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nutritious protein sparing modified fast diet foods

June 17, 2017 Marty Kendall 13 Comments

The Protein Sparing Modified Fast (PSMF) is regarded by many to be the most effective way to lose body fat while preventing loss of lean muscle and rebound binge eating due to nutrient deficiencies.

First developed in the 1970s, the PSMF has seen various permutations in weight loss clinics and the bodybuilding community.

While the details vary depending on context, a PSMF generally defined as an energy restricted diet with adequate protein while simultaneously limiting carbohydrates and fat.

Technically, the PSMF will be ketogenic because a significant amount of body fat will be burned due to a restricted energy intake.

Adequate protein is provided to prevent loss of lean muscle mass. Supplements are often used to prevent nutrient deficiencies.

This article outlines the key principles of the PSMF that can be applied to weight loss or maintenance over the long-term.

Optimal nutrient dense foods are identified for someone looking for an aggressive weight cut (e.g. a bodybuilder leading up to a competition) as well as a hybrid low carb – PSMF approach for someone who is insulin resistant wanting to lose a significant amount of weight over a longer period.

Medical applications of the PSMF

In the medical application of the PSMF patients obtain the majority of their energy from protein while keeping energy from carbohydrates and fat low.^[1]

Protein levels are set at 1.2 to 1.5 g/kg of ideal body weight per day. (For someone with 30% body fat wanting to get to 10% body fat this would be equivalent to 1.5 to 1.9g protein per kilogram of lean body mass or LBM.)
Carbohydrate intake is typically restricted to less than 20 to 50 g/day.
Additional dietary fat beyond what comes with lean protein sources is minimised.
Patients in the weight loss clinic setting are restricted to less than 800 kcal/day.

The Cleveland Clinic has done extensive research into the use of adequate protein low-calorie diets for aggressive weight loss with the following encouraging findings:^[2] ^[3] ^[4]

patients are encouraged by the initial period of rapid weight loss which leads to a lower dropout rate;^[5]
meal replacements in the form of commercial shakes or bars can be used, however learning to make meals from whole foods critical to developing habits that lay the foundation for long-term success;
the PSMF is effective for people with normal glycemic control as well as pre-diabetes or type 2 diabetes;^[6]
people on a whole food-based PSMF are significantly less hungry and preoccupied with eating compared to those on a liquid-formula based version of the PSMF; and
most of the weight lost during a PSMF is from fat tissue rather than muscle.^[7]

Adherence to a very-low-calorie, ketogenic PSMF program results in major short-term health benefits for obese patients with type 2 diabetes. These benefits include significant weight loss, often more than 18kg, within 6 months.

In addition, significant improvements in fasting glucose and haemoglobin A1c levels are linked to the caloric and carbohydrate restriction of the PSMF.

Insulin resistance was also attenuated, with possible partial restoration of pancreatic beta-cell capacity.^[8] ^[9]

Body building applications

Lyle McDonald reinvented the PSMF in body building community with his 2005 Rapid Fat Loss Handbook.

McDonald details how someone can individualise the PSMF based on their goals and context.

Someone who is already very lean and undertaking heavy weight training will need higher levels of protein.
Someone who isn’t yet lean may do better with a less aggressive approach over a longer period.
McDonald’s recommended protein intake ranges from 2.2g/kg LBM to 4.4g/kg LBM!
Unlimited green leafy fibrous veggies are strongly encouraged as they are filling and provide the vitamins and minerals with minimal calories.
McDonald also recommends supplementing with a good multivitamin, sodium potassium, magnesium, taurine, calcium and fish oil.
A PSMF is typically not a long-term proposition due to nutrient deficiencies.

KetoGains’ Luis Villasenor added:

McDonald’s recommendations seem “massive” to most people due to the book being geared toward strength athletes who DO require more protein as they are effectively breaking it down when strength training.

Bodybuilders who diet down to 4 – 5% bodyfat need an increased protein intake when preparing for a contest as their aim is to maintain as much as lean mass as possible; and for that, one needs protein and resistance exercise.

With my clients, to avoid nutrient deficiencies, we use a “Ketogains PSMF” which adds 3-4 whole eggs a day, at least 150g spinach, plus other green veggies, and some avocado. The rest is lean sources of protein and more veggies, plus electrolytes. This effectively puts the person in between 35 to 50g fats and 20g net carbs. The rest of their energy comes from lean protein.

Protein drives satiety

The body strongly defends loss of muscle mass by increasing appetite after periods of fasting or low protein consumption to ensure that muscle mass is retained.^[10]

Conversely, the Protein Leverage Hypothesis (Simpson, 2005) suggests that we continue to eat food until we get enough protein for critical bodily functions.^[11] ^[12]

“Protein generally increases satiety to a greater extent than carbohydrate or fat and may facilitate a reduction in energy consumption under ad libitum dietary conditions.”^[13] ^[14]

If we eat lower protein foods we may end up consuming more energy to obtain our adequate protein. Conversely, we can ‘hack’ our appetite by prioritising adequate protein while minimising energy from carbohydrate and fat.

Minimum carbohydrate requirement: While there is a need for the vitamins and minerals that are often packaged with carbohydrate containing foods (i.e. vegetables), there is indeed no such thing as an essential nutrient.
Minimum fat requirement: Most people have plenty of body fat stores that they can draw on and hence do not have an immediate need for dietary fat other than the essential Omega 3 fatty acids.

So, theoretically, if we get adequate protein as well as vitamins, minerals, the essential fatty acids can go a long way to providing everything that we need for long-term survival with less energy which is really the holy grail of weight loss and long-term maintenance.

Thermic effect of food

The other advantage of consuming a higher protein diet is increased thermogenesis (i.e. the energy lost in the process of converting food into energy). The thermic effect (or specific dynamic action) is 5 to 15% for carbohydrates and fat and 20 to 35% for protein.^[15]

The thermic effect of food is illustrated nicely by these images from Physioqonomics.^[16] We lose a lot more calories metabolising protein compared to fat or carbohydrates.

While we can convert protein to glucose (i.e. gluconeogenesis), it is really hard and our body doesn’t like to do unless it has to.^[17]

Satiety typically kicks in quickly once we have had adequate protein and we go in search of fat or carbs which are easier to convert to energy. Just think, you can only eat so much steak, but you always have a ‘dessert stomach’, even after a big meal.

While there is much debate over the “metabolic advantage” of fat vs carbohydrates with claims that we can eat more calories of fat than carbs there is actually an advantage’ when it comes to how many calories of protein we eat versus how much we can convert to energy.

Should you just eat the highest protein foods?

So, the obvious question is:

What should I eat on a PSMF?

The table below lists the foods with the highest protein content as a percentage of energy. These foods may be useful if you are looking to boost your protein intake.

food	% protein
cod	92%
haddock	92%
white fish	92%
orange roughy (fish)	92%
crab	91%
lobster	91%
egg white	91%
mozzarella cheese (non-fat)	90%
pollock	90%
protein powder (whey)	89%
turkey breast (fat-free)	88%
halibut	86%
crayfish	86%
whiting	86%
rockfish	86%
molluscs	86%
veal	84%
perch	81%
shrimp	81%
trout	81%
chicken breast	79%
lean beef	79%
whey protein concentrate (WPC)	78%
octopus	77%
ground beef	76%
pork chop	75%
flounder	74%
beef tripe	74%
pork shoulder	74%
scallop	74%
leg ham	74%
sirloin steak	73%
ham (lean only)	73%
beef heart	73%
turkey (skinless)	72%
clam	72%
turkey gizzard	72%
top round steak (fat trimmed)	72%
lamb kidney	71%
beef heart	70%
beef kidney	70%

I have summarised these in this image for easy reference.

The problem with a very high protein diet

But wait!

While you may be getting plenty of essential amino acids if you focus purely on high protein foods, there is a good chance that you may not be getting all the vitamins and minerals you need.

As shown in the chart below, there is a strong relationship between protein and nutrient density. However, if we just focus on high protein foods we may still end up missing out on the harder to find vitamins and minerals.^[18]

The chart below shows the micronutrients provided by the top 10% of the foods in the USDA database when sorted for maximum protein content.

Now imagine, that rather than getting 2000 calories, we are getting only 800 or 400 calories during long-term fasting or extreme dieting. We have a higher chance of becoming deficient in many key nutrients which may in turn increase appetite and drive us to eat more than we would like to.

Ensuring you are getting adequate micronutrients is a key component to long-term success in weight loss and maintenance.

In the Rapid Fat Loss Handbook McDonald mentions ‘The Last Chance Diet’ which was popular in the 1970s and 80s. It was essentially a PSMF centred around liquid nutrition which led to the death of a number of devotees due to a number of fatal flaws.^[19] ^[20]

First, they picked the cheapest protein source available, collagen; a protein that provides essentially zero nutrition to the body. Second, they provided zero supplemental vitamins and minerals (some of which would have been obtained if the dieters had been eating whole foods in the first place). This caused a couple of problems including cardiac heart loss (from the total lack of protein) and arrhythmias from the lack of minerals.

Basically, the problem wasn’t with the approach so much as with the food choices.

PSMF’s based around whole foods (which provide high quality proteins as well as vitamins and minerals) and with adequate mineral supplementation have shown no such problems.^[21]

Bruce Ames’ Triage Theory

Nutrient density becomes even more important when we consciously try to limit our energy intake.

Attaining adequate micronutrients can help to mitigate metabolic/mitochondrial slowdown and adaption to the severe calorie deficit. If we are getting the range of micronutrients we need the body is more likely to keep on feasting on our own excess fat stores without reacting like there is a famine and holding onto our excess fat stores.

Similar to the protein leverage hypothesis, it seems if we provide the body with low nutrient density food it is driven to consume more energy to ensure that it gets the nutrients it needs.

I get a number of comments in response to the Nutrient Optimiser analysis suggesting that the Daily Recommended Intakes (DRI) for various micronutrients are excessive because a certain person has done fine on a diet per for a period of time with a less than optimal nutrient profile.

While we can argue that the some of the DRIs for various nutrients are overly conservative you also don’t have to look too far to find people that argue that we need multiple times the DRI for another specific nutrient to optimise our health and longevity.

I don’t think we need to worry about precisely meeting the daily recommended intake for every single micronutrient every single day. There is no diet that meets the daily recommended intake for every nutrient without overdoing others. I think a healthy well-balanced diet will achieve the DRI for the majority of the essential micronutrients most of the time.

More research is required to understand whether our requirements for different nutrients change depending on our diet (e.g. how much less vitamin C do we require if we are not consuming as much glucose) and how much more bioavailable nutrients are from plants versus animals.

However, if you are an order of magnitude under the DRI for a handful of nutrients perhaps you should consider focussing on foods that contain that contain higher levels of that cluster of nutrients. If you are an order of magnitude over the DRI for a certain group of nutrients you don’t need to prioritise foods that contain those nutrients.

Bruce Ames’ sobering Triage Theory suggests that if we are low in critical nutrients the body will prioritise those nutrients for functions critical to short term survival rather than longevity and preventing the diseases of ageing (e.g. cancer, heart disease, Parkinson’s, Alzheimer’s etc).

“The triage theory posits that some functions of micronutrients (the approximately 40 essential vitamins, minerals, fatty acids, and amino acids) are restricted during shortage and that functions required for short-term survival take precedence over those that are less essential. Insidious changes accumulate as a consequence of restriction, which increases the risk of diseases of ageing.”^[22] ^[23]

So, while we might do OK with poor nutrition for a period of time, we will probably do better if we obtain a solid amount of all the essential nutrients. Ideally, we would obtain these nutrients from whole foods which are more likely to contain all the non-essential but also beneficial vitamins and minerals that we don’t track.

Low energy density

Another way to maximise nutrient density and prioritise protein at the same time is to reduce the energy density of the food we eat.

As shown in the chart below there is a relationship between the harder to find nutrients and energy density.^[24] While fat is a great fuel source and should not be feared or avoided, refined high-fat foods do not typically contain high levels of the harder to find vitamins and minerals that we need to thrive. Foods with more fibre and water are also more filling and are harder to overeat and will lead to increased short term satiety.

If we prioritise adequate protein while minimising fat and carbohydrates we make up the deficit from our own body fat stores, hence there is no need to prioritise dietary fat.

The nutrient dense adequate protein diet

So, to recap:

getting adequate protein is important, especially if we are fasting or restricting energy intake, and
not getting adequate nutrients is potentially dangerous and possibly the fatal flaw of the PSMF.

We can use the Nutrient Optimiser to prioritise foods with the nutrients we want to obtain more of. Listed below are the 20 nutrients that have been prioritised in the following list of prioritised foods.

Alpha-linolenic acid
EPA + DHA
Vitamin E
Vitamin D
Choline
Calcium
Magnesium
Potassium
Thiamine
Phosphorus
Pantothenic acid
Manganese
Folate
Zinc
Niacin
Riboflavin
Valine
Selenium
Leucine
Tyrosine

Prioritising amino acids is usually unnecessary because maximising vitamins and minerals generally leads to more than adequate protein. However, in a PSMF where we are severely limiting energy we want to increase protein as well (hence valine, leucine and tyrosine have been included). As well as nutrient density, we have also prioritised low energy density foods in the multicriteria analysis.

The chart below shows the resultant micro nutrient profile achieved if we ate 2000 calories per day of these foods. In the chart above we saw that if we just focus on protein we will not be meeting the DRI for eleven nutrients. However, when we focus on nutrient density we get adequate quantities of all nutrients other than the Omega 3 fatty acid alpha-linolenic acid.

The chart below shows the same foods if we only ate 600 calories per day rather than 2000. Even with these highly nutrient dense foods, we miss the DRI for eight of the essential nutrients. Hence, we may still benefit from supplementing with Omega 3, vitamin D, calcium, magnesium and potassium. The nutrients provided by an energy restricted diet without also prioritising nutrient density would be much worse.

It’s not hard to imagine that our ability to maintain a low energy intake and achieve sustained weight loss is likely related to getting adequate levels of the various essential micronutrients without having to over consume energy. Conversely, a nutrient poor diet will likely drive us to consume excess energy which will lead to obesity.

Best foods for a PSMF

The tables below summarise highest ranking 10% of foods in the USDA database when we prioritise for high nutrient density and low energy density.

Also included in the tables are:

the nutrient density score (based on the 20 nutrients listed above),
energy density, and
the MCA which is the overall ranking from the multi criteria analysis.

Compared to the highest protein food listed above which are 80% protein, these foods work out to be 59% protein, 20% fat, 13% net carbs and 8% fibre. While this may seem high, as we will see in the ‘calorie math’ section below, it becomes more reasonable once we account for the energy from body fat.

Vegetables

It would be hard to imagine getting fat by overeating the vegetables listed below.

Maximising your intake of these vegetables will ensure you are getting adequate vitamins and minerals and hence maximise your chance of long-term success.

While these vegetables have a very high nutrient density score (ND) in terms of nutrients per calorie, they also have a low energy density which means you need to eat a lot of them to get the nutrients you need.

The downside of vegetables is that they can be expensive and take time to prepare fresh.

food	% protein	ND	calories/100g	MCA
watercress	60%	25	11	3.1
spinach	41%	23	23	2.9
seaweed (laver)	50%	22	35	2.7
asparagus	34%	21	22	2.7
basil	44%	20	23	2.5
endive	25%	19	17	2.5
white mushroom	43%	19	22	2.4
brown mushrooms	36%	18	22	2.4
portabella mushrooms	36%	18	29	2.4
Chinese cabbage	42%	17	12	2.3
lettuce	30%	16	15	2.2
coriander	31%	16	23	2.1
chicory greens	24%	16	23	2.1
alfalfa	52%	16	23	2.1
spirulina	64%	16	26	2.1
chard	30%	15	19	2.1
zucchini	24%	15	17	2.1
seaweed (wakame)	22%	15	45	2.0
parsley	27%	15	36	2.0
escarole	25%	15	19	2.0
okra	27%	15	22	2.0
beet greens	32%	14	22	2.0
shiitake mushroom	29%	15	39	2.0
turnip greens	36%	14	29	1.9
chives	35%	14	30	1.9
broccoli	23%	14	35	1.8
mung beans	35%	13	19	1.8
arugula	33%	12	25	1.7
dill	27%	12	43	1.7
cauliflower	26%	12	25	1.7
celery	16%	11	18	1.6
summer squash	18%	10	19	1.5
seaweed (kelp)	13%	11	43	1.5
yeast extract spread	52%	12	185	1.5
radicchio	22%	9	23	1.4
pickles	14%	9	12	1.4
cucumber	14%	9	12	1.4
mustard greens	34%	9	27	1.4
peas	26%	9	42	1.4
snap beans	18%	9	15	1.4
collards	27%	9	33	1.3
cabbage	18%	8	23	1.3
soybeans (sprouted)	34%	8	81	1.2
onions	19%	7	32	1.2
pumpkin	12%	7	20	1.2
kale	23%	7	28	1.2
radishes	16%	7	16	1.2
banana pepper	21%	7	27	1.2
bamboo shoots	43%	7	11	1.2
Brussel sprouts	28%	7	42	1.1
edamame	37%	8	121	1.1
artichokes	23%	6	47	1.1
sauerkraut	17%	5	19	1.0
red peppers	13%	6	31	1.0
eggplant	13%	5	25	1.0
chayote	9%	5	24	1.0

Animal products

These animal products are both nutrient dense and have a low energy density compared to fattier cuts of meat. While the nutrient density scores are not as high as for the vegetables, the energy density is higher so you will be able to get more nutrients in using these foods.

food	% protein	ND	calories/100g	MCA
lamb kidney	71%	19	112	2.2
chicken liver	62%	19	172	2.2
beef liver	63%	18	175	2.1
veal liver	61%	18	192	2.0
lamb liver	61%	17	168	2.0
turkey liver	59%	17	189	2.0
ham (lean only)	73%	16	113	1.9
pork liver	66%	16	165	1.9
beef kidney	70%	15	157	1.7
chicken breast	79%	13	148	1.6
pork chop	75%	13	172	1.5
veal	84%	12	151	1.5
pork shoulder	74%	12	162	1.4
lean beef	79%	11	149	1.4
leg ham	74%	11	165	1.4
ground pork	69%	11	185	1.4
turkey heart	60%	11	174	1.3
lamb heart	65%	11	161	1.3
beef tripe	74%	9	103	1.3
ground beef	76%	10	144	1.2
sirloin steak	73%	10	177	1.2
beef heart	70%	10	179	1.2
turkey meat	66%	10	158	1.2
turkey drumstick	66%	10	158	1.2
bison	69%	9	171	1.1
chicken liver pate	27%	9	201	1.1
turkey gizzard	72%	8	155	1.1
lamb sweetbread	59%	8	144	1.0
chicken drumstick	62%	8	149	1.0
veal loin	63%	8	175	1.0
roast pork	53%	8	199	1.0

Seafood

Omega 3 fats (EPA, DHA and ALA) are essential and harder to get so you should prioritise fish in your nutrient dense PSMF.

food	% protein	ND	calories/100g	MCA
crab	91%	20	83	2.4
fish roe	58%	19	143	2.2
crayfish	86%	18	82	2.2
lobster	91%	18	89	2.2
halibut	86%	17	111	2.1
pollock	90%	16	111	1.9
salmon	68%	16	156	1.9
rockfish	86%	15	109	1.9
flounder	74%	14	86	1.8
oyster	46%	14	102	1.8
shrimp	81%	14	119	1.8
haddock	92%	14	116	1.8
perch	81%	14	96	1.7
cod	92%	16	290	1.7
sturgeon	64%	14	135	1.7
whiting	86%	13	116	1.6
trout	59%	13	168	1.6
octopus	77%	13	164	1.5
white fish	92%	12	108	1.5
anchovy	57%	13	210	1.5
clam	72%	12	142	1.5
tuna	68%	11	184	1.3
scallop	74%	9	111	1.3
caviar	36%	11	264	1.2
orange roughy	92%	8	105	1.2
sardine	49%	10	208	1.2
molluscs	86%	8	130	1.1

Egg and dairy

Eggs are nutritious. Only a couple of low fat dairy products make the list. Higher fat foods such as butter and cream need to be minimised on a PSMF to allow your body to use the fat from your butt and your belly.

food	% protein	ND	calories/100g	MCA
cream cheese (low fat)	61%	11	105	1.5
whole egg	36%	9	143	1.2
egg white	91%	7	52	1.1
cottage cheese (low fat)	51%	7	81	1.1

These nutrient dense PSMF foods are summarised in this image for easy reference.

Calorie math

To make this a little more practical let’s look at some calorie math using a hypothetical scenario.

Let’s say Super Ted is looking to get shredded for the Ketogains conference in two weeks where he wants to pose for shirtless but also wants to stay strong and to win the arm wrestle and beat the reigning champion, Mighty Mouse.

Super Ted currently weighs 160 lbs or 73kg and has 10% body fat. His maintenance energy intake is 2336 cal/per day.

While getting the majority of your energy intake from protein might seem excessive…

… it’s not so dramatic when you also take into account the body fat being burned.

Between the 8% dietary fat (8%) his body fat stores (60%) Super Ted will be getting a ketogenic level of 68% of his energy from fat while also adequate protein to maintain his muscles and enough carb containing vegetables to get the vitamins and minerals that are also critical to his long-term success.

The details of the calorie math are shown below. Once you take the energy deficit into account Super Ted is consuming 2.2g/kg LBM.

body weight (kg)	73
body weight (lbs)	160
body fat (%)	10%
lean body mass (kg)	62
maintenance (cal)	2336
deficit	60%
diet (calories)	934
protein (% diet)	59%
fat (% diet)	20%
net carbs (% diet)	13%
diet protein (g)	138
dietary fat (g)	21
body fat (g)	156
body fat (kg/week)	1.1
net carbs (g)	30
fibre (g)	19
protein (% energy burned)	24%
dietary fat (% energy burned)	8%
carbohydrate (% energy burned)	5%
protein (g/kg LBM)	2.2

These calculations assume that Super Ted’s insulin levels are going to be low enough to allow him to yield a significant amount of energy from his body fat stores. Similar to fasting, it may take a few days before glycogen stores to be depleted enough for his insulin levels to drop which will allow his fat stores to more easily flow out of storage.

These calculations also do not account for the metabolic slowdown that you will get during long term energy restriction. This is the same with any way of eating that consciously restricts energy intake. However, I think if we can minimise nutrient deficiencies we will have a better chance of avoiding an increase in which could drive our body to seek out the missing nutrients that it is not getting enough of.

When you look at his Nutrient Optimiser analysis you see that Ted Naiman (aka Super Ted) is actually consuming 2.4g/kg LBM.

Meanwhile, Luis Villasenor (aka Mighty Mouse) is also consuming protein at 2.4g/kg LBM during his PSMF. Luis says his normal protein intake is around 140g increases this up to 180g during a strict PSMF.

Insulin resistant long-term fat loss scenario

For most of us, such an aggressive fat loss approach might be hard to maintain long-term. So, let’s consider another scenario with another hypothetical character.

Introducing… Big Ted.

As you can see, Big Ted doesn’t post shirtless for photos on the internet.

At 110kg and 30% body fat Big Ted is far from shredded.

Big Ted is also pre diabetic.

His doctor has warned him that if he doesn’t lose a significant amount of weight he will need to take Metformin and then insulin before too long.

Big Ted is motivated to drop a significant amount of weight with perhaps a calorie deficit of 30% which will take him about 30 weeks to get to his goal weight of 90kg.

We can refine Big Ted’s PSMF approach given that his circumstances and goals are different from Super Ted’s.

Nutrients to prioritise

Given Big Ted is not looking to be as dramatically calorie restricted we only need to prioritise the following nutrients.

Alpha-linolenic acid
EPA + DHA
Choline
Vitamin D
Vitamin E
Calcium
Magnesium
Potassium
Phosphorus
Zinc

Although amino acids are not prioritised the resultant list of foods is still 36% protein, 30% fat and 20% net carbs.

Rather than simply prioritising nutrient density and energy density, this scenario also prioritises a lower insulin load in view of Big Ted’s looming pre diabetes situation.

This is basically a hybrid between a PSMF and a low carb diet.

The chart below shows the nutrient profile of these foods once we take a 30% energy deficit into account. Big Ted will be meeting the DRI for all his nutrient other than Omega 3s which he may need to supplement.

Calorie math

The charts below show the energy consumed and energy burned.

There is a significant amount of fibre which will not be metabolised for energy but rather feed his gut bacteria. There is still a solid amount of net carbs from veggies, however, there is no sugars or processed grains to be seen so they’re not about to boost his insulin or send him on a blood sugar roller coaster.

Once his body fat loss is accounted for, half of Big Ted’s energy expenditure is still coming from fat.

Although we didn’t prioritise amino acids we still get a solid 2.2g protein per kilogram LBM.

body weight (kg)	110
body weight (lbs)	242
body fat (%)	30%
lean body mass (kg)	77
maintenance (cal)	3000
deficit	30%
diet (cals)	1875
protein (% diet)	36%
fat (% diet)	30%
net carbs (% diet)	20%
fibre (%)	14%
diet protein (g)	169
dietary fat (g)	63
body fat (g)	100
body fat (kg/week)	0.7
net carbs (g)	94
fibre (g)	66
protein	23%
dietary fat	19%
carbohydrate	13%
protein (g/kg LBM)	2.2

Optimal foods for Big Ted are listed below.

Vegetables

food	% protein	ND	calories/100g	MCA
endive	25%	11	17	2.5
chicory greens	24%	11	23	2.4
coriander	31%	10	23	2.2
escarole	25%	9	19	2.1
spinach	41%	12	23	2.1
basil	44%	11	23	2.0
alfalfa	52%	7	23	2.0
zucchini	24%	9	17	1.9
chard	30%	11	19	1.9
arugula	33%	10	25	1.9
beet greens	32%	8	22	1.9
mustard greens	34%	8	27	1.8
watercress	60%	12	11	1.7
asparagus	34%	9	22	1.7
parsley	27%	9	36	1.7
Chinese cabbage	42%	9	12	1.6
curry powder	14%	6	325	1.6
collards	27%	7	33	1.6
summer squash	18%	8	19	1.6
lettuce	30%	8	15	1.6
paprika	15%	7	282	1.6
turnip greens	36%	7	29	1.5
broccoli	23%	8	35	1.5
cloves	6%	7	274	1.4
sauerkraut	17%	6	19	1.4
banana pepper	21%	5	27	1.4
okra	27%	7	22	1.4
pickles	14%	5	12	1.4
cucumber	14%	5	12	1.4
chives	35%	7	30	1.3
celery	16%	7	18	1.3
brown mushrooms	36%	10	22	1.3
sage	11%	5	315	1.3
artichokes	23%	6	47	1.3
marjoram	14%	5	271	1.3
thyme	10%	6	276	1.3
cauliflower	26%	6	25	1.3
edamame	37%	5	121	1.2
portabella mushrooms	36%	7	29	1.2
radishes	16%	5	16	1.2
eggplant	13%	4	25	1.2
cabbage	18%	6	23	1.2
blackberries	11%	3	43	1.2
shiitake mushroom	29%	6	39	1.1
radicchio	22%	8	23	1.1
jalapeno peppers	12%	3	27	1.1
caraway seed	19%	4	333	1.1
chayote	9%	4	24	1.1
rhubarb	15%	5	21	1.0
avocado	5%	-0	160	1.0
snap beans	18%	6	15	1.0
red peppers	13%	3	31	1.0
olives	3%	-1	145	1.0
turnips	26%	5	21	1.0
white mushroom	43%	7	22	1.0
dill	27%	6	43	1.0
poppy seeds	13%	3	525	1.0
kale	23%	5	28	0.9
seaweed (kelp)	13%	8	43	0.9
raspberries	8%	1	52	0.9
seaweed (laver)	50%	8	35	0.9
soybeans (sprouted)	34%	4	81	0.9
seaweed (wakame)	22%	8	45	0.9
Brussel sprouts	28%	4	42	0.9
celery flakes	14%	6	319	0.9
cumin	16%	4	375	0.8
bamboo shoots	43%	3	11	0.8
carrots	6%	3	37	0.8
onions	19%	5	32	0.8
carrots	9%	5	23	0.8
dill seed	15%	3	305	0.7
mustard seed	19%	2	508	0.7

Animal products

food	% protein	ND	calories/100g	MCA
beef brains	32%	5	151	1.5
turkey ham	63%	4	124	1.0
lamb brains	36%	2	154	1.0
lamb sweetbread	59%	4	144	0.9
turkey (skinless)	72%	3	170	0.8
turkey liver	59%	4	189	0.8
ground turkey	39%	2	258	0.8
lamb liver	61%	4	168	0.8
turkey drumstick (with skin)	50%	1	221	0.8
turkey bacon	29%	0	226	0.8
headcheese	36%	– 0	157	0.8
lamb kidney	71%	4	112	0.8
turkey heart	60%	3	174	0.8
sweetbread	16%	– 1	318	0.7

Seafood

food	% protein	ND	calories/100g	MCA
fish roe	58%	9	143	1.6
oyster	46%	10	102	1.5
mackerel	25%	4	305	1.4
caviar	36%	6	264	1.4
molluscs	86%	8	130	1.4
crab	91%	10	83	1.3
sardine	49%	6	208	1.2
flounder	74%	7	86	1.2
trout	59%	6	168	1.2
cisco	38%	4	177	1.2
sturgeon	64%	6	135	1.2
crayfish	86%	8	82	1.2
salmon	68%	7	156	1.2
lobster	91%	9	89	1.1
halibut	86%	8	111	1.1
anchovy	57%	5	210	1.0
perch	81%	7	96	1.0
herring	47%	4	217	1.0
rockfish	86%	7	109	1.0
pollock	90%	7	111	1.0
cod	92%	8	290	0.9
shrimp	81%	7	119	0.9
whiting	86%	6	116	0.8
white fish	92%	6	108	0.8
haddock	92%	6	116	0.7

Egg

food	% protein	ND	calories/100g	MCA
egg yolk	21%	4	275	1.4
whole egg	36%	4	143	1.3

Nut sand seeds

food	% protein	ND	calories/100g	MCA
tofu	43%	3	83	1.0
sunflower seeds	13%	2	546	0.9
pumpkin seeds	20%	3	559	0.8
flax seed	13%	1	534	0.8
almonds	13%	2	607	0.7

This image below summarises these foods for easy reference.

The nutrient profile of these foods is also excellent. These foods will help Big Ted to minimise his chance of developing nutrient deficiencies which may lead to rebound binge eating and derail his long term weight loss efforts.

How often should I eat on a PSMF?

Big Ted is fond of intermittent fasting. He finds it easier to not eat for a day or two and then eat to satiety rather than trying to count calories or restrict energy.

Meanwhile, Super Ted likes to eat two meals per day which save him time and helps him not overeat.

Personally, I don’t think it matters exactly when you eat as long as you stick to the foods that align best with your goals. Recent research suggests that in the fasted state we can use up to 3.5 g/kg/day and digest up to 4.3 g/kg/day.^[25] This makes sense in an evolutionary context when there wouldn’t have been a regular supply of food but we would have needed to be able to use the food when we came across a big hunt after a long famine.

Either Super Ted or Big Ted could still utilise their required protein intake if they followed an alternate day fasting or 5:2 plan or really any other permutation of fasting. What is important though is that they ensure that they stick to their nutrient dense diet when they break their fast rather than reaching for the more energy dense foods when they eat again.

How low can you go?

Hopefully, this article has given you some actionable principles:

During weight loss, you should ensure that you get adequate protein while fat and carbs can be limited to achieve the energy deficit required to suit your target rate of loss.
As well as protein intake, we should aim to maximise all micro nutrients (vitamins, minerals, essential fatty acids and amino acids) ideally using whole foods.
You will find it hard to obtain adequate vitamins, minerals and essential fatty acids at one extreme or the other of protein intake.

As discussed in the ‘How Much Protein is Too Much’ article I noted that the minimum intake of protein and minimum essential fats tally up to around 314 calories as shown in the table below.

If we could stick to this approach we would have a massive and highly ketogenic 85% of our energy coming from our body fat. However, you would be at an increased risk of inadequate vitamins, mineral and fatty acids with such a low energy intake.

macro	DRI (g)	DRI (calories)	% energy
minimum protein	56	224	71%
essential fats	10	90	29%
total	66	314	100%

If you’re starving to death and only have lean protein available you might call it “rabbit starvation”. However, if you still have plenty of body fat to burn it’s a PSMF.

#context matters

PSMFs for aggressive weight loss in a medical context generally aim for around 800 calories per day.

Lyle McDonald suggests that people following a PSMF for aggressive weight loss over a short period (e.g. cutting in the lead up to a bodybuilding show) might be eating between 400 and 800 calories per day.

Each person needs to find the ideal approach that they can live with in the long-term.

How to do a nutrient dense PSMF

Eat mostly foods from the lists below.
- The nutrient dense PSMF diet foods are ideal for aggressive short term weight loss (i.e. leading up to a bodybuilding comp).
- The nutrient dense weight loss foods for insulin resistance may be more appropriate if you have more weight to lose over a longer period.
- Minimum protein intake in a weight loss clinic setting is 1.2g/kg total body weight.
- Appetite will likely drive you to eat more protein if you are working out. 2.4g/kg lean body mass is typical for someone lifting heavy.
- The highest protein foods can be used to increase protein intake if required.
- Focusing on these foods will ensure you still get adequate protein as well as vitamins and minerals while minimising energy intake.
- Limit carbs to what comes with non-starch veggies (i.e. no processed grains or sugars).
- Limit fat to what comes with the lean protein foods.

Don’t eat too much
- It will be hard to overeat these high nutrient density low energy density foods.
- You may not have to consciously limit your food intake if you can focus only eat these foods.
- It may be beneficial to track or plan your energy intake to achieve your goals.
- Ratchet down your energy intake until you achieve your desired rate of weight loss.
Lift heavy / exercise (optional)
- Working out will help you to use the protein to build lean muscle and keep your metabolic rate up.
Repeat

Summary

The protein sparing modified fast (PSMF) provides adequate levels of protein to support lean muscle mass while restricting energy from carbohydrates and fat.
Protein intakes vary widely depending on the goals and the level of energy restriction between.
Providing adequate nutrients, ideally from whole foods, is critical to long term weight loss and maintenance.
Simply maximising protein may not provide optimal levels of vitamins and minerals. Therefore, it’s important to prioritise nutrient dense foods to improve your chances of long-term success.
While the PSMF is commonly used in weight loss clinics and in the bodybuilding community, the principle can also be applied in other situations.

References

^[1] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

^[2] https://www.ncbi.nlm.nih.gov/pubmed/9149474

^[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4784653/ama

^[4] https://www.ncbi.nlm.nih.gov/pubmed/4037162

^[5] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

^[6] https://www.ncbi.nlm.nih.gov/pubmed/24513578

^[7] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

^[8] https://www.dropbox.com/s/rjfyvfsovbg9fri/The%20protein-sparing%20modified%20fast%20for%20obese%20patients%20with%20type%202%20diabetes%20What%20to%20expect.pdf?dl=0

^[9] http://www.mdedge.com/ccjm/article/96116/diabetes/protein-sparing-modified-fast-obese-patients-type-2-diabetes-what-expect

^[10] http://www.nature.com/ejcn/journal/v71/n3/full/ejcn2016256a.html

^[11] http://onlinelibrary.wiley.com/doi/10.1111/j.1467-789X.2005.00178.x/abstract

^[12] https://www.dropbox.com/s/zej4razn4dn993y/protein%20leverage%20hypothesis%20-%20simpson2005.pdf?dl=0

^[13] http://ajcn.nutrition.org/content/87/5/1558S.long

^[14] https://www.ncbi.nlm.nih.gov/pubmed/15466943

^[15] https://en.wikipedia.org/wiki/Specific_dynamic_action

^[16] http://physiqonomics.com/calories-child-friendly-version/

^[17] http://www.biologydiscussion.com/biochemistry/energy-production/specific-dynamic-action-factors-and-example-energy-production/43998

^[18] https://optimisingnutrition.com/2017/05/27/is-there-a-relationship-between-macronutrients-and-diet-quality/

^[19] http://www.dietsinreview.com/diets/last-chance-diet/

^[20] https://www.amazon.com/Last-Chance-Diet-When-Everything-Failed/dp/0818402393

^[21] http://www.bodyrecomposition.com/the-rapid-fat-loss-handbook/

^[22] https://www.ncbi.nlm.nih.gov/pubmed/19692494

^[23] http://ajcn.nutrition.org/content/90/4/889.full.pdf+html

^[24] https://optimisingnutrition.com/2017/05/27/is-there-a-relationship-between-macronutrients-and-diet-quality/

^[25] http://www.sciencedirect.com/science/article/pii/S0261561417302030

post updated July 2017

articles, carbohydrates, fat, nutrient density, protein

micronutrients at macronutrient extremes

March 19, 2017 Marty Kendall 7 Comments

In the previous article, Which Nutrients is YOUR Diet Missing?, we looked at the micronutrients that you might be lacking when following popular dietary strategies such as vegan, Paleo, keto, or zero carb.

As a follow-up, I thought it would be interesting to look at the effect on essential micronutrients if we define our dietary approach in terms of macronutrient extremes such as low carb, high fat, high protein, high carb, or low protein.

Humans tend to think in extreme terms. It’s easy to follow a binary approach to nutrition, but which, if any, of these are the most useful in terms of maximising the nutrition provided by our diet?

For most of my life, best practice nutrition has been defined by a fear of fat which spawned the low-fat processed food era.

And because protein is necessary for muscle growth, more must be better?

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

And then of course there is low carb, which has been popular since the appearance of the Atkins diet appeared in the early 1970s.

But then there are a good number of people who still define their diet as being high carb.

All of them seem to be similarly zealous about their all-or-nothing approach.

But are any of these macronutrient extreme approaches beneficial? And if so, which one leads us to the optimal selection of nutritious foods that will lead to health, happiness, optimal weight, and longevity?

why bother with nutrient density?

The premise of nutrient density is that we want to maximise the quantity of essential micronutrients that we need to support our bodily functions while not overdoing energy intake.

Micronutrient dense foods allow us to obtain adequate nutrition with fewer calories. Then, with our nutrients accounted for, higher micronutrient density might just lead to higher satiety levels, reduced appetite, reduced food intake and optimal body fat levels.

At the other extreme, if we consume fewer foods with a lower nutrient density, we will likely end up needing to consume more food to obtain the nutrients we need to survive and thrive. If our appetite drives us to keep on eating until we obtain the nutrients we need, we may end up having to consume too much energy and and end up storing unwanted energy as fat.

macronutrient comparison

In this post, we’ll look at the micronutrients provided by the highest-ranking foods when we sort the eight thousand foods in the USDA database by the most and least fat, protein, and carbs.

Approach	% protein	% fat	% net carbs	% fibre
high fat	14%	82%	3%	1%
low net carbs	33%	67%	0%	0%
most nutrient dense	49%	19%	20%	12%
high protein	77%	22%	1%	0%
least nutrient dense	7%	32%	59%	2%
low protein	1%	27%	68%	3%
low fat	8%	1%	84%	7%
high net carbs	3%	2%	92%	2%

This chart shows the macronutrient split for these extreme approaches.

fat

While low carb is still in the lead in terms of internet searches (as shown in the Google Trends data below), the ketogenic diet is becoming pretty popular these days.

The chart below shows the nutrients provided by 2000 calories of the fattiest foods. Nutrients are expressed in terms of the percentage of the daily recommended intake (DRI), for each nutrient, per 2000 calories (i.e. a typical daily intake).

While we achieve adequate amounts of about half of the essential micronutrients with a therapeutic ketogenic diet, we may need to consider supplementing some of the harder to obtain nutrients such as vitamin C^[1], vitamin D, potassium, choline, vitamin K, and magnesium.

Looking at things from the other extreme, a low-fat diet will give you a ton of vitamin C, sodium, manganese, and iron. However, it will be harder to obtain adequate quantities of the twenty-one essential nutrients, particularly essential fatty acids.

saturated fat

These days, the US Dietary Guidelines have lifted their limit on fat and cholesterol but retained their limitation on saturated fat. Saturated fat and trans fats remain the two nutrients that we are advised to avoid.

The chart below shows the outcome when we avoid saturated fat. The top 10% of foods with the lowest saturated fat are lacking (i.e. < 100% DRI) in nineteen essential nutrients.

At the other extreme, foods with the most saturated fat are slightly better with seventeen essential micronutrients lacking.

As discussed in the ‘What about Saturated Fat?’ article, I think saturated fat is neither a concern nor a priority. Saturated fat a great clean-burning fuel, but there’s no need for us to make up for the last four decades of avoidance by suddenly binging on it.

The chart below shows a comparison of the nutrient density of the quartiles of saturated fat in terms of percentage of energy. It seems that the foods with moderate levels of saturated fat that are the most nutrient dense.

protein

Once you move past the fear of fat, the next hot topic is optimal protein levels.

The ‘high protein bros’ recommend more protein for muscle growth and satiety, while many in the low carb/keto community target lower protein levels for longevity and ketosis through minimising insulin and mTOR signalling.^[2]

As shown in the chart below, when rank foods to minimise protein, we end up with only four essential nutrients meeting the recommended daily guidelines to prevent malnutrition.

At the other extreme, if we prioritise protein we end up with ten nutrients that we fall short of. The other twenty-six essential nutrients meet the minimum recommended levels.

Not only does protein contain essential amino acids, this analysis indicates that higher protein foods generally come bundled with high amounts of vitamins and minerals, such as vitamin B-12, selenium, vitamin B-6, riboflavin and copper.

It’s one thing to talk about targeting the minimum daily protein that you can get away with if you are looking to preserve muscle in fasting or extreme calorie deprivation during long term weight loss. It’s a whole different discussion if you’re looking to minimise protein while making up the rest of your daily energy intake with fats or carbs!

carbohydrates

The chart below shows the nutrients we obtain if we maximise energy from non-fibre digestible carbohydrates (i.e. net carbs). This high carb approach provides adequate amounts of twelve of the essential nutrients, while still being inadequate in twenty-four essential nutrients.

The chart below shows that low carb performs better than high carb, only falling short in sixteen essential micronutrients.

One of the benefits of a low carb approach, is that it often forces the elimination of many processed foods that fill the supermarket shelves to satisfy the demand for low fat foods driven by the admonition by the for the last four decades by the ruling dietary establishment to minimise fat.

A nutrient dense diet contains less non-fibre carb than the typical diet, but some people will do better, at least for a while, on a carb restricted diet. Another major benefit of low carb is for insulin resistant people when they can lower their blood glucose and insulin levels on a carb restricted diet. Many people find it easier to lose excess body fat once they have restored their insulin sensitivity.

nutrient density

You’re probably wondering where all these analyses are headed.

With all of these extreme approaches being so deficient in many micronutrients, you must be thinking “I hope there is a happy ending to this story, and soon.”

The good news is that we can manipulate our food selection to maximise micronutrients. But first, here’s something to scare you even more.

The chart below shows the outcome when we minimise the harder-to-find nutrients. This low nutrient density approach ends up being adequate in only three essential nutrients: sodium, vitamin C and iron.

The good news is shown in the chart below, which quantifies the nutrients provided by the most nutrient dense foods when we prioritise for the harder to find nutrients. Alpha linolenic acid (found mainly in nuts and seeds) is hard to come by in adequate quantities, however we can obtain the daily recommended intake of all the other nutrients when we prioritise the harder to find micronutrients.

comparison of nutrients adequate

It’s a little hard to present and digest this analysis clearly. There is no agreed protocol to compare the nutrient density foods. So I’ve tried to summarise it in a number of different ways to allow you to draw your own conclusions.

Firstly, the chart below shows the number of nutrients that each macronutrient extreme is adequate in, from the most nutrient dense at the top to the least nutrient dense at the bottom.

The chart below shows a stacked bar chart of the various nutrients in terms of % DRI. It’s like we have added up all the above charts for each nutrient and stacked them on top of each other. This chart demonstrates that there is a is a massive difference between the most nutrient dense and least nutrient dense approaches. If you’re foods that have a lower nutrient density you might just be hungrier compared to if you are eating the same number of calorie of the most nutrient dense foods which will much more effectively provide you with your essential micronutrients.

But we needn’t be too concerned about the micronutrients that are easy to obtain. What we really care about is the nutrients that are harder to obtain. The chart below shows the sum of the eighteen nutrients that are harder to obtain for each extreme approach.

application

It seems that thinking in terms of macronutrient extremes has some usefulness. However, focusing on micronutrient density seems to provide an order of magnitude improvement in the level of actual nutrients provided by our food.

Maybe it’s time for a new trend?

The ‘problem’ with nutrient dense foods is that that they are so lean and contain so much fibre that it can be hard to consume enough calories to maintain weight. You’ll just be too full!

If you are insulin sensitive and not looking to lose weight, then you could consider adding some more ‘Paleo friendly’ carbs such as beets, squash, yams, and sweet potatoes, and/or some fattier cuts of meat to fuel your activity. If you are insulin resistant, you may need to add some fattier (but still relatively nutrient dense) foods to maintain your weight while also keeping your blood glucose and insulin levels in check.

Perhaps micronutrient density is the most important parameter to pursue in our diet. Then with that cornerstone in place we can personalise our nutritional approach to suit our goals (e.g. weight loss, ketosis, athletic performance or healthy maintenance).

The various food lists in the table below are designed with micronutrient density as the main priority, but also consider insulin load and energy density to suit different goals.

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

personalisation

In the end, no one sticks to an optimal list of foods that perfectly balances their diet 100% of the time.

I’ve been working on a system that will give you feedback on YOUR current diet, identify which nutrients you are currently lacking, and which supplements or real whole foods you may need to add or subtract to optimise your nutrition. Most people don’t eat perfectly all the time, but we could all use some help moving forward towards optimal.

Check out the Nutrient Optimiser page for more details.

notes

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

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

fasting, recipies, weight loss

eggs florentine with chicken livers and bacon

December 26, 2016 Marty Kendall Leave a comment

This recipe for eggs florentine with chicken livers and bacon is from Rebecca Latham who runs the My Low Carb Road – Fasting Support Facebook group.

By using her regular fasting routine and nutrient dense feasting she has been able to lose 37.5 lb (17kg) of body fat during 2016 (which is significant given she is only 5′ 3″).

This was one of her favourite go to recipes during her weight loss. Rebecca says:

I originally started eating ketogenically a few years ago by eating very high fat, lower protein, and very low (sometimes zero) carbs.

That worked for a while, and I lost weight, but as time went on, I found that I was eating so much fat and so little protein that I was getting hungry all the time.

I now get plenty of protein on my eating days. I am 5’3″ and eat 125g on the days that I feast

It seems that as you approach your goal weight your body works increases appetite to maintain lean muscle mass. I think this style of higher protein meal will maximise your chance of managing appetite during weight loss as well as maximising nutrient density to prevent rebound binges due to cravings for nutrients.

Rebecca’s recipe is:

114g (4 oz.) raw chicken livers, cut into small pieces
1/4 tsp. chopped, dried rosemary
1/4 tsp. ground, dried thyme
1/4 tsp. garlic powder
1/4 tsp. sea salt
114g (4 oz.) frozen, chopped spinach, cooked, drained, warm
1 Tbs. butter, divided
57g (2 oz.) raw onion, chopped
114g (4 oz.) raw white mushrooms, chopped
2 thick slices bacon, cooked and cut into small pieces
1 Tbs. whiskey
2 raw eggs
Additional sea salt, as desired

In a small bowl, combine chicken livers, spices, and salt, stirring to combine. Set aside.

Preheat a small cast iron skillet on medium-low heat, then add 1/2 Tbs. butter. Add onions, cover and cook for 1 minute. Add mushrooms, cover and cook for an additional 2 minutes, or until veggies start to brown. Add chicken livers to the skillet, and continue to cook, stirring, until liver is cooked medium well. Add bacon and whiskey and stir again.

Cut the remaining 1/2 Tbs. butter into a several pieces and add to the skillet, allowing it to melt down into the bottom of the pan. Do not stir it in.

Carefully break the eggs into the skillet, letting them rest on top of the mixture. Cover the skillet and cook just long enough for the eggs to cook to however you like them. For the whites to be firm and the yolks to be runny, it may take 2-3 minutes.

Arrange the warm spinach on a plate, and with a spatula, carefully lift out the food from the skillet and set on top of the spinach. If there is any butter left in the skillet, pour it over the eggs. Add additional sea salt if desired, and enjoy!

The nutritional analysis for this recipe is shown below. This recipe comes in at #52 of 400 in the nutrient dense meals ranking and #67 in the diabetes and nutritional ketosis meal ranking.

However if we sub out some of the onion and add some spinach it comes up to #23 of 400 in the nutrient nutrient dense meals ranking and #27 in the diabetes and nutritional ketosis. Not bad.

Look out for the article detailing Rebecca’s fasting / feasting Protocol which will be published on 1 January 2017 just in time for your New Years resolutions.

The table below shows the nutritional data per 500 calorie serving.

net carbs	insulin load	carb insulin	fat	protein	fibre
6g	30g	19%	56%	44g	6g

articles, insulin index, insulin load, nutrient density

optimising protein and insulin load

December 3, 2016 Marty Kendall 8 Comments

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

context matters

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

“What insulin load should I be aiming for?”

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

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

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

disclaimers

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

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

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

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

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

insulin is not the bad guy

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

insulin load = total carbohydrates – fibre + 0.56 * protein

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

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

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

different degrees of the ketogenic diet

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

ketogenic ratio

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

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

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

ratio of fat to protein

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

protein grammes per kilogramme of lean body weight

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

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

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

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

gluconeogenesis

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

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

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

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

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

carbohydrate counting

Then there is carb counting.

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

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

protein, insulin load and nutrient density

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

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

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

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

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

what is ketosis?

“Ketogenic” simply means “generates ketones”.

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

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

insulin load = total carbohydrates – fibre + 0.56 * protein

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

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

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

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

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

alcohol,
protein (not used for muscle protein synthesis),
non-fibre carbohydrate, and then
fat.

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

insulin load versus nutrient density

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

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

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

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

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

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

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

macronutrient splits

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

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

nutrient density

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

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

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

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

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

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

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

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

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

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

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

choosing the right approach for you

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

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

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

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

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

more numbers

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

ketogenic ratio
ratio of fat to protein
protein (g)/kg LBM
insulin load (g/kg LBM)

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

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

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

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

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

what about mTOR?

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

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

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

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

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

As my wise friend Raymund Edwards from Optimal Ketogenic Living says

“FAST WELL, FEED WELL.”

how much protein?

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

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

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

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

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

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

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

insulin load

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

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

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

summary

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

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

references

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

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

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

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

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

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

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

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

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

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

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

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

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

post last updated July 2017

articles, nutrient density

building a better nutrient density index

May 16, 2016 Marty Kendall 44 Comments

Nutrient dense foods can increase satiety by providing adequate nutrition and reduced cravings with less energy.
Some approaches to nutrient density focus on vitamins and minerals while others use a broader range of nutrients that include essential amino acids and essential fatty acids.
This article outlines a new system for prioritisation of foods that focuses on essential nutrients that are more difficult to obtain.

why nutrient density matters

Dr Joel Fuhrman has done some great work developing and testing his dietary approach based on high nutrient density foods.^{^[1]}

Fuhrman’s research suggests that a high nutrient density approach (HND) to food selection leads to a range of benefits including improved:

blood sugar control,
weight loss,
blood pressure, and
blood markers.^{^[2]}

People following a high nutrient density approach tend to feel more satiated with fewer calories and are able to skip meals more easily.^{^[3]}

Harvard researcher Dr Christopher Gardner has also shown the benefits of a high fibre, nutrient dense dietary approach with his recent paper Weight loss on low-fat vs. low-carbohydrate diets by insulin resistance status among overweight adults and adults with obesity: A randomized pilot trial.^{^[4]}

In this study all participants were encouraged to eat nutrient dense, higher fibre, unprocessed foods. While the participants who were insulin resistant benefited more from a low carbohydrate approach and insulin sensitive people benefited more from a low energy density / low fat approach, everyone lost weight and improved their blood markers without having to consciously count calories!

calories or nutrients?

It’s generally accepted that people will lose weight if they consume less calories, however the real challenge is managing appetite in the long term.

“Appetite is a dragon. Losing weight is brutally tough. Harder than particle physics.”

says RD Dikeman (pictured) who has made some great progress via tight blood glucose control (using the process outlined in the article how to use your blood glucose meter as a fuel gauge), avoidance of processed carbs and intermittent fasting.^{^[5]}

Most people find that appetite and metabolism win out over willpower or conscious calorie counting in the long run. Either we end up binging on the foods we were craving or our metabolism slows down to cope with the reduced energy intake.^{^[6]}

But what if satiety is influenced by the quantity of nutrients rather than the calories in our food? Paul Jaminet in his Perfect Health Diet books says:

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

But how do we know if we are getting the required nutrients in the right proportions? Which foods will help us maximise our chance of achieving nutrient density while minimising energy?

The chart below (click for a larger image) shows the percentage of the recommended daily reference intake (DRI)^{^[7]} of the various nutrients that you would obtain if you ate a little bit of ALL of the 7000+ foods in the USDA foods database.

Without following any particular dietary approach it seems from this that it’s fairly easy to obtain the recommended amounts of most of the amino acids, iron, phosphorus, selenium, niacin and Vitamin B-12.
However, without paying attention to the nutrient density of your diet or supplementation you will have to consume well beyond 2000 calories to obtain the recommended daily intake of calcium, magnesium, potassium, copper, vitamin E, vitamin D, pantothenic acid, choline and the essential fatty acids EPA and DHA.

Satiety is a complex and controversial topic. There are many factors including, palatability, mouth feel, smell, protein, fibre, mood, insulin resistance etc etc etc. Obtaining adequate nutrients may not be the only thing that influences appetite, but it just might be a significant piece of the complex puzzle. As you will see below, nutrient dense foods are typically also unprocessed whole foods that you would be less likely to binge on than a packet of Pringles, pizza and a bottle of coke (i.e. ‘foods with no brakes‘).

The slide below from a presentation by Bruce Ames demonstrates that there might be some room for improvement in the nutrient density of most people’s diets.^{^[8]}

This slide shows how many people are lacking in a range of key micro-nutrients. Very few people are getting adequate omega-3 essential fatty acids.

limitations of daily reference intake values

The daily recommended intake (DRI)^{^[9]} values are typically conservative. You may do fine with much lower levels than the recommended intake levels. The only way to really know if you are lacking in a particular nutrient would be to get blood tests to see if you are deficient in any nutrients.^{^[10]}

In lieu of regular blood testing of all the essential nutrients you can use the DRI values as a guide to understand if you are getting a ‘balanced diet’ with adequate amounts of the essential nutrients. Some people use apps like cronometre to see if they are meeting their minimum levels of various nutrients, but how do you know which foods will give you the best chance of maximising your nutrition?

There are meal replacement shakes (e.g. Soylent, Optifast, Ambronite etc) that enable you to theoretically meet the DRI values with a minimum amount of calories. However the safest approach is probably going to be to focus on nutrient dense unprocessed foods that contain all the essential nutrients that we know about as well as the other nutrients that we don’t yet know about.

Your metabolism may not have read the World Health Organisation’s research on the daily reference intake of the various nutrients however, if appetite is at least partially driven by obtaining adequate nutrition you can see why we are less likely to binge on nutrient dense whole foods.

The slide below from Bruce Ames shows the commonly accepted essential vitamins, minerals, amino acids and fatty acids that we require.

how to calculate nutrient density

Calculation of nutrient density is far from a precise science. Different people have taken different approaches and arrived at different food rankings.

Joel Fuhrman’s take on nutrient density uses vitamins and minerals with no consideration of amino acids or fatty acids. Fuhrman’s ANDI index also includes phytosterols, glucosinolates, angiogenesis inhibitors, organosulfides, aromatase inhibitors, resistant starch, resveratrol and Oxygen Radical Absorbance Capacity (ORAC) in the scoring. These additional parameters are not available in the USDA food database and are not part of the generally accepted list of essential nutrients, so it’s hard to include them in a comprehensive analysis.^{^[11]} The highest scoring foods with or without these additional parameters are similar (i.e. green leafy veggies) so I don’t think omitting these parameters will materially change the overall outcome.

Based on his analysis Fuhrman recommends a diet high in vegetables and fruit with a minimum of animal products and processed carbohydrates. Fuhrman recommends eating animal products only occasionally, ideally fish to provide omega 3 fatty acids. It’s not hard to see how restricting yourself to non-starchy veggies would help you to reduce your energy intake.

More recently Dr Mat Lalonde developed an alternative approach to analysing nutrient density which also includes essential amino acids and essential fatty acids. With the inclusion of animal products this approach tends to prioritise high protein animal based foods. Lalonde’s approach is based on nutrients per weight of food which may be useful for an athlete wanting to quickly refuel, however Fuhrman’s nutrietns per calorie may be more useful for someone wanting to lose weight.

The low carb community’s criticism of Fuhrman’s approach is that it is too high in carbohydrates and that it is unnecessarily biased towards plant based foods. Meanwhile the vegan community’s criticism of Lalonde’s approach is that the higher protein and fat levels are unnecessary and even dangerous.^{^[12]} They claim you can get adequate amounts without going out of your way to make it a priority.

As detailed in the optimal foods for different goals I previously had a go at developing a nutrient density ranking system that includes forty three (43) beneficial nutrients including vitamins and minerals as well as beneficial amino acids and fatty acids. While this ‘belt and braces’ approach to nutrient density will ensure that you maximise the nutrient density of your food there is also a risk that it will prioritise nutrients that are easy to obtain at the expense of nutrients that are less common in our food system.

So which approach is optimal? Vitamins and minerals only, all beneficial nutrients, or perhaps something else? Which approach will enable you to obtain a nourishing, balanced diet that provides all the required nutrients in the right proportions to minimise appetite and eliminate hunger with a minimal caloric intake.

comparison of approaches to nutrient density

The chart below (click for a larger image) compares the nutrients we obtain for the following approaches:

all foods,
top 500 foods prioritised using vitamins and minerals, and
top 500 foods prioritised using all 43 beneficial micro-nutrients.

We can see from this analysis that:

Following either approach to maximising nutrient density provides an immense improvement compared to the average of all of the foods in the USDA database.
The vitamins and minerals only approach does better in terms of most of the vitamins and minerals.
The most nutrient dense approach using forty three micro-nutrients does better when it comes to amino acids (protein), essential fatty acids (DHA and EPA), vitamin B-12, zinc, selenium and niacin.
There is a lot of variability in the amounts of nutrients in terms of percentage of the DRI.

So if our goal is to avoid malnutrition with the minimum amount of calories, which approach is optimal?

Perhaps what we need, rather than amplifying all nutrients, is to prioritise the foods with the nutrients that are harder to obtain?

removing the overachievers

The chart below shows the proportion of the population that consume less than the recommended amount of various essential nutrients. From this it seems we should, as a minimum, prioritise vitamin D, vitamin E, magnesium, calcium, vitamin A and vitamin C.

Starting with the full list of forty-three beneficial nutrients I have progressively removed the ‘overachievers’ so we only prioritise the harder to obtain nutrients. The nutrients that you could obtain more than 500% of the daily recommended intake (DRI) with 2000 calories have been removed from the system.

I have also removed the fatty acids that could be considered contentious in a minimalist food ranking system. So rather than 43 nutrients we end up prioritising only the 27 hardest to obtain essential nutrients.

vitamins

Choline
Thiamine
Riboflavin
Niacin
Pantothenic acid
Vitamin A
Vitamin B12
Vitamin B6
Vitamin C
Vitamin D
Vitamin E
Vitamin K

minerals

Calcium
Copper
Iron
Magnesium
Manganese
Phosphorus
Potassium
Selenium
Sodium
Zinc

amino acids

Cysteine
Isoleucine
Leucine
Lysine
Phenylalanine
Threonine
Tryptophan
Tyrosine
Valine
Methionine
Histidine

fatty acids

Docosahexaenoic acid (DHA) (22:6 n-3)
Eicosapentaenoic acid (EPA) (20:5 n-3)
Docosapentaenoic acid (DPA) (22:5 n-3)
Alpha-linolenic acid (18:3 n-3)
Arachidonic acid (20:4)
Oleic acid (18:1)
Lauric acid (12:0)
Capric acid (10:0)
Pentadecanoic acid (15:0)
Margaric acid (17:0)

The chart below (click for larger image) shows the outcome of the moderated approach compared to the other approaches (i.e. all foods, vitamins and minerals only and all 43 nutrients). A number of the nutrients that were lower using the “all nutrients” approach have improved (i.e. calcium, magnesium, vitamin A, vitamin C, selenium, vitamin E and vitamin D).

which one is best?

The moderated approach does pretty well across the board. The problem is that it’s hard to make sense of all this data to confirm which approach is optimal. How do we simplify the decision process?

In engineering we often think in terms of reliability statistics.^{^[13]}

Let’s say Acme brand widget is really strong on average but highly variable. If you buy a box of Acme widgets most of them will be strong, but you might get some low strength duds. Acme of widget not reliable so we have to be conservative when it comes to the design assumptions. In the design we might assume that a widget is only as strong as the average minus one or two standard deviations of the strength to make sure our design is conservative.

However if we can decrease the variability by improving the manufacturing process and produce a box of widgets that are not quite as strong on average but less variable we can assume a lower factor of safety and assume more capacity in a design using that bolt.

Perhaps we can use a similar analysis approach when it comes to nutrient density. What we ideally want is a diet that has high levels of all of the essential nutrients without any nutrient deficiencies that would require supplementation.

The chart below plots the average of all the nutrients as a proportion of the DRI (blue bars). We can see that all three approaches to ranking nutrient density do better than the average of all foods in the USDA database, with the “43 micro-nutrients” approach scoring the best. However we know from the chart above that this high score is largely due to very high amino acid scores for the “all 43 micro-nutrients” approach.

The vitamins and minerals only approach also does well, however we also know that this is due to the higher score in the vitamins and minerals with lower scores in some of the other nutrients such as the proteins and essential fatty acids.

The orange bars in the plot represent the average minus 0.8 times the standard deviation of the nutrients as a percentage of the DRI requirement. Using this approach to comparison it appears that the moderated nutrient density approach is better because we have less variability across the nutrients, with some lower highs and lots of higher lows compared to the other approaches.

What this means in practice is that the moderated approach will more reliably provide you with the essential vitamins, minerals, amino acids and fatty acids that you require without needing to supplement or overeat to provide the missing nutrients. The moderated nutrient density approach seems to give us a better outcome in terms of nutrient density.

most nutrient dense foods

Listed below is a summary of the top 1000 foods prioritised by the moderated nutrient density system detailed above.

In addition to nutrient density score (note: 0 is average and a score of 2 means that a food is two standard deviations above the mean) I have also included a number of other parameters that may be of interest.

The percentage of insulinogenic calories and net carbs per 100g of food will be of interest for someone who aiming for a high fat therapeutic ketogenic diet.
The insulin load may be of interest for someone who is insulin resistant and wanting to consume a diet that their pancreas can keep up with.
Net carbs will be useful for someone doing standard carbohydrate counting.
The energy density (calories per 100g) will be of interest for someone looking to decrease the energy density of their diet for weight loss.

I have also shown the vitamin, mineral and protein plots for some of the highest ranking foods in each category to get a feel for the nutrition provided by each of these foods.

Choosing nutrient dense whole foods typically ensures that the other relevant parameters are favourable, though these other factors may be of interest depending on your situation.

Future articles will look at how we can fine tune our food selection to suit people who are insulin resistant and wanting to normalise their blood glucose levels or who are insulin sensitive and still looking to lose weight. In the meantime you can check out these summary food lists that are based around these ideas:

vegetables

If you look down the nutrient density (ND) scores of all the foods you will see that the vegetables do really well compared to the other food groups. If you were aiming to maximise nutrient density you could simply focus on eating as many vegetables as you could with perhaps some supplemental seafood for essential fatty acids.

Celery tops the list of nutrient dense dense foods because it has a lot of vitamins and minerals with very few calories. The chart below from Nutrition Data shows that we would obtain 81% of our required vitamins and minerals from 1000 calories and 52% of the protein. The is that we would need to eat 100 celery stalks to obtain that 1000 calories! However you can see how in terms of nutrients per calorie celery is amazing and you wouldn’t go wrong trying to fill up on these high nutrient density low calorie density foods.

food	ND	% insulinogenic	net carbs/100g	insulin load (g/100g)	calories/100g
celery	2.63	49%	1	2	17
rhubarb	1.46	57%	3	3	21
turnip greens	1.31	39%	1	4	37
lettuce	1.34	52%	2	2	17
winter squash	1.22	80%	7	8	39
broccoli	1.21	57%	4	6	42
asparagus	1.12	46%	2	3	27
Chinese cabbage	1.02	60%	1	2	16
summer squash	1.00	65%	2	3	19
okra	0.94	57%	4	5	37
bamboo shoots	0.90	52%	3	4	28
bell peppers	0.86	64%	6	7	43
artichokes	0.83	33%	3	4	54
cabbage	0.81	53%	3	4	30
kale	0.75	74%	8	10	56
parsnip	0.73	38%	7	7	76
seaweed (kelp)	0.74	43%	4	5	50
snap green beans	0.74	47%	4	5	40
peas	0.69	58%	5	7	51
radishes	0.70	50%	2	2	19
mushrooms	0.65	70%	2	5	30
sweet potato	0.51	82%	17	18	87
onions	0.52	77%	7	8	41
jalapeno peppers	0.52	54%	4	5	35
pinto beans	0.44	60%	16	21	142
sweet corn	0.43	47%	10	13	111
collards	0.44	46%	2	5	40
dill	0.42	30%	2	4	52
eggplant	0.39	67%	7	7	41
beets	0.34	44%	4	5	48
shallots	0.27	60%	46	56	377
mung beans	0.33	46%	1	3	26
thyme	0.27	21%	14	19	359
black pepper	0.24	36%	24	29	327
bay leaf	0.21	37%	34	38	406
chives	0.27	34%	1	3	37
mustard greens	0.27	45%	2	3	30
Brussels sprouts	0.24	54%	5	7	52
shiitake mushrooms	0.20	68%	51	59	349
paprika	0.19	17%	8	16	389

fruit

The list of nutrient dense fruits is shorter than the vegetables due to the higher amount of calories and sugar in proportion to the amount of nutrients.

The plot below shows that we get 57% of the vitamins and minerals and 44% of our protein from 1000 calories of mandarin orange.

food	ND	% insulinogenic	net carbs/100g	insulin load (g/100g)	calories/100g
cherries	0.72	84%	10	11	54
orange	0.49	77%	10	11	55
apples	0.48	77%	10	10	53
grapes	0.45	80%	15	15	77
figs	0.37	81%	16	17	82
blueberries	0.32	72%	16	16	91
mandarin oranges	0.31	63%	9	9	59
honeydew melon	0.30	88%	8	9	40
passion fruit	0.24	54%	13	15	109
raisins	0.20	84%	68	70	336
litchis	0.20	80%	14	15	73
dates	0.17	72%	54	56	308

legumes

Legumes tend to have a higher energy density than the vegetables and thus may be useful if you need some more calories to support your activity and can’t fit in any more celery, lettuce and broccoli.

The Nutrition Data plot below for lentils shows that 1000 calories will provide 58% of your vitamins and minerals and 86% of your protein.

food	ND	% insulinogenic	net carbs/100g	insulin load (g/100g)	calories/100g
lima beans	0.56	71%	16	23	129
navy beans	0.47	55%	15	20	143
lentils	0.35	62%	12	18	118
hummus	0.26	32%	8	14	175
peanuts	0.17	18%	7	28	605

grains

The nutrient dense grains tend to be the least processed. Unfortunately most grains are consumed in a highly processed form.

The plot below shows that oats will give us minerals and a substantial amount of protein, but are not as high in the vitamins compared with a number of the other foods.

food	ND	% insulinogenic	net carbs/100g	insulin load (g/100g)	calories/100g
oatmeal	0.77	58%	8	10	67
teff	0.70	54%	11	14	101
spelt	0.58	54%	14	18	135
rice noodles	0.54	87%	22	23	105
quinoa	0.45	55%	14	16	120
oat bran	0.35	57%	29	38	264
millet	0.34	76%	20	22	118
rye bread	0.30	64%	37	45	282
rice bran bread	0.25	54%	31	37	273
wheat bran bread	0.24	68%	37	44	257
oat bran muffins	0.23	48%	29	35	288

dairy and eggs

The nutrient density score for eggs and dairy is not as high as the vegetables, however the proportion of insulinogenic calories and net carbohydrates is lower which will mean that these foods have a minimal impact on blood glucose levels.

The plot below shows that we would get half of our required vitamins and minerals and 136% of our protein requirements from 1000 calories of eggs (i.e. 14 eggs).

food	ND	% insulinogenic	net carbs/100g	insulin load (g/100g)	calories/100g
parmesan cheese	0.18	30%	3	31	411
goat cheese	0.17	22%	2	25	451
edam cheese	0.17	22%	1	20	356
gruyere cheese	0.17	21%	0	22	412
Swiss cheese	0.17	26%	5	25	379
egg yolk	0.17	19%	4	15	317
gouda cheese	0.17	23%	2	20	356
provolone	0.17	24%	2	21	350
blue cheese	0.16	20%	2	18	354
cheddar cheese	0.15	20%	1	20	403
limburger cheese	0.16	18%	0	15	327
camembert cheese	0.16	20%	0	15	299
Monterey	0.15	20%	1	19	373
muenster cheese	0.15	20%	1	18	368
Colby	0.15	20%	3	20	394
whole egg	0.16	29%	1	10	138

nuts and seeds

Nuts and seeds are more energy dense but lower in carbohydrates due to their higher fat content. While nuts and seeds will help someone achieve more stable blood glucose levels it is common knowledge in low carb circles that you need to watch your intake of nuts, seeds and dairy if you’re trying to lose weight.

food	ND	% insulinogenic	net carbs/100g	insulin load (g/100g)	calories/100g
coconut water	1.51	66%	3	3	20
sunflower seeds	0.18	20%	11	24	491
tahini	0.17	16%	13	26	633
pine nuts	0.16	11%	9	18	647
pecans	0.15	5%	4	9	762
pistachio nuts	0.16	23%	19	34	602

seafood

Omega 3 fatty acids are important but hard to get in the diet, so it’s worth going out of your way to ensure you are getting enough.

The plot below shows that we can get more than half of our vitamins and minerals and 148% of our protein requirements from 1000 calories of sardines.

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g
anchovy	0.34	42%	21	203
caviar	0.30	32%	22	276
tuna	0.30	50%	17	137
oyster	0.31	57%	14	98
rainbow trout	0.28	43%	17	162
mackerel	0.28	45%	17	149
swordfish	0.28	41%	17	165
lobster	0.30	69%	14	84
herring	0.26	34%	18	210
salmon	0.28	50%	15	122
whitefish	0.27	67%	17	102
octopus	0.26	69%	27	156
halibut	0.27	63%	16	105
Pollock	0.27	66%	17	105
sturgeon	0.26	47%	15	129
sardine	0.24	36%	18	202
shrimp	0.26	66%	19	113
crab	0.26	69%	13	78
snapper	0.25	64%	15	94
haddock	0.24	67%	18	110
mussel	0.22	61%	25	165
whiting	0.21	63%	17	109
crayfish	0.21	64%	12	78
abalone	0.21	76%	19	99
haddock	0.21	69%	15	85
clam	0.20	71%	24	135

animal products

When it comes to animal products the lower fat cuts tend to rank higher when it comes to nutrient density.

Liver ranks the highest overall and the vitamin and minerals score as well as the protein score is substantial.

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g
beef liver	0.46	58%	24	169
chicken liver	0.43	48%	20	165
ham	0.26	55%	20	146
pork	0.25	54%	21	154
veal (leg)	0.25	56%	25	174
emu	0.24	63%	25	159
beef	0.22	50%	25	197
chicken breast	0.22	56%	25	178
turkey breast	0.22	70%	22	127
bacon	0.18	23%	30	522
ground turkey	0.19	37%	19	203
ostrich	0.19	46%	19	168
veal (sirloin)	0.18	38%	19	195
pork	0.18	46%	21	182
chicken drumstick	0.17	36%	22	238
goose	0.17	37%	21	230
duck (meat only)	0.17	36%	17	195
beef steak	0.16	28%	21	305

should everybody eat just these nutrient dense foods?

As a general rule most people would do well eating from this list of nutrient dense whole foods. Unprocessed nutrient dense foods would be a major improvement for most people. There is however opportunity to further refine this for specific goals such as weight loss or diabetes.

In future articles we will look at how we can use the concepts of energy density and insulin load to further refine this list for people who are looking to lose weight and for people who have diabetes and need to control their blood glucose levels. In the mean time you may be interested in these summary food lists:

references

^{^[1]} http://www.wholefoodsmarket.com/healthy-eating/andi-guide

^{^[2]} https://www.drfuhrman.com/members/m_library/OJPM20120300014_73341742.pdf

^{^[3]} https://www.drfuhrman.com/library/changing_perceptions_of_hunger.pdf

^{^[4]} http://onlinelibrary.wiley.com/doi/10.1002/oby.21331/full

^{^[5]} RD also happens to be a physicist and a chief scientist with defence contractor Lockheed Martin. He is also an admin on the TYPE ONE GRIT facebook group for people with type 1 diabetes (his son has type 1 diabetes) and produces Dr Bernstein’s Diabetes University.

^{^[6]} http://www.amazon.com/Obesity-Code-Unlocking-Secrets-Weight/dp/1771641258

^{^[7]} https://ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.aspx

^{^[8]} https://www.youtube.com/watch?v=ZVQmPVBjubw

^{^[9]} http://www.mydailyintake.net/nutrients/

^{^[10]} http://www.lifeextension.com/vitamins-supplements/blood-tests/nutrient-testing

^{^[11]} http://www.wholefoodsmarket.com/healthy-eating/andi-guide

^{^[12]} http://www.vegsource.com/articles/protein.danger.htm

^{^[13]} https://en.wikipedia.org/wiki/Reliability_(statistics)

articles, carbohydrates, protein

the cost of going low carb

July 30, 2015 Marty Kendall 7 Comments

Analysis of the USDA Cost of Food at Home database shows that fat is the cheapest macronutrient.
Protein is the most expensive macronutrient, however a reduced carbohydrate diet does not necessarily require an increase in protein.
Reducing the amount of carbohydrate and increasing the amount of fat in your diet is the most effective way to reduce your grocery bill.

background

One of the common concerns about eating differently from the norm is that it will be more expensive.

Apparently one of the reasons for the relatively low Recommended Daily Intake for protein of 0.8g/kg is that many people can’t afford to eat more protein. [1] One of the common criticisms of Paleo or the Banting Diet (LCHF) is that it will be too expensive due to the extra protein. [2]

To see if these concerns were valid I thought it would be interesting to see what the data has can tell us about the relative cost the three macronutrients, protein, carbohydrate and fat.

protein

The chart below shows the cost per calorie versus the percentage of protein in the thousand or so foods in the USDA Cost of Food at Home database. [3]

Protein is indeed the most expensive of the three macronutrients. As you move to the right in the chart you can see that your weekly grocery bill will increase.

Average intake of both protein and fat in the United States decreased between 1971 and 2004, with an overall increase in carbohydrate. [4]

While from a nutritional point of view there area lot of good reasons for people to eat higher levels of protein, a low carbohydrate diet is not necessarily high in protein.

People aiming for therapeutic ketosis may aim for lower amounts of protein to minimise insulin.

Tim Noakes’ Banting diet recommends that people get between 20 and 30% of their calories from protein. He says that those with diabetes and / or insulin resistance issues should aim for the lower end of this range, while people who are active and healthy can aim for higher amounts. [5]

Practically it is difficult to eat much more than 30% to 35% protein from real foods.

The table below shows the relative change in cost if we were to increase our protein from current average levels back to 1970s levels, or to moderate levels such as the Mediterranean diet or even the higher protein Atkins approach.

scenario	% protein	cost ($/kcal)	change
2004 average	14.7%	4.67	–
1970 average	16.9%	4.83	+3%
Mediterranean	20%	5.06	+8%
Atkins	30%	5.79	+24%

As shown in the table below, the most expensive high protein foods tend to be seafood. For reference, the average cost of food across the more than one thousand foods in the database is $5.37/kcal.

food	cost ($/kcal)
crayfish	26
spinach	26
crab	24
spirulina	23
lobster	22
scallops	17
clam	16
haddock	16
cod	15

While protein can be expensive there are some low cost high protein options available.

food	cost ($/kcal)
whole egg	1.70
ground turkey	2.13
beef liver	2.81
chicken heart	2.94
cottage cheese	3.58
pork	3.59
chicken liver	3.81
ham	4.10

If you are willing to try organ meats you might get them even cheaper as they are often discarded. The cheaper organ meats also typically have a much higher nutrient density than the more popular muscle meats or even fruits or vegetables.

carbohydrates

You often hear the term ‘cheap carbohydrates’, but does this mean that a diet of processed grains and sugars is the most economical way to fill your shopping trolley?

While sugar and corn starch are very cheap food ingredients per calorie, the analysis of the data suggest that a higher carbohydrate diet is actually more expensive overall.

The cheaper high high carbohydrate foods tend to be processed and calorie dense. While the most expensive high carbohydrate foods tend to be natural foods that have a much lower calorie density. The table below shows that someone switching from a typical western diet to a reduced carbohydrate diet could make some significant savings.

scenario	% carbohydrate	cost ($/kcal)	change
2004 average	51%	5.57	–
1970 average	45%	5.37	-4%
low carb	30%	4.77	-14%
ketogenic	5%	3.80	-32%

fat

So if increasing the proportion of protein and carbohydrate both increase the cost of our food bill then what makes it cheaper? Yes it’s the other macronutrient, fat.

Increasing the proportion of fat in your diet while decreasing the carbohydrates will make your meals tastier, gentler on your blood glucose and cheaper. Not to mention the fact that people typically spontaneously consume less calories when they consume less carbohydrates.

You may pay a premium for coconut oil, butter or olive oil relative to corn oil which is the cheapest food ingredient, however these fats are still much cheaper than the other macronutrients.

food	cost ($/kcal)
corn oil	0.20
coconut oil	0.31
chicken fat	0.86
butter	1.10
bacon fat	1.12
coconut milk	1.15
cream cheese	1.76
sesame oil	2.00
cream	2.81
olive oil	2.81

It appears that the it’s the very cheapest ingredients that are so prevalent in processed foods – sugar, corn starch, corn oil, high fructose corn syrup. Regardless of cost you’re always going to have to make a value judgement on the nutritional value of your food.

summary

Increasing the protein content of your diet will increase your grocery bill marginally.

While higher levels of protein may be ideal for people who are healthy and active, LCHF is not necessarily high protein, particularly for those who struggle to regulate their blood glucose levels.

The LCHF approach, with its combination of moderate protein, lower carbohydrates and high fat provides an optimal solution with respect to blood glucose management, nutrition and cost.

references

[1] https://www.facebook.com/physiquescienceradio/posts/378943502302499

[2] http://talkfeed.co.za/lchf-diet-on-a-budget/

[3] http://www.cnpp.usda.gov/USDAFoodPlansCostofFood

[4] http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=9146789&fileId=S1368980012005423

[5] http://www.biznews.com/health/2015/01/19/complete-idiots-guide-tim-noakes-diet-banting-lchf/

articles, blood sugar, carbohydrates, diabetes, insulin index, protein

the food insulin index v2

July 6, 2015 Marty Kendall 19 Comments

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

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

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

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

the food insulin index… a quick refresher

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

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

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

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

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

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

insulin load = total carbohydrates – fibre + 0.56 * protein

digestion time for protein versus carbohydrates

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

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

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

Wilder’s ketogenic formula

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

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

This formula is based on the understanding that:

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

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

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

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

carbohydrate counting

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

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

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

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

thermic effect of food

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

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

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

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

Steve Phinney’s “well formulated ketogenic diet”

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

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

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

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

amino acid potential

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

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

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

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

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

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

the krebs cycle

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

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

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

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

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

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

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

tallying up the amino acids

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

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

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

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

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

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

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

which foods have the most ketogenic protein?

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

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

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

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

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

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

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

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

summary

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

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

the most ketogenic foods… updated

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

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

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

least insulinogenic foods

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

Eggs

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

Dairy products

Cheese

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

Milk

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

Yogurt

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

Fruits

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

Vegetables

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

Nuts, seeds and legumes

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

Fish

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

Meat

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

post last updated May 2017

references

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

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

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

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

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

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

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

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

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

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

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

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

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

articles, carbohydrates, diabetes, insulin index, weight loss

why we get fat and what to do about it v2

June 22, 2015 Marty Kendall 25 Comments

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

background

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

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

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

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

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

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

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

do calories count?

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

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

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

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

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

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

what does insulin do?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

meal timing

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

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

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

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

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

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

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

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

when a calorie is not a calorie

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

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

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

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

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

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

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

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

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

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

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

fat and insulin

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

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

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

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

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

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

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

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

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

can you eat too much fat?

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

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

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

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

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

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

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

carbohydrate

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

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

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

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

fibre

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

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

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

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

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

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

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

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

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

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

protein

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

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

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

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

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

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

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

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

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

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

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

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

nutrient hunger

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

In his Perfect Health Diet, Paul Jaminet notes that

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

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

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

liver storage and insulin sensitivity

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

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

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

practical application

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

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

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

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

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

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

summary

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

[1] http://garytaubes.com/

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

articles, blood sugar, diabetes, insulin index

the blood glucose, glucagon and insulin response to protein

June 15, 2015 Marty Kendall 39 Comments

The food insulin index data indicates that there is both a blood sugar and an insulin response to the glucogenic component of protein. [1]
A higher protein intake tends to lead to better blood sugar control, increased satiety and reduced caloric intake.
Digested amino acids from protein circulate in the bloodstream until they are required for protein synthesis, gluconeogenesis or the production of ketones.
The release of glucose from protein via gluconeogenesis is a demand driven process that is smoother and slower compared to carbohydrate.
Someone who is insulin resistant and/or whose pancreas is not producing adequate insulin may benefit from higher protein with lower carbohydrate (LCHP) in order to smooth out the blood sugar response while still obtaining adequate protein.

background

Protein doesn’t significantly raise blood sugars, at least compared to carbohydrates.

At the same time, it is generally acknowledged (at least by people with Type 1 Diabetes) that protein requires insulin to metabolise. Managing the blood glucose response to protein is a challenge for diabetics, particularly if they are minimising carbohydrates and hence may have a higher protein intake.

Recently, an increasing number of people trying to achieve nutritional ketosis have found that they need to moderate protein in addition to limiting carbohydrates to reduce insulin to the point where significant levels of ketones can be measured in the blood.

My aim here is not to criticise protein, but rather to better understand the insulin and glucose response to protein in light of the food insulin index data.

My wife Monica has Type 1 Diabetes, anything information that can help refine insulin dosing or help inform food choices that will lead to more stable blood sugars is of interest to me.

Personally, I have a family tendency towards obesity and pre-diabetes (based on my 23andMe testing and a lifetime of personal experience trying to keep the weight off) so I am also interested in how I can optimise my blood sugars and insulin levels. I would also love to dodge the weight creep that seems to come with middle age for most people.

This has been a challenging topic to get my head around. It is complex and there is a lack of definitive research to provide clear guidance. Hopefully, more data and discussion can help to progress the understanding and the practical application of the theory.

I do not claim to have all the answers, but rather plenty of observations and questions. I hope that by documenting some of these I can help move this discussion forward.

the blood glucose response to protein

The food insulin index data contained in Clinical Application of the Food Insulin Index to Diabetes Mellitus by Kirstine Bell (Sept 2014) [2] intrigues me. There is a lot to be learned from looking at the body’s insulin response to food and the interrelationship to other parameters such as fat, protein, carbohydrates, fibre or blood glucose.

The data points on the right-hand side of the chart below [3] indicate that high protein foods (e.g. fish, tuna and steak) cause a small rise in blood glucose. However, the blood sugar response to protein is still small relative to the high carbohydrate foods on the left-hand side of the plot.

For most people, the discussion ends there. Protein does not raise blood sugar much, therefore it is a non-issue. !

But is it really that simple? What does the expanded food insulin index data set tell us?

the insulin response to protein

One of the challenges I see for type 1 diabetics is that, even if they eat a low carbohydrate diet, they still struggle with blood sugar control after a high protein meal.

Type 1s who have a continuous glucose monitor know that they need to watch out for a rise in their blood glucose three or four hours after a high protein meal and apply correcting doses of insulin to keep their blood sugar from going too high.

Looking at the plot of protein versus insulin index below, we can see that the insulin response to protein is more significant than the blood glucose response to protein.

For instance, the insulin index score for white fish is 42%, however, it only receives a 20% glucose score (note: the percentage scores are relative to pure glucose which has a glucose score and a food insulin index score of 100%).

Maybe there is something going on that can’t simply be explained by the blood sugar response alone?

If we plot the glucose score versus the insulin index we see that glucose and insulin are not directly proportional.

Low carbohydrate high protein foods such as chicken, cheese, tuna and bacon require a lot more insulin than would be anticipated if insulin was directly proportional to the blood glucose response.

On the lower side of the trend line, we have high carbohydrate foods from whole food sources such as raisins, wholemeal pasta, brown rice and water crackers having less of an insulin response than would be anticipated from the blood glucose response.

diabetic versus normal response to protein

The figure below compares the blood sugar and insulin response to 50g of protein (200 calories) in type 2 diabetics (yellow lines) and healthy non-diabetics (white lines). [4] We can see that:

Blood glucose remains fairly stable for healthy people after eating 50g of protein. However when someone with Type 2 Diabetes eats a high protein meal the insulin secreted seems to bring the blood sugar down from elevated levels!
Insulin is elevated for more than five hours after ingestion of protein, particularly for the insulin resistant type 2 diabetic. There’s definitely something going on with insulin in response to high protein foods, even if we don’t see a sharp increase in blood sugar.
The diabetic requires a lot more insulin to deal with the same quantity of protein and it takes a lot longer for the insulin levels to peak and comes down.

We can also see from the insulin response that protein takes more than three hours to digest and metabolise. It is possible that the food insulin index data (which is based on the measurement of insulin over only three hours) underestimates the insulin response to protein-containing foods and that the insulinogenic demand of protein is actually higher than predicted by the food insulin index data (i.e. protein requires more than 56% of the insulin relative to carbohydrate).

what happens when we eat a lot of protein?

The question of what happens to ‘excess’ protein that is not required for muscle growth and repair is controversial and the science is not exactly clear.

Does the energy from unused protein magically disappear? If it did then protein would be the ultimate macro nutrient that everyone should eat to lose weight. We could effectively ignore calories from protein.

Does it turn into nitrogen and get excreted in the urine?

Or does it turn into glucose ‘like chocolate cake’?

There is limited authoritative information on this topic, however, some helpful guidance that I’ve found on the topic is outlined below:

Richard Feinman says that “…after digestion and absorption, amino acids not used for protein synthesis may be trashed. The nitrogen is converted to ammonia which is converted to urea and excreted. The remaining carbon skeleton can be used for energy either directly or converted to ketone bodies, particularly on a very low carbohydrate diet.” [5]
Richard Bernstein says “Dietary protein is not the only source of amino acids. The proteins of your muscles continually receive amino acids from and return them to the bloodstream. This constant flux ensures that amino acids are always available in the blood for conversion to glucose (gluconeogenesis) by the liver or to protein by the muscles and vital organs.” [6]
According to David Bender “In fasting and on a low carbohydrate diet as much of the amino acid carbon as possible will be used for gluconeogenesis – an ATP-expensive, and hence thermogenic, process.” [7]

So it appears that amino acids circulate in the bloodstream and can be used as required for protein synthesis or to stabilise blood glucose levels.

The figure below [8] shows a comparison of the blood glucose response to ingestion of glucose and 600g of lean beef (i.e. a very big serving of steak!).

During the more than eight hour period that the steak takes to digest you can see the nitrogen levels continue to rise. Meanwhile, blood glucose rises only slightly until around four hours after the meal and comes back down.

What appears to be happening here is that the amino acids from digestion are being progressively released into the blood stream (over a period of digestion of more than eight hours) but are not immediately converted to blood glucose. Thus the digestion of protein does not cause a sharp rise in blood glucose.

It is said that gluconeogenesis is a demand driven process, not a supply driven process. What I think this means is that the body can draw on the amino acids circulating in the blood stream for muscle growth and repair (protein synthesis) or to balance the blood sugar (via gluconeogenesis) depending on requirements from moment to moment.

The fact that we don’t see a sharp rise in blood glucose in response to protein indicates that excess protein does not immediately turn into glucose. Gluconeogenesis occurs slowly over time with the amino acids being used up as required.

However as noted by David Bender above, if we are fasting or minimising carbohydrates then our body will maximise the use of protein to produce glucose via gluconeogenesis. Conversely, if we eating more carbohydrates and less protein the body doesn’t need to rely on protein as much for glucose.

do amino acids spill over into glucose in the bloodstream?

Most people aren’t eating so much protein that their amino acid stores in their blood are full to overflowing like peoples’ livers and are typically overflowing with glucose from a higher carbohydrate diet.

It would be interesting to see what happens in someone whose blood stream became saturated with amino acids from long term consistently high protein consumption.

Would we see more protein excreted or perhaps a larger amount removed from the blood via gluconeogenesis with subsequent conversion to fat using insulin?

By comparison, when carbohydrate is eaten we typically see glucose causing an immediate rise in blood sugar because the liver is often already full.

glucagon response

A healthy non-diabetic person will release both insulin and glucagon in response to a high protein meal.

Insulin helps to metabolise the protein and grow and repair muscles (i.e. insulin is ‘anabolic’). Glucagon helps to keep blood sugar stable and prevent it from going too low due to the action of the insulin used in the muscle growth and repair process.

The body secretes both glucagon and insulin in response to a high protein meal (as shown in the figure below [9]). In a healthy insulin-sensitive non-diabetic person the glucagon will effectively cancel out the insulin response to the protein used for protein synthesis. Hence we see a flat line blood glucose response in the insulin-sensitive non-diabetic.

In a diabetic, particularly type 1s, we often see blood sugar rising after a high protein meal due to the initial glucagon response and then gluconeogenesis as some of the protein converts to glucose. In the diabetic, the insulin response is either inadequate (due to poor pancreas function) or ineffective (due to high insulin resistance) and therefore the blood sugar does not remain stable as it would in a metabolically healthy person.

By contrast, after we eat a high carbohydrate meal glucagon decreases as the insulin increases and the body moves into fat storage mode as shown in the following figure. [10] The basic thesis of Protein Power is that we want to do whatever we can to maximise glucagon which promotes fat burning rather than insulin which leads to fat storage.

Even though glucagon offsets the insulinogenic effect of protein used for protein synthesis, it seems that the glucogenic portion of protein requires insulin.

I haven’t found any data on the subject, but I wonder if the body does not secrete glucagon to negate the effect of the ‘excess’ protein over and above the body’s requirement for protein synthesis (say 7 to 10% of calories)?

If this were the case then the glucogenic proportion of excess protein will behave largely like a carbohydrate with no glucagon to counteract the insulin?

glucagon, the antidote to insulin?

The observation that glucose does not rise significantly in response to protein is often taken to mean that protein is a non-issue. [11] [12]

This may be largely true for someone who is insulin sensitive, however, diabetics with impaired pancreatic function may not be able to secrete adequate insulin to offset the effects of glucagon and keep their blood sugars stable.

If you are a type 2 diabetic or someone with impaired insulin sensitivity I suggest that it would be better to keep your carbohydrate AND protein intake to the point where your body can keep up and maintain normal blood sugars?

The image below shows the continuous glucose monitor (CGM) plot of a type 1 diabetic after ingestion of a protein shake (46.8g protein and 5.6g of carbs).

Without insulin, there is a blood sugar rise over a period of more than eight hours, not dissimilar to what you would see from carbohydrates.

Is this blood glucose rise from gluconeogenesis of the protein or is the blood glucose rise from glucagon in response to the ingested protein or a bit of each? It’s hard to know.

What we do know is that there is a rise in blood glucose that needs to be managed if we are going to achieve optimal blood sugar control.

letting your pancreas keep up

For a diabetic who is insulin resistant and/or whose pancreas is not producing adequate insulin, the issue is that the total insulin load of their diet (from carbohydrates and the glucogenic component of protein) is in excess of their body’s ability to keep blood glucose under control.

From the insulin index data, we know that the body’s blood sugar and insulin response are proportionate to carbohydrate plus about half of the ingested protein.

So potentially we can balance our blood glucose response by managing the glucogenic inputs, that is, by moderating protein and keeping carbohydrates adequately low. And by doing this we can minimise, or perhaps eliminate, the need for insulin or other medications.

the high protein ‘hack’ for diabetics

To some extent, obtaining glucose from protein rather than carbohydrate is a beneficial ‘hack’ for someone who is not able to manage their blood sugars given:

eating higher levels of protein will ensure that the body’s needs for essential amino acids are met or exceeded;
the blood sugar rise from protein is much slower than it is for carbohydrate foods and hence it is easier to keep blood sugars under control;
protein takes more energy to convert to glucose than using carbohydrate directly, hence there is additional energy lost in the process (i.e. a calorie of protein is not really a calorie if you have to convert it to glucose before it can be used), [13] and
protein is more satiating than carbohydrates.

Paul Jaminet argues that obtaining glucose from protein is not ideal given that it’s not as energy efficient as obtaining it directly from carbohydrates.

However, I think that the optimal approach is to ensure that you maximise vitamins, minerals, fibre and amino acids from carbohydrate and protein containing foods while at the same time not overwhelming your body’s ability to maintain optimal blood sugars due to excess glucose from either carbohydrates or excess protein.

To some extent, it’s a balancing act between gaining adequate nutrition from things that will raise blood glucose while at the same time not overwhelming the ability of your pancreas to produce insulin to keep blood sugars in the ideal range.

The food ranking and meal ranking systems have been designed around this approach.

what is the optimum amount of protein and carbohydrates?

I find Steve Phinney’s well formulated ketogenic diet chart helpful when it comes to understanding how to optimise protein and carbohydrate intake.

The minimum protein intake is around 10% of calories or 0.8g/kg body weight. [14] At this point the vast majority of the protein will go to muscle growth and repair. Based on the guidance given by the WFKD triangle you might even be able to tolerate up to 20% carbohydrates and stay in nutritional ketosis if you were to keep your protein levels low. At this point you won’t have to worry too much about gluconeogenesis messing up your blood sugars because all of the protein will be used up in protein synthesis.
If you are active then you will likely want higher levels of protein, with 1.2 to 1.7g/kg body weight recommended for athletic performance. [15] Higher levels of protein will ensure that you have enough amino acids for optimal physical and mental function rather than just being adequate.
As we move to higher levels of protein above the minimum 10% of calories we should consider also reducing carbohydrate and increasing fat, due to the fact that the glucogenic portion of the protein that is over and above the basic needs for growth and repair will likely be turned into glucose, requiring increased levels of insulin which will work against you if your goals are reducing your insulin load in order to stabilise blood sugars or to lose weight.

I have discussed the concept of balancing glucose load from protein and carbohydrates with your body’s ability to produce insulin in more detail in the article the Goldilocks glucose zone. However if you are keeping track of your food intake you can use the formula below to calculate and track your insulin load.

If you are not yet achieving normal blood sugar levels then you could try winding back your insulin load. Most people find that they will achieve stable blood sugars and nutritional ketosis with an insulin load of around 125g, however, your mileage may vary and you will likely have to tweak this level to find your optimum based on your goals and your situation.

What do you think of all this? I would love to hear your response in the comments below.

references

[1] See http://en.wikipedia.org/wiki/Glucogenic_amino_acid, https://www.dropbox.com/s/4dkl03mz2fci71v/The%20metabolism%20of%20%E2%80%9Csurplus%E2%80%9D%20amino%20acids.pdf?dl=0 and http://www.medschool.lsuhsc.edu/biochemistry/Courses/Biochemistry201/Desai/Amino%20Acid%20Metabolism%20I%2010-14-08.pdf

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

[3] Glucose score is the area under the curve of the rise in blood glucose response over three hours relative to pure glucose tested in healthy non-diabetics.

[4] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC524031/

[5] Chapter 5 of The World Turned Upside Down: The Second Low Carbohydrate Revolution.

[6] Dr Bernstein’s Diabetes Solution, page 96.

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

[8] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC424828/pdf/jcinvest00541-0071.pdf

[9] https://books.google.com.au/books?id=3FNYdShrCwIC&printsec=frontcover&dq=marks+basic+medical+biochemistry&hl=en&sa=X&ei=-ctaVcivOJfq8AXL84CAAw&redir_esc=y#v=onepage&q=glucagon&f=false

[10] https://books.google.com.au/books?id=3FNYdShrCwIC&printsec=frontcover&dq=marks+basic+medical+biochemistry&hl=en&sa=X&ei=-ctaVcivOJfq8AXL84CAAw&redir_esc=y#v=onepage&q=glucagon&f=false

[11] http://caloriesproper.com/dietary-protein-does-not-negatively-impact-blood-glucose-control/

[12] http://www.ketotic.org/2013/01/protein-gluconeogenesis-and-blood-sugar.html

[13] See chapter 15 of Richard Feinman’s The World Turned Upside Down: The Second Low Carbohydrate Revolution for an in depth discussion of this topic.

[14] This is based on the point where at least half of the population has adequate protein! Not exactly an ideal goal to be shooting for!

[15] https://www.dropbox.com/s/zelfo3n0q8kvtfx/Paoli%20et%20al.%20(2015)%20The%20Ketogenic%20Diet%20and%20Sport%20A%20Possible%20Marriage.pdf?dl=0

post updated July 2017

blood sugar, diabetes, insulin index

is the insulin response to protein dose dependent?

April 18, 2015 Marty Kendall 14 Comments

The observation that protein requires insulin initially appears to conflict with a number of studies and anecdotal evidence that suggest protein does not have a significant effect on blood sugar. [1] [2] [3]

I think there are two issues to consider.

Firstly, a healthy non-diabetic will be able to deal with the blood glucose rise caused by gluconeogenesis due to protein, hence the overall blood sugar rise may not be significant. The extension of this argument is that almost any level of protein intake is a good thing. I haven’t however seen any real discussion around on the insulin effects of eating a diet high in protein diet.

However type 1 diabetics certainly do see a rise in their blood sugar levels that they need to cover with insulin. Without insulin to blunt the glucogenic effect of the protein, the blood sugar rise from the fast acting protein is not dissimilar to what you would see from carbohydrates.

The picture below shows how a well controlled type 1 will give small additional boluses as they see they blood sugar rising due to protein. This is sometimes called “sugar surfing”. While this approach provides good blood sugar control wouldn’t it be even better if a type 1 diabetic could better predict the insulin requirements before the meal to proactively predict the blood sugar rise rather than just reacting to the blood sugar roller coaster?

If you’re metabolically healthy the blood sugar rise and insulin secretion due to gluconeogenesis after a large protein meal may not be cause for concern. However if you are not metabolically healthy and / or are aiming for nutritional ketosis moderating protein to manage excessive gluconeogenesis may be something you want to do.

Secondly, the degree of gluconeogenesis appears to be dose dependent. If you exercise intensely and the amount of protein you eat is moderate then your body will likely shuttle protein to your muscles for growth and repair as the highest priority.

If you are not active, and you eat a large amount of protein then excess protein will be converted to glucose in your blood stream, raise insulin levels and be sorted as fat.

So while the effect of protein on your blood sugars and insulin is dependent on a number of factors, allowing for about half the insulinogenic effect of carbohydrates from protein appears to be a reasonable starting point..

[next article… is sugar really toxic?]

[this post is part of the insulin index series]

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[1] http://caloriesproper.com/dietary-protein-does-not-negatively-impact-blood-glucose-control/

[2] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342171/pdf/IJE2015-216918.pdf

[3] http://www.ketotic.org/2013/01/protein-gluconeogenesis-and-blood-sugar.html

Medical applications of the PSMF

Body building applications

Protein drives satiety

Thermic effect of food

Should you just eat the highest protein foods?

The problem with a very high protein diet

Bruce Ames’ Triage Theory

Low energy density

The nutrient dense adequate protein diet

Best foods for a PSMF

Vegetables

Animal products

Seafood

Egg and dairy

Calorie math

Insulin resistant long-term fat loss scenario

Nutrients to prioritise

Calorie math

How often should I eat on a PSMF?

How low can you go?

How to do a nutrient dense PSMF

Summary

References

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why bother with nutrient density?

macronutrient comparison

fat

saturated fat

protein

carbohydrates

nutrient density

comparison of nutrients adequate

application

personalisation

notes

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context matters

disclaimers

insulin is not the bad guy

different degrees of the ketogenic diet

ketogenic ratio

ratio of fat to protein

protein grammes per kilogramme of lean body weight

gluconeogenesis

carbohydrate counting

protein, insulin load and nutrient density

what is ketosis?

insulin load versus nutrient density

macronutrient splits

nutrient density

choosing the right approach for you

more numbers

what about mTOR?

how much protein?

insulin load

summary

references

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why nutrient density matters

calories or nutrients?

limitations of daily reference intake values

how to calculate nutrient density

comparison of approaches to nutrient density

removing the overachievers

vitamins

minerals

amino acids

fatty acids

which one is best?

most nutrient dense foods

vegetables