Tag Archives: type 1 diabetes

articles, insulin index, insulin load, nutrient density

optimising protein and insulin load

December 3, 2016 Marty Kendall 8 Comments

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

context matters

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

“What insulin load should I be aiming for?”

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

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

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

disclaimers

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

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

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

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

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

insulin is not the bad guy

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

insulin load = total carbohydrates – fibre + 0.56 * protein

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

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

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

different degrees of the ketogenic diet

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

ketogenic ratio

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

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

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

ratio of fat to protein

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

protein grammes per kilogramme of lean body weight

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

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

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

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

gluconeogenesis

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

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

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

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

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

carbohydrate counting

Then there is carb counting.

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

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

protein, insulin load and nutrient density

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

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

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

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

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

what is ketosis?

“Ketogenic” simply means “generates ketones”.

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

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

insulin load = total carbohydrates – fibre + 0.56 * protein

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

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

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

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

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

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

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

insulin load versus nutrient density

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

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

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

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

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

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

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

macronutrient splits

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

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

nutrient density

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

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

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

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

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

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

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

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

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

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

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

choosing the right approach for you

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

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

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

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

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

more numbers

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

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

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

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

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

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

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

what about mTOR?

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

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

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

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

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

As my wise friend Raymund Edwards from Optimal Ketogenic Living says

“FAST WELL, FEED WELL.”

how much protein?

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

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

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

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

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

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

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

insulin load

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

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

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

summary

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

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

references

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

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

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

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

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

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

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

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

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

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

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

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

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

post last updated July 2017

articles, insulin index, weight loss

insulin load… the greatest thing since carb counting?

May 2, 2016 Marty Kendall 60 Comments

In previous articles I have outlined the idea of the insulin load ^[1] ^[2]which is similar to carbohydrate counting, but also accounts for the effect of protein, fibre ad fructose.

insulin load = total carbohydrates – fibre + 0.56 x protein

show me the data!

Most people understand that dietary carbohydrate is the primary nutrient that influences blood glucose and insulin as shown in the charts below. However, indigestible fibre^{^[3]} and glucogenic amino acids (protein)^{^[4]} ^{^[5]} also affect our blood glucose and our insulin response to food.

We can better predict the insulin and glucose response to our food if we also account for the effect of protein and indigestible carbohydrates (i.e. fibre). People aiming to follow ketogenic diet will want to eat foods towards the bottom left of these charts.

I was pleased to see Jason Fung even mention the food insulin index and the Optimising Nutrition blog at the recent low carb conference in Vail Colorado and it has been great to see a handful of people like Patricia and Mike put this theory into practice with great results as detailed in this article.

Patricia Berry Moore

This comment from Patricia Berry Moore made my day.

Marty! Are you the Low Carb Down Under Marty??!

You and Sarah Hallberg are why I started LCHF. And went from a very unhealthy type 2 diabetic at 156 lbs to a very healthy 113 lbs.

THANK YOU!

Patricia had seen my presentation on the food insulin index, applied the theory, and it worked!

Patricia said:

I use the insulin load concept.

I find it helps me refine my macros. A little less protein a bit more carbs and you can find that sweet spot. For me 50g per day is perfect.

My doctor threatened me with insulin and so I started went digging and found your lectures.

Over 10 months I lost 43 lbs (I’m 5’2″). I was pre-diabetic for ten years and then type 2 diabetic for ten years.

I am now off all my meds. I was on eight different ones for high blood pressure, high cholesterol, arthritis, re-flux, diabetes.

I’m never going back, so thank you!

This is Patricia’s “before photo.” You can see a ‘puffiness’ in her face characteristic of insulin resistance and hyperinsulinemia, which causes fluid retention. I showed this photo to my 12 year old daughter who said “that’s how you used to look.” Thanks dear… I think.

If you’ve hit a plateau it might be worth tracking the insulin load of your food for a while to fine tune your diet. Patricia says:

I use the app Lose it! which helps me track macros. So it’s pretty easy to keep a running total of my insulin load too.

I started at around 80g per day. As I decreased it, my blood sugars improved.

At this point my fasting blood glucose run at 65 – 75 mg/dL with an insulin load around 50g per day or so.

LCHF has really saved my life Marty.

This is Patricia now. Congratulations Patricia!

a little closer to home

As mentioned by my daughter, this is me before and after trying out my low insulin load, high nutrient density foods. I don’t think my hair moved in the 18 months between when these work profile photos were taken, but some inflammation and weight certainly did. My family assures me that at my worst I was bigger and unhealthier looking than the photo on the left!

The photo below on the left is my daughter’s “before photo” after spending 9 months in a high insulin environment. Children born to mothers who are type 1 diabetic and dosing with lots of insulin tend to be delivered early via C-section due to their excessive size caused by the high levels of insulin from the mother. The photo on the right is her twelve years later, all grown up!

The photos below are the same child, “JL,” who was one of the first type 1 diabetic children to receive insulin treatment in 1922. Without insulin he’s wasting away, literally eating his own fat and muscle, unable to metabolise carbohydrate. Two months later the photo on the right shows that he’s been able to make a full recovery with insulin injections.

The photo below is of another Type 1 sufferer before and after receiving exogenous insulin.

Hopefully from these photos you can see how there’s a “Goldilocks zone” for insulin. Not too little. Not too much. Just right. You can use the quantification of insulin load to find your sweet spot.

Mike Alward

I received similar feedback recently from Mike Alward who has also successfully applied the insulin load theory. Mike says:

I just wanted to say thanks for your work on insulin load, food insulin index and glucose : ketone index. It really helped me to understand what was holding me back from reaching and being able to maintain a state of optimal ketosis.

I manage my insulin load to ~75g per day. My BG has come down and my ketones are now in the optimal range. My GKI is now below 3.

I used to be pre-diabetic with blood glucose up around 6.5 mmol/L. Now, I am in the 4.5 – 4.7mmol/L range.

Being in optimal ketosis has helped to control my appetite and cravings (especially sugar), which has made intermittent fasting so much easier.

Keep up this important work!

With this reduced insulin approach Mike is able to accommodate a solid amount of protein into his diet while maintaining excellent blood glucose and ketone levels. Like anything, you can have too much of a good thing, including protein.

Many people find that as their insulin resistance improves they are able to handle a higher insulin load diet which may enable a higher nutrient density and less fat. If you are highly insulin resistant you may need to focus on a very low insulin load, high fat approach. As your blood glucose levels stabilise you will be able to transition to more nutrient dense foods that may have a higher insulin load.

Mike says:

My insulin load target is ~90g – 100g of protein / day. I am 6’0″.

Mike likes to track a range of different health makers.

I track my weight calories, macros, calculated insulin load, blood glucose, blood ketones and GKI.

Not everybody “geeks out” on this stuff. I am totally into “nerd safaris” to research non-conventional wisdom health.

I just got several folks to calculate their insulin load, and their heads almost exploded when I introduced them to GKI.

You can see in the chart below how Mike’s ketones have increased as he has reduced the insulin load of his diet.

The chart below shows how Mike’s glucose : ketone index (an approximation of insulin levels) has decreased as he lowered the insulin load of his diet.

Tracking the insulin load of your diet is a little more complex than just counting carbs, but not that much more work if you’re already tracking your food intake. Personally, I’m not a big fan of tracking everything you eat forever, but it can be useful to keep a food diary for a time to reflect and refine.

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

how to calculate your insulin load

So how do you calculate the insulin load of your diet?

If you’re already tracking your food intake it’s a pretty simple thing to do. Below is an example output from MyFitnessPal^{^[6]} showing the food intake for the day comprising of:

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

So we start with the insulin load formula:

insulin load = carbohydrates (g) – fibre (g) + 0.56 x protein (g)

Insert our values:

insulin load = 70g carbohydrates – 63g fibre + 0.56 x 104g protein

and calculate insulin load:

insulin load = 65g

It’s not that much different to tracking net carbs, but instead you also account for protein which also requires insulin.

I initially developed this calculation for people with Type 1 Diabetes (like my wife) who need to calculate their insulin dosage but it can work in a similar way for someone wanting to reduce the demand on their pancreas to the point that it can keep up and maintain normal blood glucose levels.

Reducing your insulin levels to normal healthy levels will allow your stored fat to be used for energy and manage your appetite. As you track your insulin load you can keep eliminating the foods that are driving it up until the point that you see the weight loss and blood glucose levels that you’re chasing. More recently I have incorporated this as a metric you can track in the Nutrient Optimiser to achieve your target glucose and ketone levels.

The appropriate insulin load will vary from person to person. A small woman aiming for weight loss using a lower protein ketogenic approach might have an insulin load as low as 40g per day while a larger man looking who is active and looking build muscle might have an insulin load as high as 300g per day.

A higher insulin load diet would allow more plant based foods, less fat and potentially a higher nutrient density (e.g. 40 to 50% of insulinogenic calories). The first priority will be to reduce the insulin load of your diet to the point where you can normalise your blood glucose levels and reduced insulin (e.g. 20 to 30% of insulinogenic calories).

The best idea is to start tracking where you’re currently at and look to reduce your daily insulin load until you achieve excellent blood glucose levels (i.e. average less than 5.6 mmol/L or 100 mg/dL). Once you normalise your blood glucose levels you could keep winding it down further until you achieve your desired level of ketones. As your body heals and you start to reduce the amount of fat around your organs you may be able to tolerate a higher insulin load diet and more nutrient dense diet in time.

a little more on the insulin load theory

So is it all about the insulin load? What about calories and conservation of energy?

In a metabolic ward context we typically find conservation of energy / CICO holds true. If anything someone on a high fat diet may be able to maintain their weight with less calories because fat is easier to digest and products less wasted energy (enthalpy). But in a free living environment how much we eat is influenced by our appetite which is influenced by the nutrient density of our food choices as well as our levels of insulin resistance.

This video gives a good overview of how insulin (either injected or from our own pancreas) affects whether we store fat on our body or release it to be used for fuel and how excess insulin can be problematic.

Most people think of macro nutrients in terms of carbohydrates, protein and fat as per the the picture below. They think that if we eat too much fat it will be stored as body fat. But the reality is a little bit more complex than that.

In the chart below the grey slices of the pie chart (i.e. the non-fibre carbohydrate and the glucogenic protein) are the components of your food that are glucogenic and will require insulin to metabolise.

The blue components are ketogenic (i.e. the dietary fat and the ketogenic protein) and do not require insulin to metabolise. If you’re lucky enough to be insulin sensitive you will burn the food you eat and your appetite will be well regulated with minimal change in body weight.

Indigestible fibre (black slice) doesn’t significantly affect our insulin response or even contribute to calories for us but rather is used to feed the bacteria in our gut. Fibre is a true ‘free food’.

If the insulin load of our diet is too high we are more likely to store a portion of the food. If we are insulin resistant our body will have to generate more insulin to deal with the non-fibre carbohydrate and glucogenic protein while increasing our chances that some of the food we eat will be stored on our body. We feel hungry and need to keep eating to obtain adequate energy. Calories still matter, but outside a controlled metabolic ward, body fat accumulation is more about managing fat storage and appetite than about counting calories.

Calories still matter, but outside a controlled metabolic laboratory, body fat accumulation is more about managing fat storage and appetite than consciously counting calories. Many people refer to insulin as the thermostat that controls our metabolism and our fat storage.

The good news here is that we can use our understanding of the storage properties of insulin to our advantage. If we are able to decrease the insulin load of our diet we are less likely to store fat and more likely to be able to use some of our stored body fat for energy. This will mean that we feel less compelled to eat because we are able to use up our own body fat rather than constantly eating. This reduced dietary insulin load scenario will lead to lower insulin levels, less storage, more use of body fat for fuel, a decreased appetite and a reduction in energy intake.

So, to reduce the insulin load of diet include you can:

eat more fibre,
eat less digestible carbohydrates, and
make sure your protein intake is not excessive.

can you eat too much fat?

Can you still eat too fat much while keeping the insulin load of your diet low?

The short answer is yes, especially if you’re chasing a certain macro nutrient value or high ketone values. Some people are able to stay very lean on a high fat ketogenic diet, but others need to also manage their dietary fat inputs to achieve their goal of body fat output.

The good news is that a low insulin load nutrient dense diet diet will typically lead to increased satiety and reduced energy intake.

The bad news is that excess energy, whatever the source, will lead to fat gain, inflammation and insulin resistance.

Many people recommend that you should eat ‘fat to satiety’. Unfortunately, high fat foods can be easy to overeat, at least for some individuals. There is no need to force yourself to eat extra fat if you are trying to lose weight. There’s no need to go out of your way to add extra fat and oils to your food. If your goal is weight loss, you can obtain more than enough fat from whole-food sources.

basal insulin and insulin resistance

The other unfortunate fact is that the insulin produced in response to food is less than half of the amount of insulin that your body produces. You pancreas is constantly producing basal insulin to manage the flow of energy out of your liver and to remove excess energy from your blood stream.

In addition to reducing the insulin load of your diet you may also need to increase the periods between your meals (intermittent fasting) and focus on building lean muscle mass to improve your insulin sensitivity. This will allow your insulin levels to decrease even more so that body fat can be accessed for fuel.

Implementing an intermittent fasting regimen can be useful for people who find that reducing the dietary insulin load doesn’t lead to enough reduction in appetite.

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

You can get a substantial decrease in insulin levels with a regular 18 to 24 hour fast. After this drop in insulin you may find your hunger levels actually decrease after a longer period of not eating.

summary

To regain control of your appetite you need to insulin load of your diet to the point that your pancreas can keep up and maintain normal blood glucose levels consistent with your personal metabolic health and level of insulin sensitivity.
If your blood glucose and insulin level are high then you should work to decrease the insulin load of your diet.
As the insulin load of your diet decreases you should see your blood glucose levels come down, your appetite reduce and your ketone levels come up.
If you’re still not seeing the results you want then the next step is to try intermittent fasting to further reduce your insulin and blood glucose as well as mitigate your overall food take.
As your blood glucose levels start to normalise you can start to focus on more nutrient dense foods with a lower energy density that may be helpful if weight loss is your goal.

The foods lists in the table below have been optimised to suit different levels of insulin resistance and tailored to your weight loss goals.

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

post last updated: April 2017

references

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

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

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

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

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

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

articles, blood sugar, diabetes

balancing diet and diabetes medications

August 17, 2015 Marty Kendall 16 Comments

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.

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]

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.

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!

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.

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:

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.
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.
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.

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.

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:

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.
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.
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/

articles, blood sugar, diabetes, insulin index, nutrient density, protein

how to calculate insulin dosing for type 1 diabetes (including protein and fibre)

August 10, 2015 Marty Kendall 11 Comments

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.

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.

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.

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.

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

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).

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

articles, blood sugar, diabetes, dikemans

standing on the shoulders of giants

August 2, 2015 Marty Kendall 16 Comments

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.

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-three 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.

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 thebasal/boluss 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.

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”.

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.

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.

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.

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.

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.

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

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

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%.

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

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

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.

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.

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.

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!

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:

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

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

post last updated July 2017

blood sugar, diabetes, nutrient density

why is good blood glucose control so important?

July 3, 2015 Marty Kendall 15 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

blood sugar, carbohydrates, diabetes, insulin index

how much insulin is required to cover protein?

April 8, 2015 Marty Kendall 10 Comments

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.

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.

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.]

blood sugar, diabetes, insulin index, insulin load, ketosis, low carb diet shopping list, nutrient density

superfoods for diabetes & nutritional ketosis

April 6, 2015 Marty Kendall 73 Comments

These foods will help you to maintain excellent blood glucose levels by reducing the insulin load of your diet while at the same time maximising nutrient density to minimise cravings and allow you to get the nutrients you need with less food.

More than carbohydrates or the glycemic index, the food insulin index data suggests that our blood glucose and insulin response to food is better predicted by net carbohydrates plus about half the protein we eat.

There is a relationship between carbohydrate and our insulin response to the food we eat, but it is not that strong, particularly when it comes to high protein foods or high fibre foods.

Accounting for fibre and protein enables us to more accurately predict the amount of insulin that will be required to metabolise a particular food. This knowledge can be useful for someone with diabetes and/or a person who is insulin resistant to help them calculate their insulin dosage or to choose foods that will require less insulin. People wanting to follow a ketogenic diet will want to select foods towards the bottom corner of this chart.

If your blood glucose levels are high you are likely insulin resistant (e.g. type 2 diabetes) or not able to produce enough insulin (e.g. type 1 diabetes) it makes sense to reduce the insulin load of your food so your pancreas can keep up.

This list of foods has been optimised to reduce the insulin load while also maximising nutrient density. These low insulin load, high nutrient density foods will lead to improved blood sugar control and normalised insulin levels. Reduced insulin levels will allow body fat to be released and be used for energy to improve body composition and insulin resistance.

As shown in the chart below this selection of foods is also nutrient dense and provides a substantially greater amount of nutrients compared to the average of all foods available.

From a macronutrient perspective, these foods have a similar protein content to the rest of the foods in the USDA database, more fibre but much less digestible non-fibre carbohydrate. And the carbohydrates that are there come from nutrient dense veggies that are hard to overconsume compared to the processed nutrient poor carbs that are typically causing the issues for people.

Included in the tables are the nutrient density score, percentage of insulinogenic calories, insulin load, energy density and the multicriteria analysis score (MCA) that combines all these factors. Why not use these lists to inspire your next trip to the grocery store?

vegetables and fruit

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
endive	17	23%	1	17	1.9
chicory greens	15	23%	2	23	1.8
alfalfa	12	19%	1	23	1.7
escarole	14	24%	1	19	1.7
coriander	14	30%	2	23	1.6
spinach	19	49%	4	23	1.3
curry powder	5	13%	14	325	1.3
beet greens	12	35%	2	22	1.3
basil	18	47%	3	23	1.3
zucchini	14	40%	2	17	1.3
asparagus	17	50%	3	22	1.2
paprika	8	27%	26	282	1.2
mustard greens	8	36%	3	27	1.1
parsley	14	48%	5	36	1.1
turnip greens	12	44%	4	29	1.1
banana pepper	7	36%	3	27	1.0
collards	8	37%	4	33	1.0
arugula	12	45%	3	25	1.0
lettuce	14	50%	2	15	1.0
chard	14	51%	3	19	1.0
eggplant	5	35%	3	25	1.0
pickles	8	39%	1	12	1.0
cucumber	8	39%	1	12	1.0
okra	13	50%	3	22	1.0
summer squash	10	45%	2	19	1.0
sage	4	26%	26	315	0.9
poppy seeds	1	17%	23	525	0.9
Chinese cabbage	14	54%	2	12	0.9
watercress	20	65%	2	11	0.9
chives	12	48%	4	30	0.9
broccoli	13	50%	5	35	0.9
edamame	8	41%	13	121	0.9
sauerkraut	6	39%	2	19	0.9
jalapeno peppers	4	37%	3	27	0.9
cloves	6	35%	35	274	0.9
cauliflower	11	50%	4	25	0.9
marjoram	4	31%	27	271	0.9
caraway seed	3	27%	28	333	0.8
thyme	5	34%	31	276	0.8
red peppers	6	40%	3	31	0.8
radishes	7	43%	2	16	0.8
celery	10	50%	3	18	0.8
portabella mushrooms	12	55%	5	29	0.8

eggs and dairy

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
egg yolk	5	18%	12	275	1.2
whole egg	6	30%	10	143	1.1
cream	-6	6%	5	340	1.0
sour cream	-5	13%	6	198	0.9
limburger cheese	-1	19%	15	327	0.9
cream cheese	-5	11%	10	350	0.9
camembert	-1	21%	16	300	0.8
feta cheese	-1	22%	15	264	0.8
Swiss cheese	-0	22%	22	393	0.8
butter	-7	2%	3	718	0.8
blue cheese	-1	21%	19	353	0.8
gruyere cheese	-0	22%	23	413	0.8
edam cheese	-1	23%	21	357	0.8
cheddar cheese	-2	20%	20	410	0.8
brie	-3	19%	16	334	0.8
Monterey cheese	-2	20%	19	373	0.8
goat cheese	-3	21%	14	264	0.8
muenster cheese	-2	21%	19	368	0.8
gouda cheese	-1	24%	21	356	0.8
Colby	-2	21%	20	394	0.7
ricotta	-2	27%	12	174	0.7

nuts, seeds and legumes

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
sunflower seeds	3	15%	22	546	1.0
flax seed	0	11%	16	534	1.0
coconut milk	-6	8%	5	230	1.0
sesame seeds	-2	10%	17	631	0.9
brazil nuts	-2	9%	16	659	0.9
coconut cream	-7	8%	7	330	0.9
pumpkin seeds	1	19%	29	559	0.9
hazelnuts	-2	10%	17	629	0.9
coconut meat	-6	10%	9	354	0.8
walnuts	-1	13%	22	619	0.8
almonds	-1	15%	25	607	0.8
pine nuts	-3	11%	21	673	0.8
almond butter	-1	16%	26	614	0.8
pecans	-5	6%	12	691	0.8
macadamia nuts	-6	6%	12	718	0.7

seafood

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
mackerel	0	14%	10	305	1.1
fish roe	15	47%	18	143	1.1
caviar	9	33%	23	264	1.1
cisco	5	29%	13	177	1.0
trout	13	45%	18	168	1.0
sardine	9	37%	19	208	1.0
sturgeon	14	49%	16	135	0.9
salmon	15	52%	20	156	0.9
anchovy	11	44%	22	210	0.9
herring	7	36%	19	217	0.9

offal

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
beef brains	3	22%	8	151	1.1
lamb brains	5	27%	10	154	1.1
sweetbread	-3	12%	9	318	1.0
lamb liver	14	48%	20	168	1.0
turkey liver	13	47%	21	189	1.0
chicken liver	14	50%	20	172	0.9
liver sausage	-4	13%	10	331	0.9
chicken liver pate	5	34%	17	201	0.9
lamb kidney	14	52%	15	112	0.9
veal liver	15	55%	26	192	0.8
liver pate	-4	16%	13	319	0.8
lamb sweetbread	7	43%	15	144	0.8
beef kidney	11	52%	20	157	0.7

animal products

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
bratwurst	0	16%	13	333	1.0
ground turkey	5	30%	19	258	0.9
bacon	-4	11%	11	417	0.9
pork sausage	1	25%	13	217	0.9
salami	-1	18%	17	378	0.9
pork ribs	-1	18%	16	361	0.9
kielbasa	-3	15%	12	325	0.9
turkey bacon	-3	19%	11	226	0.8
pork sausage	-2	20%	16	325	0.8
knackwurst	-4	16%	12	307	0.8
roast pork	8	41%	20	199	0.8
bologna	-7	11%	9	310	0.8
pepperoni	-4	13%	16	504	0.8
beef sausage	-3	18%	15	332	0.8
lamb rib	-2	19%	17	361	0.8
duck	-3	18%	15	337	0.8
pork ribs	6	39%	21	216	0.8
blood sausage	-5	14%	13	379	0.8
pork loin	7	41%	19	193	0.8
frankfurter	-5	17%	12	290	0.8
meatballs	-3	19%	14	286	0.8
headcheese	-5	20%	8	157	0.8
roast ham	6	41%	18	178	0.8
chorizo	-3	17%	19	455	0.8
roast beef	5	38%	21	219	0.7
turkey	-2	20%	21	414	0.7
chicken (leg with skin)	6	42%	18	184	0.7
T-bone steak	-1	26%	19	294	0.7
ground beef	1	30%	18	248	0.7

other dietary approaches

The table below contains links to separate blog posts and printable .pdfs detailing optimal foods for a range of dietary approaches (sorted from most to least nutrient dense) that may be of interest depending on your situation and goals. You can print them out to stick to your fridge or take on your next shopping expedition for some inspiration.

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 identify the optimal dietary approach for you.

blood sugar, carbohydrates, diabetes, insulin index

carbohydrates, protein, type 1s and canaries

April 2, 2015 Marty Kendall 2 Comments

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

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.

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)…

…and now on a high fat diet.

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.]

carbohydrates, meal plans, nutrient density, recipes

the most nutritious diabetic friendly meals

March 22, 2015 Marty Kendall 20 Comments

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.

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.

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;

insulinogenic load,
nutritional completeness (vitamins and minerals),
amino acid sufficiency (protein),
fibre content, and
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.

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.

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

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.

context matters

disclaimers

insulin is not the bad guy

different degrees of the ketogenic diet

ketogenic ratio

ratio of fat to protein

protein grammes per kilogramme of lean body weight

gluconeogenesis

carbohydrate counting

protein, insulin load and nutrient density

what is ketosis?

insulin load versus nutrient density

macronutrient splits

nutrient density

choosing the right approach for you

more numbers

what about mTOR?

how much protein?

insulin load

summary

references

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show me the data!

Patricia Berry Moore

a little closer to home

Mike Alward

how to calculate your insulin load

a little more on the insulin load theory

can you eat too much fat?

basal insulin and insulin resistance

summary

references

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when do you need insulin?

Fasting and improving insulin sensitivity

the balance between diet and medication

the dangers of glucose toxicity

the dangers of insulin toxicity

two sides of the same coin?

refining insulin levels for type 1 diabetics

the law of small numbers

adjusting insulin doses for type 2 diabetics

references

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introduction

carbohydrate counting

Bernstein’s own approach

sugar surfing

food Insulin Index

Total Available Glucose (TAG)

separate boluses for carbohydrates and protein

insulin calculator

inputs

outputs

meals

our experience

References

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background

Dr Richard Bernstein

Troy Stapleton

Dave and RD Dikeman

Lisa & Daniel Scherger

Angela Erickson

Lucy Smith

Allison Bleckley Herschede

our journey

references

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vegetables and fruit

eggs and dairy