HbA1c.

I also get plenty of breath acetone from endogenous ketones as shown on my Ketonix below.

Don’t forget the basal insulin!

While there has been a lot of focus on what we can do to not have too much insulin, we need to remember that insulin has a number of important roles including:

to help us get glucose into cells to be used by our mitochondria,
to help build and repair our muscles, and
to control the release of glucose from our liver while the energy in our bloodstream is used up.

People with type 1 diabetes demonstrate happens if we don’t have enough insulin. Not only would we not be able to store the energy we eat as fat and muscle, the brake comes off the liver and all the stored energy in our body comes flowing out in the form of excess glucose and ketones (i.e. diabetic ketoacidosis).

The image below is the same child, “J.L.”, in the 1920s before and after receiving insulin therapy. In a healthy person, insulin suppresses the fuel flow from the liver to healthy levels.

In someone on a standard western diet, basal insulin represents about 30% of the today daily dose. Basal insulin drops to about 50% for someone on a low carb or keto diet. But you can never drop your insulin requirements to zero. You always need this basal to stop the uncontrolled flow of fuel from your liver into your bloodstream.

We focus so much on the effect of the food we eat but we forget that it’s also the excess fuel on your body and floating around in our bloodstream that also plays a massive role in the insulin demand on our pancreas.

Whenever there are high levels of energy sitting in our bloodstream (from glucose, ketones or fat) the pancreas has to ramp up basal insulin production until the fuel in our bloodstream is used up. The more fat there is on our body the harder our pancreas has to work to hold back the pressure of excess fat on our body from being released into our bloodstream.

So, you may believe that your mug of Bulletproof coffee or the fat bomb may not be raising your insulin levels because it does not contain glucose or protein. However, your pancreas is still working overtime to produce more insulin to hold the fat on your bum and until the energy coming in via your mouth is used up.

You may be able to ramp up your energy expenditure for a while by shivering and fidgeting, more but after a time of overdriving energy you’ll likely end up fat and insulin resistant.

If you really want to reduce your insulin levels you need to work on reducing the excess level of energy floating around in your bloodstream (from any source, including fat, carbs, protein or exogenous ketones) so your pancreas will decrease its production of insulin to allow body fat to be used.

Focusing on obtaining the nutrients you need without too much energy seems like common sense to me.

Therapeutic ketosis

Someone targeting therapeutic ketosis to assist with the management of chronic conditions such as cancer, epilepsy, dementia or Alzheimer’s may benefit from higher levels of ketosis and less reliance on glucose. But I don’t think the vast majority of people who are Googling “keto” at the moment are looking for a therapeutic treatment.

Understanding how to quantify the insulin load of our food enables us to accurately tailor or food choices to suit our goals. When it comes to insulin load we need to keep it low enough to get the results we need without compromising the nutritional value of the food we eat too much.

The chart below shows that nutrient density peaks at around 40% insulinogenic calories.

If you are insulin resistant it would be prudent to have less than 40% insulinogenic calories.
Someone on a low carb diet might have less than 25% insulinogenic calories.
Someone targeting therapeutic keto will likely need to have less than 15% insulinogenic calories to see therapeutic levels of ketones.

Unless you really require therapeutic keto then I don’t think there is a need to worry too much about the impact of protein on your blood ketone levels. Actively avoiding protein tends to lead to compromising nutrient density unnecessarily which may lead to nutrient cravings or deficiencies in the long term.

The glucose : ketone index

People who require therapeutic ketosis should also ensure that they are not driving the total energy in their system too high. To do this they can track their glucose as well as ketones. The glucose:ketone ratio (GKI) which was developed by Dr Thomas Seyfried to measure the degree of therapeutic ketosis.^[12]

If you’re interested, your GKI can be calculated by dividing your glucose (in mmol/L) by your ketone values. For example, if your blood glucose is 108 mg/dL and your blood ketones are 0.5mmol/L, GKI = blood glucose / ketone = (108 mg/dL / 18) / 0.5 mmol/L = 6 mmol/L / 0.5mmol/L = 12.

People who are chasing therapeutic ketosis typically do not need to worry about ingesting too much energy. Driving a hypercaloric state with refined fats is not a major concern for someone trying to keep weight on (e.g. cancer cachexia). However, ensuring that they are achieving lower glucose levels will ensure that they are not driving insulin resistance.

For reference, the table below shows the relationship between HbA1c, average glucose, ketones and GKI for different scenarios showing how your GKI and ketones correlate with HbA1c and blood glucose.

metabolic health	HbA1c	average blood glucose		blood ketones	GKI
metabolic health	(%)	(mmol/L)	(mg/dL)	(mmol/L)
low	4.1	3.9	70	> 0.3	< 4
optimal	4.5	4.6	83	> 0.3	< 15
excellent	< 5.0	< 5.4	< 97	> 0.3	< 20
good	< 5.4	< 6	< 108	< 0.3	< 40
danger	> 6.5	7.8	> 140	< 0.3	> 40

Really low GKI values (i.e. very high ketones and very low glucose) are typically seen in extended fasting when glucose levels to drop and ketones from body fat increase in a low insulin state.

The chart below shows my blood ketone and glucose levels during a seven day fast. Amazingly, as my blood glucose levels dropped below 4.0 mmol/L my ketones drifted up to 8 mmol/L. During more recent, however, I haven’t been able to achieve such high ketone levels.

While we can get these high ketone levels during fasting, we typically don’t see them in the fed state. To give you an idea of what to expect, the chart below shows GKI values over time during fasting for RD Dikeman (from Type 1 Grit), Jimmy Moore, Simon Saunders (Keto Island) and myself. As a rule of thumb, you might expect to see a GKI value less than 2 after two or three days of water fasting.

Nutrient density analysis

Being a big fan of Dr Phinney and the Art and Science books, I couldn’t help running his recommended diet through the Nutrient Optimiser. I entered all the meals in the Art and Science of Low Carb Living into Cronometer and ran it through the Nutrient Optimiser.

If you’re interested, you can see the full report here and where these meals rank on the leaderboard here.

So what should you do with all this information?

So, to summarise:

If you have great blood sugars and just want to lose weight then you should focus on maximising nutrient density while reducing the energy levels in your bloodstream. There is no need to worry about “being in ketosis”. You will produce ketones if you are successfully achieving an energy deficit and burning your own body fat stores.
If you are insulin resistant then you will want to limit your insulin load to a maximum of 2.9 g/kg LBM. This will restrict carbohydrates in your diet so your blood sugars stabilise.
If you are trying to manage diabetes then you want to keep your insulin load under 1.8 g/kg LBM. This will restrict carbohydrates and may reduce your protein intake a little.
If you require therapeutic keto then you will want to keep your insulin load less than 1.1 g/kg LBM and may need to consider limiting protein.

The recommended values for protein and insulin load are shown in the table below.

approach	min protein (g/kg LBM)	max insulin load (g/kg LBM)
therapeutic ketosis	0.8	1.1
diabetes / nutritional ketosis	1.8	1.8
weight loss (insulin resistant)	1.8	2.9
weight loss (insulin sensitive)	1.8	–

Can run the numbers for me?

I realise all this data can be confusing if nutrition is not your hobby.

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

The first instalment of the Nutrient Optmiser is a free calculator that will help you identify the ideal macronutrient ranges to suit your goals as well as a shortlist of optimal foods and meals. The table below shows how we can determine the optimal approach for you based on your metabolic health, waist to height ratio and goals.

We’d love you to check it out the Nutrient Optimiser. We’d love to hear what you think and how we can refine it to suit your goals.

We hope it will be really helpful for a LOT of people on their journey towards health through optimal nutrition

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, 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, 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, average glucose levels, blood ketone levels ketogenic diet, blood sugar, diabetes, ketone level for ketosis, ketosis, normal blood ketone levels, normal ketone levels, therapeutic ketosis, what should my blood glucose be in ketosis

optimal ketone and blood sugar levels for ketosis

July 20, 2015 Marty Kendall 87 Comments

A reduced carbohydrate diet will help reduce your blood sugars and increase your blood ketone levels.
Blood glucose control and improved metabolic health will help to reduce your risk of many of the diseases of modern civilisation such as diabetes, heart disease, stroke, cancer, Parkinson’s and Alzheimer’s.
We become ‘insulin resistant’ when our fat cells get full and can’t store any more energy. Once our adipose tissue becomes insulin resistant, excess energy is stored in the liver, pancreas, heart, brain, eyes and other organs that are more insulin sensitive. We also see increased levels of energy in our blood in the form of glucose, ketones and triglycerides.
Endogenous ketosis occurs when we eat less food than we need. Our insulin and blood sugar levels decrease and ketones rise to supply the energy we need. Exogenous ketosis occurs when we eat high levels of fat and/or take exogenous ketones. While a low carb or ketogenic diet helps to stabilise blood sugars, most of the good things associated with ketosis occur due to endogenous ketosis.
If your goal is blood sugar control, longevity or weight loss then endogenous ketosis with lower blood sugars and lower ketones is likely a better place to be than driving high blood ketones with exogenous ketosis.
This article reviews blood ketone (BHB), breath ketone (acetone) and blood sugar data from a large number of people on a ketogenic diet to understand what “normal” and “optimal” ketone levels might look like.

low carb diets reduce blood glucose levels

Many people start a low carb diet to manage their blood glucose levels, insulin resistance or diabetes. As shown in the chart below, foods that contain less carbohydrate cause a smaller rise in our blood sugar levels.^[1] ^[2] ^[3]

If you are insulin resistant, have prediabetes, diabetes (Type 1 or Type 2) it makes sense to reduce the carbohydrates in your diet to the point where you can achieve the blood glucose levels of a metabolically healthy person.

If you cannot produce enough insulin to maintain your blood sugars it makes sense to reduce the insulin load of your diet to the point that your pancreas can keep up.

What are optimal blood sugar levels?

According to mainstream medical definitions:

“normal” blood sugar regulation is defined as having an HbA1c of less than 6.0%,
“Prediabetes” is diagnosed when you have an HbA1c between 6.0 and 6.4%, and
Type 2 diabetes is diagnosed when you have an HbA1c of greater than 6.4%.

However, as shown in the charts below, the mainstream definition of “normal” is far from optimal.

By the time you have “pre-diabetes”, you are at risk of many of the most common western diseases of ageing and causes of death such as heart disease, stroke, Parkinson’s, Alzheimer’s and cancer.^[4] ^[5]

However, if you’re interested in optimal rather than what passes for normal, the table below shows some suggested HbA1c and average blood sugar targets.

risk level	HbA1c	average blood sugar
risk level	(%)	(mmol/L)	(mg/dL)
optimal	4.5	4.6	83
excellent	< 5.0	< 5.4	< 97
good	< 5.4	< 6.0	< 108
danger	> 6.5	> 7.8	> 140

In this video, diabetes pioneer Dr Richard Bernstein tells how he refined his understanding of optimal blood sugar levels by asking healthy your sale reps to demonstrate their blood sugar metres on themselves. They always seemed to come out at about 83 mg/dL (or 4.6mmol/L). This correlates well with the level at which we see the lowest level of risk of various common diseases. Today, people with Type 1 who follow Dr Bernstein’s recommendations balance their food and insulin to maintain a blood sugar of around 83 mg/dL or 4.6 mmol/L.

ketosis vs. hyperinsulinemia

While high glucose levels are bad news (due to glucose toxicity and excessive glycation) they typically go hand in hand with high insulin levels.^[6] ^[7] ^[8]

A metabolically healthy person will store excess energy in their fat cells, ready for easy access when required later. But if we continue to fill our fat cells with the excess energy they get to the point where they cannot continue to expand to absorb the excess energy. It is at this point that our adipose tissue becomes insulin resistant.

Ted Naiman does an excellent job explaining insulin resistance in this video. If you want to dig into the subtitles of this topic you should also check out:

The “good news” is that becoming insulin resistant will slow the expansion of your fat cells. Unfortunately, the bad news is that once our fat cells become insulin resistant the excess energy will be re-directed to the parts of our body that are more insulin sensitive such as our liver, pancreas, heart, brain and other vital organs.

Our pancreas works overtime, secreting more insulin to try to keep the energy in the liver and fat cells in storages while we use up the glucose in our bloodstream. High insulin levels mean that we will find it harder to release energy from our fat stores when we go without food.^[9]

Without easy access to our body fat stores, we will be driven by our appetite to eat again sooner. Without easy access to their fat stores, someone who is insulin resistant may be driven to eat more often.

Fasting insulin levels in healthy populations tend to range between 2 to 6 mIU/L.^[10] ^[11] ^[12] The average insulin levels in western populations are 8.6 mIU/L. Meanwhile, the official reference range for “normal” fasting insulin is less than 25 mIU/L.^[13] ^[14]

Given that the western world is going through a crisis of metabolic health, it is safe to say that this cut off for ‘normal’ is also far from optimal.

how to manage your dietary insulin load

The good news is that you can tailor the insulin load of your diet to suit your current level of insulin resistance. As shown in the chart below, the insulin generated by our pancreas is proportional the net carbs in our diet plus about half the protein it contains.

Reducing the insulin load of your diet can help to reduce your insulin and blood sugar levels to the point where your pancreas (and any insulin resistance you may have) can keep up and maintain normal blood sugars. With lower insulin levels, we can access our body fat for fuel, either from our body or our food.

A person with type 1 diabetes is not able to produce enough insulin to keep energy tucked away in their liver, fat stores and even muscle tissue. Without exogenous insulin, people with type 1 diabetes see both their blood glucose and blood ketones rise to very high levels. This is called ketoacidosis which is dangerous and requires exogenous insulin as soon as possible.

As shown in the image below of JL, one of the first children with type 1 diabetes to receive insulin, people with type 1 diabetes quickly regain weight with exogenous insulin administration.

Rather than minimising insulin, it’s important to find the optimal dose of insulin. Too much insulin can slow the release of fat from your body to be used for fuel. Too little insulin and we effectively disintegrate.

People who switch to a low carb diet often find that their blood glucose and insulin levels drop and they are not hungry. However, the problem with a very low insulin load dietary approach is that it may not contain enough of the vitamins and minerals that you need to help you avoid nutrient cravings in the long term.

High-fat foods have a high energy density which can make it hard for some people to manage their satiety. This can be problematic if their goal is weight loss. Very high-fat foods also tend to be less nutrient dense and are less satiating than high fibre or high protein foods.

The most ketogenic foods also contain lower levels of protein which is critical to managing satiety.

We need to find the right balance between a lower insulin load diet that will stabilise our blood sugar while still getting the essential nutrients that our mitochondria need to thrive and produce energy efficiently.

If you need help with the process of balancing your blood sugars and nutrient density, the Nutrient Optimiser is a tool to help you refine your diet to stabilised your blood sugar and insulin levels while also maximising nutrient density as much as possible.

blood glucose and ketones in fasting

When we go without food, our blood glucose levels decrease as the glucose in our bloodstream and liver (glycogen) are used up. With less glucose available our body turns to our body fat stores. Our liver converts our body fat to ketones for use in the brain rather than glucose.

This process is termed “endogenous ketosis” (endogenous = originating from within an organism).

As explained by Dr Sinclair in this video, there are many of beneficial things that occur during endogenous ketosis such as autophagy, mitogenesis, mitophagy, upregulation of SIRT1 and increase of NAD+). The body effectively goes into repair mode so it can make it through to reproduce in the next time of plenty.

The chart below shows my blood sugar and blood ketone (BHB) levels during a seven day fast. As glucose levels decrease ketone levels rise to compensate for the lack of energy.

The sum of glucose and ketones continues to increase during fasting. The sum of glucose and ketones can be thought of as the “total energy” (i.e. glucose + ketones).

Often in fasting, the body will let the total energy in the blood go quite high. This high-energy state enables you to be at a very high state of alertness and be ready to find food to survive.

Exogenous ketosis vs endogenous ketosis

The mental clarity after a few days of fasting great! But in practice, it’s hard to mimic all the benefits of going without food by forcing higher ketones with a very high-fat diet.

I think it’s important however to understand the difference between exogenous ketosis and endogenous ketosis.

Endogenous ketosis is when we eat less and our body is forced to use some of our body fat to make up the difference.

Exogenous ketosis occurs when we eat lots of fat (or take exogenous ketones), and we see blood ketones (beta-hydroxybutyrate) build up in the blood.

Higher levels of ketones can build up in the blood when you are eating more fat than you are burning. As a general rule, higher blood ketones are not a cause for concern as long as your blood glucose levels are also low (i.e. low total energy).

You will always be somewhere on the spectrum between exogenous and endogenous ketosis. We need to ingest enough energy to not fade away and while building and repairing our organs and muscles.

Keep in mind that most of the good things we attribute to ketosis and the ketogenic diet occurs due to endogenous ketosis when fat is coming from our body (e.g. autophagy, increase in SIRT1, increase in NAD+).

What should your blood sugars and ketone levels be in ketosis?

Our understanding of the ketogenic diet is still evolving. Keto Clarity co-author Eric Westman recently admitted that there is still a lack of clarity ideal ketone levels.^[15]

The image below shows the ‘optimal ketone zone’ from Volek and Phinney’s Art and Science of Low Carb Living. which has unfortunately led to a lot of confusion.

In reality, it’s hard for most people to achieve “optimal ketone levels” (i.e. 1.5 to 3.0mmol/L) without fasting for a number of days or eating a LOT of additional dietary fat (which may be counterproductive if your goal is weight loss).

Recently, I had the privilege of having Steve Phinney (pictured below in our kitchen making his famous blue cheese dressing) stay with us when he spoke at a Low Carb Down Under event in Brisbane.

I quizzed Steve about the background to this optimal ketosis chart. He said it was based on the blood ketone levels of participants in two studies. One was with cyclists who had adapted to ketosis over a period of six weeks and another ketogenic weight loss study. In both cases these ‘optimal ketone levels’ (i.e. between 1.5 to 3.0mmol/L) were observed in people who had recently transitioned into a state of nutritional ketosis (Capacity for moderate exercise in obese subjects after adaptation to a hypocaloric, ketogenic diet, Phinney, 1980).

Since the publication of this chart in the Art and Science books, Phinney has noted that well-trained athletes who are long-term fat adapted (e.g. the athletes in the FASTER study) actually show lower levels of ketones than might be expected.

Over time, many people, particularly metabolically healthy athletes, move beyond the ‘keto adoption’ phase and are able to utilise fat as fuel even more efficiently and their ketone levels reduce further.

Urine ketone strips are often considered to be of limited usefulness because the body stops excreting ketones as it learns to use them.

As our blood glucose levels decrease, our ketones increase to make up for the lack of fuel. When we have less glucose available our insulin levels go down, more fat is burned, and blood ketone levels rise. But it seems that over a longer period of time as our body learns to use blood ketones more effectively.

As discussed in this post, BHB ketones enable our body to store and transport ketones around the body before they are converted back to acetoacetate to be burned in the mitochondria. Similar to high blood glucose levels, chronically high ketone levels are not necessarily a desirable thing. As you will see below, a healthy metabolism tends to operate with less fuel mobilised in the bloodstream whether that be in the form of glucose, ketones or free fatty acids.

Crowdsourced ketone and glucose values

In late 2015 I pooled a range of data from myself and a number of people on the Optimal Ketogenic Living (OKL) Facebook group. After sharing this data initially, a number of other people sent me their data. Later, Michel Lundell from Ketonix agreed to share an extensive set of anonymised data for me to analyse.

I hope that this crowd-sourced data will help to provide more clarity about optimal ketone levels in a similar way to Dr Bernstein surveying the glucose metre sales reps helped to provide a better understanding of what normal ketone values are.

The chart below shows the sum of the blood glucose and ketones (i.e. total energy) from nearly three thousand data points from a broad range of people following a low carb or ketogenic dietary approach.

On the right-hand side of the chart, we have a high energy situation from both glucose and ketones. While not as extreme, high energy situation is similar to someone with Type 1 diabetes with high glucose and high ketone levels due to inadequate insulin. High levels of energy in the blood causes the pancreas to secrete insulin to hold the glycogen back in the liver and stop lipolysis (i.e. the release of fat from storage) until the energy in the bloodstream is used up.

On the left-hand side of the chart, we have a low energy situation. These people do not have too much energy floating around in their bloodstream. They are also likely insulin sensitive and can easily access their body fat stores for fuel.

As shown in my fasting ketone data above, we may see high blood ketone levels when we go without food for an extended period. However, trying to replicate high ketone levels with high levels of exogenous ketones or an oversupply of dietary fat will not provide the same positive benefits as endogenous ketosis.

Based on this crowd-sourced data it seems the body tries to maintain a blood glucose level of around 4.9mmol/L and a blood ketone level (BHB) of around 1.5mmol/L. The table below shows this data in terms of average as well as the 25th percentile and 75th percentile points.

	ketones (mmol/L)	BG (mmol/L)	BG (mg/dL)	HbA1c	GKI	BrAc	total energy (mmol/L)
25th	0.6	4.2	76	4.3	1.8	46	3.4
average	1.5	4.9	89	4.7	7.3	56	6.4
75th	2.1	5.6	101	5.1	14	66	12.9

blood glucose and ketone levels during exogenous ketosis

Some people come to low carb or keto for therapeutic purposes (i.e. to manage chronic conditions such as cancer, epilepsy, traumatic brain injury or dementia). These people can benefit from higher ketone levels to fuel the brain when glucose cannot be processed due to high levels of insulin resistance. If you are trying to avoid cancer cachexia or trying to feed a child with epipepsy then an energy dense diet can be an advantage. However, most people do not require this degree of therapeutic ketosis, particularly if weight loss or reversing insulin resistance is the priority.

People following a therapeutic ketogenic diet may be fuelling up with MCT oils to achieve high ketone levels and low glucose:ketone index values (GKI) value for therapeutic purposes. Others will target high levels of ketones for brain performance. Others will load up on exogenous ketones and glucose to ‘dual fuel’ the system for athletic performance.

One of the benefits of a low carb or keto diet is that it tends to eliminate a lot of hyper-palatable processed foods. Stabilising blood sugar and insulin levels can also help normalise appetite and cause people to eat less.

The danger, however, with trying to drive high levels of ketones primarily through exogenous ketosis is that it will lead to an energy excess which will drive insulin and slow the use of fat and glucose stores until the energy in the bloodstream is used up.

Even though we are getting most of our energy from fat rather than carbs, the body will still work to bring maintain lower levels of energy in the bloodstream using insulin, and stop the release of stored glycogen and body fat until you have used up the energy in your blood from your food. This is why Thomas Seyfried and Dominic D’Agostino talk specifically about the benefits of a calorie restricted ketogenic diet. ^[16] ^[17] ^[18]

blood glucose and ketone levels for weight loss and endogenous ketosis

Many people embark on a ketogenic dietary approach to manage their diabetes and achieve long-term weight loss. They want lower insulin levels to enable them to burn more body fat for long-term insulin sensitivity and health.

On the left-hand side of the total energy chart below, we have a situation where we are generating endogenous ketosis, meaning that our own body fat is being burned for fuel.

With lower levels of energy in our blood, our body needs to draw on fat from our body fat stores as well as use excess stored fat and old proteins in our liver, pancreas, brain and other organs (i.e. autophagy).

To understand what all this means, the chart below shows the data divided into three thousand data points into five quintiles, from lowest to highest total energy. For each quintile, I have calculated the average, 25th percentile and 75th percentile blood ketone (BHB) value. Half of the ketone values fit between the 25th and 75th percentile values.

quintile	average BG (mmol/L)	BG (mg/dL)	ketones (mmol/L)			total energy (mmol/L)
quintile	average BG (mmol/L)	BG (mg/dL)	25th	average	75th	total energy (mmol/L)
1	4.5	80	0.3	0.6	0.7	5.0
2	4.9	88	0.4	0.8	1.1	5.7
3	5.1	92	0.6	1.1	1.5	6.2
4	5.1	92	1.2	1.8	2.3	6.9
5	5.1	92	2.2	3.2	4.0	8.3

In the discussion above we see that the lowest risk of the modern diseases of ageing and metabolic health occurs when we have an HbA1c of less than 5%. It seems that as a general rule (other than when we are fasting or aiming for therapeutic ketosis) being somewhere to the left of this chart is (in the first or second quintile) with blood glucose levels less than 5.0mmol/L (or 90mg/dL) is optimal.

In summary, it appears that the lowest blood sugar levels are associated with lower ketone levels and a lower total energy overall. Or to put it another way, higher ketones are not an indicator of improved metabolic health.

Virta study ketone values

The crowd-sourced data above seems to also align well with ketone data from the Virta study (Phinney et al., 2017).

In this study, they aimed to get their patients into nutritional ketosis (which was defined as blood ketone levels between 0.5 and 3.0mmol/L as per the optimal ketone zone chart above) using a ketogenic diet.

The distribution of BHB levels is shown in the chart below. The average blood ketone levels over the first 10 weeks of the study were 0.6mmol/L, with a standard deviation of 0.6mmol/L. The chart below shows the distribution of blood ketone levels.

In spite of consuming a ketogenic diet under the supervision of Steve Phinney and the Virta team, many of the study participants did not achieve ketone levels that qualified as nutritional ketosis. Although the ketone values were reasonably low, the reduction in HbA1c was still substantial.

Many of the people on insulin were able to reduce or eliminate their insulin requirements. Also, most of the participants lost a significant amount of weight.

Do ketone values change after long-term adaption?

Anecdotally it seems that people who are very physically fit may find they have lower blood ketone levels as well as lower blood sugar levels.

In fact, unless you are managing a chronic condition that benefits from high ketone levels (e.g. Alzheimer’s, Parkinson, dementia or epilepsy) you could save your money on testing ketones and focus on making sure your blood sugars are closer to optimal.

Anything ‘keto’ is very trendy at the moment, as discussed in this article, ketones

Is it the ketones or NAD+ that is really doing the good stuff?

A smart friend of mine, Robert Miller, has been challenging my thinking recently around ketones recently. Robert’s theory is that the benefits that people attribute to ketones are actually mainly due to an increase in nicotinamide adenine dinucleotide (NAD+).^[19] ^[20]

Adequate levels of NAD are critical to moving energy around our body, from our food to our mitochondria.^[21] NAD+ declines with age, increases in fasting, during a ketogenic diet or in response to exercise. When NAD+ rises, SIRT1 helps our body to repair and improve our insulin resistance.^[22]

Our NAD+/NADH balance is critical to controlling our appetite and telling the body whether we need more fuel, or if it’s time to tap into our body fat stores.

We can increase our circulating levels of NAD+ by eating a nutrient dense diet, particularly with adequate niacin (vitamin B3).^[23] There is a range of NAD+ supplements that seem to have positive benefits.

Nicotinamide Riboside is a close precursor to NAD+ which can be helpful for people who struggle to make NAD+ directly from food.

However, Nicotinic Acid (i.e. full flush niacin) is a much cheaper supplement that will work just as well for most people.

NAD+ metabolism is a fascinating rabbit hole if you want to do some research, but for now, let’s say that it’s essential to have adequate NAD+ to enable your mitochondria to convert the food you eat to energy rather than having it back up in your body.

What about breath ketones (acetone)?

You will likely be aware that three separate types of ketone bodies:

acetone (breath ketones),
acetoacetic acid, and
beta-hydroxybutyric acid (BHB in the blood).

Fatty acids come to the liver either from our food or lipolysis (mobilisation of fat from our body) and converted to acetoacetate. Unfortunately, we have no way to directly measure acetoacetate, only BHB in the blood and acetone in the breath.

The Ketonix is a device that you blow into that measures the acetone which is akin to exhaust that is released when you burn acetoacetate.

Blood ketones (BHB) are the most well-known form of ketone bodies. There is some relationship between blood ketones and breath ketones, but it is not direct. The chart below is Measuring Breath Acetone for Monitoring Fat Loss: Review (Anderson, 2015)^[24] which states

“Endogenous acetone production is a by-product of the fat metabolism process… Breath acetone concentration (BrAc) has been shown to correlate with the rate of fat loss in healthy individuals… A strong correlation exists between increased BrAce and the rate of fat loss.”

The data below provided by Michele Lundell from Ketonix data shows a similar relationship between breath ketones and blood ketones but with a lot of scatter!

Breath acetone is likely a stronger marker of burning ketones for fuel, not just buffering energy in the blood. A higher NAD+:NADH ratio means that less AcAc is stored as BHB and is available to be oxidised, at which point we see more breath acetone.

What I’m trying to illustrate with the dodgy clip art in the chart above is that having high blood ketones and low levels of breath acetone appear to be a sign that you are not burning the fat you’re eating.

By contrast, a high level of breath acetone with a low level of blood ketones (BHB) and low blood glucose may be a sign that you are very efficiently burning the fat you eat.

If you had a choice, I think it’s better to have high breath acetone (BrAce) and lower blood ketones (BHB) (which would suggest that you were efficient at burning fat) than high BHB and low BrAc (which would indicate that you were good at eating fat but not necessarily burning fat).

The figure below shows BHB vs BrAce for the different purposes that people nominate for using the Ketonix. What we see is that people with diabetes (red trend line) have both higher blood glucose and higher blood ketone (BHB) levels (i.e. higher total energy). Fuelling the mitochondria with the right nutrients that increase NAD+ will both help to burn off the excess energy and manage appetite through the NAD+: NADH ratio.

The second law of thermodynamics states that the total entropy (chaos) of an isolated system can only increase over time. It seems that an organism that is ageing will decay and not be able it’s energy packed in storage, but instead, we will see increasing levels of energy floating around in the bloodstream (e.g. diabetes).

What can we use blood ketones for?

Blood glucose levels are likely more useful than worrying about blood ketones, I think tracking BHB can still be helpful in diabetes management.

You will remember that people with uncontrolled type 1 diabetes will have blood glucose and blood ketones that are sky high. This is called ketoacidosis.

The mainstream approach to treating diabetes is by ramping up the insulin to suppress both blood glucose and blood ketones. Unfortunately, without modification of diet to reduce the insulin load, excessive amounts of exogenous insulin will just slow fat burning as well as suppressing blood glucose levels.

Having low blood glucose and very low ketone levels (say less than 0.4 mmol/L) can just be a sign that you are taking too much exogenous insulin and need to back off the exogenous insulin dosing. If you are taking exogenous insulin, this would be worth checking periodically to make sure you’re not overdoing the insulin.

summary

Metabolic related diseases such as heart disease, cancer, stroke, diabetes, Alzheimer’s disease, kidney disease are the leading causes of death.
People with the best metabolic health (i.e. low HbA1c, insulin and blood sugar levels) have the lowest risk of dying from these common western diseases of ageing.
Keeping your processed and starchy carbohydrates low will help to keep your blood glucose and insulin levels and reduce your risk of obesity.
When we fast, our glucose levels decrease, and ketones increase to maintain our energy levels.
People who are metabolically healthy and insulin sensitive typically have a lower level of total energy (i.e. glucose + ketones) in their bloodstream.
We can mimic the rise in ketones with added fats or exogenous ketones that we see during fasting. However, the real benefits occur when the body is forced to draw on its own stored energy, and we experience autophagy, upregulation of SIRT1, and a rise in NAD+.
The benefits that we often attribute to ketones may also be due to increased NAD+ levels which occur in fasting and/or with a nutrient-dense diet.
We can only measure beta-hydroxybutyrate (in the blood) and acetone (in the breath). We can think the BHB as a buffer ready for use, and acetone as the exhaust showing that the ketones have been burned for fuel. Higher levels of fat burning with a lower need for buffering is a better place to be than a large buffer in the blood and minimal fat burning.