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vegan vs keto for diabetes… which is one optimal?

I recently watched the Mastering Diabetes teleseminar on ketogenic diets with high hopes of picking up some gems of wisdom from the rising stars of the plant-based diabetes community.

Unfortunately, I was underwhelmed with what I heard.

I shared my frustration on Facebook.

Robb Wolf suggested I put together a response to some of the misinformation in the teleseminar.  Hence this post.  [Robb did an excellent breakdown on the claims in the What the Health Netflix doco, What the Health: A Wolf’s Eye View, which I highly recommend checking out if you haven’t already.]

What’s actually wrong with the keto diet for diabetes?

Cyrus Khambatta (aka Mangoman) and Robby Barbaro (The Mindful Diabetic) should be uniquely qualified, both academically and experientially having themselves lived with type 1 diabetes for decades.

If I were was going to attack keto for diabetes management, then there would have been a couple of ‘free kicks’ I think they could have taken.  So, in fairness to both sides, I’ll touch on a few of what I see as legitimate issues with ‘popular keto’ before I dissect the Mastering Diabetes presentation.

Giving fat a free pass

Humans like things to be straightforward and binary.

Yes or No.

Black or white.

High fat or low fat.

Low carb or high fat.

High protein or low protein.

Plants only or animals only.

For the last four decades, we have been told that fat, particularly saturated fat, is bad because it causes heart diseases and should be avoided.

The tide is now turning.  However, there will always be people who take things to the extreme.

Now fat is healthy.  But is more is better?

Ketones are good.  So more is better?

For many people, a higher fat diet will be more satiating, particularly compared to processed grains and sugars.  However, not everyone can ‘eat fat to satiety’ without some level of restraint and self-discipline.  We can’t all trust our appetite to kick in to effortlessly provide the lean and chiselled body that they dream of.

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My personal experience is that you can overdo the fat and drive insulin resistance by pushing fat too hard.  If you exceed your ‘personal fat threshold’[1], your adipose tissues will become insulin resistant, and the body will start pushing excess energy to the vital organs.

While there is no need to fear fat, there is no reason to go hog wild to compensate for the butter and bacon deficiencies that we all developed over the past four decades.

When it comes to nutrition, you need to get your big rocks in place first (i.e. the nutrient dense foods).  You can then fill up with fuel such as fattier foods if you do not want to burn any body fat.  You could even add some starchy carbs if your blood sugars allow.

Having some level ketones is an indication that your insulin levels aren’t too high and your metabolism is working.  However, if you are not yet metabolically healthy, chasing ‘fauxtosis’ by loading up on butter, coconut oil, cream and exogenous ketones to achieve high blood ketone levels can be a recipe for hypercaloric metabolic disaster that will drive insulin resistance.

People with type 1 diabetes (such as the Mastering Diabetes guys and my wife Monica) have a unique insight into the various factors that affect their insulin sensitivity.  They can monitor their daily insulin dose.

I know some people with type 1 diabetes who have made an effort to chase higher ketones with more refined fat and less protein but found that they ended up needing more insulin.  Retreating to a moderate to high protein approach with less added fat (as per Dr Bernstein’s recommended approach for Type 1 diabetes) enabled them to improve their insulin sensitivity (e.g. check out Allison’s Nutrient Optimiser analysis here).

This phenomenon is not unique to people with type 1 diabetes.  There seem to be more and more people start out believing calories don’t count, only hormones.  They then put their faith in the ‘magic ketone fairy’ and end up driving insulin resistance and obesity chasing ‘optimal ketone levels’ with more and more added fat.[2]

I have a dream

Before we get into the nutritional analysis, permit me this indulgence to share my vision (with a hat tip to Martin Luther King) from Martin Laurence Kendall.

I have a dream that one-day nutrition will be defined by the nutrients that a food contains and the health benefits that it confers rather than religious and ethical beliefs or commercial interests.

I have a dream that all people, mothers and children, fathers and brothers, would be able to clearly understand the foods that are truly optimal for them.

I have a dream that one day all people afflicted with diabetes will be able to choose foods that will enable them to achieve normal blood sugars and restore the health and vitality that they deserve. 

Further, that they will be able to choose optimal foods, with engineering precision, without being affiliated with the needless ridicule that they will needlessly die of a heart attack due to unnecessary fears about ‘artery-clogging saturated fat’ or ‘harmful animal proteins’. 

I have a dream that one day people will have, freely in their grasp, quality nutritional information that enables them to make informed choices that will, in turn, bring about a new day in the commercial food environment. 

I dream that one day all people, obese, diabetic, children and athletes alike,  will be free from the corruption of Big Food and Big Pharma working through diabetes educators, diabetes associations, heart associations, medical institutions and animal welfare advocates.   

Free at least.  Free at last. 

I hope that one day we will be free at last. 

Indulgence over.  On with the data.

On with the data.

Nutrient deficiencies in a high-fat diet

Another fact that I thought Cyrus and Robby would mention was that very high-fat foods tend to have a weak nutrient profile, especially compared to non-starchy vegetables.

The chart below shows the nutrients provided by the 800 highest fat foods out of the 8000 foods in the USDA database.   If we prioritise fat, we will likely be lacking in around half of the essential nutrients.

A summary of some of the highest fat foods is shown below.

[For some real-life examples of the poor nutrient profiles achieved by people chasing high ketone levels in the misguided pursuit of weight loss check out the Nutrient Optimiser reports here, here, here here and here.]

Vitamins and minerals,  in particularly electrolytes such as potassium, magnesium and calcium are critical to support our mitochondria, enabling them to produce energy and maximise insulin sensitivity.

People in the keto community are conscious that electrolytes are essential and go out of their way to supplement with magnesium, calcium, sodium and potassium as well as taking bone broth.

The kidneys let go of water and electrolytes when insulin levels drop.  A ketogenic diet without attention to green leafy veggies is at risk of being very low in electrolytes.  This will cause the pancreas to secrete more insulin to hold onto the scarce electrolytes.  This increase in insulin levels may[3] ironically drive insulin resistance.

Whether you call them electrolytes or alkaline foods[5], our bodies need enough substrate to allow our kidneys to maintain a good acid/base balance without having to work too hard.  Focusing on minerals can helps us maximise insulin sensitivity and ensure oxygen is efficiently be carried around our bloodstream.

There are plenty of foods available to provide the micronutrients that you need if you actually require therapeutic ketosis as an adjunct to cancer, epilepsy or dementia.  We can achieve the Daily Recommended Intake (DRI) for most of the nutrients while still maintaining a low dietary insulin load.

The short list of foods that comprise a ‘well formulated ketogenic diet’ are shown below.

However, if you just need to manage diabetes with a low-carb diet (rather than therapeutic ketosis), you can achieve even higher levels of nutrition while maintaining stable blood sugars.

Given my family history of Type 2 and my wife Monica’s Type 1 diabetes, we generally focus on the foods listed below.  Lots of people have found these lists useful.  You can pin them to the fridge as a reminder of what you should focus on or print it out to take shopping next time when you need some inspiration.   (There is a complete list of nutrient dense foods to suit different goals at the end of this article.)

Now my blood glucose levels are more stable, I’ve been trying to back off on the higher fat foods and focus on more nutrient-dense foods to build muscle and lose fat.

The ‘problem’ with the most nutrient-dense foods (as shown below) is that they typically have a very low energy density so it will be nearly impossible to get enough energy to prevent rapid weight loss.

Prioritising nutrient-dense foods is the secret to obtaining the nutrients you need with the lowest energy intake.  If you don’t want to keep losing weight or want to run a marathon then adding some higher energy density foods will be useful.

High carbohydrate foods are not  nutritious

After watching the Mastering Diabetes teleseminar, you will get the feeling that the Mastering Diabetes guys believe carbohydrate can do no wrong and we should only fear fat.

The reality, however, is that the foods with the least fat are generally even more nutritionally corrupt than the highest fat foods.

Not all of the low-fat foods are going to be beneficial.

Defining your nutritional approach as ‘high carbohydrate’ is not wise, especially if you are trying to manage diabetes.  The foods with the most carbohydrates in our food system are typically very nutritionally deficient as well as highly insulinogenic.

If a ‘low carb diet’ leads you to avoid processed foods you may be better off.  However, I don’t think defining nutrition in terms of macronutrient extremes is particularly useful. [6]

Plant-based versus animal-based foods

One area where vegans potentially have it over carnivores is vitamins and minerals.  As shown in the chart below, a zero carb diet does not provide really high levels of many nutrients.

2017-06-26-5[1]

At the same time, there are plenty of people who appear to be thriving on a zero carb dietary approach.  Many people with severe autoimmune related digestive issues succeed when they switch to a zero carb approach.   Zero carb advocates will also tell you that they don’t need the recommended daily intake levels of the various micronutrients that are based on limited data or deficiency studies in people eating a standard high carb western diet.

2017-06-26-4[1]

A plant-based diet can provide a reasonably nutrient dense outcome.  However, it will be hard to get adequate levels of omega 3, vitamin D and vitamin B-12.  People following a strictly plant-based approach may need to supplement with these nutrients.

Achieving the minimum protein intake levels is possible.  However, many people have concerns about the reduced bioavailability of plant based proteins and whether or not the minimum protein intake levels are actually optimal, particularly if you are active or older.

It’s also worth noting that other nutrients such as iron, vitamin A and omega 3 will be more bioavailable from animal-based sources.  So it’s not as simple as comparing the nutrients in the food, what gets into your body is what really matters.

If you are going to follow a plant-based diet then prioritising the food listed below will give you the best chance of success.  Most people are going to do best somewhere on the spectrum between exclusively plant-based and solely animal-based foods.

The real problem comes when we start to heavily process our food.  Rather than prioritising the most nutrient dense and minimally processed vegetables, fruits and legumes, many vegans end up living on processed grains, cereal, sugar and soy products that have been treated with a host of fertilisers and pesticides.  Meanwhile, many zero carbers or keto peeps end up living on nothing but bacon or processed meats from animals that were fed nutrient poor corn and grains with added antibiotics to make them grow quicker.

The vegan echo chamber

I have spent a good chunk of time hanging out in many vegan or plant-based groups trying to understand their position and gain insights about nutrient density.  I have learned a lot from people like Professor Christopher Gardner, Ray Cronise and Dr Joel Fuhrman.  Much of the analysis in this is based on the integration of my learnings their work with Dr Richard Bernstein and Dr Matt Lalonde.

Unfortunately, it seems that the vast majority of vegan/plant-based education comes from Dr Michael Greger through his sanitised, highly processed and hyper-palatable “Nutrition Facts” videos.

While Greger covers a lot of relevant research and raises some valid points, a lot of the time he seems to twist the science to ensure that the moral of the story is always ‘eat plants, not animals’.  Plant-based is better.  Eating animals will be bad for your health.

Without evolutionary context, we are asked again and again to believe that fat (particularly saturated fat) and ‘animal protein’ (whatever the hell that is!) is the primary cause of heart disease, the complications of diabetes and practically every other modern health ill.

There is no demonstrated biochemical mechanism provided as to how we suddenly became allergic to animal products.  Meanwhile, vegans advocates generally give a free pass to sugar and processed grains.

With more than six million views and an estimated earnings of more than $100k per year from YouTube[7] (not to mention donations[8]), there appear to be a LOT of people eager to lap up the nutritional and medical justification of their ethical position.

Greger’s unique ‘interpretation’ of the scientific data all starts to make sense once you understand that he is the Director for Public Health and Human Agriculture for the Humane Society International.[9]

The mission of the Humane Society is to celebrate animals, confront cruelty and shape public opinion.

I wonder if Greger does his researching, writing, filming and editing the Nutrition Facts videos as a hobby after he gets home after working 50 hours a week and commuting?   Or perhaps he creates these videos as an employee of the Humane Society as part of their stated goal to shape public opinion on animal cruelty?

It seems Mangoman and Robby are pretty tight with Greger.[10]  Makes me wonder if Mastering Diabetes is a coordinated and strategic assault by the Humane Society on the low carb/keto/diabetes community who have become immune to Dr Greger.

I am by no means advocating animal cruelty.  However, as a human,  if you are looking for the best advice on human nutrition, is it wise to put your blind faith and unswerving trust in someone whose explicitly stated primary goal is animal welfare?

Do you really want to save the planet?

Worrying about whether we eat plants or animals exclusively is a modern luxury, an intellectual indulgence of sorts.

For the majority of human history, we have been opportunistic omnivores.  When plants were the only thing that was available, we would eat them.  When we could, we would chase down an animal to get the protein we need to thrive.  We never had to worry about nutrient density because the foods we ate grew in fertile soil without pesticides.  The animals we ate were eating their natural foods which were also nutritious for them.

Humans thrived and were able to populate the world because we learned to hunt, store, cook and process food.  We became very good at getting the nutrients we needed with the minimum amount of effort.[11][12] [13]

Unfortunately, we have now become too good at processing food.

Many of us are now fantasising nostalgically about Paleo times.

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It’s one thing to worry about saving animals, but ultimately we need to save the planet and our human race from accelerated extinction.

Our newfound ability to harvest fossil fuels enables us to move around in cars and grow a massive amount of food with chemical fertilisers.  These foods grow quickly and give us plenty of energy, but few nutrients that we then process and feed to animals or humans.[14]

Take a moment to think about how your life would be different if we had never discovered fossil fuels (e.g. coal or oil).  For as long as it lasts we are gorging ourselves on stored energy that is making us lazy and obese and driving not just us, but life as we know it to an early grave. If you want to care about something it should be the sustainability of the global environment (including animals and humans).

If you want to care about something it should be the sustainability of the global environment (including animals and humans).

While humans are probably the biggest threat to the long-term sustainability of earth as we know it, most of us aren’t willing to volunteer ourselves or our family as the first ones to check out to save the planet.

[If you want some challenging thoughts on this topic you should check out Daniel Vitalis’ Why I Hunt podcast.]

The plural of anecdote is not data

So, finally, onto the Mastering Diabetes video.

Cyrus and Robbie look like genuinely nice guys.

They are both living with type 1 diabetes.

They look like they’re happy and thriving on a plant-based diet full of fruits and vegetables.

To be honest, they look a lot healthier than many recovering diabetics in the low-carb scene.

But at the same time, the zero carbers will hold up anecdotes of people who have not eaten a plant for decades and look as great as the Johnson Family.

Or Dr Shawn Baker who is setting world records as a masters athlete since cutting plants out of his diet.

Then the keto folks will point to Dr Dominic D’Agostino who thrives on high fat and exogenous ketones and is exceptionally smart and can lift very heavy stuff at the same time.

 [15]

While it’s useful to look at populations of people following a particular diet to look for trends, anecdote does not equal data.

It is more useful to look at underlying metrics (such as nutrient density and insulin load) that we can use to identify the optimal diet for humans.

I thought they would know better

Cyrus Khambatta is a smart guy.  He was studying mechanical engineering at Stanford before he got type 1 and changed course to study nutritional biochemistry.

However, for all his ability in nutrition, engineering and mathematics (I took those classes, and I know how hard they are!), I thought he would have more to offer than what was presented!

People with diabetes get screwed around by the mainstream medical system and ‘diabetes education’ system.  The system doesn’t really understand how it works, so they give them bad advice (e.g. “just eat like we tell everyone else to and cover it with insulin”)!

I remember clearly the anxiety and confusion we experienced after going to an appointment with the hospital endocrinologist when my wife Monica was pregnant with our daughter.

At her visits, she would routinely be told that she needed to reduce her blood sugars to avoid the many serious risks and complications and risks for her and the baby.  Monica asked what else she could do to get the blood sugars down, but they had no advice.  They just wanted to see them lower.

We now have two healthy and wonderful kids, but I if I can I would love to see other people spared the anxiety as well as minimise the genuine health risks related to diabetes.  Hence my quest to understand how we can make intelligent food choices to optimise blood sugar and insulin levels.

What is the actual relationship between insulin and the food we eat?

The food insulin index data is a highly valuable resource that helps us to understand what causes us to secrete insulin and our blood sugars to rise.   The chart below shows the results of the food insulin index testing on more than 100 different foods (click to enlarge).

The food insulin index testing demonstrates clearly that we have the lowest insulin response to fats and oils while we have the highest insulin response to high carbohydrate foods like jelly beans and rice bubbles.   However, when we plot this data, we see that carbohydrate does not fully explain our insulin response.

We get a much better prediction of our insulin response when we account for protein (which requires insulin to metabolise) and non-digestible fibre.

Eating more fat will decrease the amount of insulin required to keep our blood sugars stable.

Eating more protein will reduce the amount of insulin your pancreas has to produce because it will push the more insulinogenic processed carbohydrates and sugar out of your diet.

How to improve your insulin sensitivity

If you reduce your intake of processed carbs and sugars, your insulin requirements will come down.  Once your organs and muscles are no longer swimming in insulin, you will become more insulin sensitive (just like you become more sensitive to coffee or alcohol if you cut back your intake).

If you are injecting insulin, reducing the insulin load of your diet will enable you to significantly reduce your insulin dosage which will, in turn, allow you to more easily access your own body fat stores for fuel.[16]

This data is an inconvenient truth for both high carb vegans or the nutritional recommendations such Food Pyramid / My Plate generated by the US Dept of Agriculture.  But I think it could be beneficial for people who want to effectively manage their diabetes.

Granted, if you switch your processed grains and sugar for fruits and vegetables, you will do better.  But is it really optimal?

If you can’t win, move the goalposts!!!!

So what do you do if you can’t win with science?

You change the rules!  You move the goalposts.

It was Cyrus and Robby’s unique definition of insulin resistance that really frustrated me.

So you can understand my frustration, I need to explain the difference between basal and bolus insulin which is a daily reality for someone with type 1 diabetes.

  • Bolus insulin is taken with food and is proportional to the insulin load of the food they eat (i.e. carbs – fibre + half protein)[17].
  • Basal insulin is the insulin that your pancreas would produce through the day and night whether or not you eat anything.  It’s the basal insulin that keeps your fat in storage and your muscles from being used for fuel.

You need both, but their function is different.

For someone eating a standard western diet about one-third to a half of their insulin will be basal insulin with the majority being bolus insulin for the food you eat.

When you switch to a low carb or keto diet this ratio flips and the majority of your insulin is basal insulin.  You only need a little bit of bolus insulin to cover the small amount of carbohydrates and protein that you eat.   With less glucose to deal with, you don’t need as much insulin, and your blood sugars stabilise.[18]

A significant portion of the Mastering Diabetes video was devoted to explaining their new creative definition of insulin sensitivity.  The fundamental problem with this central piece of the Mastering Diabetes argument is that it conflates basal and bolus insulin.  Your basal insulin is irrelevant if you are trying to do this sort of insulin sensitivity calculation!

It’s just the bolus insulin (i.e. for food) that matters when it comes to insulin sensitivity.  The calculations in the table below demonstrate my point.   If you take the denominator to your insulin sensitivity calculations to be the basal + bolus insulin, then the high carb approach has a better insulin sensitivity.  If you only consider the bolus insulin (the only sensible approach in my view), then you declare the low-carb approach to be the winner.

  low carb high carb conclusion
ISF (g carb/unit insulin) 6 5
carbs (g) 50 500
bolus insulin (units) 8.3 100
basal insulin (units) 20 20
total daily insulin (per day) 28 120
24 carb / 24-hour insulin (basal + bolus) 1.8 4.2 High carb is better
24 carb / 24-hour insulin (bolus only) 6.0 5.0 Low carb is better

The chart below shows the difference in the daily blood sugar fluctuations of someone on a standard western diet and then after switching to a lower carb diet.  The difference in the blood sugar levels is night and day!  The difference in the quality of life between these two situations when it comes to energy levels, anxiety, depression, mood etc. is also immensely different.

I pinged Mastering Diabetes on their Facebook page to clarify if the cornerstone of their whole argument includes basal and bolus insulin.  Unfortunately, my fears were confirmed (though they have since deleted their response and kicked me out of their Facebook Group).

Tight blood sugar control isn’t that important after all?

The next argument they try to run is that tight blood sugars really aren’t that necessary.

Cyrus (who is very active and practices intermittent fasting) has a Hba1c in the high 5s.

Robbie has a Hb1c in the low 6s.

Granted, this is good compared to the majority of the Type 1 population. They’ll have a better chance of thriving with good blood sugars if they are eating lots of vegetables and fruit compared to more processed grains and sugars that make up the typical diet.  But it’s still a far cry from the blood sugar control of people following the type of low-carb approach advocated by Dr Richard Bernstein.

The problem I see with defining your diet as vegan or plant-based is that most people don’t have the self-discipline to stick with eating only vegetables and fruit and end up filling up on more processed (but still technically vegan) processed junk food.

Cyrus and Robbie argue that normal blood glucose fluctuations are between 70mg/dL to 145 mg/dL or 3.8 to 8.0mmol/L.

The problem with this argument is that what currently passes for ‘normal’ is far from optimal.[19]  Complications from diabetes start to kick in well below what is widely considered “normal”.


Just because it’s normal for most people to do Facebook on their phone while they drive doesn’t mean it’s ideal or optimal.  Just because it’s normal to have poor blood sugar and most people are dying of metabolic diseases doesn’t sound like a persuasive argument for plant-based diet being optimal to me!

If you’re happy to settle for less than optimal blood sugar control because you have a strong ethical position, then that’s fine, but don’t construe it as optimal for everyone when it’s not.

The reality is that many people over at Type 1 Grit following Dr Bernstein’s approach are doing fabulously!  Not everyone will achieve optimal, but it’s useful to know what to aim for and how to get there.

If you had a child or loved one with Type 1 diabetes would you want the opportunity to choose the approach that would yield the best results or would you prefer your advice to be tainted with ethical or commercial bias?

Check out the video the Type 1 Grit group put together for Dr B’s 83rd birthday to thank him for changing their lives.

Insulin resistance and metabolic syndrome are a big deal, so let’s not ruin more lives than we need to with bad advice that is based on bad math or putting ethical convictions or religious beliefs ahead of human health.

Understanding physiological insulin resistance

Cyrus and Robbie argue that someone on a low carb diet won’t deal with carbohydrate well when they are exposed to them.  This phenomenon is real, but is typically due to what is termed ‘physiological insulin resistance’.

Someone who eats a lot of carbohydrates will have high levels of insulin floating around in their bloodstream.  Then when they eat a carb bolus, their pancreas is primed to shoot out some more insulin to mop up the glucose and stop more glucose being released into the bloodstream via the liver.  By contrast, someone who doesn’t eat a lot of carbohydrates will have low levels of insulin in their bloodstream and need to wind up their pancreas to produce insulin to bring down the glucose.

This phenomenon is also referred to the first phase versus second insulin response.  Someone who is not eating a lot of carbs will have a slower first phase insulin response.

It’s like comparing someone’s time over 100m when they are starting from a standstill versus someone using a rolling start.  It’s not a relevant comparison.  This phenomenon will go away after a few days on a high carb diet.

At the same time though, micronutrients such as potassium, magnesium and calcium are critical to maintaining healthy insulin sensitivity and glucose uptake.   Metabolic acidosis (caused by a lack of dietary electrolytes) appears to cause an upregulation in insulin by the pancreas to hold onto precious electrolytes.  Over the long term, this could be another driver of insulin resistance, metabolic syndrome and diabetes. [20]

Getting adequate dietary electrolytes from green leafy vegetables will make it easier for our body to maintain acid/base balance.  However, I don’t think we need to feed all diabetics a high carbohydrate exclusively plant-based diet to achieve this.

Eating fat makes you fat?

The vegan community seems to confuse eating fat and storing fat.  The Ancel Keys / vegan story is that we store fat in our body because we overeat dietary fat.  However, the reality is that we get fat because we eat more than we burn.

As shown in the graphic below from Ray Cronise’s Oxidative Priority paper, we will only burn fat (from our body or diet) once we’ve burned through the alcohol, ketones, protein and carbohydrate and fat that we eat (in that order).[21]

When we eat our body prioritises the refilling of our glucose and glycogen stores in our blood stream and liver (which can hold about 1200 to 2000 calories) before we start to store the excess energy in our adipose tissue.  Our body fat stores can hold a lot more energy, but not an unlimited amount.  Once our fat stores are full and can hold no more, they become insulin resistant.  We then start to store the excess energy in our vital organs such as our liver, kidney, brain, eyes, heart, etc.

The trick to weight loss is to keep your blood sugar levels low enough so that your liver glycogen is being replenished from your body fat rather than always having overfull glycogen stores, so we need to offload excess energy to our fat stores.[22]

One of the many roles of insulin is to shut off the flow of stored energy from the liver into the bloodstream.  If energy is coming in the pancreas will upregulate insulin to stop the flow of glucose from the liver back into the bloodstream (regardless of whether you’re eating carbs, fat or protein from animal or plant-based sources).  The best way to reduce insulin is to stop eating and let your stored energy flow back into your bloodstream.

In a way, you can think of your liver as your fuel tank and you your blood glucose meter as the fuel gauge.  If your blood sugars are high, you should think twice about whether you really need more fuel now.

If you are insulin sensitive, the bad news is that you can easily store excess energy as body fat very efficiently.  Insulin is an anabolic hormone that will help you to grow.  However, when you are insulin sensitive, you can lose fat relatively quickly when you reduce energy intake.  If you are insulin sensitive your circulating insulin levels will be low, and fuel will more easily flow from storage.  Hence you won’t be such a mindless slave to your uncontrollable appetite.

If you are insulin resistant and have high levels of circulating insulin, you may struggle to release your stored body fat.  Your appetite will drive you to seek out food because you can’t efficiently access it from your body stores.   You won’t be able to go very long between meals.

A low-carb diet can be helpful for someone who is insulin resistant because it can help lower insulin which in turn help them to normalise their appetite.  Teaching that we get fat because we eat fat is just outdated science.

Even Dr Joel Fuhman will tell you that actively avoiding fat is stupid.  He will also tell you that there is some value in eating fish on a regular basis to ensure you get adequate amounts of omega 3s and vitamin B-12.

Complications on a ketogenic diet

There are plenty of studies that show the shortcomings of a ketogenic diet.  Sarah Ballantyne did a great job of summarising these on her Paleo Mom Blog here.

When you look in detail however you find that the adverse reactions the ketogenic diet are typically due to ‘keto in a can’ formula products.

While these food substitutes will help achieve therapeutic ketosis to help manage epilepsy or other chronic conditions, many of these keto formula products end up being very low in micronutrients.[23]

Obtaining a significant amount of your energy intake from processed food-like products that have been separated from nutrients is not a good idea (e.g. whether it be sugar, processed grains, refined oils or exogenous ketones).

Is a low-carb diet actually good for diabetes?

Unfortunately, Cyrus and Robby didn’t mention the benefits of a low-carb diet for people with diabetes which are fairly well documented.  The seminal paper that summarises much of the latest work in this area is documented in Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base.

Anyone who is on the fence about using a low-carb diet to manage diabetes should check out this paper which shows that a low-carb diet is better for weight, HbA1c, glucose, HDL and triglycerides compared to low GI or a grain-based diet.

Another well-known study is Christopher Gardener’s A to Z trial[24]  where they found that the Atkins diet did much better than the low-fat, particularly if you were already insulin resistant.[25]

Image result for atkins at to z

What should you eat if you are a vegan with diabetes?

So, after all this, what should we eat to maintain optimal blood sugar levels?  Cyrus and Robby’s view is shown below.    Unfortunately, it appears that their recommendations are driven more by their philosophical and ethical views rather than the nutrient content of the food or their ability to stabilise blood sugars.

  • In the green column, most people with diabetes aren’t going to do too well with a lot of fruits, starchy veggies, and beans. Intact whole grains do contain substantial nutrients but are very hard to find in our modern food system.  Who actually eats wheat bran as a significant part of their diet?  The vast majority of grains are processed with the nutrients discarded, so they are tasty and shelf stable.
  • In the red column, dairy eggs, meat, fish and poultry can be nutrient dense and keep your blood sugars stable (as long as you’re not afraid of fat in whole foods or ‘animal protein’).
  • In the orange column, higher fat foods like nuts, seeds, avocados, coconut and olives can be useful to help stabilise your blood sugars, but it is possible to overconsume them if your goal is to lose weight.

We want to maximise nutrient density as much as possible while keeping the insulin load of our diet down to the point that we keep blood sugars stable.

This does not end up being super high fat or super low fat.  Fat just comes along with nutritious whole foods.

If you have diabetes, then a little more dietary fat initially may help to stabilise blood sugars.  Once your blood glucose levels have stabilised, you can start to decrease the dietary fat and increase nutrient density as much as you can while still maintaining excellent blood sugar levels.

A low insulin load diabetes-friendly plant-based nutritional approach will be lacking omega 3 and vitamin B-12.

The shortlist of nutrient dense low insulin load plant-based foods is shown below.  The foods at the top of each section should be reasonably safe for most people with diabetes.  You should test your blood sugars to see how you respond to some of the foods further down the list.

Many people who are conscious of animal welfare will eat fish (i.e. pescetarian).  Adding some fish will provide a much better nutritional profile than eating plants alone, with plenty of vitamin B12 and omega 3 available from the seafood.

I hope this is helpful for people who want to choose a plant-based approach to maximise nutrient density and maintain excellent blood sugar control.

If you’re still confused, I have designed the Nutrient Optimiser to identify what foods you should add or remove from your diet to ensure you are getting the nutrients you need while maintaining excellent blood sugar levels.

So which approach is optimal?

It depends.

The optimal approach for you will depend on your situation and goals.

Going plant based may be an improvement if your diet is currently full of sugar and processed grains, but it is not the singular solution to every ill.  (For an excellent example of a very nutrient dense plant-based dietary approach check out David’s Nutrient Optimiser analysis here.)

To help you make more informed food choices, I have devised two different ways of measuring food quality:

  • Proportion of insulinogenic calories, and
  • Nutrient density.

The proportion of insulinogenic calories is the percentage of the food you eat that will require insulin to metabolise.  The table below lists a range of nutritional approaches ranked by the percentage of insulinogenic calories (right-hand column).

If you’re interested in any of these approaches, you can download the list and save it to your phone or print it out to take shopping for some inspiration.

approach pdf foods nutrient profile % insulinogenic
well formulated ketogenic diet pdf foods profile 21
low carb pdf foods profile 34
plant based (diabetes friendly) pdf foods profile 56
weight loss and insulin resistance pdf foods profile 59
low carb pescitarian pdf foods profile 61
the most nutrient dense foods pdf foods profile 67
plant-based pdf foods profile 68
plant based (without ND) profile 73

Simply switching to a plant-based nutritional approach will leave you with 73% of your diet requiring insulin to metabolise.  The diabetes-friendly plant-based approach will be an improvement, but a low-carb or ketogenic diet may be better if your goal is stable blood glucose levels.

Another way to look at things is nutrient density.  You may have noticed the nutrient profiles shown above have a red dotted box.  If a particular nutritional approach provides two times the Daily Recommended Intake for all essential nutrients, then you would get a perfect score of 100%.  You can see below that the most nutritious foods below are pretty close to 100%.

By contrast, if we only focus on ‘plant-based foods’ nutritional outcome is not so flash.  Thinking only in terms of plant-based is not automatically nutrient dense.

I have sorted the various food lists in the table below based on their nutrient score.  My suggestion is to start at the top with the most nutrient dense foods and work your way down until you find an approach that suits your ethical framework or religious beliefs that will also enable you to stabilise your blood glucose levels (i.e. lower % insulinogenic calories).

approach score pdf foods nutrient profile % insulinogenic
the most nutrient dense foods 99.7% pdf foods profile 67
weight loss and insulin resistance 99.3% pdf foods profile 59
low carb pescitarian 94.5% pdf foods profile 61
low carbohydrate 81.0% pdf foods profile 34
plant based 78.0% pdf foods profile 68
plant based (diabetes friendly) 76.0% pdf foods profile 56
well formulated ketogenic diet 74.0% pdf foods profile 21
plant based (without ND) 57.0% profile 73

Summary

  • While many people chose exclusively plant-based foods, they are not necessarily a better dietary choice compared to a more varied diet.
  • Someone following an exclusively plant-based approach will require supplementation with vitamin B-12, vitamin D and omega 3s.
  • Fat is not necessarily good or bad. Swinging to macronutrient extremes will not lead to an optimal outcome.
  • Reducing the insulin load of your diet will help to normalise your blood sugar and insulin levels.
  • Ideally, you should aim to achieve the blood sugars of a metabolically healthy person while maximising nutrient density at the same time.

 

references

[1]https://www.ncbi.nlm.nih.gov/pubmed/25515001

[2]https://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

[3]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC301822/

[4]https://www.quackwatch.org/01QuackeryRelatedTopics/DSH/coral2.html

[5]https://authoritynutrition.com/the-alkaline-diet-myth/

[6]https://optimisingnutrition.com/2017/03/19/micronutrients-at-macronutrient-extremes/

[7]https://socialblade.com/youtube/user/nutritionfactsorg

[8]https://nutritionfacts.org/donate/

[9]http://www.hsi.org/about/who_we_are/leadership/subject_experts/michael_greger.html

[10]https://www.facebook.com/mangomannutrition/videos/656469947843978/

[11]https://optimisingnutrition.com/2016/10/23/energy-density-food-hyper-palatability-and-reverse-engineering-optimal-foraging-theory/

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

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

[14]https://www.amazon.com/Dorito-Effect-Surprising-Truth-Flavor/dp/1476724237

[15]https://fineartamerica.com/featured/8-muscleart-marius-poser-classic-jake-hartz.html

[16]https://www.ncbi.nlm.nih.gov/pubmed/21241239

[17]https://optimisingnutrition.com/2015/08/10/insulin-dosing-options-for-type-1-diabetes/

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

[19]https://optimisingnutrition.com/2015/07/20/the-glucose-ketone-relationship/

[20]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC301822/

[21]http://online.liebertpub.com/doi/full/10.1089/met.2016.0108

[22]https://optimisingnutrition.com/2016/02/15/how-to-use-your-glucose-meter-as-a-fuel-gauge/

[23]http://ketotalk.com/2016/06/23-responding-to-the-paleo-mom-dr-sarah-ballantynes-claims-against-the-ketogenic-diet/

[24]http://jamanetwork.com/journals/jama/fullarticle/205916

[25]http://onlinelibrary.wiley.com/doi/10.1002/oby.21331/full

 

post udpated September 2017

 

 

which nutrients is YOUR diet missing?  

I recently took a look at which nutrients might be missing from various popular dietary approaches in preparation for a recent on nutrient density.  At a population level, the chart below shows the proportion of the US population that are deficient in various micronutrients.  Many people are not getting enough vitamin D, vitamin E, magnesium, calcium, etc.

While your body hasn’t read the World Health Organisation’s reports on the Daily Recommended Intake of the various essential nutrients,[1] it’s likely that your appetite will drive you to seek out the nutrients that are lacking.  If we are deficient in something that is required the body kicks in “nutrient hunger” and cravings that will make sure it gets what it needs.[2] [3] [4]

If you work hard to restrict your food intake to a certain dietary approach, but the body doesn’t receive the nutrients it needs, it may slow down and not function at full capacity.   By contrast, adequate nutrition, without too much energy, slows many of the modern diseases of aging such as diabetes, Alzheimer’s and cancer and improves your chance of living healthfully to a ripe old age.[5]

USDA foods database

The chart below shows the nutrients that are both easiest and hardest to obtain from the eight thousand foods in the USDA foods database.  At the bottom of this plot we have iron, various amino acids, and vitamin C, all of which are easy to obtain in adequate quantities.

However, at the top of the chart, we can see that it is much harder to obtain adequate quantities of six essential nutrients (omega 3 fatty acids, vitamin D, choline, vitamin E, and potassium).  We would obtain sufficient quantities of all the other essential nutrients if we ate just a little of each of the foods in the USDA food database.

If we want to maximise nutrient density, it makes sense to prioritise foods that contain more of the harder-to-obtain nutrients.  The chart below shows the nutrients for the top 10% of the 8000 foods in the USDA database (blue bars) when we prioritise for those.  Not only do we get an increase in the more difficult to obtain nutrients, we also get a massive boost in all nutrients.  Rather than being inadequate in six nutrients, we are now lacking only one (alpha-Linolenic acid, an Omega 3 fatty acid).

Limiting our food selection to the most nutrient dense foods makes it easier for us to consume the required nutrients without excessive energy, which is ideal if we are trying to lose fat or reduce calorie intake to slow the diseases of ageing.[6] [7]  Nutrient density becomes even more important if you’re fasting or restricting calories to achieve long term weight loss.

Optimising nutrient density

If you’re reading this, then you’re likely aware that there is a wide variety of dietary approaches that people follow to optimise their health depending on their preferences and beliefs.

I’ve tried to turn many of these beliefs about nutrition into a quantitative algorithm that we can use to evaluate and compare these approaches, and make sure we’re getting the outcome we want (e.g. low insulin, blood glucose control, nutrient density, or low/high energy density).

After testing a number of options, the three quantitative parameters that I have found the three parameters that are most useful are:

  • insulin load,
  • nutrient density, and
  • energy density.

My aim in this post is to show how considering nutrient density can improve various dietary approaches, from therapeutic ketogenic, vegan, paleo, and low fat.   This post highlights which nutrients you will most likely be lacking with each of the different nutritional approaches, which foods you can use to fill these nutritional gaps, and perhaps which supplements you may need if you are still looking for some added nutritional insurance.

There’s been a lot of talk lately by Taubes[8] and Lustig[9] about how bad sugar and fructose are, but I think these nutritive sweeteners are just extreme examples of nutrient poor foods that are highly insulinogenic and energy dense.  At the other end of the spectrum, we have foods like liver, broccoli, and spinach.  Everything else is somewhere in the middle and will support or work against your goals, whatever they may be, to different degrees.

My aim here is to help you see where each of these foods sits on that continuum and use this information to help you refine your food choices to reach your personal goals.

Therapeutic ketogenic diet

Let’s start with the therapeutic ketogenic dietary approach.   I have previously noted that a number of the issues and concerns with the ketogenic diet seem to relate to being able to obtain essential nutrients rather than consuming excessive levels of fat.[10] [11] [12]  On one hand, I’m excited that the concepts of insulin load and percentage of insulinogenic calories have been helpful for people with chronic conditions such as epilepsy, cancer, dementia, Alzheimer’s etc.  However, I think there is a risk their ultra-high fat diet will not contain the nutrients which are critically important for mitochondrial function and energy production.

The chart below shows the vitamins and minerals provided by a therapeutic ketogenic dietary approach if we simply prioritise for low insulin load (red bars)[13] in comparison to the average of all foods in the USDA database (orange bars).  If you don’t pay attention to nutrient density a therapeutic ketogenic diet can provide lower levels of nutrition.

As shown in the chart below if we ate a little of all the foods in the USDA database, we would be deficient in six essential nutrients, whereas if we follow a therapeutic ketogenic diet, we will likely be lacking in ten essential nutrients.

The chart below shows the effect of how thinking in terms of nutrient density can improve the therapeutic ketogenic dietary approach (blue bars) compared to prioritising for insulin load only (red bars).  All nutrients are boosted, particularly the harder to obtain ones.

While lots of people find that higher fat whole foods are hard to overeat, there are still some hyper palatable high fat foods that go down easily.  We talk about eating “fat to satiety”, but what happens when nutrient hunger kicks in and your body is craving more potassium, magnesium, calcium, or one of the other nutrients that are harder to obtain in a very high fat dietary approach?  If you keep on consuming large amounts of processed fats that don’t contain the nutrients you require, your appetite may not automatically turn off before you’ve consumed a lot of excess energy!

Low carb

The chart below shows the boost in nutrients when we consider nutrient density combined with a low carbohydrate approach.  It appears that, based on this analysis, that without a focus on nutrient density, a low carbohydrate diet is likely to be deficient in folate, vitamin D, choline, potassium, magnesium, pantothenic acid, calcium, vitamin E and manganese.  With a focus on nutrient dense foods, a low carb diet provides adequate amounts of the majority of nutrients.

Weight loss (insulin sensitive)

The weight loss approach is intended for people who are insulin sensitive but still have excess body fat to lose.  Foods with a lower energy density (e.g. spinach, broccoli cucumber, celery, lettuce etc) typically are harder to overeat because they are bulky.

This approach doesn’t pay any attention to insulin load because it is assumed that people using this approach are not insulin resistant and are able to maintain good blood glucose levels.  Practically, it’s also difficult to achieve a really high insulin load with these foods because they do not contain a large amount of processed carbs and are hard to overeat.

Without consideration of nutrient density, the essential fatty acids tend to be low along with vitamin B-12, choline, and tyrosine.  However, once we factor in nutrient density all these nutrients dramatically improve.

This approach may not be viable for long term maintenance due to the extremely low energy density which would make it hard to get in enough energy.  However, in the short term, it may be appropriate for a period of substantial energy restriction, and will provide maximum nutrition with a minimum amount of energy.

Zero carb

Getting adequate protein on a zero-carb approach is not a problem.  However, unless there is a major focus on organ meats, there are a large number of vitamins and minerals, such as   vitamin K, manganese, vitamin C, vitamin E, vitamin D, potassium, magnesium and calcium that may be worth supplementing.

Vegan

At the other extreme, the chart shows the nutritional analysis of the vegan diet.  The main deficiencies in a vegan approach are omega 3s and vitamin B-12, which are hard to obtain without animal products.  It may be prudent for vegans to consider fish oil supplementation and B-12 injections, or alternatively adding some seafood occasionally.

While it appears possible to obtain the recommended levels of protein, it’s hard to get very high levels of it.    If you are insulin resistant, the fat levels can be increased using added coconut products and nuts.

Higher insulin load foods for bulking

The bulking approach is designed for people who are looking to gain strength and size by combining nutrient density with more calories and insulin load.  Without consideration of nutrient density, a high insulin load means very low nutrient density foods.  However, once we factor in nutrient density, we get a range of highly nutritious foods that may be helpful if you want to gain size and strength, while still maximising health and nutrition.

Paleo

The chart below shows the nutrients provided by the Paleo approach (i.e. no processed foods, dairy or grains) both with and without consideration of nutrient density.  While ‘going Paleo’ eliminates many of the nutrient-poor processed food, it appears to be beneficial to also consider nutrient density as well in addition.

What does this all mean?

So, how do we decide which approach is best?  Unfortunately, it’s not straightforward so I’ll look at this a number of ways.

What we ideally want is to identify the foods that will provide us with high amounts of all of the nutrients.   The blue bars in the chart below represents the average of the % daily recommended intake of all the nutrients in the various approaches evaluated above, without considering nutrient density.  The orange bars represent the average minus 0.5 x the standard deviation which is a measure of reliability.  The higher the reliability the more consistent and high are the nutrients over all.

This chart shows that, in comparison to the other approaches, Paleo foods have a high and consistent level of nutrients; while the vegan and low energy density weight loss foods have high levels of some individual nutrients, but low levels of some others.  Without consideration of nutrient density, the high insulin, low carb and zero carb approaches are a bit lacking in nutrients.

Things become a little more interesting once we factor in nutrient density.  The vegan, therapeutic keto, low carb and zero carb approaches do poorly against the paleo, higher insulin load, most nutrient dense of all foods, and the lower energy density weight loss foods.

Many people will benefit on a high fat therapeutic ketogenic dietary approach, at least until their blood glucose and insulin levels normalise.  However, in time, it may be beneficial to transition to more nutrient dense foods to continue their journey towards optimal health.

As detailed in the ‘how to optimise your diet for insulin resistance’ article, I think you should eat the most nutrient dense foods your pancreas can keep up with while maintaining good blood glucose levels.  In time, someone who is highly insulin resistant may be able to progress to a more nutrient dense and more moderate fat approach if your ultimate goal is to normalise blood glucose levels and lose weight.

Food lists

If you identify with any of these goals, you may be interested in following these food lists.   If blood glucose levels are sky high or you are managing a chronic condition such as epilepsy, cancer, Alzheimer’s or dementia, you may benefit from a higher fat therapeutic keto dietary approach, for a period.  As your glucose levels come under control, you can transition to more nutrient dense foods that will also help you to achieve your weight goals.

approach average glucose waist : height

(mg/dL)

(mmol/L)
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

Getting even more personal

As you can see, nutrients are provided at different levels depending on the approach.  However, most people don’t follow any dietary approach strictly, so the nutrients in your diet will be different depending on your personal habits and preferences.

Rather than trying to pick up someone else’s nutrition plan, or live by a strict list, I think it’s better to refine your current habits, emphasising the good foods, minimising the bad, and progressively trying new foods that may be beneficial.

To this end, I’ve been developing a Nutrient Optimizer algorithm that can help you refine your food choices to suit your goals.  By identifying the foods you are currently eating that align most with your current goals, which ones don’t, and which new foods perhaps you should consider.

Most current nutritional advice is driven by the avoidance of fat, particularly saturated fat, and therefore ends up being next to useless.  Calorie counting apps like MyFitnessPal does nothing but count calories, which is also of limited use.  Cron-o-meter tracks your micronutrients and can recommend foods to boost a single nutrient.  However, there doesn’t seem to be anything available that will tell you which foods will help you actually correct multiple deficiencies and  achieve a diet that is truly balanced in micronutrients.

The Nutrient Optimiser also allows you to tailor the approach to your goals, such as:  therapeutic ketosis, diabetes management, weight loss or just nutrient dense maintenance.  Food preferences like vegan, pescetarian, autoimmune, or paleo can be factored in to the recommended food lists.

At the moment, the process involves manually exporting food intake data from Cron-o-meter, then analysing it in a spreadsheet to manually generate a personalised report.  I am eager to do this as a proof-of-concept for a range of people with various goals (particularly therapeutic ketosis, vegetarian, zero carb, fruitarian) to demonstrate how it works.  So, if you’re happy to have your report shared publicly, and have a couple of weeks of Cron-o-meter data, feel free to send it to me and  have your data analysed.

In time, the plan is to automate the process via an online interface and then ideally an independent mobile app.    To keep up-to-date with progress, watch this space and check out the various analysed examples on the Marty Kendall’s Nutrient Optimiser Facebook page.

Epilogue…  limitations

For completeness, I thought it would be worth mentioning a few limitations relating to calculating nutrient density…

  1. Measuring foods in terms of calories has its own limitations as different macronutrients provide different amounts of energy (ATP) in different people. Some smart friends of mine are working on calculating ATP yield for different foods based on their macronutrient content.  I’ll happily update this analysis in terms of nutrients per ATP as soon as that data is available.  Initial indications are that people who are fat-adapted are able to use fat more efficiently (i.e. less entropy/losses in metabolism) and hence require less calories to yield the same amount of energy in the body (i.e. ATP).  Hence, it appears that it is even more important for someone following a low carb or ketogenic approach to maximise nutrient density in terms of nutrients per calorie.
  2. The official dietary reference values are based on limited research.[14] Typically, they relate to the minimum amount of a nutrient to avoid disease rather than the amount required for optimal function.  They may also vary by person (e.g. someone who is more active may need more protein) and by their diet type (e.g. someone who is on a low carb diet may need less vitamin C to process the limited amount of glucose).  Hence, I think the DRI values should be seen as a minimum.  Ideally, we want to get more than the minimum while not having to ingest too much energy.  I also don’t think nutrients are meant to come as individual vitamins and minerals in a bottle.  The nutrients required to metabolise a certain food typically come packaged in whole foods, and often work synergistically.  Taking supplements or fortifying foods will always be inferior to obtaining nutrients from whole foods.
  3. Species-specific bioavailability and anti-nutrients are contentious topics. Zero carbers will tell you that nutrients in animal based foods are more bioavailable than plant based foods, while the vegans will tell you the opposite.  To date, I haven’t been able to find useful data that would enable me to quantitatively refine the nutrient data in the USDA database regarding bioavailability.  All we currently have is a measure of the nutrients contained in the food– rather than the nutrients that make it into your body after digestion.  Again, if this data ever comes to hand, I’ll eagerly update the analysis.

Overall, I don’t think these limitations make a difference in the outcomes of the analysis.  This is not an exact science and the body doesn’t operate like a rigid machine.  Calculation of nutrient density is just a way to identify the foods that contain the most raw materials with the least amount of calories that your body can work with.

referecnes

[1] http://www.who.int/nutrition/publications/nutrient/en/

[2] https://books.google.com.au/books?id=gtQyAgAAQBAJ&pg=PA185&lpg=PA185&dq=%22nutrient+hunger%22&source=bl&ots=VMRQ8EbvHx&sig=l_xJEksBS538UX3QwQNxVJBXTLw&hl=en&sa=X&ved=0ahUKEwjRj6mSs5DSAhWKyLwKHXBQAjEQ6AEIKDAC#v=onepage&q=%22nutrient%20hunger%22&f=false

[3] https://www.amazon.com/Perfect-Health-Diet-Regain-Weight/dp/1451699158

[4] https://www.amazon.com/Dorito-Effect-Surprising-Truth-Flavor/dp/1476724237

[5] https://optimisingnutrition.com/2016/03/21/wanna-live-forever/

[6] http://ajcn.nutrition.org/content/78/3/361.full

[7] http://www.nature.com/articles/ncomms14063

[8] https://www.amazon.com/Case-Against-Sugar-Gary-Taubes/dp/0307701646

[9] https://www.youtube.com/watch?v=dBnniua6-oM

[10] https://www.thepaleomom.com/adverse-reactions-to-ketogenic-diets-caution-advised/

[11] http://ketotalk.com/2016/06/23-responding-to-the-paleo-mom-dr-sarah-ballantynes-claims-against-the-ketogenic-diet/

[12] http://www.thelivinlowcarbshow.com/shownotes/10888/868-dr-sarah-ballantyne-challenges-the-wisdom-of-low-carb-diets-for-women-2/

[13] In terms of macronutrients this high fat dietary approach comes out at 80% fat, 15% protein, 2% fibre and 3% net carbs.

[14] http://www.who.int/nutrition/publications/nutrient/en/

Dr Rhonda Patrick’s Ultimate Micronutrient Smoothie versus Zero Carb Gregg

I recently ran the numbers on Dr Rhonda Patrick’s Ultimate Micronutrient Smoothie that Rhonda and her husband have for breakfast every day.   

I enjoy Rhonda’s podcasts as well as her mentor Bruce Ames’ pioneering work in the area of nutrient density.   I was pretty hopeful that Rhonda’s daily breakfast would knock it out of the park.  

So far I’ve run 235 meals through a system that ranks meals in terms of nutrient density, protein score, energy density and insulin load.  A score of 100 in the Nutrition Data analysis means that you would achieve all your daily requirements with 1000 calories (notwithstanding the limitations of bio-availability, anti-nutrients, fat soluble vitamins etc).  

In terms of vitamins and minerals, it did pretty well ranking at number 40 of 235 meals analysed to date. Liberal doses of kale and spinach always tend to boost the vitamin and mineral score.  These green leafies contain heaps of vitamins A, C, K, B and folate as well as solid amounts of the minerals magnesium, phosphorus, copper and manganese.

rhonda's smoothie

If you’re interested, the meal that ranks the highest in terms of vitamins and minerals score is Terry Wahls’ lamb skillet meal (shown below).  While you might think that a vegetarian meal might win in the vitamins and minerals category, Dr Wahls’ combination of broccoli, garlic, and spinach along with lamb and coconut oil actually does even better with a score of 94 compared to the green smoothie which has a score of 75.   

image04

The good thing about blending everything into a smoothie is that you will be able to get more green leafy veggies down the hatch.  The downside is that you might lose some of the beneficial effects of the fibre.  The same thing can be said for cooking.  

In terms of amino acids though, the smoothie was a bit disappointing coming in at 196 of 235. Some people will argue that low protein isn’t a big deal and that 9% protein is adequate.  Others think you would need more protein. 

The answer for you will depend on your activity levels and whether you want to be big and strong or whether you have some muscle mass that you don’t mind donating in the name of nutrition and weight loss.  

image03

The 57g of fibre was pretty good from all those leafy greens, ranking at 75 of 235 in terms of fibre.  Energy density was also pretty good, ranking at 100 of 235, which means that the smoothie will be quite filling and not easy to binge on.   

The insulin load was a bit disappointing.  At 50% carbs, the smoothie mixture came in just above the porridge with blueberries in terms of insulin load.  This may not be a problem if you’re insulin sensitive, but people struggling with diabetes might suffer from the apple and banana which don’t add much in terms of nutrient density (other than sweetness which would add to the palatability of the smoothie).  

minus the apple and banana

So for interest, I dropped out the apple and banana and the ranking improved in terms of vitamins and minerals, though it didn’t change the protein score.   The insulin load ranking improved marginally from 228 to 206.  

image06

Overall, this may not be a bad option for breakfast if you’re not diabetic and get some additional protein later in the day.  Living on Rhonda’s smoothe may also not be optimal if you’re looking to maintain/build lean muscle.

and now for something completely different… zero carb Gregg

After releasing the ketogenic fibre article in October 2015 I got into an interesting discussion with Gregg about zero carb and ended up running the numbers on his typical daily diet which largely consists of meat, butter and cream.

As shown below, the protein score of Gregg’s daily diet is solid, though the vitamin and mineral scores are not so great (214 of 235).   The insulin load of Gregg’s typical daily diet is pretty good coming in at #50. 

image05

[note: Just for interest Bulletproof Coffee comes in at #1 on the insulin load ranking but last in terms of vitamins and minerals and second last on the protein.]

Many people find that they do really well with a zero carb approach, particularly if they have major digestive issues.  People who are fans of zero carb often speak highly of Fibre Menace by Konstantin Monastrysky.  It seems that people with major digestive issues can get relief from their inability to digest FODMAPS using a zero carb approach.  

Overall I’m a fan of fibre and wonder if people might benefit from the slow reintroduction of some fibre for the sake of their gut microbiome and promoting well-rounded nutrition once their gut has settled.  

It’s also interesting to note that protein makes up only 22% of Gregg’s zero carb diet because of the solid amount of fat from the beef and the added fat from the butter and cream.  This sort of approach might work well for people who are insulin resistant.  

can you get enough vitamins and minerals from a zero carb diet?

Lots of people who use a zero carb approach say that they can get all the vitamins and minerals they could even need from animal products, so I threw in some sardines and liver to see how high we could get the vitamins and minerals score without any green stuff.  

As you can see below, the protein score improves with the fish and liver (I’m not vouching for the palatability though).  This meal now ranks at #1 for protein score with a massive score of 159 on the amino acid score!  The vitamins and minerals take a significant jump to #142 of 235 with the addition of the sardines and liver.

So it seems that there are some benefits of a zero carb dietary approach, but perhaps some limitations when it comes to the vitamin and mineral side of the equation.  

image01

joining forces

But then I thought, “what if Rhonda made Gregg breakfast and Gregg made dinner for Rhonda?”

As you can see from the analysis below, combining the green smoothie (without the fruit) with the zero carb approach (with sardines and liver) went really well in both the vitamins and minerals ranking (#20) and amino acid score (#41).  Not a bad balance overall!  

On the weight loss ranking, this meal combination would come in at #26 of 235, on the athlete ranking it comes in at #10, on the diabetes and nutritional ketosis ranking it comes in at #23, and for therapeutic ketosis ranking it comes in at #67.  

Overall, not a bad balance of the extremes?

image00

what to make of all this?

Lots of people get hung up on a particular magic nutrient and spend a lot of money to supplement just one missing ingredient.  However, perhaps it would be optimal (and cheaper?) to get a high quantity of a broad range of nutrients from whole food sources.

Real foods that were recently alive are going to be a better bet than relying on supplements.  

Should you eat more plant foods, more protein, or more fat?  The answer will depend on your situation, your goals and your preferences.  As always, optimal lies somewhere between the extremes.  

image13

enter…  Nutrient Optimiser

More recently, I have been working on a tool to help people optimise their micronutrient balance while also being tailored to their metabolic health and goals.

The Nutrient Optimiser reviews your food log diet and helps you to normalise your blood glucose and insulin levels by gradually retraining your eating habits by eliminating foods that boost your insulin level and blood glucose levels.

Once your glucose levels are normalised, the Nutrient Optimiser focuses on refining your micronutrient fingerprint to identify foods that will fill in your micronutrient deficiencies with real food.

2017-03-08-2

If you still have weight to lose, the Nutrient Optimiser will focus on the energy density of your diet until you have achieved your desired level of weight loss.  Alternatively, the Nutrient Optimiser can help you if you were looking to increase your insulin levels for bulking or identify higher energy density foods for athletes.

It’s early days for the Nutrient Optimiser, but the initial results are very promising!

2017-03-082

Post last updated July 2017

want to live forever?

Living a long, vibrant, healthy life is a common goal.  But what can we do to extend our health span?

Should we eat more fruit and veggies?  Less processed foods?  More protein?  Less protein?  Exercise more?  Lose weight?  Sleep more?  Get more sun?  Less blue light?

Confused yet?

The numerous facets of health and longevity are complex and above my pay grade.  However, I am willing to add my two cents to the discussion in the areas of insulin, blood glucose, fasting and nutrition along with some input from people I respect.

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Dr Ted’s top tips

My wise mate Dr Ted Naiman recently commented on the topic of longevity.

I see centenarians at work, and as far as I can tell it is important to be:

– insulin sensitive,

– active, and

– relatively strong

Extreme careful protein restriction? Not so much.  I for one will focus on the first three.

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Not only is Ted enviably buff, he also has a neat way of condensing wisdom into short bites that are worth unpacking a little further.

insulin sensitive

The leading causes of death in adults in the western world (i.e. heart disease, stroke, cancer, Alzheimer’s and Parkinson’s)[1] all have something in common.  They are diseases of modern society, related to metabolic health and exacerbated by excessive insulin and / or high blood glucose levels.

People who live longer still die from these same diseases, they just succumb to them later.

This chart (from Barbieri, 2001) shows that insulin resistance generally deteriorates with age.  However if you’re one of the few to make it past 90 then chances are your insulin resistance is pretty spectacular!

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Ted’s infographic below explains how insulin resistance and metabolic syndrome leads to hyperinsulinemia (elevated insulin) and hyperglycaemia (elevated blood glucose) and then to heart disease and many of the other diseases of modern society.

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The chart below indicates that you have a much better chance of delaying the top two causes of death in western society (i.e. heart attack and stroke) if you have a lower HbA1c.[2] [3]

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And your chance of maintaining a big brain that is free of Alzheimer’s and Parkinson’s (causes of number four and five)[4] seems to be greatly improved if you keep your blood glucose levels low.

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We’ll come back to cancer, cause of death number three, a little later.

relatively strong

While you might be able to make an argument for longevity around restricting protein or even calories based on laboratory experiments, people live in the real world and need adequate strength to move around, stay active and be relatively strong.  People who are lean and strong intuitively look healthy and attractive to us.

Longevity research is typically done in yeast, worms, mice or other animals who live protected in captivity.  Unfortunately, real people don’t live in protected laboratory environments in a petri dish.  We live in the real world where real people break.

Loss of muscle as we age (i.e. sarcopenia) is a major issue.  Many older people become brittle and weak.  They take a fall, break their hip and never get up.  Maintaining strength and lean muscle mass is important.

You don’t see many fat animals in the wild, but at the same time you don’t see skinny animals, unless they are sick.  Animals that survive in their natural environment are lean, strong and fast.  They have to be to survive, to catch food and avoid being eaten.

Humans in the wild also tend to be strong and lean.

Similar to Ted Naiman, Ian Rambo (pictured below), 62, is a fan of intermittent fasting and a moderate protein diet.  Rambo doesn’t look like he’s about to trip and break his hip any time soon.

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active

A lot can be said about exercise, longevity and metabolic health.

Peter Attia, who recently left NUSi to go back to practice medicine with a focus on longevity, says:

Glucose disposal is everything. The best way to get there is by increasing the muscle’s capacity to take up glucose and make glycogen, and that’s best accomplished through lifting heavy weights. Doing so also increases health span (i.e. reducing injuries, lowering pain, and increasing mobility through life).[5]

Exercise depletes the glucose in our blood, liver and muscles and causes us to tap into our fat stores.  But it’s more than just about using up energy.

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As metabolic health and mitochondrial density improves through exercise, our fat oxidation rate increases.  We become metabolically flexible which means that we can easily use glucose or fat for fuel.  Once we improve our fitness and insulin sensitivity we get to the point that we can even obtain some of the glucose we need from fat.

My friend Mike Julian commented:

Every triglyceride that is broken down gives up one glycerol molecule.  Two glycerol molecules will make one glucose.   So the more fat we are capable of burning, the more glucose we can make from fat oxidation, thus the better we get at restoring muscle glycogen without eating carbohydrates.

Also the glycogen that we do burn produces lactate, which is then recycled to make more glucose in the cori cycle, which also contributes to muscle glycogen stores during recovery.

The goal is to increase mitochondrial density so that we are very good at oxidizing fats. When we have poor mitochondrial density we are far more prone to switching over to anaerobic metabolism at low activity levels and anaerobic activities require glucose.

So if we can’t burn fat at high rates due to low numbers of mitochondria, we can’t make much glucose from glycerol via fat oxidation, so in turn our bodies go to plan B which is to make it out of amino acids in order to make up for the rest of what it needs.

So if you increase your mitochondrial density through exercise, you’ll oxidize a higher volume of fat, which will give a higher yield of glucose from glycerol and thus reduce your body’s need to break down aminos from dietary protein and lean mass.

Post exercise increased fat oxidation due to mitochondrial density produces more ketones during the recovery period which get used preferentially so the increased glucose production during that time can go towards refilling of glycogen stores rather than be oxidized for energy. This is why many top keto athletes will fast for a few hours post training. If they eat straight away they miss out on this phenomenon and actually will recover slower.

caloric restriction

Building on the prior trials in yeast and worms, the current dietary restriction longevity experiments in rhesus monkeys are looking positive.  You can see the monkey on the right who has been living on 30% less calories looks younger and healthier than the monkey on the left who is the same age.

The monkeys who eat less have less age related disease and live longer.[6]

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While avoiding excess energy intake is beneficial, there are differing opinions on how this translates to humans in the real world in terms of increased life span.

Peter Attia says:

Most people in this space, the super-in-the-weeds people on this topic that I’ve spoken with at length, do not believe caloric restriction actually enhances survival in the wild. 

Nobody disputes that for most species it enhances survival in the laboratory, but once you get into the wild, you’re basically trading one type of mortality for another.[7]

So many things in life are a balance and involve compromise.  While you need adequate nutrition to be strong and active, our bodies also age more slowly if we don’t subject ourselves to excess energy.

Another problem with calorie restriction is that unfortunately most of us don’t have the self-discipline to limit our food intake all the time.  When we do eat we find it hard to stop until we are satisfied.  Our survival instincts don’t know about the studies in the monkeys, the worms and the yeast.

Most people find it hard to maintain constant caloric restriction when they have free will and unlimited access to food.  And then the cruel trick for people who do have the discipline to consistently reduce their energy intake is that the body will scale back its energy expenditure to stay within the reduced energy intake.

intermittent fasting

 “Complete abstinence is easier than perfect moderation.”

Saint Augustine[8]

So if caloric restriction doesn’t necessarily work, then what’s the solution?  Jason Fung makes a compelling case for the benefits of intermittent fasting rather than chronic calorie restriction.

When there is a lack of food a process called autophagy (from the Greek auto, “self” and phagein, “to eat”) kicks in and we turn to our own old cells for nutrients.  Autophagy is nature’s way of getting the energy we need when we don’t eat in addition to cleaning out the old junk in our bodies and brains.  When we get to eat again we build up new, fresh healthier cells.

But this process of cell clean up and regeneration cannot occur without giving the body the chance to clean out the old cells first.[9]  We regenerate and slow aging when we don’t always have a constant supply of energy.  One of the advantages of intermittent fasting over simply reducing calories is that you get a deeper cleanse of the old cells with total restriction of energy inputs.

In the video below David Sinclair explains how our body makes a special effort to repair itself when there is a lack of food.  In a famine your body senses an emergency and sends out Sirtuin proteins to maximise the health of our mitochondria to increase the chance that you will survive the famine and have the best chance of living until a time when food is more plentiful and you can reproduce and pass on your genes.  Unfortunately, this emergency repair function just doesn’t happen when food is plentiful.  They’re working on drugs that will mimic this effect, but in the meantime, intermittent fasting is free.

As detailed in the how to use your glucose meter as a fuel gauge article, it can be useful to track blood glucose or weight to help guide the frequency and duration of intermittent fasting to make sure you’re moving towards your goals.

protein restriction?

Many people hypothesise that restricting protein is an important component to slow aging.

Dr Ron Rosedale talks a lot about the dangers of glycation and the kinase mTOR.  His hypothesis, as articulated in the Safe Starches Debate and AHS 2012, is that we should avoid carbohydrates to avoid the dis-benefits of glycation, particularly as we can get the glucose we need from protein and to a lesser extent from fat.  When you see that all the major diseases of aging are correlated with high blood sugars and high insulin levels you might think that he is onto something.

In his AHS 2012 talk Rosedale discusses the dangers of mTOR (mammalian target of rapamycin).  mTOR is activated when we eat protein and raise insulin and leads to suppression of autophagy.  In view of this Rosedale recommends relatively low levels of protein for people with diabetes (e.g. 0.6g/kg) and even lower for people who are battling cancer (e.g. 0.45g/kg).

Vegan luminary Dr Michael Gregor points to the various drawbacks of excess dietary protein and makes a compelling case for restricting animal protein by focusing on plant foods rather than caloric restriction or intermittent fasting.

There’s a fascinating August 2015 paper by Valter Longo et al that gives an overview of the current thinking in longevity.[10]   While it mentions protein restriction as a possible area for future investigation, discussion of protein restriction generally seems to be in the context of intermittent restriction with subsequent re-feeding.

To date, very few studies have been performed in humans on the potential beneficial effects of protein and/or amino acid restriction on aging processes or age-associated chronic diseases. [11]

There are obvious benefits in having periods where the body can clean out old proteins, however you also need high quality nutrition to build back the new shiny parts.

While I have gone to great lengths to bring attention to the fact that protein contributes to the insulin load of the diet, I struggle with the concept of chronic protein avoidance when so many of the things I read talk about the mental health benefits of protein,[12] [13] the benefits of lean muscle mass for metabolic health, the satiety benefits of protein and the importance of lean muscle as we get older to ensure we can be active and strong rather than brittle.[14]

Like everything though it’s a balancing act.  Binging on protein supplements and egg whites to get big and jacked is not going to lead to optimal health and longevity.  Some of these guys are even injecting extra insulin for its anabolic hypertrophy effects on top of the anabolic hormones.  This is not healthy and not natural.

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So how much protein do you need when you do eat?   I think you need enough to be strong and active but at the same time without raising insulin and blood sugars and decreasing ketones.

Lean muscle = good

Insulin sensitivity = good

Excess body fat = bad

High insulin = bad

cancer

There’s also a growing momentum around the metabolic theory of cancer (the number three leading cause of death) which hypotheses that excess glucose feeds cancer growth and restricting glucose through a therapeutic ketogenic diet with intermittent fasting will reduce your risk of cancer.

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There is some great work by Thomas Seyfried, Travis Christoferson and Domonic D’Agostino that is well worth your time if you haven’t already seen it.

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When you hear Seyfriend talk he seems very proud of and excited about the glucose : ketone index (GKI) which he developed as a proxy for a person’s insulin levels.  As you can see in the chart below, as our blood glucose levels decrease ketone levels rise.

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More than blood glucose or ketones alone, the relationship between your blood glucose and ketones seems to be a good proxy for your insulin sensitivity.

It seems that someone with a GKI of less than 10 has fairly low insulin levels, someone with a GKI of less than 3 has excellent metabolic health, while someone battling cancer might want to target a GKI of 1.0.

Reducing the insulin load of your diet can reduce your glucose levels, increase your ketones and reduce your risk of metabolic syndrome and the most prominent causes of death (i.e. heart disease, stroke, cancer, Alzheimer’s and Parkinson’s).

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Just to be clear, you people who achieve these excellent insulin resistance levels don’t get get there by simple adding more fat to their morning coffee but through disciplined intermittent fasting which tends to lead to reduction in body fat which improves insulin resistance.

finding the optimal balance

On one extreme too much food will make us fat and insulin resistant and stop the body from repairing itself.

On the other extreme calorie restriction will make us frail and vulnerable to disease and accidents.

So how do we find the middle ground?

On the topic of carbohydrates Peter Attia says:

You want to consume basically as much glucose as you can tolerate before you start to get out of glucose homeostasis. For me there’s a different number than for the next person, and you have to find what the level is.

I’ve been wearing a continuous glucose monitor for several months now. Every day I just have it spit out my 24-hour average of glucose plus a standard deviation, and I now know my sweet spot. I like to have a 24-hour average of between 91 and 93 mg/dL with a standard deviation less than 10.

We can’t measure insulin in real time. To me, the Holy Grail would be to have an area under the curve of insulin, but this becomes a pretty good proxy.

It’s fascinating to see that Attia, who is a super fit semi pro athlete is going to the effort of wearing a continuous glucose meter full time.  CGMs are generally worn by people with type 1 diabetes like my wife.

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The process he is describes of reducing dietary glucose intake to a point where blood glucose levels are normalised is essentially the process used by the people we see who are managing type 1 diabetes as well as possible.

The food insulin index testing measured the area under the curve response to various foods (i.e. what Attia describes as the Holy Grail) and has been really useful for us to understand which dietary inputs cause the greatest blood glucose swings and require largest amounts of insulin.

I think the reason that Attia is recommending ‘as much glucose as you can tolerate’ is to fuel your energy needs for activity, maximise nutrition and dietary flexibility.  This level of blood glucose control will give him an HbA1c of 4.8% which will put him in the lowest risk category for the most common diseases of aging.  But to maintain such a tight standard deviation he’s going to be managing the net carbs and protein in his diet so his blood sugar doesn’t go over 100mg/dL or 5.6mmol/L too often.

Dr Roy Taylor recently released an interesting paper where he proposes that each person has a personal fat threshold[15].  Rather than the BMI chart or body fat, there is a certain level at which the body fat becomes inflamed and insulin resistant which leads to diabetes and all the issues related to metabolic syndrome.  What this means in practice is if your blood glucose levels are rising above optimal you need to eat less to lose body fat.

When it comes to protein Attia says:

What I’m telling my patients is really you only need as much protein as is necessary to preserve muscle mass.

You have a sliding scale, which is carbohydrate goes up until you hit your glucose and insulin ceiling, protein comes down until you’re about to erode into muscle mass and slip into positive nitrogen balance, and then fat becomes the delta.

So in somebody like me, that’s probably about 20% carb, 20% protein 60% fat.

I’ve done everything from vegan to full ketogenic.  I’ve experimented with the entire spectrum of religions, but nevertheless, that’s the framework.[16]

It’s worth noting here that this quote from Peter is in the context him talking at length about mTOR, ROS, glucose control and protein restriction.  Attia is one of the smartest guys in nutrition, medicine and anti-aging science, but he’s not avoiding protein.  He’s making sure he gets enough to maintain lean muscle mass but not so much that it messes with his glucose levels or requires a significant glucose response.

Attia also talks about maximising glucose and minimising protein to normalise blood glucose and insulin.  Given that the focus is on managing insulin levels, I think you could also take the opposite approach to minimise carbs and maximise protein as much as you can without disrupting glucose or losing ketones.   People with type 1 diabetes will tend to consume medium to higher protein levels (which provide glucose but without the same degree of glucose swing) with lower levels of carbohydrates.

Or alternatively find your own balance of net carbs and protein that gives excellent blood glucose levels and some ketones.

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When it comes to finding the optimal level of protein and energy Dr Tommy Wood said:

The anti-IGF-1 (insulin like growth factor) crowd confuse me. Lots = bad (cancer). Very little = also bad (sarcopenia and broken hips).[17]

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caloric restriction

One of the pioneers in the field of longevity is Roy Walford,[18] who developed the concept of Calorie Restriction with Optimal Nutrition (CRON).  Many of the ideas in this article and the blog overall are built around Walford’s ideas regarding optimising nutrition for health and longevity.

While Walford lived his theories in practice, he unfortunately died at 79 of ALS so we didn’t really get to find out whether calorie restriction delayed the major diseases of aging for him.  The pictures below are taken of Dr Walford before and after two years living in Biosphere 2.[19]

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Walford was the crew’s physician and meticulously recorded the health markers of the Biosphere 2 ‘crew members’[20].  It’s interesting to see how markers like the BMI chart, glucose, insulin and HbA1c all improved markedly with the semi-starvation conditions during the experiment, however they reverted to more normal levels after resuming normal eating.

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optimal nutrition

If we are going to fast and / or restrict calories to optimise our metabolic health it’s even more important that we make sure that the food we do eat, when we eat it, provides all the nutrients that we need to thrive and build back new shiny parts of our body.  Unfortunately it seems that the optimal nutrition component of Walford’s CRON concept is not discussed much these days.

In the article optimal foods for different goals I have detailed a system that can be tailored to identify nutrient dense foods for different goals to balance nutrient density and insulin load.  I hope this will help to spark further discussion around the topic of nutrient density and which foods would be most helpful for different people.

summary…

So what does all this mean?  What do we know about maximising our metabolic health and avoiding the primary diseases of aging?

Is too much energy bad… yes.

Is eating all the time bad…. yes.

Is excess protein bad… maybe, maybe not, however the vegans would say that we should avoid animal protein and stick to only plant based foods.

Are excess carbohydrates bad… maybe, maybe not, however the low carb / keto crowd would say that you need to avoid carbohydrates because they raise your insulin.

Is excess protein and excess non-fibre carbohydrates bad… most likely, yes.

Both carbohydrates and protein will raise insulin, blood glucose, IGF-1 and upregulate mTOR which all accelerate aging.

In the end though we have to eat.  We are programmed for survival.   While not eating too much and intermittent fasting are important considerations, when we do eat though we should maximise the nutrient density and prioritise foods that do not not raise our insulin and blood glucose levels.  I think if you get that right a lot of the other things will follow.

There is no perfect dietary solution for all.  What is best for you will come down to your situation, goals and preferences.

Some people will prefer zero carb with lots of meat.

Some people feel strongly about avoiding animal products and do well on a plant based diet with minimal processed foods.

Some will aim for a therapeutic ketosis approach to tackle major metabolic issues.

All of these extremes are viable but a balance somewhere in the middle might be easier to maintain in the long term while also maximising the nutrient density of the calories we consume.

What is almost certainly dangerous for most people is the low fat, high insulin load approach that has been recommended for the past few decades and seems to have led to increased consumption of low nutrient density highly processed food products by many.

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references

[1] http://chriskresser.com/the-keys-to-longevity-with-peter-attia/

[2] http://cardiab.biomedcentral.com/articles/10.1186/1475-2840-12-164

[3] http://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/1749-8090-3-63

[4] http://chriskresser.com/the-keys-to-longevity-with-peter-attia/

[5] http://chriskresser.com/the-keys-to-longevity-with-peter-attia/

[6] http://www.nature.com/ncomms/2014/140401/ncomms4557/fig_tab/ncomms4557_F1.html

[7] http://chriskresser.com/the-keys-to-longevity-with-peter-attia/

[8] http://www.goodreads.com/quotes/6741-complete-abstinence-is-easier-than-perfect-moderation

[9] https://intensivedietarymanagement.com/fasting-and-autophagy-fasting-25/

[10] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4531065/

[11] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4531065/

[12] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738337/

[13] https://www.moodcure.com/safe_alternatives_to_antidepressants.html

[14] http://www.webmd.com/healthy-aging/sarcopenia-with-aging

[15] http://www.clinsci.org/content/128/7/405

[16] http://chriskresser.com/the-keys-to-longevity-with-peter-attia/

[17] http://press.endocrine.org/doi/full/10.1210/jc.2011-1377

[18] https://en.wikipedia.org/wiki/Roy_Walford

[19] https://en.wikipedia.org/wiki/Biosphere_2

[20] https://m.biomedgerontology.oxfordjournals.org/content/57/6/B211.full

[21] http://www.walford.com/cronmeals1.htm

[22] https://www.drfuhrman.com/library/andi-food-scores.aspx

[23] https://www.youtube.com/watch?v=ZVQmPVBjubw

optimal foods for different goals

A number of attempts have been made to rank foods based on their nutrient density or some other measure.

Useful parameters that can be used to optimal foods for different goals include:

  • nutrient density / calorie,
  • nutrient density / cost,
  • nutrient density / weight,
  • fibre / calorie,
  • fibre / weight,
  • calorie / weight,
  • cost / calorie, and
  • percentage insulinogenic calories.

This article details a new system that combines these parameters to identify optimal foods for different goals such as:

  • weight loss,
  • diabetes and nutritional ketosis,
  • therapeutic ketosis, and
  • athletes and the metabolically healthy.

My hope is that all this number crunching will help take the some of the guess work and ambiguity out of nutrition.

If we agree that we should focus on nutrient dense foods that don’t overload our pancreas’s ability produce adequate insulin, then we can move closer to agreeing which foods are optimal for an individual’s individual needs.

If you want to skip the detail, the end result of is a number of simple lists of optimal foods for different goals that you can access via the links below. If you want more detail then read on.

goal blog cheat sheet detailed list
therapeutic ketosis visit download download
diabetes and nutritional ketosis visit download download
fat loss visit download download
athletes and metabolically healthy visit download download

Firstly let’s take a look at a number of approaches that have previously been used to rank and prioritise foods.

low carbohydrate diets

As popularized by Dr Robert Atkins, limiting carbohydrates is a simple way to prioritise foods to reduce insulin demand.

By restricting carbohydrates intake, a range of foods are excluded, particularly those that are highly processed and contain added sugars.

While a low carb approach will reduce the insulin load of our food, no specific consideration is given to nutrient density or food quality.

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Aggregate Nutrient Density Index (ANDI)

In contrast to Akins’ approach, Joel Fuhrman’s Aggregate Nutrient Density Index (ANDI)[1] ranks foods based on micronutrients per calorie.[2]

I think there is an element of genius to Fuhrman’s nutrient density ranking system.  However when you look in the detail you find it is based on a select range of vitamins and minerals without any consideration of beneficial amino acids or fatty acids.

Fuhrman’s nutritarian approach has come under criticism for excluding a number of essential nutrients and placing extra emphasis on more fringe measures such as “oxygen radical absorbance capacity”.

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To determine the ANDI scores, an equal-calorie serving of each food was evaluated. The following nutrients were included in the evaluation: fiber, calcium, iron, magnesium, phosphorus, potassium, zinc, copper, manganese, selenium, vitamin A, beta carotene, alpha carotene, lycopene, lutein and zeaxanthin, vitamin E, vitamin C, thiamin, riboflavin, niacin, pantothenic acid, vitamin B6, folate, vitamin B12, choline, vitamin K, phytosterols, glucosinolates, angiogenesis inhibitors, organosulfides, aromatase inhibitors, resistant starch, resveratrol plus ORAC score.

While claiming to be “evidence driven”, without the inclusion of amino acids or fatty acids Fuhrman’s “nutritarian” approach ends up being heavily biased towards plant based foods.[3]   

Another issue with Furhman’s ANDI is that it can be skewed by a single nutrient present in very high quantities. For example, kale ranks at the top of Furhman’s list primarily due to its massive amount of Vitamin K.  Unfortunately, a mega dose of Vitamin K, which is a fat soluble vitamin, may have limited use by itself.  Rather than finding foods that are high in one nutrient it would be ideal to identify foods that were high in a broad range of nutrients.

Ranking foods in terms of nutrient density per calorie also tends to prioritise leafy veggies, which is great if you are trying to lose weight but not ideal if you’re an athlete trying to fuel up for an intense workout on kale and watercress.

While I think most people would benefit from consuming more green leafy vegetables, in the long term I think they will also benefit from foods with adequate protein protein and beneficial fatty acids.

In the short term someone who is obese has plenty of excess fatty acids and amino acids to spare so they will likely feel great as they are losing weight, however as their weight loss slows and they stop feasting off their own protein and fat the benefits of the a very low fat, very low protein approach may diminish.

NuVal

Professor Dr David Katz and an auspicious group of friends have developed the NuVal[4] food ranking system which uses the following sixteen positive ‘numerator nutrients’ to compare and rank common foods:

  • Fibre
  • Folate
  • Vitamin A
  • Vitamin C
  • Vitamin D
  • Vitamin E
  • Vitamin B12
  • Vitamin B6
  • Potassium
  • Calcium
  • Zinc
  • omega-3 fatty acids
  • total bioflavonoids
  • total carotenoids
  • Magnesium
  • Iron

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The sum of the ‘numerator nutrients’ is divided by the sum of the ‘denominator nutrients’ listed below to calculate a score of between one and one hundred:

  • saturated fat
  • trans fat
  • sodium
  • sugar
  • cholesterol

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The NuVal system also considers the following ‘additional entries’:

  • protein quality
  • fat quality
  • glycemic load
  • energy density

It’s interesting to note the foods to which it gives a score of 100 including:

  • non-fat skim milk,
  • sweet potato,
  • tomatoes,
  • beans,
  • bananas,
  • blueberries,
  • mango, and
  • wheat bran.

While the stated goal of the NuVal system is to combat diabetes, the food insulin index[5] shows that many of these foods will be problematic for a diabetic trying to maintain normal blood glucose levels.

Some of the more puzzling scores thrown up by the system include:

  • shrimp – 40
  • lobster – 60
  • coconut – 24
  • chicken – 57
  • beef – 46

Other concerns with the NuVal system include:

  • Because it biases heavily against saturated fat, some diabetic friendly foods like beef and coconut are further down the list.
  • The number of foods analysed is fairly limited.
  • Only sixteen vitamins and minerals are included in the analysis.
  • Dietary cholesterol is penalised by the NuVal system although dietary cholesterol does not necessarily lead to cholesterol in the blood or heart disease.
  • The NuVal algorithm has been calibrated to fit the views of the panel of experts, hence it is likely that it will simply reinforce previously held views.
  • Considering added sugar and the glycemic index are a good start, however I think using the food insulin index would be more useful as it is a better measure of the actual amount of glucose being metabolised.

Dave Asprey’s Bulletproof Diet Roadmap

Dave Asprey has developed the Bulletproof Diet Infographic[6] which is a simple ranking of foods to avoid, and preference based on both nutritional density and toxins.

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While I think Asprey’s ranking system is excellent, the downside is that it features only a select range of foods and does not explain why each of the foods has been given a particular ranking, although there is a good discussion of the toxins and various other considerations in his Bulletproof Diet Book.[7]

Asprey’s list also doesn’t differentiate between what would be most appropriate for someone with diabetes versus an athlete, or someone aiming for therapeutic ketosis or wanting to lose weight.

Soylent

Another noteworthy foray into the realm of optimising nutrition is Rob Reinhardt’s Soylent.[8]

Reinhardt set out to produce a manufactured food that ticked off all of the micronutrient Recommended Daily Intake (RDI) values, while reducing the cost and the hassle of food preparation.

While Reinhardt notes that his creation would be healthier than the ramen noodles that he was living on before creating Soylent[9], there are a number of downsides to this food replacement which is basically a protein shake on steroids.

Using manufactured foods leaves you exposed to not getting all of the non-essential micronutrients or even the beneficial nutrients that haven’t made it to the current list.  Eating real whole foods seems to be a safer option to ensure you are getting all the nutrients you need.

Mat Lalonde’s nutrient density

After reviewing the various options available and finding them lacking, Dr Mathieu Lalonde developed an excellent ranking of foods based on nutrient density per weight of food using the USDA food database.[11]

Lalonde also included a broader range of nutrients than Fuhrman or Katz by also considering beneficial amino acids and fatty acids.

This analysis identified organ meats as one of the more nutritious foods, followed by herbs and spices, nuts and seeds.

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In this video of his AHS2012 presentation Lalonde noted that people wanting to lose weight may wish to prioritise in terms of nutrient density per calorie, however he chose to analyse nutrient density in terms of weight as that might be more relevant for athletes (Lalonde is a CrossFit athlete as well as a biochemist). [12]

After watching this video and hearing about his quantitative approach to nutrient density I was left excited, yet a little unsatisfied, wondering what the ranking might look like in terms of nutrient density / calories.

fibre per calorie

One of the more interesting concepts in the area of nutrition recently is that what you eat could affect your gut bacteria.

Typical daily fibre intake is around 17g for those of us in western civilisation compared to the Recommended Daily Intake (RDI) of 25 to 30g per day.[17]

It is said that African hunter gatherer children obtain more than 150g of fibre per day from eating unprocessed foods in their natural state[18], and before the invention of fire and cooking our ancestors were eating more than 100g of fibre per day.[19]

Fibre is not digestible by the human gut and hence it does not provide energy or cause a rise in blood sugar or insulin.  Fibre in our food neutralises the insulinogenic effect of carbohydrate.[20]

If we rank for fibre per calorie we end up with a few spices such as cinnamon, curry powder, or cocoa at the top of the list along with veggies such as turnip, artichoke, sauerkraut, and cauliflower.

  1. cinnamon
  2. turnip greens
  3. artichoke
  4. curry powder
  5. sauerkraut
  6. cauliflower
  7. raspberries
  8. lettuce
  9. blackberries
  10. lemon peel

Again, this list is interesting, but not something you can live by.  Somehow we need to combine all these approaches to arrive at a more useful list that balances all of these considerations.

what are the “essential nutrients”?

So after reviewing these ranking systems I thought it would be interesting to design my own that would build on these previous approaches as well as considering the insulin response to food to make it more useful for people with diabetes.

The obvious starting point is to agree on the nutrients that should be included.  Listed below are the commonly accepted list of essential amino acids, vitamins and minerals.[21]

vitamins

  1. Choline
  2. Thiamine
  3. Riboflavin
  4. Niacin
  5. Pantothenic acid
  6. Vitamin A
  7. Vitamin B12
  8. Vitamin B6
  9. Vitamin C
  10. Vitamin D
  11. Vitamin E
  12. Vitamin K

minerals

  1. Calcium
  2. Copper
  3. Iron
  4. Magnesium
  5. Manganese
  6. Phosphorus
  7. Potassium
  8. Selenium
  9. Sodium
  10. Zinc

amino acids

  1. Cysteine
  2. Isoleucine
  3. Leucine
  4. Lysine
  5. Phenylalanine
  6. Threonine
  7. Tryptophan
  8. Tyrosine
  9. Valine
  10. Methionine
  11. Histidine

fatty acids

The list of essential and conditionally essential fatty acids is shorter than the other lists and is largely made up of omega 3 fats that the human body cannot manufacture in sufficient quantities. We need to go out of our way to incorporate these into our diet.

  1. Docosahexaenoic acid (DHA) (22:6 n-3)
  2. Eicosapentaenoic acid (EPA) (20:5 n-3)
  3. Docosapentaenoic acid (DPA) (22:5 n-3)
  4. Alpha-linolenic acid (18:3 n-3)

Given that a large part of my focus is to create a system that prioritises diabetic-friendly foods, I thought it would be good to give some more detailed consideration to other ‘good fats’, given that fat typically comprises more than half of the calories for someone following a reduced carbohydrate approach.  Listed below are the additional fatty acids that research shows to be beneficial.

  1. Arachidonic acid (20:4)
  2. Oleic acid (18:1)
  3. Lauric acid (12:0)
  4. Capric acid (10:0)
  5. Pentadecanoic acid (15:0)
  6. Margaric acid (17:0)

You can read more on the reason for inclusion of these additional good fats the Good Fats, Bad Fats article.

nutrient density score

Building on Joel Fuhrman and Matt Lalonde’s nutrient density approach, the nutrient score score is a relative score calculated by comparing the amount of a particular nutrient in each food against all of the foods.

For example, if a particular food has an average amount of Vitamin C compared to the 8,000 other foods in the database it will get a score of zero because it is zero standard deviations from the mean.  If it has a large amount of a certain nutrient then it will receive a high score.

If the amount that a particular nutrient is two standard deviations from the mean then it will get a score of two for that nutrient.  If however it is five standard deviations from the mean it gets a maximum score of three in order to avoid prioritising foods that have massive amounts of one single nutrient versus foods that have solid amounts of a range of essential nutrients.

image011

One example of where this limitation comes into play is kale, which has a massive amount of Vitamin K versus spinach which has a high amount of Vitamin K but also has a range of other nutrients.  Because of the upper limit on the score for a single nutrient the system gives a higher priority to spinach, which has a more well-rounded nutrient profile rather than simply being an overachiever in one or two nutrients.

image013

The nutrient score for a food is the sum of the individual nutrient scores across the forty three nutrients.  The higher the score the more nutritious that food is in comparison to the other foods in the database.

Weighting one nutrient as more important than another could be useful for an individual with a particular goal or health condition (e.g. DHA for someone battling brain cancer).  However I have chosen to keep ‘clean’ to avoid arguments about bias with equal weighting given to each nutrient.[22]  This system will simply highlight foods that have a wide range and a high quantities of nutrients.

weighted multi criteria analyses

Ranking foods by an individual parameter is interesting, however it doesn’t produce a balanced list of foods that you can live by.  Where things start to get interesting is when we combine the different parameters using a multi criteria analysis to suit different goals.

As an engineer I often use a multi criteria analysis (MCA) to analyse a lot of data.  A numerical MCA is a useful way to make sense of a large amount of data and shortlist from a wide range of options.

 

The available parameters from the USDA foods spreadsheet are:

  • nutrient density / calorie,
  • nutrient density / weight,
  • fibre / calorie,
  • fibre / weight,
  • calorie / weight, and
  • percentage insulinogenic calories.

The table below shows the weightings given to each criteria refined to create a shortlist of foods to suit different goals.

goal

ND / cal

ND / weight fibre / cal fibre / weight calories / weight

insulinogenic (%)

fat loss

40%

5% 5% 5% 25%

20%

athlete

5%

30% 10% 5% 5%

45%

diabetes & nutritional ketosis

5%

20% 10% 5% 10%

50%

therapeutic ketosis

5%

20% 5% 5% 0%

65%

  • Someone aiming for therapeutic ketosis will want to minimise their insulin load while maximising nutrition in the context of a very high fat diet.
  • Someone with diabetes or trying to achieve nutritional ketosis will also want to minimise their insulin load, however they should also look to maximise nutrient density and obtain adequate fibre.
  • Someone who has control of their blood glucose levels but is still trying to achieve fat loss will likely benefit from a diet with a reduced calorie density while still maximising fibre and nutrition.
  • An athlete’s primary priority will be to maximise nutrients without as much concern for calorie density or insulin load.

reality check

I have refined these weightings used in the MCA by reviewing the top 500 foods (of the 8000 foods in the USDA foods database) for each scenario.

goal

fibre (g) 

weight (g)  % protein % net carbs % insulinogenic

% fat

fat loss

45

1614 29% 13% 33%

31%

athlete

25

436 26% 12% 31%

56%

diabetes & nutritional ketosis

25

413 30% 4% 21%

58%

therapeutic ketosis

13

357 14% 3% 14%

80%

average all foods

26

899 26% 38% 52%

31%

It’s interesting to see that the net carbohydrates ends up being relatively low for all scenarios when we maximise nutrient density.  It appears that starchy carbs (e.g. grains and sugars) have a relatively low nutrient density compared to other available foods.

image015

The big differentiator across the approaches is calorie density.  If someone has stabilised their blood glucose and insulin levels then the next step in the journey may be to decrease calorie density to naturally manage food intake.  The fat loss approach is slightly more insulinogenic however practically it will be difficult to fit in all the food.

the results

While this process is somewhat convoluted the end result is a fairly simple list of foods that are ideal for different goals.  I have included a shortlist of the highest ranking foods on the blog here along with ‘cheat sheets’ that you can print and stick to your fridge or compile your food lists from.

It’s been great to see many people benefit from focusing these shortlists.  If you’re inquisitive and like to ‘peek under the hood’ I have also included links to a more detailed list that shows the basis of the rankings for each food.

goal blog cheat sheet detailed list
therapeutic ketosis visit download download
diabetes and nutritional ketosis visit download download
fat loss visit download download
athletes and metabolically healthy visit download download

references

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

[2] http://www.wholefoodsmarket.com/healthy-eating/andi-guide

[3] http://www.westonaprice.org/book-reviews/eat-to-live-by-joel-fuhrman/

[4] https://www.nuval.com/

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

[6] http://www.bulletproofexec.com/wp-content/uploads/2014/01/Bulletproof-Diet-Infographic-Vector.pdf

[7] http://www.amazon.com/The-Bulletproof-Diet-Reclaim-Upgrade/dp/162336518X

[8] https://www.soylent.com/

[9] http://www.newyorker.com/magazine/2014/05/12/the-end-of-food

[10] http://robrhinehart.com/?p=424

[11] http://ketopia.com/nutrient-density-sticking-to-the-essentials-mathieu-lalonde-ahs12/

[12] https://www.youtube.com/watch?v=HwbY12qZcF4

[13] http://solvingnutrition.com/engineering-the-cheapest-and-healthiest-diet-on-a-budget/

[14] http://blog.paleohacks.com/ultimate-guide-paleo-diet-budget/

[15] https://www.youtube.com/watch?v=VvfTV57iPUY

[16] http://perfecthealthdiet.com/

[17] https://www.nrv.gov.au/nutrients/dietary-fibre

[18] http://www.abc.net.au/catalyst/stories/4067184.htm

[19] http://www.gregdavis.ca/share/paleo-articles/academic/The%20Ancestral%20Human%20Diet%20by%20S.%20Boyd%20Eaton.pdf

[20] https://optimisingnutrition.wordpress.com/2015/03/30/what-about-fibre-net-carbs-or-total-carbs/

[21] http://ketopia.com/nutrient-density-sticking-to-the-essentials-mathieu-lalonde-ahs12/

[22] http://www.westonaprice.org/book-reviews/eat-to-live-by-joel-fuhrman/

Atkins versus the vegans

Dr Fung also noted that the Atkins approach often doesn’t work over the long term because things other than carbohydrates require insulin.

The food insulin index data demonstrates that a number of high protein foods such as steak, cheddar cheese, white fish and tuna cause a significant insulin response even though they contain minimal carbohydrate.

image003

The irony of low carbers eating protein to avoid carbs to minimise insulin secretion although the insulin index data shows that protein foods cause a significant insulin effect has not been lost on the vegan community as shown in this thought provoking video below.

In response to this, Gary Taubes has acknowledged that protein does stimulate insulin, however has stated that

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

Is protein a significant issue an issue for people trying to control blood sugar and reduce the insulinogenic load of their food?

Does the fact that protein takes longer to digest mean that the insulin secreted in response to protein doesn’t matter?

Perhaps the food insulin index data can help us find the answer.

[next article…  how much insulin is required to cover protein?]

[this post is part of the insulin index series]

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