Tag Archives: type 1 diabetes

the complete guide to fasting (review)

Considering the massive amount of research and interest in the idea of fasting, not a lot has been written for the general population on the topic.

Brad Pilon’s 2009 e-book Eat Stop Eat was a great, though fairly concise, resource on the mechanisms and benefits of fasting.

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Martin Berkhan’s LeanGains blog had a cult following for a while in the bodybuilding community.

image17Michael Mosley’s 2012 documentary Eat, Fast and Live Longer documentary piqued the public interest and was followed by the popular 5:2 Diet book.

Then in 2013, Jason Fung emerged onto the low carb scene with his epic six part Aetiology of Obesity YouTube Series in which he detailed a wide range of theories relating to obesity and diabetes.

Essentially, Jason’s key points are that:

  • simply treating Type 2 diabetes with more insulin to suppress blood glucose levels while continuing to eat the diet that caused the diabetes is futile,
  • people with Type 2 diabetes are already secreting plenty of insulin, and
  • insulin resistance is the real problem that needs to be addressed.

Jason’s Intensive Dietary Management blog has explored a lot of concepts that made their way into his March 2016 book, The Obesity Code.  However surprisingly, given that Jason is the fasting guy, the book didn’t talk much about fasting.

my experience with fasting

I have benefited personally from implementing an intermittent fasting routine after getting my head around Jason’s work.  I like the way I look and perform, both mentally and physically, after a few days of not eating.  I also like the way my belt feels looser and my clothes fit better.

Complete abstinence is easier than perfect moderation.

St Augustine

I recently did a seven day fast and since then I’ve done a series of four day fasts, testing my glucose and blood and breath ketones with a range of different supplements (e.g. alkaline mineral mix, exogenous ketones, bulletproof coffee / fat fast and Nicotinamide Riboside) to see if they made any difference to how I feel and perform, both mentally and physically.

Fasting does become easier with practice as your body gets used to accessing fat for fuel.

I love the mental clarity!   My workout performance and capacity even seems to be better when I’ve fasted for a few days.

My key fasting takeaways are:

  1. Fasting is not that hard. Give it a try.
  2. You can build up slowly.
  3. If you don’t feel good. Eat!

The more I learn about health and nutrition, the more I realise how critical it is to be able to burn fat and conserve glucose for occasional use.  We get into all sorts of trouble when we get stuck burning glucose.

Our body is like a hybrid car with a slow burning fat motor (with a big fuel tank) and high octane glucose motor (with a small fuel tank).  If you’re always filling the small high octane fuel tank to overflowing, you’ll always be stuck burning glucose and your fat burning engine will start to seize up (i.e. insulin resistance and diabetes).

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Reducing the processed carbs in our diet enables us to lower our insulin levels and retrain our body to burn fat again.  But nothing lowers insulin as aggressively and effectively as not eating.

Even though lots of Jason’s thoughts on fasting seem self-evident, his blog elucidating them has been very popular, perhaps because the concept of fasting is novel in the context of our current nutritional education.

We’ve been trained, or at least given permission, to eat as often as we want by the people that are selling food or sponsored by them.[1]

context

Jason’s angle on obesity and diabetes comes from his background as a nephrologist (kidney specialist) who deals with chronically ill people who are a long way down the wrong track before they come to his office.  Jason also talks about how he had tried to educate his patients about reducing their carbs, however after eating the same thing for 70 years this is just too hard for many people to change.

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Desperate times call for desperate measures!

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Many of these patients come to him jamming in hundreds of units a day of insulin to suppress blood glucose levels, even though their own pancreas is still likely secreting more than enough insulin.

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Rather than continuing to hammer more insulin to suppress the symptom (high blood glucose), the solution, according to Jason, is to attack the ultimate cause (insulin resistance) directly.

Jimmy Moore is well known to most people that have an interest in low carb or ketogenic diets.  Whether you agree with his approach, it’s safe to say that low carb and keto would not be as popular today without his role.

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Meanwhile Jason talks about trying to educate people about reducing the processed carbs from their diet not working, not because of the science but more due to people not being able to change their eating habits after 70 years.

the Complete Guide to Fasting

You’ve probably heard by now that Jason has teamed up with Jimmy to write The Complete  Guide to Fasting which captures Jason’s extensive thoughts on fasting from the blog along with Jimmy’s n=1 experiences and wraps them up in a cohesive comprehensive manual with a colourful bow.

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Jason and Jimmy both sent me a copy of their new 304 page book, The Complete Guide to Fasting, to review (thanks guys).   So here goes…

Similar to The Obesity Code, TCGTF is a compilation of ideas that Jason has developed on his Intensive Dietary Management blog.  Blogging is a great way to get the ideas together and thrash them out in a public forum.   Some people love to read the latest blog posts and debate the minutiae, however most people would rather spend the $9 and sit down with a comprehensive book and get the full story.

Unlike The Obesity Code, TCGTF is a bright, full colour production with great graphics that will make it worth buying the hard copy to have and to hold.

TCGTF did originally have the working title Fasting Clarity as a follow on from Jimmy’s previous Cholesterol Clarity and Keto Clarity.   However, other than Jimmy’s discussion of his n=1 fasting experiences, TCGTF is predominantly written in Jason’s voice building from his blog, so it wouldn’t be appropriate for it to have become the third in Jimmy’s Clarity series.

What is similar to Jimmy’s clarity series is that it’s easy to read and accessible for people who are looking for an entry level resource.  This book will be great for people who are interested in the idea of fasting.  It is indeed the complete guide to fasting and is full of references to studies, however it doesn’t go into so much depth as to lose the average reader with scientific detail and jargon.

The book covers:

  • Jimmy’s n=1 experience with fasting,
  • Dr George Cahill’s seminal work on the effects of fasting on metabolism, glucose, ghrelin, insulin, and electrolytes,
  • the history of fasting over the centuries,
  • myth busting about fasting,
  • fasting in weight loss,
  • fasting and diabetes, physical health, and mental clarity,
  • managing hunger during a fast,
  • when not to fast, and
  • when fasting can go wrong.

The book is complete with a section on fasting fluids (water, coffee, tea, broth) and a range of different protocols that you can use depending on what suits you.  What did seem out of place are the recipes for proper meals.  Apparently, the publisher insisted they include these to widen the appeal (If you don’t like the fasting bit you’ve still got some new recipes?)

Overall, the book will be an obvious addition to the library (or Kindle) of people who are already fans of Jason and / or Jimmy and want a polished, consolidated presentation of all their previous work with a bunch of new material added.

TCGTF will also be a great read for someone who is interested learning more about fasting and wants to start at the beginning.   TCGTF is the most comprehensive book on the topic of fasting that I’m aware of.

my additional 2c…

Jason doesn’t mind weighing into a controversial argument, using some hyperbole or dropping the occasional F-bomb for effect and Jimmy’s no stranger to controversy either, so I thought I’d take this opportunity to give you my 2c on some of the topical issues at the fringe that aren’t specifically unpacked in the book.  We learn more as we thrash out the controversial issues at the fringes.   Many arguments come down to context.

target glucose levels

Jason has come under attack for using the word ‘cured’ in relation to HbAc1 values that most diabetes associations would consider non-diabetic,[2] though are not yet optimal.[3]

In the book Jason does discuss relaxing target blood glucose levels during fasting.  This makes sense for someone taking a slew of diabetic medications.   They’re probably not going to continue the journey if they end up in a hypoglycaemic coma on day one.

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The chart below shows the real life blood glucose variability for someone with Type 1 Diabetes on a standard diet.  With such massive fluctuations in glucose levels, it’s impossible to target ideal blood glucose levels (e.g. Dr Bernstein’s magic target blood glucose number of 4.6 mmol/L or 83 mg/dL).

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If your glucose levels are swinging wildly due to a poor diet coupled with lots of medication, your glucose levels are simply going to tank when you stop eating.  Hence, a safe approach is to back off the medication, at least initially, until your glucose levels have normalized.

Being married to someone with Type 1 Diabetes, I have learned the practical realities of getting blood glucose levels as low as possible while still avoiding dangerous lows.[4]  My wife Monica doesn’t feel well when her blood glucose levels are too low, but neither does she feel good with high blood glucose levels.  Balancing insulin and food to get blood glucose levels as low as possible without experiencing lows requires constant monitoring.

The chart below shows how scattered blood glucose levels can be even if you’re fairly well controlled.   Ideally you want the average blood glucose level to be as low as possible while minimising the number of hypoglycaemic episodes (i.e. below the red line).  If you can’t reduce the variability you just can’t bring the average blood glucose level down.  The last thing you want is to be eating to raise your blood glucose levels because you had too much blood glucose lowering medication.

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Pretty much everyone agrees that it’s dumb to be eating crap food and dosing with industrial levels of insulin to manage blood glucose levels.   High levels of exogenous insulin just drive the sugar that is not being used to be stored as fat in your belly, then your organs, and then in the more fragile places like your eyes and the brain.

Jason’s perspective is that people who are chronically insulin resistant and morbidly obese are likely producing more than enough insulin.  The last thing they need is exogenous insulin which will keep the fat locked up in their belly and vital organs.  Dropping insulin levels as low as possible using a low insulin load diet and fasting coupled with reducing medications will let the fat flow out.

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fasting to optimise blood glucose levels

In the long run, neither high insulin nor high glucose levels are optimal.

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Once you’ve broken the back of your insulin resistance with fasting, you can continue to drive your blood glucose levels down towards optimal levels.

One of the most popular articles on the Optimising Nutrition blog is how to use your glucose meter as a fuel gauge which details how you can time your fasting based on your blood glucose levels to ensure they continue to reduce.

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Your blood glucose levels can help calibrate your hunger and help you to understand if you really need to eat.  I think this is a great approach for people whose main issue is high blood glucose levels and who aren’t ready to launch into longer multi day fasts.

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In a similar way, a disciplined fasting routine can help optimise blood glucose levels in the long term.  The chart below shows a plot of Rebecca Latham’s blood glucose levels over three months where she used her fasting blood glucose numbers AND body weight to decide if she would eat on any given day.

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While there is some scatter in the blood glucose levels, you can see that regular fasting does help to reduce blood glucose levels over the long term.

Once you’ve lost your weight , broken the back of your insulin resistance and stopped eating crap food, you may find that you still need some exogenous insulin or other diabetic medication to optimise blood glucose levels if you have burned out your pancreas.

fasting frequency

The TGTF book covers off on several fasting regimens such as intermittent fasting, 24 hours, 36 hours, 42 hours and 7 to 14 days.  One concept that I’m intrigued by, similar to the idea of using your glucose meter as a fuel gauge, is using your bathroom scale as a fuel gauge.

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The reality, at least in my experience, is that we can overcompensate for our fasting during our feasting and end up not moving forward toward our goal.

If your goal is to lose weight I like the idea of tracking your weight and not eating on days that your weight is above your goal weight for that day.

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Again, Rebecca Latham has done a great job building an online community around the concept of using weight as a signal to fast through her Facebook group  My Low Carb Road – Fasting Support.

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The chart below shows Rebecca’s weight loss journey through 2016 where she initially targeted a weight loss of 0.2 pounds AND a reduction of 0.25 mg/dL in blood glucose per day.   After three months, she stabilized for a period (during a period when she had a number of major family issues to look after).  She is now using a less aggressive weight loss goal as she heads for her long-term target weight at the end of the year.

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The chart below shows the fasting frequency required to achieve her goals during 2016.  Tracking her weight against her target rate of weight loss has required her to fast a little more than one day in three to stay on track.

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Eating quality food is part of the battle, but managing how often you eat is also an important consideration.  After you’ve fasted for a few days, you can easily excuse yourself for eating more when you feast again.  And maybe it’s OK to enjoy your food when you do eat rather than tracking every calorie and trying to consciously limit them.

The obvious caveat is that there are a lot of other things that influence your scale weight such as muscle gain, water, GI tract contents etc, but this is another way to keep yourself accountable over the long term.

FAST WELL, FEED WELL

Fasting is a key component of the metabolic healing process, but it’s only one part of the story.

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Fasting is like ripping out your kitchen to put in a new one.   You have to demolish and remove the old stovetop to put the new shiny one back in.  You don’t sticky tape the new marble bench top over the crappy old Laminex.  You have to clean out the old junk before you implement the new, latest, and greatest model.

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In fasting, the demolition process is called autophagy, where the body ‘self eats’ the old proteins and aging body parts.   The great thing about minimising all food intake is that you get a deeper cleanse than other options such as fat fast, 500 calories per day or a protein sparing modified fast (PSMF).

But keep in mind that it’s the feast after the fast that builds up the shiny, new body parts that will help you live a longer, healthier, and happier life.

“Fasting without proper refeeding is called anorexia.” 

Mike Julian

Even fasting guru Valter Longo is now talking about the importance of feast / fast cycles rather than chronic restriction.  In the end you need to find the right balance of feasting / fasting, insulin / glucagon, mTOR / AMPK that is right for you.

In TCGTF, Jason and Jimmy talk about prioritising nutrient dense, natural, unprocessed,  low carb, moderate protein foods after the fast.  I’d like to reiterate that principle and emphasise that nutrient density becomes even more important if you are fasting regularly or for longer periods.

In the long term, I think your body will drive you to seek out more food if you’re not giving it the nutrients it needs to thrive.  Conversely, I think if you are providing your body with the nutrients it needs with the minimum of calories I think you will have a better chance of accessing your own body fat and reaching your fat loss goals.

optimising insulin levels AND nutrient density

It’s been great to see the concept of the food insulin index and insulin load being used by so many people!  In theory, when people reduce the insulin load of their diet they more easily access their own body fat and thus normalizes appetite.

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Some people who are very insulin resistant do well, at least initially, on a very high fat diet.  However, as glycogen levels are depleted and blood glucose levels start to normalise, I think it is prudent to transition to the most nutrient dense foods possible while still maintaining good (though maybe not yet optimal) blood glucose levels.

The problem with doubling down on reducing insulin by fasting combined with eating only ultra-low insulinogenic foods is that you end up “refeeding” with refined fat after your fast.

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While lowering carbs and improving food quality is the first step, I think that, as soon as possible you should start focusing on building up your metabolic machinery (i.e.  muscles and mitochondria).   A low carb nutrient dense diet is part of the story, but I don’t see many people with amazing insulin sensitivity that don’t also have a good amount of lean muscle mass which is critical to ‘glucose disposal’, good blood sugar levels and metabolic health.

This recent IHMC video from Doug McGuff provides a stark reminder of why we should all be focusing on maximising strength and lean muscle mass to slow aging.

The chart below shows a comparison of the nutrient density of the various dietary approaches.  Unfortunately, a super high fat diet is not necessarily going to be as nutrient dense and thus support muscle growth, weight loss, or optimal mitochondrial function as well as other options.

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The chart below (click to enlarge) shows a comparison of the various essential nutrients provided by a high fat therapeutic ketogenic dietary approach versus a nutrient dense approach that would suit someone who is insulin sensitive.

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I developed a range of lists of optimal foods that will help people in different situations with different goals to maximise the nutrient density that should be delivered in the feast after the fast.   The table below contains links to separate blog posts and printable .pdfs.  The table is sorted from highest to lowest nutrient density.   In time, you may be able to progress to a more nutrient dense set of foods as your insulin resistance improves.

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

protein

Jason had  a “robust discussion” with Steve Phinney over the topic of ideal protein levels recently during the Q&A session at the recent Low Carb Vail Conference.

To give some context again, Phinney is used to dealing with athletes who require optimal performance and are looking to optimise strength.  Meanwhile Jason’s patient population is typically morbidly obese people who are on kidney dialysis and probably have some excess protein, as well as a lot of fat that they could donate to the cause of losing weight.

I also know that Jimmy is a fan of Ron Rosedale’s approach of minimising protein to minimise stimulation of mTOR.  Jimmy and Ron are currently working on another book (mTOR Clarity?).  Protein also stimulates mTOR which regulates growth which is great when you’re young but perhaps is not so great when you’ve grown more than enough.

The typical concern that people have with protein in a ketogenic context is that it raises blood insulin in people who are insulin resistant.  ‘Excess protein’ can be converted to blood glucose via gluconeogenesis in people who are insulin resistant and can’t metabolise fat very well.

Managing insulin dosing for someone with Type 1 Diabetes like my wife Monica is a real issue, though she doesn’t actively avoid protein.  She just needs to dose with adequate insulin for the protein being eaten to manage the glucose rise.

The chart below shows the difference in glucose and insulin response to protein in people who have Type 2 Diabetes (yellow lines) versus insulin sensitive (white lines) showing that someone who is insulin resistant will need more insulin to deal with the protein.

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As well as insulin resistance, these people are also “anabolic resistant” meaning that some of the protein that they eat is turned into glucose rather than muscle leaving them with muscles that are wasting away.

People who are insulin resistant are leaching protein into their bloodstream as glucose because they can’t mobilise their fat stores for fuel.  They are dependent on glucose and they’ll even catabolise their own muscle to get the glucose they need if they stop eating glucose.

While it’s nice to minimise insulin levels, I wonder whether people who are in this situation may actually need more protein to make up for the protein that is being lost by the conversion to glucose to enable them to maintain lean muscle mass.  Perhaps it’s actually the people who are insulin sensitive that can get away with lower levels of protein?

As well as improving diet quality which will reduce insulin and thus improve insulin resistance, in the long term it’s also very important to maintain and build muscle to be able to dispose of glucose efficiently and also improve insulin resistance.

In TCGTF Jason talks about the fact that the rate of the use of protein for fuel is reduced during a fast and someone becomes more insulin sensitive.  He goes to great lengths to point out that concern over muscle loss shouldn’t stop you trying out fasting (which is a valid point).

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A big part of the magic of fasting is that you clean out some of your oldest and dodgiest proteins in your body and set the stage for rebuilding back new high quality parts.   But the reality is that you will lose some protein from your body during a fast (though this is not altogether a bad thing).[5] [6]

Bodybuilders often talk about the “anabolic window” after a workout where they can maximise muscle growth after a workout.  Similarly, one of the awesome things about fasting is that you reduce your insulin resistance and anabolic resistance meaning that when at the end of your fast your body is primed to allocate the high quality nutrients you eat in the right place (i.e. your muscles not your belly or blood stream).

In the end, I think optimal protein intake has to be guided to some extent by appetite.  You’ll want more if you need it, and less if you don’t.

I think if we focus on eating from a shortlist of nutrient dense unprocessed foods we won’t have to worry too much about whether we should be eating 0.8 or 2.2 g/kg of lean body mass.

However, avoiding nutrient dense, protein-containing foods and instead “feasting” on processed fat when you break your fast will be counter-productive if your goal is weight loss and waste a golden opportunity to build new muscle.

are you really insulin resistant?

Insulin resistance and obesity is a continuum.

Not everyone who is obese is necessarily insulin resistant.

If you are really insulin resistant, then fasting, reducing carbs, and maybe increasing the fat content of your diet will enable you to improve your insulin resistance.  This will then help with appetite regulation because your ketones will kick in when your blood glucose levels drop.

However, if you continue to overdo your energy intake (e.g. by chasing high ketones with a super high fat, low protein diet), then chances are, just like your body is primed to store protein as muscle, you will be very effective at storing that dietary fat as body fat.

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I fear there are a lot of people who are obese but actually insulin sensitive who are pursuing a therapeutic ketogenic dietary approach in the belief that it will lead to weight loss.  If you’re not sure which approach is right for you and whether you are insulin resistant, this survey may help you identify your optimal dietary approach.

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optimal ketone levels

Measuring ketones is really fascinating but confusing as well.

“Don’t be a purple peetone chaser.”

Carrie Brown, The Ketovangelist Podcast Ep 78

Urine ketones strips have limited use and will disappear as you start to actually use the ketones for energy.

In a similar way blood ketones can be fleeting.  Some is better than none, but more is not necessarily better.  As shown in the chart of my seven day fast below I have had amazing ketones and felt really buzzed at that point but since then I haven’t been able to repeat this.  I think sometimes as your body adapts to burning fat for fuel the ketones may be really high but then as it becomes efficient it will stabilise and run at lower ketone levels even when fasting.

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If your ketone levels are high when fasting then that’s great.  Keep it up.  They might stay high.  They might decrease.  But don’t chase super high ketones in the fed state unless you are about to race the Tour de France or if you want your body to pump out some extra insulin to bring them back down and store them as fat.

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The chart below shows the sum of 1200 data points of ketones and blood glucose levels from about 30 people living a ketogenic lifestyle.  Some of the time they have really high blood ketone levels but I think the real magic of fasting happens when the energy in our bloodstream decreases and we force our body to rely on our own body fat stores.

the root cause of insulin resistance is…

So we’ve worked out that large amounts of processed carbs drive high blood glucose and insulin levels which is bad.

We’ve also worked out that insulin resistance drives insulin levels higher, which is bad.

But what is the root cause of insulin resistance?

I think Jason has touched on a key component in that, as with many things, resistance is caused by excess.  If we can normalise insulin levels, then our sensitivity to insulin will return, similar to our exposure to caffeine or alcohol.

However, at the same time, I think insulin resistance is potentially more fundamentally caused by our sluggish mitochondria that don’t have enough capacity (number or strength) to process the energy we are throwing at them, regardless of whether they come from protein, carbs, or fat.

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A low carb diet lowers the bar to enable us to normalise our blood glucose levels.  However, the other end of the spectrum is focusing on training our body and our mitochondria to be able to jump higher.  In the long term this is achieved through, among other things, maximising nutrient dense foods and building lean body mass through resistance exercise.

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summary

  1. The Complete Guide to Fasting is, as per the title, the complete guide to fasting. It’s the most comprehensive guide to the nuances of fasting out there and there’s a good balance between the technical detail, while still being accessible for the general public.
  2. Fasting can help optimise blood glucose and weight in the long term, with a disciplined regimen.
  3. Fasting makes the body more insulin sensitive and primes it for growth. When you feast after you fast, it is ideal to make sure you maximise nutrient density of the food you eat as much as possible while maintaining reasonable blood glucose levels.
  4. Understanding your current degree of insulin resistance can help you decide which nutritional approach is right for you. As you implement a fasting routine and transition from insulin resistance to insulin sensitivity you will likely benefit from transitioning from a low insulin load approach to a more nutrient dense approach.

 

references

[1] https://intensivedietarymanagement.com/of-traitors-and-truths/

[2] https://www.diabetes.org.uk/About_us/What-we-say/Diagnosis-ongoing-management-monitoring/New_diagnostic_criteria_for_diabetes/

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

[4] https://optimisingnutrition.com/2015/08/17/balancing-diet-and-diabetes-medications/

[5] https://www.dropbox.com/s/h3pi53njcfu4czl/Physiological%20adaptation%20to%20prolonged%20starvation%20-%20Deranged%20Physiology.pdf?dl=0

[6] https://www.facebook.com/groups/optimisingnutrition/permalink/1602953576672351/?comment_id=1603210273313348&comment_tracking=%7B%22tn%22%3A%22R9%22%7D

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

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

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[yes, I may be a Robb Wolf fan boy.]

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

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

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

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

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

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

OFT in the wild

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

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… gone to extraordinary lengths to obtain energy dense honey …

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

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OFT in captivity

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

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

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

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

 sweet = good = energy to survive winter

But now we have entered a brave new world.

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These days we have are surrounded by energy dense hyperpalatable foods that are designed to taste good without providing substantial levels of nutrients.

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When these foods are available our primal programming leaves us defenceless.

Our willpower or our calorie counting apps are no match for engineered foods with an optimised bliss point.

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

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

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

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

what happens when we go low fat?

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

Sounds logical, right?

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

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

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

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Maybe a little too well.

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

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

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

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

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

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

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


what happens when we go low carb?

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

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

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

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

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

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

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what happens when we go paleo?

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

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Well, maybe.  Maybe not.

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

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

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

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

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

enter nutrient density

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

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

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

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

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

optimal rehabilitation plan?

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

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

the solution

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

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

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

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

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

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

survey

I hope this helps.

Good luck out there!

references

[1] http://ketosummit.com/

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

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

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

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

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

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

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

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

balancing diet and diabetes medications

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

when do you need insulin?

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

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

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

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

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

Fasting and improving insulin sensitivity

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

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

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

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

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

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

the balance between diet and medication

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

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

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

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

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

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

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

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

the dangers of glucose toxicity

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

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

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

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

the dangers of insulin toxicity

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

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

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

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

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

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

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

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

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

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

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

two sides of the same coin?

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

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

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

refining insulin levels for type 1 diabetics

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

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

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

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

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

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

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

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

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

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

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

the law of small numbers

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

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

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

adjusting insulin doses for type 2 diabetics

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

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

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

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

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

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

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

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

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

 

references

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

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

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

[4] https://intensivedietarymanagement.com/

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

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

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

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

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

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

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

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

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

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

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

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

insulin dosing options for type 1 diabetes

  • This article reviews a range of approaches to calculating insulin requirements for people with type 1 diabetes.
  • The simplest approach is standard carbohydrate counting, which may be ideal for someone whose diet is dominated by carbohydrates.
  • Bernstein recommends standardised meals for which the insulin dose is refined based on ongoing testing and refinement.
  • Stephen Ponder’s ‘sugar surfing’ builds on carbohydrate counting, with correcting insulin given when blood glucose levels rise above a threshold due to gluconeogenesis.
  • The food insulin index approach predicts insulin requirements based testing in healthy people of the insulin response to popular foods.
  • The total available glucose (TAG) advocates a ‘dual wave bolus’ where insulin for the carbohydrates is given with the meal, with a second square wave bolus given for the protein which is typically slower to digest and metabolise.

introduction

In the article Standing on the Shoulders of Giants we met a handful of people who have achieved excellent blood sugar control in spite of having type 1 diabetes.  Common elements of their success include:

  • keeping carbohydrates low to prevent the blood sugar roller coaster,
  • accurately dosing for a controlled amount of dietary carbohydrate,
  • targeting normal blood sugar ranges (i.e. 83mg/dL or 4.6mmol/L) with regular correcting doses,
  • regular exercise and / or intermittent fasting to improve insulin sensitivity, and
  • having a reliable method to account for the insulinogenic effect of protein.

Everyone’s diabetes management regimen is going to be different.  There will be a degree of trial and error to find what will work best for you.  This article reviews a number of approaches that you can learn from to see what suits you.

carbohydrate counting

In the 1970s Dr Richard Bernstein got hold of a blood glucose meter (long before they were easily available) and started experimenting on himself to understand how much a certain amount of carbohydrate raised his blood glucose levels and how much insulin he required to bring his blood glucose back down.

From this style of experimentation we can determine the “carbohydrate to insulin ratio” (i.e. how much insulin is required for a certain amount of carbohydrates).

Carbohydrate counting is now the standard approach that most people with type 1 diabetes are taught.  This approach involves estimating the grams of carbohydrate in your food for each meal.  With this knowledge you can then program the amount of carbohydrates eaten into the insulin pump which calculates the insulin dose based on a pre-set carbohydrate to insulin ratio.

The advantage of this approach is that it is relatively simple.  However it does not consider the insulin required for protein which is typically addressed with correcting doses or sometimes basal insulin.

Carbohydrate counting is a good starting point, but it is by no means perfect. [1] [2]

Bernstein’s own approach

Dr Richard Bernstein advises that his patients, in addition to restricting carbohydrates (i.e. no more than 6g of carbohydrates for breakfast, 12g for lunch and 12g dinner), to have the same meals every day which allows insulin doses to be refined to optimise for blood sugars.  If your blood glucose levels run high one day you can add a little more insulin the next day or a little less if they are running low.

Bernstein also advises targeting an average blood glucose of 83mg/dL (4.6mmol/L), and that you correct if blood glucose levels go outside a ten point range from this target (i.e. 73mg/dL to 93mg/dL or 4.0mmol/L to 5.2mmol/L).  A small bolus of insulin is given to bring blood glucose levels down and a certain portion of a glucose tablet is used to bring blood sugars back up precisely.

Bernstein advises that people with type 1 diabetes modulate the quantity of protein to manage their weight.  If you’re a growing child, protein is essentially unrestricted.  If you’re trying to lose weight protein can be reduced to further reduce insulin.

Bernstein says that protein requires about half as much insulin as carbohydrates and outlines how to dose for it in this video from Dr Bernstein’s Diabetes University.  In practice, though, his approach to dosing for protein requires consistent meals and fine tuning of insulin dose.

sugar surfing

Another popular method is ‘sugar surfing’ which is effectively a ‘bolt-on’ to carbohydrate counting developed by Dr Stephen Ponder to manage the glucose response to things other than carbohydrates.

This approach involves dosing for carbohydrates with the meal, and then watching the continuous glucose monitor (CGM) and giving regular ‘micro doses’ of insulin to keep blood sugar under around 93mmol/L (5.2mmol/L).  Typically two or three separate doses will be required to bring a ‘protein spike’ under control for someone with type 1 diabetes.

Injected insulin works over a period of up to eight hours and it is difficult to match the timing of the insulin action with digestion.  The advantages of this approach are that it allows for the variability in the time of protein digestion which varies from person to person and is different for different foods and hence difficult to predict accurately.

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I think the secret to making ‘sugar surfing’ work is to turn the waves that you’re surfing into more manageable ripples by following a diet with a reduced insulin load.

food Insulin Index

“It is possible that other methods of matching insulin with food are not being studied because of the belief that carbohydrate counting is a well-founded, evidence-based therapy,” the researchers concluded. “Indeed, this meta-analysis shows the scarcity of high-level evidence.” [3]

One of the experiments documented in Clinical Application of the Food Insulin Index to Diabetes Mellitus (Bell, 2014) [4] demonstrated that type 1 diabetics calculating their insulin requirement using the food insulin index approach achieved significantly improved blood glucose control compared with those using standard carbohydrate counting.

Estimating the insulin required for the meal from carbohydrate and protein rather than carbohydrate alone is potentially a massive step forward in improving blood sugar control for people with type 1 diabetes.

The limitation of using the approach practiced in the study is that the food selection tested is limited to the one hundred or so popular processed supermarket foods.

If you’ve read my blog you’ll know that I’ve tried to develop a robust method for calculating the insulin requirement for foods based on their macronutrients without having to test them in vivo (i.e. in real, living people). [5] [6] [7]  The chart below shows how we can use the food insulin index test data to more accurately predict the insulin demand of a particular food using this formula.

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Rather than separating doses for carbohydrates and protein, the food insulin index approach assumes that all of the insulin is given with the meal.  The risk with this is that the insulin will take action before the protein digests which will lead to low blood glucose.

Total Available Glucose (TAG)

The TAG (Total Available Glucose) approach is based on a book by Mary Joan Oexmann published in 1989. [8]  This method calculates the insulin required for carbohydrate, protein (54% of carbohydrate) and fat (10% of carbohydrate).

If we gave all the insulin calculated for both carbohydrates and protein when we sat down to eat a high protein meal it is possible that the insulin would take effect before the protein digested, leading to low blood glucose before the gluconeogenesis from the protein had time to kick in.

To deal with the fact that glucose from protein can take longer to show up in the blood stream people who follow the TAG approach typically use a ‘dual wave bolus’.  The insulin for the carbohydrates is dosed with the meal, while the insulin for the protein is infused slowly as a separate “square wave bolus” over a period of three hours or so.  The need for the carbohydrate and protein boluses to be split will depend on the amount of protein in your meal and how quickly protein raises your blood sugars.

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separate boluses for carbohydrates and protein

A few people who achieve excellent blood sugar control simply use two separate boluses – one for carbohydrates before the meal with another one for protein around an hour after the meal.

This approach requires that the insulin for the protein and carbohydrate are calculated separately with the protein bolus being given a number of hours after the meal.

This approach can be refined using a CGM to confirm when the blood sugar response to the protein kicks in and hence when the bolus for protein is required.

insulin calculator

To assist in calculating the bolus for carbohydrates and protein Ted Naiman of Burn Fat Not Sugar has created this insulin calculator.

You can run it on your computer or phone, enter the properties of the food that you are about to eat and it will calculate the appropriate dose for carbohydrate and protein.  The outputs from this calculator will give you all the required data to follow any of the insulin dosing strategies above.

People who have used it so far have found it beneficial.

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An example screen grab from the calculator is shown below with the explanation of inputs and outputs following.

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inputs

  • If you are using a manufactured food product in a packet you can simply use the nutritional details per serve (protein, fat, carbohydrates) and then factor for the number of serves.
  • If you are in the US you will need to enter the total carbohydrates and fibre values. If you’re in the UK or Australia you don’t need to enter the fibre as it is already subtracted from the carbohydrate count.
  • The protein multiplier is based on the food insulin index testing in non-diabetic people, [9] however you can modify this if you want, based on your own trial and error testing. The analysis of the quantity of amino acids (as detailed in the article the insulin index v2) suggests that this value is unlikely to exceed 80 to 90%.
  • A default carb to insulin ratio of 22 has been used, however you can enter yours from your pump or calculate it based on this article.  [10]
  • You can enter your bolus insulin on board (BoB) which will be subtracted from the carbohydrate insulin dose.

outputs

  • The first line of the outputs is the percentage of insulinogenic calories. As a reference keep in mind that a whole egg is about 25% insulinogenic calories.  A high percentage of insulinogenic calories is not ideal for people with diabetes and insulin resistance.  It may be helpful to select nutritious foods with a low insulin load from this list.
  • The insulin load is calculated using the following formula (i.e. for both carbohydrates and protein).

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  • The percentage of glucose from carbohydrate could be used if you were going to split your dose into an initial bolus for carbohydrates with a separate bolus for protein. This value can be entered into your pump if you’re using a dual wave bolus, with the protein bolus typically given over a longer period.
  • You can use the grams of carbohydrates or the quantity of insulin for the carbohydrates and the protein if you’re using separate boluses.

meals

If you are following the meals from the blog you will notice that the net carbs, total insulin load and percentage of insulin for carbohydrates have been included in a table at the end of each recipe assuming a standardised 500 calorie meal.

our experience

Moni has experimented with dosing separately for the protein component of the meal, however it typically turns out that her blood glucose has risen by the time she doses for the protein.  It seems that for her, the glucose from the protein (via gluconeogenesis) hits her bloodstream quickly and hence delaying the dose for protein is not appropriate for her.

We are also trying to focus on a handful of nutrient dense meals with pre-determined insulin doses.  The table below shows the insulin required for a 500 calorie serving for a range of meals.  All of these have limited carbohydrates and the insulin dose for the protein is greater than the carbohydrate dose.  I have provided hyperlinks to some of the meals that are already published on the blog.

If you can’t handle the thought of weighing and measuring and then calculating the insulin dose for everything you eat, as a ‘rule of thumb’ all of these meals require dosing as if they were about 20 to 25 grams of carbs.  If you are choosing meals with a low insulin load then the insulin dosing for food ends up representing only about 20% of the daily dose.

meal

carbs (g)

protein (g)

 insulin load (g)

bacon, eggs, avocado and spinach

4

15

19

spinach and cheddar scrambled eggs

6

18

24

steak, broccoli, spinach, haloumi

6

20

26

coffee with cream and stevia

1

1

2

chia seed pudding – no fruit

7

4

11

broccoli, bacon, cream and mozzarella

3

17

20

sausages, avocado, sour cream, tomato

7

13

20

bacon, eggs, spinach and pesto

4

16

20

bacon and eggs

3

18

21

bacon, eggs, avocado and sauerkraut

5

21

26

fathead pizza with anchovies and pesto

4

13

17

bacon asparagus and eggs

3

18

21

For us, this approach combines a number of aspects from the various approaches discussed above:

  • all of these meals having less than 12g of carbs as recommended by Bernstein,
  • calculated insulin dose for both protein and carbohydrates,
  • nutrient dense meals, and
  • relatively low percentage of insulinogenic calories (i.e. high fat meals) meaning that the overall insulin dose stays relatively low.

We’re all on a journey.  I hope this helps you move towards finding a strategy that is optimal for you.

References

[1] http://www.thelancet.com/journals/landia/article/PIIS2213-8587(13)70144-X/abstract

[2] http://www.medpagetoday.com/Endocrinology/Diabetes/42610

[3] http://www.thelancet.com/journals/landia/article/PIIS2213-8587(13)70144-X/abstract

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

[5] https://optimisingnutrition.wordpress.com/2015/03/23/most-ketogenic-diet-foods/

[6] https://optimisingnutrition.wordpress.com/the-insulin-index/

[7] https://optimisingnutrition.wordpress.com/?p=2637

[8] http://www.amazon.com/T-A-G-A-Diabetic-Food-System/dp/0688084583

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

[10] http://www.bd.com/us/diabetes/page.aspx?cat=7001&id=7303

standing on the shoulders of giants

  • People who have type 1 diabetes and excellent blood glucose control are statistically rare.
  • These ‘overachievers’ typically have been influenced by the work of Dr Richard Bernstein.
  • People successful in their management of type 1 diabetes control the amount of carbohydrate in their diet to prevent “the blood sugar roller coaster”.
  • As well as calculating the insulin required for carbohydrate, those who manage type 1 diabetes well typically also have a way to calculate their insulin dose for protein.
  • Exercise and fasting also help to improve insulin sensitivity.

background

According to the T1D Exchange [1], 1.2% of type 1 diabetics in the US have a ‘normal’ HbA1c of less than 5.7%.  Twenty nine (29) of the twenty five thousand type 1 diabetics in the database (i.e. 0.1%) have an HbA1c of less than 5.0%.

I am privileged to know quite a few people who are conquering type 1 diabetes through the TYPEONEGRIT Facebook group [2] where you will regularly see posts like this one.

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Rather than just talking about the theory I thought it would be useful to profile a handful of the people that have been an inspiration to us and have shown what it takes to not just survive but thrive with type 1 diabetes.

What do each these people have in common that we can learn from?  What do they do differently based on their situation?

Dr Richard Bernstein

Dr Richard K Bernstein [3] has been the ‘voice in the wilderness’ of the low carbohydrate movement for four decades.  I first came across Dr Bernstein in episode 683 of Jimmy Moore’s LLVLC Show.[4]

Despite having type 1 diabetes himself since the age of twelve he is still going strong at eighty one years of age.  Bernstein’s is a fascinating story and an example of what can be achieved.

Richard Bernstein started his working career as an engineer.  His wife is a doctor so he was able to purchase one of the early blood glucose metres in 1969.  In those days blood glucose metres were primarily used to determine if someone who landed in the hospital emergency department at night was unconscious because they were drunk or had high blood glucose levels.

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Bernstein, an avid self-experimenter, measured his blood sugars six times a day, and over time gained an understanding of how much a certain amount of carbohydrate raised his blood glucose levels, and conversely, how much a certain amount of insulin lowered them.

At the time he was told it was a waste of time encouraging people with diabetes to measure their blood glucose levels because there was no value in people with diabetes achieving normal blood glucose levels. [5]  In spite of this, Bernstein’s early learnings are now the basis of the basal / bolus insulin dosing calculations built into every insulin pump which is used today by the majority of type one diabetics.

At 45 years of age Bernstein went to medical school in an effort to get people to listen to his theories.  These theories are still considered fringe today, possibly because they do not align with the dietary recommendations generated by the USDA.

Bernstein documented his system in the comprehensive book Dr Bernstein’s Diabetes Solution[6]  He is also in the process of recording a series of YouTube videos, Dr Bernstein’s Diabetes University. [7]  I find it fascinating to hear him talk about his Body By Science-style heavy lifting workouts at eighty-one! [8]

He recommends that people with type 1 diabetes eat no more than 6g of carbohydrate at breakfast, with no more than 12g of carbohydrates at lunch and dinner.  This enables people with diabetes to stay off the blood sugar roller coaster and manage their blood glucose levels with smaller doses of insulin.

Bernstein also acknowledges that protein requires insulin, [9] however, for the most part he accounts for this by eating consistent meals and refining insulin doses based on blood glucose measurement after each meal.

Troy Stapleton

I had the privilege of meeting Dr Troy Stapleton at a screening of Cereal Killers [10] in Brisbane in August 2014 where he was on a panel fielding questions after the movie.  After the session we cornered him for about an hour.

It was inspiring for us to see someone thriving with type 1 diabetes.  At the time my wife Monica was struggling to even think of working because she didn’t have the energy to make it through the day without an afternoon nap before picking up the kids from school.  But here was Troy successfully running a radiology department!

The photo below shows Troy (right) with Tim Noakes [11] (centre) and Ron Raab [12] (left) when they debated Carbohydrates – Victims or Villains at the  Annual Scientific Meeting of the Australian Diabetes Society and Australian Diabetes Educators Association in Melbourne in August 2014.

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I got to catch up with Troy again at the Low Carb Down Under seminar in Brisbane in November 2014. [13]  His presentation was excellent and I got to spend some time with him during the Steve Phinney masterclass [14] the next day.  He warmly asked how Moni was doing and took a real interest in helping us on our journey.

Troy’s story is worth checking out if you have not seen it yet.

There is nothing confrontational about Troy’s approach.  Troy just eats real whole healthy food.  Troy  just shows what can be done and gets on with doing it.

Rather than saying that everyone should do what he is doing he just says that people should be educated about the options and given the choice.

As well as following Bernstein and Taubes he’s also a fan of Mark Sisson’s primal / Paleo approach and likes to check everything against the evolutionary template rather than relying on associational studies.

When he initially self-diagnosed himself with type 1 diabetes and he went to the endocrinology department of his hospital, they told him to eat 240g of carbs each day and cover it with insulin.

Troy says “Within one week I went back to ask about low carb but was told I needed carbs and that low carb would not work. I continued reading for the next 2 months and became increasingly convinced that low carb was the way to go. I switched to low carb in December 2012 and have never looked back. My blood glucose lowered and stabilised, my insulin dose reduced, my hypos almost vanished and my depression/anxiety resolved.”

He explains how he has been able to extend the ‘honeymoon phase’ [15] of his type 1 diabetes in spite of having the disease for two and a half years.  By keeping his carbohydrates low he is able to maintain the function of the beta cells of his pancreas.    At this point in time he only needs to dose with long acting insulin, and with only an occasional bolus of insulin with a meal.

Unfortunately people newly diagnosed with type 1 diabetes often burn through their remaining pancreatic beta cells by following the standard dietary guidance and hence their ‘honeymoon phase’ is short (and sweet?), with insulin doses increasing as the pancreas gives out and insulin resistance progressively worsens.

Troy told me his HbA1cs are running in the low fives.  His diabetes is controlled with long acting insulin, a low insulin load diet and regular cycling and surfing which he loves!  He said if his HbA1c starts to drift up in the future he will add more regular insulin boluses with meals.

Dave and RD Dikeman

I came across Dave Dikeman and his father RD Dikeman via episode 831 of Jimmy Moore’s LLVLC show. [16]  I still remember nine year old Dave saying “finger pricks now or amputations later, the choice is pretty simple”.

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It seemed so clear and logical for young Dave.  However, what he was saying was radical to us after muddling around with mainstream advice for diabetes and no clear direction on how to achieve excellent blood sugar control.

Dave’s father, RD, is a theoretical physicist and chief scientist for Department of Defence contractor Lockheed Martin.  RD became passionate about diabetes after finding Dr Bernstein’s book, and after floundering with standard diabetes advice in the months following diagnosis.

Dave is now thriving on the Bernstein plan which includes lots of protein foods for growing kids.

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Like many family members of diabetics who find low carb, RD he also has his own story of how a reduced carbohydrate diet has helped him to turn his health around.

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The continuous glucose metre plot below shows RD’s own blood glucose levels after a few years of implementing Dr Bernstein’s advice in his family.

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This article by RD and Dave [17] offers a fascinating window into their thinking and the secrets of their success in managing type 1 diabetes.  Their analysis demonstrates that it is not possible to achieve normal blood sugars with large amounts of carbohydrate in the diet.

“It would be impossible for an artificial pancreas based on a CGM and automated insulin dosing via a pump – both of which have inherent lags – to respond quickly enough to high blood sugars caused by large doses of carbohydrate before unsafe levels of hyperglycemia occur.”

The Dikemans set up the TYPEONEGRIT Facebook group [18] to support others with type 1 diabetes on the journey following Bernstein’s protocols.  As recommended by Troy Stapleton, we joined the group late last year  and I can’t say enough about how helpful it has been to see people actually implementing Bernstein’s recommendations in day to day real life.

It is one thing to read the theory, but it’s a whole different thing to see all these people with flat line blood sugars, be able to ask lots of ‘dumb questions’ and share day to day struggles of what is a fairly radical departure from what most people consider ‘normal’.

Once you see the theory in practice you realise that you might be able to do it too.  When you see these healthy, vibrant passionate people you stop worrying about whether you’ll have a heart attack tomorrow due to the high fat diet.

The Dikemans also produce Dr Bernstein’s Diabetes University [19] which is getting the word out to a whole new audience through YouTube videos of Dr B.

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Lisa & Daniel Scherger

Lisa Scherger is a lady with a fire in her belly when it comes to managing her son Daniel’s type 1 diabetes!  If you haven’t seen her short presentation from the Low Carb Down Under seminar in Brisbane in November 2014 [20] make sure you take the time to do it now!

Lisa recently obtained a Dexcom continuous glucose metre [21] which has enabled them to take blood glucose management to a new level and further refine their dosing for protein.

On Lisa’s blog [22] she recently shared her ‘secret’ to flat line blood sugars and how to deal with the blood glucose ‘spike’ caused by protein.

So, for the carbs and fibre I bolused 40 minutes before dinner. Then I bolused for the protein conversion to glucose (gluconeogenesis) 1 hour after the end of the meal so that the insulin would start circulating around the time the spike was due to occur.

Lisa is adamant that accounting for protein in addition to carbohydrates is critical to optimising blood glucose control.

Last night I forgot to set my alarm to do the protein bolus, and I was up until 4am trying to get blood glucose levels down. Daniel’s protein spike starts exactly 2 hours after the meal, and once it starts I can’t stop it. He needs to inject for the protein 1.25 hours after the meal so that the insulin is circulating at the right time.

Learning to dose for protein as well as carbohydrate is a learning curve.  Getting flat line blood sugars typically takes some trial and error to refine and perfect.

image009

However the results of Lisa’s attention to detail speak for themselves, with an HbA1c consistently less than 5.0%…

image011

…and a son who is thriving in both his academic and athletic pursuits.

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Angela Erickson

Angela is another member of the TYPEONEGRIT Facebook group who recently completed an eighty hour fast in an effort to reset her insulin sensitivity.  During the fast she was measuring ketone levels of up to 3.4mmol/L and soon after recorded an HbA1c of 4.7%.

image013

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When I asked her what she would say were the secrets of her success were she said:

  1. learning my proper formula for protein that works for me,
  2. exercise, and
  3. fasting.

image012

Angela boluses for carbohydrates 15 minutes before the meal and then doses for the protein 1.5 hours after the meal using the pump, or two hours after with a faster acting intra muscular (IM) shot.

As well as ‘barely eating carbs’ she also manages her protein to make sure it’s not excessive, averaging about one gram per kilogram of body weight per day.

Angela also said she boluses to correct back to 83mg/dl (4.6mmol/L) whenever she hits 90mg/dL (5.0mmol/L) unless she has eaten within the past two hours.

Fasting is not a critical piece of Dr Bernstein’s regime, however, Angela found that she was able to improve her insulin sensitivity with periods of fasting.  After one day of fasting she found she had to decrease her basal rates to 70% and to 50% after three days of fasting.  And this improved insulin sensitivity continued after the fasting was over.

Periods of fasting can be useful for people with type 1 diabetes to refine their basal rates.   Similarly, fasting can also reset insulin resistance for people who do not have type 1 diabetes.  The fact that you can see it numerically on an insulin pump is a clear demonstration of what is occurring in the rest of the population after they fast.

When I asked whether she thought the fasting or the low insulin load diet was most important she said, “I’m not sure which is more important. I think ketones are powerful healers.  I feel somewhat euphoric after longer fasts and it gives my body a break.  I’m trying to heal and drop my few extra pounds.”

Lucy Smith

We met this gorgeous family at the Type 1 GRIT picnic in Brisbane recently.  Lucy is the one in the middle in the photo below with her new diabetes alert dog in training.

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The photo below shows Lucy with her hospital food when she was diagnosed with type 1 diabetes a bit over a year ago.  Let’s just say she doesn’t eat like that any more.

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This video of Lucy’s first year with type 1 diabetes is a touching insight into what it’s like for a young person to live with type 1 diabetes.

The Smiths are part of the CGM in the cloud crew [23] who have managed to hack their daughter’s CGM via an Android phone in her backpack that broadcasts her blood glucose level every five minutes to the cloud.  The most amazing thing about all this is that it has been created as an aftermarket hack by parents. DEXCOM have rushed the DEXCOM Share to market to keep up with this technology (US only).

Both her parents and Lucy’s teacher wear a pebble watch [24] with the Nightscout app [25] on it that that enables them to see Lucy’s current blood sugar level.  If they see it’s going out of range the parents will SMS her teacher who usually advises that she has just done a finger prick  and is treating the low.

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And it’s working!  Though at 4.8%, Lucy’s last HbA1c was outside the target range of 7.8-8.5 for someone her age!

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Allison Bleckley Herschede

Alison is one of the admins of the TYPEONEGRIT Facebook group [26] and coaches the nearly one thousand members who have type 1 diabetes and their carers towards achieving better blood sugar control.

When it comes to dealing with protein, Allison practices what some refer to as ‘sugar surfing’ [27] with a bolus given for carbohydrates with the meal.  She then watches her CGM and doses with small ‘micro doses’ to bring blood sugar back down if it goes above 93mg/dL (or 5.2mmol/L).

The difference for Allison though between normal ‘sugar surfing’ and her Bernstein-influenced approach is that she keeps her carbohydrates low so the ‘waves’ are more like ripples that are easier to manage.

Allison has developed some guidelines for achieving an excellent HbA1c, including:

  1. Target 4.6mmol/L (i.e. 83mg/dL).
  2. Veggies and protein before carbs.
  3. Multiple injections may be necessary for a high protein meal. Watch the CGM two to three hours post meal.
  4. If female, modify basal rates around monthly cycle.
  5. Take insulin sensitising supplements R-Alpha Lipoic Acid, Biotin, Chromium.
  6. Take one unit bolus upon waking to account for the Dawn Phenomenon. [28]

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You can read more about Allison’s journey with type 1 on her My Primal Nest blog including her experience with type 1 diabetes and pregnancy.

Recently she recorded these videos demonstrating how to use a home HbA1c metre…

… and her own surprise at the result is priceless.

In the comments to these videos where she showed that she’d clocked HbA1c of 4.4% she said “…I’m doing this fasting diet thing. Less than 800 cal, 5 days on 2 off. Supposed to mimic the fasting state. Well my insulin needs have greatly dropped.  It’s nuts.”

our journey

We are still on the journey but we learned so much from these awesome people!

My wife Monica has done an awesome job implementing the recipes posted on the TYPEONEGRIT Facebook group in our kitchen and has made low carbohydrate cooking a delicious art form.  After three decades of HbA1cs of around 8% she is now under 6% and the improvement in quality of life is enormous!

The greatest improvement to date for our family has been following a reduced insulin load diet which means that the insulin dose for food and correcting insulin dose is lower overall and the fluctuation in blood glucose levels are greatly reduced.

After seeing the success of all these people with CGMs, we’re now looking at getting a DEXCOM CGM for Moni, although unfortunately there are no subsidies in Australia so it’s not cheap!

It’s never going to be perfect, but when the correcting doses are smaller you’ve got a better chance of having more stable blood sugars.

The improvements to date have enabled Monica to have the energy to work as a supply teacher pretty much full time while still doing a great job of looking after the family!

When her blood sugars are under control she needs much less sleep, and her mood and energy levels are much better.

It’s always a journey.  You don’t arrive.  It’s a constant challenge.

Is it worth it?  Yes it is!  The quality of life for our whole family has seen a massive change and we’re eager to keep it moving forward.

 

references

[1] https://t1dexchange.org/pages/

[2] https://www.facebook.com/groups/660633730675058/

[3] http://www.diabetes-book.com/

[4] http://www.thelivinlowcarbshow.com/shownotes/7930/683-llvlc-classic-low-carb-diabetes-doctor-richard-bernstein/

[5] https://www.youtube.com/watch?v=WFNGdKSXx64

[6] http://www.diabetes-book.com/

[7] https://www.youtube.com/channel/UCuJ11OJynsvHMsN48LG18Ag

[8] https://www.youtube.com/watch?v=Z80-c0CXYqc

[9] https://www.youtube.com/watch?v=ctaaN9U3sGQ

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

[11] http://www.thenoakesfoundation.org/prof-noakes

[12] http://www.diabetes-low-carb.org/about-ron.html

[13] http://www.lowcarbdownunder.com.au/events/low-carb-brisbane-november-22nd-2014/

[14] https://www.youtube.com/watch?v=8NvFyGGXYiI

[15] http://www.diabetes.co.uk/blood-glucose/honeymoon-phase.html

[16] http://livinlavidalowcarb.com/blog/the-llvlc-show-episode-831-dave-dikeman-is-a-10-year-old-type-1-diabetic-on-fire-for-low-carb-living/22923

[17] https://myglu.org/articles/our-journey-with-the-low-carb-diet-and-the-manual-artificial-pancreas

[18] https://www.facebook.com/groups/660633730675058/

[19] https://www.youtube.com/channel/UCuJ11OJynsvHMsN48LG18Ag

[20] http://www.lowcarbdownunder.com.au/events/low-carb-brisbane-november-22nd-2014/

[21] http://www.dexcom.com/au

[22] http://diabeticalien.blogspot.com.au/2015/04/preventing-protein-spike.html

[23] https://www.facebook.com/groups/cgminthecloud/

[24] https://getpebble.com/#/.0kvx26:Fuqt

[25] http://www.nightscout.info/

[26] https://www.facebook.com/groups/660633730675058/

[27] http://stephenpondermd.com/

[28] https://en.wikipedia.org/wiki/Dawn_phenomenon

how much insulin is required to cover protein?

Given that protein appears to contribute to insulin demand I ran a number of scenarios with the food insulin index data to see if insulin requirement is better predicted by carbohydrate in a food plus some proportion of the protein.

Microsoft Word Document 14052015 104549 AM.bmp

The analysis indicates that insulin demand is related to carbohydrate about 60% of the protein.

There’s not a lot of information on the split between glucogenic amino acids and ketogenic amino acids out there, however it seems that only leucine and lysine are exclusively ketogenic and cannot be converted into sugar, while isolucine, threonine, phenylaline, tyrosine and tryptophan are both ketogenic and glucgoenic.  The remaining thirteen of the twenty one amino acids are exclusively glucogenic, meaning that they can be converted to sugar.

The proportion of protein that can turn to glucose relates to the amount of excess protein to the body’s needs, so it will be affected by a number of factors including a person’s activity levels, how much protein and carbohydrates they eat.

The correlation of food insulin index with carbohydrate about half the protein is better than carbohydrate alone (R2 = 0.435 compared to R2 = 0.461) and we no longer have the issue of high protein foods sitting on the vertical axis as shown below.

Microsoft Word Document 14052015 80253 AM.bmp

Accounting for protein in addition to carbohydrate seems to better predict insulin demand.

So in summary, while protein doesn’t spike blood sugar as much as carbohydrates, protein does still require a significant amount of insulin.  People not achieving the desired results from carbohydrate restriction alone may benefit from moderating their protein intake.

[next article…  fibre… net carbs or total carbs?]

[this post is part of the insulin index series]

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

carbohydrates, protein, type 1s and canaries

Quantification of insulin demand is of particular interest for type 1 diabetics who have to inject insulin to manage their blood sugars.

Insulin_Application (1)

Before diagnosis, a type 1 diabetic whose pancreas is failing will have extremely high blood glucose levels and lose weight fast because they can’t access the sugar that they’re eating without insulin.

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Without insulin the body kicks into (what some call a backup survival mechanism) ketosis which is where the body uses fat for fuel rather than sugar from dietary carbohydrates.

When combined with very high levels of blood glucose, this scenario is called diabetic ketoacidosis and can be a life threatening if left untreated.  This is rare though and only occurs in type 1 diabetics.

After commencing insulin therapy the diabetic regains weight.  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 three months after starting insulin injections.

Some type 1 diabetics injecting with needles will get localised hypertrophy where they inject their insulin, particularly if they don’t rotate their injection sites and / or are on a lot of insulin.

Though not recommended for health, some body builders will inject insulin in conjunction with their workouts to maximise muscle growth (warning: insulin promotes both fat and muscle growth).

Another example of how insulin affects body fat is the fact that children born to diabetic mothers are much heavier due to the the insulin circulating in the mothers’ blood stream.   The photos below show my two kids at birth (my wife is a type 1 diabetic and had good control through her pregnancies)…

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snug as a bug

…and now on a high fat diet.

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It’s a bit hard to argue the calories in / calories out theory saying that the in-utero kids should better manage their portion sizes and exercise more!

Carbohydrates raise blood sugars and insulin works to remove the sugar from the blood to store as fat.  In practice it’s impossible to perfectly match the insulin action with the rate of carbohydrate digestion.

While type 1 diabetics are an extreme case, they can be considerd the “canary in the coal mine” of weight maintenance and metabolic health.  To some extent everyone’s body is working to balance the effect of carbohydrates and protein driving up blood sugar and with the pancreas secreting insulin to bring the blood sugar back down.

One thing that’s not well understood is how type 1 diabetics should deal with protein.  Conventional wisdom is that type 1 diabetics should dose with about half the insulin for protein containing foods, however the basis of this is not clear.

With the food insulin index data now maybe we can better understand the insulin requirements of protein containing foods?

[next article…  protein and the foods insulin index… Atkins versus the vegans]

[this post is part of the insulin index series]

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

the most nutritious diabetic friendly meals

  • This article outlines a system to identify nutritious diabetic-friendly meals that minimise insulin load while maximising nutrition.
  • Choosing highly ranked meals will reduce the need to count carbs or calories.
  • Type 1  diabetics can use this system to calculate the total insulin required to cover carbs and protein and the split between the carb and protein bolus.
  • This approach can also be used to prioritise for weight loss and high nutrient density rather than blood sugar control.

[skip to the list of the most nutritious diabetic friendly meals]

it all started when…

Angelo Copola at Humans are not Broken ran a nutritional comparison of Bulletproof Coffee and his super nutritious breakfast tortilla using the free recipe builder function at SELFNutrition.com.  His blog post Bulletproof Coffee vs Breakfast is worth a read.

It was never going to be a fair fight if you compare these two extremes on the basis of vitamins, minerals and fibre alone.  The breakfast tortilla was always going to win out over the fatty coffee.

Personally, I’m partial to the occasional Bulletproof Coffee which has taken the world by storm and helped a lot of people.

I’m also aware that Dave Asprey’s Bulletproof Diet Book emphasis nutrient dense low toxin foods.

So using BPC to give your body a holiday from insulin and then eating highly nutrient dense foods at night makes sense.

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I also know that, as nutritious as it is, the tortilla recipe would not work for a type 1 diabetic like my wife.  A meal like that would send her on a blood sugar roller coaster.

So it got me thinking.  Is there a way to consider the nutritional value of a meal while also considering the insulin load?  Could we use our understanding of the proportion of insulinogenic calories to better prioritise nutritious meals that were also diabetic friendly?

the rules

Many people will judge whether meal is right for them based on calories alone.

Some will look deeper at the macronutrients.

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People wanting to lose weight will often target low calorie density or high fibre foods that are more filling.

Some will dig a little bit further and look at the micronutrients (i.e. vitamins and minerals).

Some body builders and people looking to optimise cognitive performance, will also look at the protein quality (i.e. the amino acids) in a food.

I suggest that an optimal diet that takes all these factors into account should be rank well across the following parameters;

  1. insulinogenic load,
  2. nutritional completeness (vitamins and minerals),
  3. amino acid sufficiency (protein),
  4. fibre content, and
  5. calorie density.

different strokes for different folks

The beauty of the food ranking system (as discussed in the previous article) is that we can tailor the weightings of different parameters to suit an individual’s unique goals.  We can also use a similar approach when comparing complete meals rather than individual food ingredients.

blood sugar control and / or nutritional ketosis

The highest priority for a diabetic is to normalise their blood sugars by reducing their insulin load in line with these weightings.   These weightings will will provide good nutrition while helping to normalise blood sugars.

insulin vitamins & minerals protein fibre calorie density
50% 15% 15% 10% 10%

weight loss

All going well, a diabetic may use a low insulin load diet with some fasting to regain insulin sensitivity and improve their blood sugar control.  If they still have weight to lose they may wish to further reduce their calorie intake to help to shed any remaining unwanted weight.

To do this they could use a a high fibre, low calorie density approach with less emphasis on insulin load that still provides excellent nutrition.

insulin vitamins & minerals protein fibre calorie density
20% 20% 20% 20% 20%

therapeutic ketosis

Many people feel that high levels of ketosis are beneficial for a range of chronic illnesses.  Someone looking to minimise insulin and drive their blood ketones up as much as possible will want to set the meal weightings to minimise insulin load as much as possible.

insulin vitamins & minerals protein fibre calorie density
70% 10% 10% 5% 5%

athletes and the metabolically healthy

If someone has lost excess weight and healed their metabolism, the person finds that they have energy to exercise they may benefit from nutritious meals with a little more carbohydrate to replenish glycogen around intense exercise.

insulin vitamins & minerals protein fibre calorie density
20% 30% 30% 10% 10%

With all of these scenarios the proviso is that they are maintaining excellent blood sugar control and that they revert back to the low insulin load dietary scenario if their blood sugars fall outside the “excellent” range shown in the table below.

HbA1c average blood sugar ketones
 (%)  (mmol/L)  (mg/dL)  (mmol/L)
low normal 4.1 3.9 70 2.1
optimal 4.5 4.6 83 1.3
excellent < 5.0 5.4 < 97 0.5
good < 5.4 6 < 108 0
danger > 6.5 7.8 > 140 0

meal ranking

I have set up a spreadsheet to compare meals using these parameters to identify healthy nutritious diabetic friendly meals for my family.

To date I have analysed nearly 200 meals.  Some of these we eat on a regular basis.  Others I found in recipe books, websites and Facebook forums that I thought looked good and I would like to try.

As we try out these meals at home I plan to take a photo and tell you a story about it, with a link to the recipe.

low carb breakfast stax

One of the highest ranking recipes using the meal ranking system is the Low Carb Breakfast Stax from the ketogenic recipe site Ruled.Me.  It’s hard to believe that something that looks so indulgent could also be so healthy.

breakfastpizza (1)

I dropped the recipe into the free recipe builder at SELFNutrionData, hit analyse and it pops out the snazzy nutritional analysis shown below.

There is a heap of interesting info here if you want to reflect on the nutritional value of your favourite foods.

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Using the macro-nutrient profile and fibre values we can calculate the percentage of insulinogenic calories using this formula:

image011

The “nutrient balance” plot on the bottom left shows the distribution of vitamins and minerals in the meal.  This chart shows us that with the egg, spinach and bacon we have covered off on most vitamins and minerals with good levels of sufficiency.

You can look at the detail to find out where you might be able to further improve a meal by filling in any deficiencies, however I’ve just taken the completeness score (82 in this case) compare with other meals.

The chart on the bottom right shows the distribution of the various amino acids in the protein which is interesting to make sure you’re getting everything you need for muscle growth and brain health.  I’ve taken the amino acid score (147 in this case) to compare with other meals.

SELFNutrionData also calculates the serving size in grams for a meal.  Using this we can calculate the calorie density of a meal (i.e. in terms of calories per gram).  This helps us prioritise meals that are bulky and contain a lot of water, however in order to avoid prioritising meals are just beverages I have also incorporated the fibre per calorie as a separate metric.

Each individual score or the meal gets a ranked score based on the highest and lowest extremes (ranking score = (score – mean) / standard deviation) and these five values are summed together to get the total score for that meal.

If you want to delve into the inner workings of the spreadsheet you can download if from the files section on  at the group facebook.com/groups/optimisingnutrition.

the end of calorie and carb counting?

This may all sound a bit complex, but the end result is a list of nutritious, diabetic friendly meals that will keep you full and minimise blood sugar swings.

If you chose foods from the top of this list and the meals from near the top of this list chances are you won’t have to worry about counting calories or even carbohydrates to keep your blood sugars stable, stay in ketosis, stay satiated or keep the weight off.

share your recipes

If you’ve got a recipe that you would like to see analysed to find out how it stacks up with the others then please post the recipie and a photos over at facebook.com/groups/optimisingnutrition.  I’d love to run the analysis and add it to the list.

In the next article we’ll compare a range of dietary approaches to see how a high fat diet stacks up.

ketosis… the cure for diabetes?

  • A reduced insulin load diet will lead to normalised blood sugars and improved insulin sensitivity.
  • A reduced insulin load diet can be achieved by reducing carbohydrates, moderating protein and choosing higher fibre foods.
  • Intermittent fasting also reduces insulin load.
  • Measuring your blood sugars is a simple and cost effective way to check that your metabolic health is on track.
  • A diet of nutrient dense, high fibre, high fat foods is the best way to optimise nutrition and minimise the risks associated with diabetes.

how to become diabetic…

In the “good old days” there were periods of feast and famine.  Food was typically eaten with the fibrous packing that it came with. In today’s modern food environment we are encouraged by the food industry (and those sponsored by it) to eat breakfast, lunch, dinner, snacks, pre-workout meals, post workout stacks, sports gels during exercise, and maybe some Gatorade to speed recovery.

Today’s food is plentiful, typically highly processed and low in fibre.  Carbohydrate and sugar based foods have a long shelf life, can be transported long distances and therefore cheap. Win, win?  Maybe not.

As we keep loading our bodies with simple sugars and carbohydrates our pancreas has to work overtime to produce insulin to shuttle excess sugar from the blood to your fat stores.

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Over time we become insulin resistant and the pancreas can’t keep up. Once your blood sugars get high enough you will be diagnosed with “type 2 diabetes” and put on medication to improve your insulin sensitivity, for a time. If nothing changes in your food intake your insulin sensitivity will continue to deteriorate until you reach a point when you’ll need to inject insulin to keep your blood sugars down.

Injecting excessive amounts of insulin will cause you gain even more body fat. Recently we have learned that it’s not just the high blood sugars that are diabolical for your health, high levels of insulin are also toxic. [1]

Doesn’t sound like much of a solution does it?

…and how to reverse it

While there are many aspects to managing diabetes including stress, sleep, food quality and environmental toxins, the simplest and most effective thing you can do to achieve optimal blood sugars is to do the opposite of what caused the problem in the first place.

Listed below are the main things that cause diabetes and what we can do to reverse it.

leads to diabetes reverses diabetes
Excessive sugar and simple carbohydrates in the diet generate high insulin load Reduce foods in your diet that require insulin [2]
Constant food with no significant periods between meals when insulin levels are reduced Create periods when your body does not have significant amounts of circulating insulin (i.e. intermittent fasting).

Sounds simple.  But it’s not easy or quick to reverse years of metabolic damage.   Your body is hard-wired to retain fat so it can survive the next famine.

Worth the effort?  People who have done it say yes.  That’s why they’re so annoyingly passionate about it!

Remember the type 1 diabetic roller coaster blood sugars in the last post?  The CGM plot shows the blood sugars of the same person a few months later on a low insulin load diet. [3] [4] [5]

image004 - Copy

foods that require insulin

You’re likely already aware that foods containing carbohydrates require your pancreas to produce insulin.

Recently I stumbled across some recent food insulin index test data [6] that indicates:

  • protein requires about half as much insulin as carbohydrates per gram on average, [7] and
  • carbohydrates in the form of indigestible fibre do not require insulin. [8]

So if you’re trying to reduce the insulin load of your diet you should:

  • limit simple processed carbohydrates that do not contain fibre,
  • choose high fibre foods (such as non-starchy vegetables) to obtain vitamins and minerals while keeping net carbohydrates low, and
  • back off on the protein if you’re not achieving the normalised blood sugars, weight loss or nutritional ketosis results you’re after.

insulin load

Rather than simply counting carbs, you could get a bit fancy and calculate your total insulin load using this formula:

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Most people will achieve nutritional ketosis with an insulin load of around 100 to 150 grams. Athletes and weight lifters will be able to tolerate more without messing up their blood sugars.  Inactive people aiming for weight loss may need to reduce their insulin load further. I don’t think that it’s ideal for most people to weigh and measure their food for extended periods.

If you’re not getting the results you want then tracking your food in MyFitnessPal or something similar can be a useful in the short term to retrain your dietary habits.

measuring for ketones versus measuring blood sugar

Once you get over seeing a little drop of your own blood, measuring your own blood sugar is pretty simple and painless, and is much cheaper than measuring blood ketones. In Australia and Canada blood sugar strips are about $0.16 compared to blood ketone strips which are about $0.80. [9]  In the US ketone strips are much more expensive, and basically unaffordable. Ketostix (which measure ketones in your urine) will typically only work for a little while until your body learns to use fat for fuel.

relationship between blood sugars and ketones

Blood sugar can be a useful way to see if you’re in ketosis. The chart below shows my blood sugars versus ketones over the last nine months or so that I’ve been trying to achieve nutritional ketosis.

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Based on my n=1 experience I’ve added the ketone levels which correlates HbA1c, average blood sugar and ketones.  This suggests that excellent blood sugar control for me is achieved when I’ve got ketone levels between 0.5 and 1.3mmol/L.

HbA1c average blood sugar ketones
 (%)  (mmol/L)  (mg/dL)  (mmol/L)
low normal 4.1 3.9 70 2.1
optimal 4.5 4.6 83 1.3
excellent < 5.0 < 5.4 < 97 > 0.5
good < 5.4 < 6 < 108 < 0.3
danger > 6.5 7.8 > 140 < 0.3

is more ketosis better?

The point way out to the right with a high ketone level of 2.1mmol/L and a blood sugar of 4.0mmol/L occurred after I cycled to work two days in a row on Bulletproof Coffee with a good amount of MCT oil.

In The Art and Science of Low Carbohydrate Performance [10] Volek and Phinney say that “light nutritional ketosis” occurs when blood ketones are between 0.5mmol/L and 1.0mmol/L and “optimal ketosis” is between 1.0mmol/L and 3.0mmol/L.

Based on the fact that an optimal blood sugar corresponds to a ketone reading of 1.3mmol/L and the low end of healthy normal blood sugars corresponds to a ketone reading of 2.1mmol/L I wonder if there is really any value in aiming for higher ketone values?

It’s interesting to note that Sami Inkenen, when rowing from the US to Hawaii on an 80% fat diet, [11] [12] was only getting ketones of around 0.6mmol/L [13]. If you’re striving for mental focus then loading up with butter, coconut oil and MCT oil to jack up your ketones might be for you.

If your aim is exercise performance or fat loss then ketones between 0.5mmol/L and 1.3mmol/L might be all you need to aim for. I also think loading up on dietary fat at the expense of getting adequate protein, vitamins and minerals may be counterproductive in the long term.

On the other end of the argument though, if you have good control of your blood sugars you should be showing some level of ketones in your blood.  If you consistently measure at a ketone value of less than 0.2mmol/L then it’s likely your blood sugar is not yet optimal.

what to do?

If you find this interesting and want to experiment I recommend that you buy a blood glucose metre and track your blood sugars for a while. I enter my results into a spreadsheet and look at the average of the past twenty results.

You can adjust your insulin load (i.e. less carbs, more fibre, moderate protein) until you achieve your target blood glucose level. As you test you’ll also notice that some foods cause your blood sugars to rise more than others.  Make sure you scratch those off your “do again” list.

You might also notice as you get your blood sugars under control you will get a metallic taste in your mouth, stronger smelling urine or a different body odour.  These are all signs that you’re transitioning into ketosis.  These symptoms typically don’t last for too long. If at first you don’t succeed, throw in some intermittent fasting.  I use bulletproof Coffee [16] to help me skip breakfast and sometimes lunch a couple of times a week.

Intermittent fasting is more effective than constant calorie restriction which can cause your metabolism to slow down due to conserve energy for the famine it thinks is coming. [17] [18] Having extended periods when insulin levels are low allows your body to learn to use body fat for fuel.

Once you begin to reset your insulin sensitivity you might start to notice a lack of inflammation and puffiness.  You may also find that you’re finally losing that stubborn weight and breaking through that dreaded plateau.  You may notice you feel great and your head is clearer than it’s been for a long time.  Or that that may just be my experience.

physiological insulin resistance

Some people find that as they reduce their carbohydrates that their fasting blood sugars will drift up.  This has been termed ‘physiological insulin resistance’ and is where the body develops a level of insulin resistance in the muscles to prioritise glucose for the brain. For some people this can be a transitionary phase on the way to stable ketosis.  It’s not thought to be something to be concerned about as it doesn’t cause elevated levels of insulin which is what can be really detrimental.

However some type 1 diabetics find it to be an issue long term and choose to increase the carbohydrates and protein in their food so they are just outside nutritional ketosis to reduce this effect.

My experience is that during this phase my post meal blood sugars were great even though the fasting blood sugars were higher than optimal.  As I continued to persist with more fat and added some intermittent fasting this went away and I was able to achieve lower fasting blood sugars.

Particularly during this time it is important to keep an eye on your average blood sugar (i.e. both fasting and after meals) and make sure it’s under 5.4mmol/L (100mg/dL).

can you eat too much fat?

It’s good to see medical researchers [19] and the media [20] coming out and admitting that the fear of fats over the past 30 years has led to diabolical health outcomes.

The fear of fat has forced people to eat more simple carbohydrates which has led to the diabetes epidemic. I analysed a number of dietary scenarios to see if there is any truth to the fear that low carbohydrate diets do not provide adequate nutrition and that you need your “heart healthy whole grains” to achieve optimal health, provide enough sugar for the brain, support growth in children etc. While a grain-based diet can be cheaper, my analysis suggest that a high fat diet that focuses on high fibre, high nutrient density, non-starchy vegetables is better in terms of the nutrition it provides and managing insulin demand.

The optimal diet to balance vitamins and minerals, amino acids and insulin load appears to contain between sixty and eighty percent calories from fat. It is possible to meet the recommended daily intake for most vitamins and minerals with 80% of calories coming from fat.

At the other end of the scale, higher levels of carbs may leave you storing more fat than you want to due to high insulin levels.

which foods are optimal?

What foods are optimal?  It all depends on your unique situation, goals and even finances.

I have developed a system to prioritise food choices based on the insulin properties of various foods as well as a range of other factors including:

  • nutrient density per calorie,
  • fibre per calorie,
  • nutrient density per dollar,
  • calorie density per weight, and
  • calories per dollar.

The list of foods below is a summary of the highest ranking foods using the weighting shown below in order to identify low insulin, high nutrient density food choices will lead to improved blood sugar control, mood, mental clarity, weight loss and overall health.

ND / calorie fibre / calorie ND / $ ND / weight insulinogenic (%) calorie / 100g $ / calorie
15% 5% 5% 10% 50% 10% 5%

Next time you’re wanting a nutritious meal that will push you into ketosis or lower your blood sugars you could consider some of these foods.

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

vegetables

  • turnip greens
  • coriander (cilantro)
  • rosemary
  • spinach
  • parsley
  • peppers / capsicum
  • chives
  • mustard greens
  • collards
  • mushrooms
  • Swiss chard
  • artichokes
  • broccoli
  • Brussel sprouts
  • kale

fats and oils

  • butter
  • coconut oil
  • olive oil
  • fish oil
  • flaxseed oil

fruits

  • avocados
  • olives

eggs & dairy

  • whole egg
  • goat cheese
  • goat cheese
  • parmesan cheese
  • cheddar
  • cream
  • camembert
  • feta
  • cream cheese
  • blue cheese
  • Colby cheese
  • Swiss cheese
  • edam cheese
  • brie
  • gouda
  • mozzarella
  • ricotta
  • cottage cheese

nuts & seeds

  • brazil nuts
  • sunflower seeds
  • pecans
  • pumpkin seeds
  • almonds
  • macadamia nuts
  • pine nuts
  • coconut milk
  • coconut meat
  • pistachio nuts
  • cashews

animal products

  • organ means (liver, kidney, heart etc)
  • chorizo
  • bratwurst
  • herring
  • chicken
  • frankfurter
  • mackerel
  • duck
  • beef sausage
  • bacon
  • turkey
  • anchovy
  • ground beef
  • lamb
  • bologna
  • turkey
  • beef steak

In the next article we’ll look at which foods are optimal for weight loss by prioritising low calorie density, high fibre high nutrient density foods that will also help stabilise your blood sugars.

references

[1] https://www.youtube.com/watch?v=4oZ4UqtbB_g

[2] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2716748/

[3] http://www.diabetes-book.com/

[4] https://www.youtube.com/channel/UCuJ11OJynsvHMsN48LG18Ag

[5] https://www.facebook.com/Type1Grit

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

[7] Some anecdotal evidence and studies such as http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342171/pdf/IJE2015-216918.pdf indicate that it’s the protein in excess of the body’s needs for muscle growth and repair that gets turned to glucose and requires insulin.

[8] http://healthyeating.sfgate.com/indigestible-carbohydrates-1023.html

[9] http://www.ebay.com.au/itm/BEST-PRICE-10-X-ABBOTT-FREESTYLE-OPTIUM-KETONE-TEST-STRIPS-10-TOTAL-100-STRIPS/181527585627?_trksid=p2054897.c100204.m3164&_trkparms=aid%3D222007%26algo%3DSIC.MBE%26ao%3D1%26asc%3D20140407115239%26meid%3Db2cedda776824d9f8ed5d131a3232ea7%26pid%3D100204%26rk%3D3%26rkt%3D24%26sd%3D281508543955

[10] http://www.amazon.com/The-Art-Science-Carbohydrate-Performance/dp/0983490716

[11] https://gumroad.com/l/CK219

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

[13] https://twitter.com/samiinkinen/status/451089012166385664

[14] https://www.facebook.com/ketogains

[15] https://www.facebook.com/ketogains

[16] https://www.bulletproofexec.com/bulletproof-fasting/

[17] https://www.youtube.com/watch?v=4oZ4UqtbB_g

[18] http://www.bodybuilding.com/fun/drsquat6.htm

[19] http://www.touchendocrinology.com/articles/nutrition-revolution-end-high-carbohydrates-era-diabetes-prevention-and-management [20] http://time.com/2863227/ending-the-war-on-fat/

[21] https://www.dropbox.com/s/h0zd5pjgw0gfqgq/Appendix%20D%20-%20Nutritional%20analysis%20of%20typical%20diets.docx?dl=0

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