Tag Archives: low carb diet

balancing diet and diabetes medications

  • High blood glucose levels (glucose toxicity) and high insulin levels (hyperinsulinemia) are both bad news for your health.
  • The highest priority in the treatment of diabetes should be to reduce foods that require large amounts of insulin.
  • Over reliance on medications can lead to ‘learned helplessness’, meaning that people do not use a dietary intervention to what is primary a dietary disease.
  • Periods of fasting and intense exercise also improve insulin sensitivity.
  • A lower insulin load diet and improved insulin sensitivity will enable you to reduce and possibly eliminate medications.

when do you need insulin?

Last year I was tracking my blood sugars.  I was concerned with what I saw.

Based on my average sugars of about 6.2mmol/L my HbA1c would have been about 5.5%.  I wasn’t happy because I knew it was still well away from ideal. [1]  I knew that improving my blood sugars was likely the key to losing the weight that I had been struggling with.

In an odd sort of way I was jealous of my wife who has type 1 diabetes.  She could manipulate her blood glucose levels manually with her insulin pump, but I wasn’t sure what to do to bring my blood glucose levels down to more healthy levels.

Given that doctors will typically not give insulin until your HbA1c is greater than 7.0% [2] there was no way a doctor was going to prescribe me with insulin.  My doctor told me to lose some weight to combat the developing signs of fatty liver in my blood tests.

In January 2015 I found Jason’s Fung’s videos [3] and kicked myself in the butt.  Intermittent fasting seemed to do the trick to break the insulin resistance even though I had been following a lower carb paleo approach for a while.  I was able to get my blood sugars back down to an average of 5.4mmol/L to give me an estimated HbA1c of about 4.8% and in the process of actively trying to manage my blood glucose levels I lost ten kilograms.

Fasting and improving insulin sensitivity

Dr Jason Fung [4] has recently increased the focus on fasting and dietary intervention and discourages an over-reliance on insulin to manage diabetes.

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Jason says that focussing on medicating the symptoms of diabetes rather than addressing the root cause of insulin resistance can lead to a ‘learned helplessness’ where people do not pursue a dietary solution to what is largely a dietary problem.

Addressing diabetes by giving insulin to address the symptom of high blood glucose levels is like giving an alcoholic alcohol to relieve the symptoms of their alcohol withdrawal. 

Meanwhile, Dr Richard Bernstein says that most of his type 2 diabetics need to remain on small doses of insulin in addition to minimising carbohydrate in order to achieve ‘normal blood sugars’.[5]

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In this video Dr Bernstein however notes a number of negative consequences of taking exogenous insulin including:

  • inconvenience,
  • it can make you fat if you eat a lot of carbohydrate, and
  • it can cause hypoglycaemia (i.e. low blood glucose levels).

the balance between diet and medication

So how do we find the optimal balance between an over-reliance on exogenous insulin and medication while still achieving normal blood sugars?

Dr Ted Naiman of BurnFatNotSugar.com says that when he sees a new diabetic patient he checks their fasting insulin and C-peptide levels to understand whether they are still producing insulin or if their pancreas is already burned out.

If you don’t have access to these tests another option is to test your ketones and blood glucose levels to establish the ratio of glucose to ketones, which can also help you estimate your insulin levels (see the glucose : ketone index).

High insulin and high blood glucose means that you are insulin resistant (i.e. hyperinsulinemia).

Low insulin and high blood glucose means that you are insulin deficient and your pancreas is not producing enough insulin (i.e. type 1.5 diabetes, LADA).

Dr Naiman (pictured below – he practices what he preaches!) says he “avoids insulin like the plague” if at all possible, preferring to focus on diet, fasting and exercise.

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Ted says that if you are still producing insulin but have high blood glucose levels the urgent need is to reduce the insulin load of the diet, start an exercise routine to improve insulin sensitivity, and ideally commence intermittent fasting ASAP!  If you continue to consume a diet with a high insulin load you risk burning out the beta cells of your pancreas at which point you will require insulin.

Ted has produced an excellent summary of intermittent fasting and the various ways to put it into practice that you can download here.  For more detail you also can check out Brad Pilon’s Eat Stop Eat or Jason Fung’s series on the topic.

the dangers of glucose toxicity

As discussed in the Diabetes 102 article there are a range of well-established risk factors for high blood sugars including accelerated brain shrinkage, cancer, obesity, heart disease and stroke.

This article from Jenny Ruhl’s Blood Sugar 101 lists a number of other complications related to high blood sugars including nerve damage, beta cell destruction, heart disease, diabetic retinopathy, and kidney disease.

Just in case you weren’t already aware… elevated blood glucose levels are very bad news!

If you want to be healthy, feel good, look good and live a long life, then your number one priority should be to do whatever it takes to achieve excellent blood sugars.

the dangers of insulin toxicity

I was interested to hear Professor Tim Noakes tell Robb Wolf in episode 273 of the Paleo Solution Podcast

You really want to keep your control through diet and minimal medication and never use insulin.

What I take this to mean is not that insulin is forbidden for people who need it, but rather that you should do whatever you can to not get to the point that you need to be injecting insulin to control your blood glucose levels.

Dr Fung points to the ACCORD Study[6] along with the ADVANCE, VADT and ORIGIN studies which showed worse outcomes for people with type 1 diabetes who targeted a lower HbA1c of 6.0% rather than a more typical 7.5%.

The figure below from the ACCORD study shows the reduction in HbA1c with intensive therapy (i.e. more insulin) to “successfully” reduce blood sugar levels.  What they found however was that the people in the intensive therapy group were 22% more likely to die (i.e. all-cause mortality) in spite of having ‘better’ blood glucose levels!

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This may sound contradictory, because at the same time we know that reduced HbA1c levels actually lead to better health outcomes in the general population.  So what’s the difference?  Why are these studies suggesting that trying to normalise blood glucose levels are dangerous?  Is there something about people with diabetes that makes it unhealthy for them to have lower blood sugars?

There is plenty of debate on what these studies really mean, [7] [8] [9] however Dr Fung says it is the use of medication in the absence of dietary intervention that is making the difference.  Simply applying more insulin or other medications without addressing the diet is not only illogical it’s very dangerous!

This aligns with the data shown below[10] which shows that reducing HbA1c is highly beneficial when it comes to heart attack and stroke risk, however doing it through the use of antidiabetic medication does not help.

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Ivor Cummings does a great job on his blog of highlighting a wide range of studies that demonstrate that insulin resistance is by far the dominant risk factor for heart disease. [11] [12] [13] [14] [15]  All we do when we medicate a high carbohydrate diet with insulin is to exacerbate the insulin resistance.

So is insulin all bad?  Not necessarily.  Insulin is important for a range of bodily functions including growth.  However, high levels of insulin to cover high levels of dietary carbohydrate is a recipe for metabolic disaster.

Rather than relying on insulin, Dr Fung recommends a low insulin load diet combined with periods of fasting to improve insulin sensitivity and reduce insulin and blood sugar levels.  Dr Fung told me that people need to “reduce both blood glucose and insulin to reduce glucotoxicity and insulin toxicity.”  He says a HbA1c of less than “6.0% is defined as normal, although the lower you get, the better. However, this only applies if you are using diet rather than medications.” [16]

two sides of the same coin?

Both Dr Fung and Dr Bernstein focus primarily on non-medical interventions which include:

  1. A low carbohydrate / low glucose load / low insulinogenic diet. I suggest you focus on foods from this list and meals from here to bring your blood sugars under control.
  2. Exercise will improve your insulin sensitivity and help to remove excess glucose from your system. High intensity short duration exercise is ideal along with regular movement through the day.  Rather than forcing yourself to exercise out of guilt you may find once you balance your blood sugars with diet rather than medication you have more energy and want to move more.
  3. Fasting is a great way to restore insulin sensitivity and reduce blood glucose levels naturally. It might be considered by some to be extreme, however it’s the most aggressive and effective approach to move the metabolic needle in the right direction.  And it’s not that hard, particularly if you’ve got a lot of weight to lose and you’re looking down the barrel of major health complications.

Bob Briggs does a great job of putting this into simple terms that are easy to understand and apply.

refining insulin levels for type 1 diabetics

For someone with type 1 diabetes balancing dietary insulin load with exogenous insulin is an ongoing process of fine tuning.

Getting the basal insulin dose is important, particularly if you’re following a reduced carbohydrate approach, as it can represent up to 80% of the daily insulin dose.  Unless you’re fasting you are unlikely to have a higher basal : bolus ratio than this.  Covering too much of your food with basal insulin can be dangerous if you need to skip or delay a meal for any reason (e.g. sleeping in on the weekend).

The scatter plot of blood glucose readings below shows my wife Monica’s blood glucose readings.  We use this data to review and refine her basal insulin rates (80% of her insulin dose) every couple of weeks.

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While we are still on a journey, her blood glucose levels are the best they’ve been in her adult life and we’ve seen massive improvements since switching to a more nutrient dense low insulin load diet.

If her blood sugars drift up in a particular period of the day she will increase the basal rate on her pump in the two hours leading up to the point where the blood glucose levels are high.  Conversely, if there are a cluster of hypos (lows) at a particular point in time she will drop back the basal insulin leading up to that time.  Ideally we try to keep the high / low bars on the top chart on the red line, but not below it.

Her basal rates (shown below) are lower over night with a higher dose in the morning to cover the ‘dawn phenomenon’ which is the body’s way of supplying glucagon and adrenaline in preparation for the day ahead.

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We’ve experimented with reducing basal insulin rates and running higher blood glucose levels to avoid lows and to reduce the overall insulin load.  However this hasn’t really worked as Moni just doesn’t feel good with higher blood glucose levels.

It’s a delicate balancing act between blood glucose levels and insulin load.  Your mileage may vary.  You’ll need to refine things based on how you feel and with what you are comfortable with.

It’s also a good idea to look at the data over a longer period to make sure you’re not just reacting to recent events.  Diet, hormones, stress, sickness and exhaustion all influence blood sugars and insulin requirements.

Knee jerk reactions to recent events can throw everything out of whack.  We’ve found it better to make small refinements rather than large changes.

Some female diabetics also refine their basal rates around their monthly cycle as insulin resistance typically increases by around 15% in the four days leading up to their period.  It’s worth tracking this and being ready to adjust insulin dosage.

the law of small numbers

The most important thing to know is that managing the insulin load of your diet is the most important thing you can do to improve blood glucose control.  If you have a high degree of variability in your blood glucose from hour to hour due to a highly insulinogenic diet you’ll never be able to bring blood glucose levels down without risking going too low.

Most endocrinologists will recommend against targeting optimal blood glucose levels due to the risk of hypoglycaemia (low glucose levels).  However reducing the insulin load of the diet will mean that the amplitude of the blood glucose swings are smaller, which will enable you to bring the overall average blood glucose level down using the basal insulin and smaller food bolus and correcting insulin doses.

Bernstein talks about the ‘law of small numbers’.  If you are consuming a high carbohydrate diet then you will need ‘industrial doses’ of insulin and there is no way to calculate the insulin dose perfectly, so the errors compound and the resulting blood sugar swings are out of control.  It’s the severe blood glucose swings that make you feel really bad, even more so than high or the low blood sugars alone.

adjusting insulin doses for type 2 diabetics

For the most part the observations from people with type 1 diabetes also apply to those with type 2 diabetes.  A type 2 diabetic can balance their dietary insulin load with the insulin produced by their own pancreas supplemented with insulin sensitising drugs such as Metformin or injected insulin.

The first priority when transitioning to a low carbohydrate diet is to avoid driving your blood sugars low with too much medication.   Rather than going low all the time it’s better to reduce your medications to a point where higher blood glucose levels will remind you that you need to manage blood glucose by controlling your diet.

If your medications are too high you will likely end up having to eat extra food to treat low blood glucose levels all the time.  So not only do you have more insulin than you want (which will stop you using stored body fat for energy) you have to eat more than you need because of excess medication (which will also get stored as fat).

It’s hard to give an exact target blood sugar range, however the following guidelines may be useful:

  1. Blood glucose levels less than 4.0mmol/L (73mg/dL) are typically considered low (unless you are young and / or have high ketone levels). If you are seeing these blood glucose levels you should decrease your diabetes medications.
  2. Post meal blood sugars should be less than 6.7mmol/L (120mg/dL). If you’re seeing higher blood glucose levels than this after meals then you shouldn’t eat what you just ate again.
  3. A fasting blood sugar of less than 5.0mmol/L (90mg/dL) and an average blood sugar of less than 5.4mmol/L (100mg/dL) is ideal.

Once you reduce your dietary insulin load (i.e. by reducing carbohydrates, moderating your protein and maximising high fibre foods) you will not require as much medication and may need to reduce your medications to prevent hypos (low blood sugars).

If your dietary insulin load reduces further you will be able to reduce, and possibly eliminate, your diabetes medications as your own pancreas is able to keep up with your decreased insulin requirements.

If you are able to further reduce your insulin load your blood sugars will come closer to normal levels.  With reduced insulin you will be able to use your body fat stores for fuel and ideally lose weight.

Depending on your goals and level of dedication (or OCD), you might get to a point where injecting small amounts of insulin is no longer worth the hassle.  This is something that you should work through with your doctor who prescribed the insulin and / or medications.

 

references

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

[2] http://www.diabetesselfmanagement.com/managing-diabetes/treatment-approaches/type-2-diabetes-and-insulin/

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

[4] https://intensivedietarymanagement.com/

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

[6] http://www.nejm.org/doi/full/10.1056/NEJMoa0802743#t=articleTop

[7] http://phlauntdiabetesupdates.blogspot.com/2012/10/new-page-why-lowering-a1c-below-60-is.html

[8] http://diatribe.org/issues/10/learning-curve

[9] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518370/

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

[11] http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2004.01371.x/epdf

[12] http://www.thefatemperor.com/blog/2015/5/5/hilarious-apob-now-being-used-as-predictor-of-insulin-resistance-cholesterol-lchf

[13] http://www.thefatemperor.com/blog/2015/4/30/insulin-resistance-the-primary-cause-of-coronary-artery-disease-bar-none-lchf

[14] http://jaha.ahajournals.org/content/4/4/e001524.full.pdf+html

[15] http://www.thefatemperor.com/blog/2015/5/3/cholesterol-lchf-whats-the-only-thing-that-matters-for-repeat-heart-attacks

[16] https://intensivedietarymanagement.com/lchf-for-type-1-diabetes/

why is good blood glucose control so important?

When my wife Monica was diagnosed with type 1 diabetes at ten she was advised to eat at least 130g of carbohydrates with every meal.

The insulin dose was kept fixed to cover this fixed amount of carbohydrates.  If she went low she had to eat more carbs to bring her blood glucose back up.

Welcome to the everyday blood sugar roller coaster that takes over your life when you have diabetes!

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It wasn’t till after we were married in 2002 and started thinking about having kids that she found a doctor with an interest in diabetes who told her that she could tailor her insulin dose to what she wanted to eat.

Up until this time even the visits to the endocrinologist were to get more scripts for insulin and thyroid medication.  No useful advice was provided about how to manage diabetes.

It’s amazing that the concept of carbohydrate counting was new and shiny in 2003 when Richard Bernstein developed the concepts back in 1970s!

Today, the standard of care for diabetes seems to have incorporated Bernstein’s carbohydrate counting, however the nutritionists and diabetes associations still advises that diabetics should not have to deprive themselves of any food in the pursuit of health.  And like everyone else, they should eat a diet full of “healthy whole grains”.

It wasn’t until we discovered Paleo and then low carb through family members and social media that she found that she could improve blood sugar control through diet.

More recently by refining our diet to prioritise low insulin load, high fibre and high nutrient density foods I’m pleased to say that she has been able to find another level of improved blood sugar control, increased energy and reduced depression and anxiety that so often comes with blood sugar dis-regulation.

Real-Food-Pyramid1 (1)

It is still not easy and we are still learning, however she is now able to enjoy working as a supply teacher rather than just getting through the morning and needing to sleep during the afternoon before picking up the kids from school.

Her big regret is that she did not discover this earlier, which would have saved her from spending decades living in a fog with limited energy.

The chart below shows the difference diet can make in the management of blood glucose, particularly for a type 1 diabetic (notice that these plots are only two months apart!).  People who find success with this dietary approach find a substantial improvement in quality of life and their state of well being that makes it well worth the effort.

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Below is a recent post on the TYPEONEGRIT Facebook group from a mother of a type 1 diabetic child describing their interaction with her health care team.  It’s still not simple to go against the main stream dietary advice.

We had our team meeting today to discuss LCHF…  they are so terrified of this, even though we have great BG readings, behaviour improvements and learning improvements (noted by us, family, friends and his school) which they didn’t even acknowledge.

The nutritionist is concerned that he won’t be getting the micronutrients that only come from grains and the higher carb vegetables (grains are fortified), then her concern was the B vitamins 1, 3 and 6. 

Then the concern about Iron (what?! have you seen the meat and spinach listed?). Then it was calcium and magnesium (clearly they don’t have a clue about LCHF).

They said they are afraid this diet may cause future developmental harm. We said your diet WILL cause future harm and way more than developmental. Back and forth and on it went. We addressed their concerns with peer reviewed research, and respect to their limited knowledge.

We will be an open book and comply because I want them to learn that T1D care can be so much better than it has been up to now, and pave the way for the next families that wishes to do LCHF.

They will check for vitamins and minerals at his 3 month blood work (again special for our case, which we have to pay for).

The good news here is that after running an intense battery of tests they decided to use this child as Canada’s first case study in LCHF paediatrics for the management of type 1 diabetes.

This post inspired me to run some numbers on a range of diets to see whether there was any issue with the nutritional content of higher fat diets.   It turns out that diets with higher levels of fat can be very nutritious while the grain based diet that everyone is recommended does very poorly, particularly when you take the insulin of these higher carbohydrate diets into account (see the Diet Wars… Which One is  Optimal article for more details).

It breaks my heart to see diabetics living with a highly diminished quality when there is the potential to greatly reduce the impact of diabetes by more informed food choices.

For people with diabetes and their carers diet is important and maybe a matter of life and death, or at least a decision that will greatly affect their quality and length of life.

can you eat too much fat on a low carb diet?

Even though Wilder’s formula allows 10% for fat being anti-ketogenic, the insulin index data does not indicate that there is any effect on insulin from fat.  The best correlation with the food insulin index was achieved with zero times fat.  This aligns with what we see in type 1 diabetics who can eat fat without raising their blood sugars or requiring insulin.

Eating a low carb, high fibre, moderate protein diet will typically naturally lead to increased satiety and reduced calorie intake.  Reducing insulin will allow stored body fat to be used for fuel.

However if someone was trying to lose weight I would not recommend emphasising dietary fat once they were fat adapted in order to allow energy to be supplied from body fat.

Some people aiming for ketosis to lose weight can overdo the fat calories and not achieve the weight loss.  If your aim is weight loss it’s better to be in calorie deficit and be burning stored body fat, than to have high blood ketones produced by MCT oil and butter.

While counting calories may be beneficial for some people to retrain their appetite initially, a better long term approach may be to try some form of intermittent fasting to reset insulin sensitivity and reduce overall calorie intake.

If your body fat and blood sugars are under control then go ahead and indulge in supplemental MCT oil or some extra butter in your coffee for the mental buzz, but keep in mind that, while ketosis will lead to increased satiety for most people, calories matter in the long run.

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[next article…  proportion of insulinogenic calories]

[this post is part of the insulin index series]

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

fibre… net carbs or total carbs?

Looking at the foods sitting above the trend line the chart below it appears that the foods with the greatest insulin response compared to what would be predicted by carbohydrate and protein tend to be the ones that are more processed such as ice-cream, baked beans, pancakes and Jelly Beans.

On the lower side of the trend line we have less processed foods (e.g. full cream milk, navy beans, porridge and All Bran with added fibre).

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Processed foods tend to contain less fibre, while carbohydrates in their original state typically contain more fibre.  Fibre is indigestible carbohydrate and hence does not raise blood sugars or require insulin.

Fibre is also important for the health of our gut and feeds the good bacteria in our digestive tract.

Could it be possible to also use fibre as a proxy for the level of processing to help refine the prediction of insulin demand by different foods?

In order to test whether fibre is useful to predict insulin demand I tested the relationship between carbohydrates plus different amounts of the fibre in the various foods.

The best correlation was achieved by removing all of the fibre.  Using net carbs gives an increased correlation compared to the carbohydrates alone (i.e. R2 = 0.435 compared to R2 = 0.482).

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Considering the carbohydrates, protein and fibre in a food enables us to more accurately predict insulin demand.

This concept is known in the low carb community as “net carbs”.  If you’re trying count carbohydrates to manage insulin people are often advised to consider the total carbohydrates minus the fibre as fibre cannot be digested but is rather digested by our intestinal bacteria.

This aligns with the understanding that carbohydrates consumed with the packaging that they came with (i.e. fibre) do not have as big an effect on insulin.

This relationship might be part of the reason why many populations have maintained good health on a higher level of carbohydrate consumed in their raw natural state compared to when they come from the supermarket in boxes with barcodes.

There is some disagreement on how to deal with fibre on a restricted carbohydrate diet:

  • Some people say you should ignore fibre because “net carbs” is just a marketing ploy.
  • Some people choose to count half the fibre as carbs as a middle ground.
  • Experienced type 1 diabetics who monitor their blood sugars using continuous glucose meters will tell you that the fibre in their veggies will not raise their blood sugars however they ignore the fibre in packaged foods because it does raise their blood sugar.

My interpretation of the food insulin index data indicates that real fibre in foods is indigestible and hence does not raise blood sugar and require insulin.  However excess cooking and processing will soften this fibre and make it digestible.

It appears that the fibre in a food is a useful proxy for the level of processing and helps us to better predict the insulin demand of a food.

If you want to reduce your insulin load you can increase the amount of non-starchy veggies such as spinach, broccoli, mushrooms, Brussel sprouts and kale in your diet.

If you’re using packaged diet products then I suggest you ignore the fibre content, or maybe don’t buy them in the first place.

The major problem I see with encouraging people to consider total carbohydrates rather than net carbohydrates is that it will encourage people to avoid vegetables which not be optimal for health in the long term.  The reality is, when you take fibre into account, you can eat a lot of non-starchy vegetables without significantly impacting your net carbohydrates.

[next article…  how do you like your veggies… cooked or raw?]

[this post is part of the insulin index series]

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

how do you like your veggies… cooked or raw?

Nutrition for athletes and the metabolically healthy

  • Most people, once fat adapted, will do fine on a high fat ketogenic diet  and not need additional carbs to be able to exercise.
  • Learning to be metabolically flexible (i.e. using both fat and carbohydrates for fuel) can be a major advantage for an athlete.
  • Athletes and may benefit from increasing carbohydrates around competitions to speed recovery and replenish glycogen stores.
  • This article highlights some nutrient dense food options that contain slightly more carbohydrates to support intense exercise.

more about me

I became interested in the concept of low carbohydrate fuelling strategies when I started commuting to work on my bike.

The first problem is that I live 30km (18 miles) from work, but still chose to ride, both ways, in an effort to get fit and lose weight.

The second problem was that when I got home after riding 60km I just wanted to eat until I stopped feeling hungry.

The third problem was that when I weighed myself, in spite of the massive amounts of exercise that I was doing, the scale wasn’t moving in the direction that I wanted it to!

I had heard that athletes such as Ben Greenfield [1], Tim Olsen [2], Zach Bitter [3] and Sami Inkinen [4] were blowing away records using a restricted carbohydrate approach.  I wanted to be just like them.  Even a little bit.

low carb versus high carb for endurance

Typical preparation for endurance events involves “carbing up” with large doses of pasta before an event and precise timing of added simple carbs such as gels during the event to keep the glycogen fuel tank full.

One of the challenges for endurance athletes is staying fuelled without gut issues from constant ingestions of sugar gels and sports drinks.

The often used analogy is that being an athlete on a high carbohydrate diets is like being a fuel tanker constantly having to stop at the gas station to fill up. [5]

The advantage to using a ketogenic fuelling approach is that we train our bodies to be “metabolically flexible” and able access our body fat in addition to the stored glycogen in our liver and muscles for fuel.

The results below show how someone who is metabolically flexible will obtain a larger proportion of their fuel from their body fat meaning and become less dependent on refuelling with carbohydrates.

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advantages of keeping carbs low for athletes

Aside from endurance performance, there are a number of reasons that you may want to control your control your carbohydrate intake if you’re an athlete:

  1. To help you get / stay lean. Keeping your power to weight ratio high is important so you don’t have to drag excess weight around the course.
  2. To reduce diabetes risk and all the associated issues. Keeping your blood sugars close to optimal for long term health should be seen as a greater goal than short term performance.
  3. To improve overall health and longevity due by decreasing inflammation, oxidation free radical damage.
  4. To improved energy stability and reduce gastrointestinal distress.

when is a ketogenic diet not a good idea?

Robb Wolf says that while he is a big fan of the ketogenic approach combined with intermittent fasting, the people that seem to do it are not the overweight sedentary office workers who might benefit the most from it, but rather the people doing intense workouts combined with intermittent fasting and burning themselves into the ground. [7]

There can also be some advantages in having your glycogen fuel tank full for explosive power in intense exercise.  Some people choose to “train low, race high”, meaning that during a race you can keep your glycogen stores reserved for intense burst efforts such as sprinting to the finish line. [8]

Minimising carbs most of the time and adding a few more for ‘game day’ can be a good strategy to maximise performance.

how much carbohydrate do you need?

Insulin is required to grow muscle (and store fat). [9]

Body builders use a protein shake or simple carbs to spike insulin and support muscle grown (anabolism) before or after a workout. [10] [11]  Some will even inject insulin before a workout to maximise muscle growth.

Programs such as the TKD or John Kiefer’s Carb Backloading [12] or Carb Nite [13] is designed for physique competitors wanting the benefits of ketogenic diet without burning themselves into the ground or stalling in the long term.  It should be noted though that this approach is not necessarily ketogenic or optimal for long term health.

Ben Greenfield recommends endurance athletes aim for a lower level of carbs most of the time (say 10%) but then increase carbohydrates to around 30% from real whole foods before and / or after demanding exercise.

Cerial Killers 2: Run on Fat [14] tells the story of Sami Inkinen working with Steve Phinney to refine his diet to 70% far, 20% protein, 10% carbs to undertaken the caloric equivalent of two marathons a day for fourth days to row between San Francisco and Hawaii, proving that you don’t need many carbs at all to undertake intense exercise. [15]

Keep in mind too that if weight loss is your goal then shorter bursts of intense exercise will raise your metabolism without leaving you wanting to eat everything in sight.  Extended cardio may leave you hungry to a point that you may just eat all the calories that you just burned, then some, particularly if you’re not yet fat adapted.

can you handle it?

This all needs to be taken in the context of keeping your blood sugars close as close to optimal as you can get them.  Even if you are lean and fit it is worth periodically checking your blood sugars.

If your blood sugars are drifting up then it might be time to take evasive action and prioritise your long term health over short term sports performance.

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

Professor Tim Noakes has stated that he believes that no athlete needs more than 200g of carbohydrates per day. [16]  Noakes himself, the author of the Bible of carbohydrate fuelling for endurance athletes, [17] switched to a low carb diet after realising that he had become a type 2 diabetic after years of following his own high carb fuelling strategies.

Similarly, Sami Ikenin [18] became a low carb advocate after realising that his high carb diet that he was following had led him to become diabetic.  After he switched to a restricted carb approach, he improved his triathlon performance and recently rowed from California to Hawaii on a 70% fat diet to raise awareness of the dangers of sugar. [19]

what should I eat?

Previously I showed how we can use the food ranking system [20] to prioritise foods for weight loss and diabetes.  We can also use the food ranking system to prioritise nutrient dense foods with a little more carbohydrates if blood sugar control is not such a concern.

This weighting system emphasises nutrient density per gram (40% weighting), and nutrient density per calorie (15%) with a lesser weighting towards the insulinogenic properties of the food (25%).

Cost is also a consideration given that an athlete might be consuming larger amounts of food than someone trying to lose weight.  The resultant food rankings are shown below.

ND / calorie fibre / calorie ND / $ ND / weight insulinogenic (%) calorie / 100g $ / calorie
15% 10% 10% 30% 20% 5% 10%

Rich Froning’s favourite peanut butter [21] rates well along with a wide range of nutrient dense nuts and seeds.

Vegetables, as always do well, with spinach and mushrooms at the top of the list.  Sweet potato scrapes in at the end of the vegetables as good nutrient dense high carb option.

A number of grain based foods such as rice and oats make the cut due to their nutrient density and low cost.  There’s been plenty of debate around the topic of ‘safe starches’ [22] however I think it depends on your context.  If you’re active and keeping your blood sugars under control then things like rice, and potatoes may be useful to speed recovery around intense exercise if you feel the need.

A number of breads make it into the list due to the fact that they are a low cost source of nutrition.  However many people will avoid these due to concerns over gluten leading to a leaky gut etc.

Organ meats, as always, ranks highly.  It’s interesting to note that bacon ranks as the first non-seafood meat.

There are also more fruit choices on this approach if you’re not worried about blood sugar.

nuts, seeds and legumes

  • peanut butter
  • sunflower seeds
  • peanuts
  • brazil nuts
  • pumpkin seeds
  • pistachio nuts
  • pecans
  • cashews
  • almonds
  • pine nuts
  • macadamia nuts
  • lentils
  • kidney beans
  • mung beans
  • chick peas
  • coconut meat

vegetables and spices

  • spinach
  • mushrooms
  • chives
  • coriander
  • chard
  • turnip greens
  • rosemary
  • spirulina
  • cinnamon
  • ginger
  • broccoli
  • lentils
  • Brussel sprouts
  • Kale
  • asparagus
  • Sweet potato

dairy and egg

  • egg yolk
  • whole egg
  • cheese
  • milk

animal products

  • organ meats (liver, heart, giblets)
  • sardine
  • oyster
  • anchovy
  • cod
  • herring
  • bacon
  • oyster
  • chorizo
  • mussel
  • trout
  • salmon
  • tuna
  • beef jerky
  • turkey
  • ground beef
  • lamb

fats and oils

  • olive oil
  • coconut oil
  • butter

fruit

  • avocado
  • olives
  • raspberries
  • blackberries
  • oranges
  • banana
  • dates
  • strawberries

grains

  • tortilla
  • oats
  • white bread
  • multi grain bread
  • croissants
  • oat bran muffins
  • rice

I’ve also developed this ‘cheat sheet’ using this approach to highlight optimal food choices depending, wither they be reducing insulin, weight loss or athletic performance.   Why not print it out and stick it to your fridge as a helpful reminder?

daily meal plan

An example daily meal plan using the highest ranking foods is shown below.  For breakfast we have bacon with spinach and eggs, a salad with tuna for lunch, salmon and veggies for dinner with nuts for snacks.

image029

This would give us a macronutrient break down of 25% carbs, 27% protein and 48% fat.   The other advantage of eating more carbohydrates is that we can increase our fibre even higher, with this scenario giving 45g fibre per day to contribute to good gut health.

In the next article we’ll look at how we can use the food insulin index data to calculate the most ketogenic diet foods.

references

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

[2] http://www.timothyallenolson.com/2013/04/10/nutrition/

[3] http://zachbitter.com/blog/2012/10/high-carb-vs-high-fat.html

[4] http://www.samiinkinen.com/

[5] http://www.thecavewomandiva.com/?p=121

[6] http://www.ultrarunning.com/features/health-and-nutrition/the-emerging-science-on-fat-adaptation/

[7] http://blog.dansplan.com/why-dietary-fat-is-fattening-and-when-its-not/

[8] http://thatpaleoguy.com/2010/09/15/high-fat-diets-for-cyclists-part-one-of-six/

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

[10] http://livinlavidalowcarb.com/blog/tag/ben-greenfield

[11] http://beyondtrainingbook.com/

[12] http://carbbackloading.com

[13] http://carbnite.com/

[14] http://www.cerealkillersmovie.com/

[15] http://www.fatchancerow.org/expedition/

[16] https://twitter.com/proftimnoakes/status/450136949459001344

[17] http://www.amazon.com/Lore-Running-Edition-Timothy-Noakes/dp/0873229592

[18] http://www.samiinkinen.com/

[19] http://www.fatchancerow.org/

[20] https://www.dropbox.com/s/ninuwyreda0epix/Optimising%20nutrition%2C%20managing%20insulin.docx?dl=0

[21] http://www.mensfitnessmagazine.com.au/2012/02/the-fittest-man-on-earth/

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