Tag Archives: weight loss

articles, nutrient density, protein, weight loss

protein sparing modified fast (PSMF) diet foods

June 17, 2017 Marty Kendall 15 Comments

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

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

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

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

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

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

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

Medical applications of the PSMF

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

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

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

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

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

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

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

Body building applications

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

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

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

KetoGains’ Luis Villasenor added:

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

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

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

Protein drives satiety

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

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

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

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

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

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

Thermic effect of food

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

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

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

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

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

Should you just eat the highest protein foods?

So, the obvious question is:

What should I eat on a PSMF?

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

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

I have summarised these in this image for easy reference.

The problem with a very high protein diet

But wait!

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

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

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

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

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

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

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

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

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

Bruce Ames’ Triage Theory

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

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

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

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

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

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

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

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

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

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

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

Low energy density

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

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

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

The nutrient dense adequate protein diet

So, to recap:

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

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

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

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

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

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

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

Best foods for a PSMF

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

Also included in the tables are:

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

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

Vegetables

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

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

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

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

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

Animal products

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

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

Seafood

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

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

Egg and dairy

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

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

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

Calorie math

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

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

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

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

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

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

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

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

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

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

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

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

Insulin resistant long-term fat loss scenario

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

Introducing… Big Ted.

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

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

Big Ted is also pre diabetic.

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

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

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

Nutrients to prioritise

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

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

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

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

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

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

Calorie math

The charts below show the energy consumed and energy burned.

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

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

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

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

Optimal foods for Big Ted are listed below.

Vegetables

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

Animal products

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

Seafood

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

Egg

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

Nut sand seeds

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

This image below summarises these foods for easy reference.

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

How often should I eat on a PSMF?

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

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

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

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

How low can you go?

Hopefully, this article has given you some actionable principles:

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

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

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

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

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

#context matters

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

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

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

How to do a nutrient dense PSMF

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

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

Summary

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

post updated August 2017

articles, nutrient density, therapeutic ketosis, vegan, weight loss, zero carb

which nutrients is YOUR diet missing?

March 11, 2017 Marty Kendall 12 Comments

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

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…

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.
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.
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/

foods, nutrient density

how to get more of the harder to find micronutrients per calorie

February 13, 2017 Marty Kendall 13 Comments

There’s a lot of talk about “nutrient density” and “superfoods”, but what do these terms really mean? Which foods actually give the most nutritional bang for your calorie buck? That is, which foods provide the most nutrients for the least number of calories?

Some approaches to quantifying nutrient density (e.g. Joel Fuhrman’s Aggregate Nutrient Density Index) have looked at vitamins and minerals (along with other parameters that are only available for fruits and vegetables) per calorie, but do not consider essential fatty acids and amino acids.

Meanwhile, Registered Dietitians’ recommendations and mainstream food ranking approaches revolve around avoiding nutrients such as saturated fat, cholesterol and salt. Unfortunately, this avoidance based approach to ranking foods does nothing to increase beneficial nutrients.

Avoidance of these demonised food elements typically ends up ignoring the whole unprocessed foods that contain the most nutrients. Instead, current ranking systems encourage prioritisation of processed foods that have been manufactured to be low in fat, saturated fat, salt or cholesterol.

The resultant fat-free manufactured products are so nutrient poor that they must be fortified with a smattering of synthetic vitamins to prevent the malnutrition that would otherwise occur. Food manufacturers also add sugar and synthetic flavours to make them palatable. After a few decades, food scientists have now learned to optimise sweetness to target “bliss point”^[1] which continues to drive upwards in sweetness.[2]

With synthetic flavourings, we can make hyperpalatable food stuffs that taste so much more intense than real foods that are found in nature. After a generation or two of fake food we have forgotten what real food, in its natural form, tastes or even looks like. Unfortunately, at the same time our food production is becoming more reliant on fertilisers to grow crops bigger and faster but the end result is food that doesn’t naturally taste as good as they used to because they don’t contain the same number of nutrients. Our senses of taste and smell don’t have a chance of being able to find real nutrients amongst the plethora of super sweet and unnaturally flavoured foods. This industrialized chemical storm also taxes your liver, kidneys, and digestive system and encourages disease instead of leading to health.

So, if we can’t trust our senses anymore to find the nutrients we need what can we do?

As much as food technology has got us into this mess, the good news is that by quantifying nutrient density we can identify the foods that contain the most nutrients. Then after a period without the distraction of sweeteners and artificial flavours and we can re-learn trust our tongue, nose, appetite and cravings to find the real nutrients that our body need.

The chart below shows the nutrients contained in the eight thousand foods in the USDA database per 2000 calories. While it’s easy to get the minimum levels of iron, vitamin C and several the amino acids (at the bottom of the chart), it’s harder to obtain adequate quantities of omega 3 fatty acids, vitamin D, choline, vitamin E and potassium (shown at the top of the list).

Rather than trying to get more of all the essential micronutrients, we can prioritise the following nutrients that are harder to find:

alpha-Linolenic acid (Omega 3 fatty acids)
Vitamin D
Choline
Vitamin E
EPA + DHA (Omega 3 fatty acids)
Potassium
Calcium
Magnesium
Pantothenic acid
Tyrosine
Thiamin
Zinc

The chart below lists the nutrients provided by the average of all food in the USDA database (orange bars) compared to the nutrients provided by the most nutrient dense foods (blue bars). But focusing on the most nutrient dense foods, not only do we get more of the harder-to-find nutrients, we also improve the quantity of all the essential nutrients!

Macronutrient split

The chart below shows a comparison of the macronutrients in the most nutrient dense foods compared to the average of all foods in the USDA database. Although we have prioritised for only one amino acid (Tyrosine), it appears that the food that contain the most essential fatty acids, vitamins and minerals are also higher in protein.

The quantity of fibre also increases substantially. Nutrient dense vegetables come with large amounts of fibre which makes these foods more filling and harder to overeat.

The most nutrient dense foods also have a much lower energy density. This makes these nutrient dense foods harder to overeat. As well as feeling physically full, your body is likely to feel satiated once it has obtained the nutrients it needs.^[3] ^[4]

Notice the proportion of fat and non-fibre carbohydrates are lower in the most nutrient dense foods. In a way, I think we need to consider foods as nutrients and fuel separately. The initial goal is to eat the foods that contain the nutrients to live an awesome life and support your bodily functions. The secondary goal is to get enough fuel from higher energy density foods to support your activity and maintain ideal body fat. Too often we sacrifice essential nutrients and nutrient density and instead choose irresistibly tasty and high calorie food products for a “quick rush”.

The most nutrient dense foods

The most nutrient dense foods (i.e. the top 10% of the eight thousand foods in the USDA database) are listed below along with their nutrient density scores (ND) which is based on the harder to find nutrients.

If you’re interested in all the gory details of the nutrient density score is calculated you can check out the Building a Better Nutrient Density Index article. But in short the system compared the nutrients per calorie across all the foods in the USDA database. A score is given based on the standard deviation from the mean. If a certain food contains a lot of a certain nutrient it gets a large score. If it contains an average amount of a certain nutrient it gets a zero score. If it contains a little bit or none it gets a negative score. We then sum all these individual nutrients scores for the nutrients that are harder to find that we want to emphasise.

If you want to check whether a particular food is nutrient dense I recommend Googling “nutrient data self [insert your favourite food here]” to see how it ranks. For example, the image below shows that spinach does exceptionally well in both the nutrient balance (vitamins and minerals) and protein quality score.

Vegetables

Fibrous green vegetables are the highest-ranking nutrient dense foods. Few people argue with the idea that veggies are good for you. The nutrient density analysis confirms this.

food	ND
watercress	16
endive	16
spinach	16
broccoli (sulforaphane)	13
escarole	13
asparagus	13
chicory greens	13
coriander	13
parsley	13
okra	12
lettuce	12
arugula	12
zucchini	12
brown mushrooms	12
Chinese cabbage	12
beet greens	11
seaweed	11
chard	11
chives	10
dandelion greens	10
cauliflower	10
turnip greens	10
celery	10
summer squash	10
yeast extract spread	10
alfalfa	9
radicchio	9
spirulina	9
white mushroom	9
pickles	8
cucumber	8
cabbage	8
mung beans	8
portabella mushrooms	8
mustard greens	8
collards	8
edamame	8
shiitake mushroom	8
snap beans	8
peas	8
artichokes	7
banana pepper	7
onions	7
soybeans (sprouted)	7
radishes	7
sauerkraut	7
pumpkin	7
kale	6
red peppers	6
butternut squash	6
Brussel sprouts	6
shiitake mushrooms	6
chayote	6
eggplant	6
jalapeno peppers	6
bamboo shoots	6
winter squash	5
turnips	5
rhubarb	5

Herbs and spices

Spices add flavour and nutrients and plenty of vitamins and minerals.

food	ND
basil	14
dill	9
paprika	7
cloves	6
thyme	6
sage	6
curry powder	5
marjoram	5
tarragon	4
pepper	3

Seafood

Seafood provides amino acids as well as Omega 3 fatty acids which are harder to get from other foods.

food	ND
crab	12
lobster	11
fish roe	10
oyster	9
crayfish	9
caviar	8
salmon	8
cod	8
trout	8
halibut	8
pollock	8
rockfish	7
sturgeon	7
shrimp	7
white fish	7
flounder	7
octopus	7
haddock	6
perch	6
whiting	6
anchovy	6
clam	6
sardine	5
scallop	5
tuna	5

Dairy and eggs

Only low fat cream cheese makes the list in terms of nutrients per calorie as other dairy products typically have more fat and not as many essential nutrients per calorie.

It’s true that eggs are a nutritional powerhouse of vitamins, minerals and protein. However, when it comes to the harder to find nutrients per calorie non-starchy veggies still win out.

It’s a similar story for nuts which don’t make the list. Full fat dairy and nuts can be a great source of energy and nutrition, particularly if you are insulin resistant or have diabetes, but if you’re just looking to maximise the harder to find nutrients per calorie the list of dairy and nuts isn’t that long.

food	ND
cream cheese (fat free)	8
whole egg	6
egg yolk	5
cottage cheese (low fat)	4
egg white	2

Animal products

Organ meats do well as well.

food	ND
turkey liver	9
veal liver	9
chicken liver	8
lamb liver	8
lamb kidney	7
ham (lean only)	6
pork liver	6
chicken breast	5
pork chop	5
turkey drumstick	4
turkey meat	4
lamb heart	4
leg ham	4
chicken liver pate	4
pork shoulder	4
veal	4

Pros and cons of nutrient density

The most obvious benefits of eating the most nutrient dense foods are that they:

provide the most essential nutrients with the fewest calories,
assist to normalize body weight (both lean tissue and body fat),
minimise cravings and the binge eating relating to nutrient hunger^[5],
provide the nutrients your body needs to thrive and optimise mitochondrial health, and
help achieve and maintain overall good health.

Maintaining a healthy weight with adequate protein and while avoiding excess energy intake will help you to avoid a lot of the diseases of aging. These foods will also be quite filling and hard to overeat due to the low energy density and high fibre content.

At the same time, it will be hard to get enough energy if you just ate from the foods in this list. If you are very active you will also find it hard to in down enough energy for a lot of intense activity. If you are insulin resistant you may want to start out with higher fat foods that will still provide plenty of energy without raising causing blood sugar swings.

Nutrient density plus…

Eating exclusively from the list of the most nutrient dense foods may not be appropriate for everyone, particularly if you are just starting out on your health food journey. The table below lists several nutritional approaches that are suitable for different people depending on their blood glucose levels / insulin resistance and weight goals.

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

Getting even more personal

If you’re interested in optimising your diet for nutrient density as well as tailoring it to your blood glucose and weight loss goals I would love you to check out an a new tool I’ve been developing, the Nutrient Optimiser. It will review your food log and, rather than just tracking calories it will identify your biggest nutrient deficiencies and the most nutrient dense foods to fix them. You can also tailor the insulin load of the food recommendations to help normalize blood sugars and then energy density if you still have weight to lose. It’s still early days, but the future looks very exciting!

references

^[1] https://www.amazon.com/Dorito-Effect-Surprising-Truth-Flavor/dp/1476724237

[2] http://www.nytimes.com/2013/02/24/magazine/the-extraordinary-science-of-junk-food.html

^[3] http://sydney.edu.au/science/outreach/inspiring/news/cpc.shtml

^[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988700/

^[5] https://books.google.com.au/books?id=gtQyAgAAQBAJ&pg=PA185&lpg=PA185&dq=%22nutrient+hunger%22&source=bl&ots=VMRPgGgALA&sig=bCs4K5AKbQdQadtSfIniBizMsQA&hl=en&sa=X&ved=0ahUKEwjL7d2eqYvSAhWRq5QKHaAjA9AQ6AEIJjAC#v=onepage&q=%22nutrient%20hunger%22&f=false

articles, fasting, weight loss

how to use your bathroom scale as a fuel gauge

January 1, 2017 Marty Kendall 9 Comments

“Complete abstinence is easier than perfect moderation.”

St Augustine

This article is a follow up to the “How to use your glucose metre as a fuel gauge” article, which has been quite popular, with lots of people reporting success in lowering their blood glucose and recalibrating their hunger signals by using the numbers they see on their glucose metre.

To recap, the process revolves around the idea that, perhaps even better than calorie counting or carbohydrate counting, the numbers you see on your blood glucose metre are a good indication of whether you are running low on fuel and need to eat or whether you are just eating out of habit, routine, social boredom or for entertainment.

While eating for pleasure occasionally or as part of a celebration is fine and part of enjoying life, in the long run, most of us need to find a way to obtain the nutrients we need with less energy if we want to avoid obesity, diabetes and all the associated negative consequences.

If we eat highly insulinogenic low nutrient density foods regularly our insulin levels stay high and our fat stays locked in storage and hunger drives us to eat more frequently. However, if we reverse this cycle to lower our glucose and insulin to normal levels we start to eat less frequently and we allow our stored energy to flow out of our fat cells, our appetite decrease and there is a good chance we will lose weight and gain health.

The table below shows the simple process whereby someone could decide if they really need to eat. Using this process would ensure that their blood glucose levels continue to trend down as their excess energy in their bloodstream and vital organs (pancreas, liver etc) flows out of storage.

blood glucose	action
> 7-day average, well slept and low-stress	delay eating and/or exercise and wait for blood glucose to come down
< 7 day average	if hungry, enjoy nutrient dense foods that align with your insulin sensitivity
< 73mg/dL or 4.0 mmol/L	if hungry, eat higher insulin load foods and delay exercise

Using numerical outputs to guide our decision making

There is no end of debate as to whether a calorie is a calorie or whether calories matter. Rather than tracking estimates of inputs like calories eaten or calories burned in exercise, there is nothing like tracking outputs such as your blood glucose levels, waist or weight to understand what your body is doing with the food you are eating and whether you are eating too much or too little.

If your glucose levels, insulin, waist or weight are increasing then chances are you’re eating too much, too often or the wrong type of food.

The plot below is a stark reminder that our chances of living longer improve if we have lower body fat levels or a waist to height ratio close to 0.5.

The problem with tracking glucose levels

The ‘problem’ with tracking blood glucose levels is that, in time, with regular fasting, our glucose levels will normalise to healthy levels but we may still be left with excess weight. So where do we turn once our blood glucose levels are optimal but our body fat levels are still above optimal?

This brings us to the star of this article, Rebecca Latham, who is a great example of how you can use your body measurements to guide your feast / fast cycle to achieve your long-term goals.

Rebecca has been following a low carb diet since the start of February 2009. She was featured in the 2010 New Atkins for a New You[1] as well as on the Atkins site as an example success story.[2] She was a guest on Episode 404 of Jimmy Moore’s Livin’ La Vida Low Carb podcast.

After a stressful time towards the end of 2015 Rebecca Latham decided she needed to make a focused effort to her lose some extra weight that had crept on. Rebecca is also particularly motivated by her family history of ALS, Parkinson’s Disease, dementia and cancer and her own ongoing battle with Type 2 Diabetes.

Rebecca’s Protocol

On 1 January 2016, Rebecca set an initial goal to lose 0.2 pounds per day over three months. Rebecca was also eager to reduce her fasting blood glucose levels from the 100mg/dL back to the 70mg/dL that they had been at before she regained her weight.

Part of Rebecca’s inspiration comes from her uncle, Buell Carlton Cole.

He was general surgeon to the President of the United States, who would control his weight by simply not eating until he returned to his goal weight. I initially thought this was an unhealthy approach until I read up a more about intermittent fasting.

Rather than simply not eating until she achieved her goal weight, Rebecca’s system involved not eating on days when her weight in the morning was above her target weight. Her only exception was to be special occasions and celebrations.

Here are Rebecca’s weight loss results during her initial 90-day challenge. Initial weight loss can be quite quick as the insulin levels drop and the body releases water. However, it gets a bit harder to continue with straight line weight loss as time goes on as you can see towards the end.

After the reached her initial goal, Rebecca had some issues that she needed to look after and ended up regaining some of the weight as you can see in the plot below of her weight over the past year. However, once these challenges were behind her she got back on her program. For the final part leading up to the end of the year she has dropped her goal weight loss back to 0.06lbs per day to hit her goal on 31 December 2016. See if you can spot the few ‘blips’ around Thanksgiving and Christmas.

This chart shows that she needed to fast for about one day in three through the year to lose nearly a quarter of her body weight over the year!

Reflecting on her journey, Rebecca says:

I reached my highest lifetime weight in February 2009, when I weighed in at 158 pounds, with a body fat percentage of 43.7%. This is my scale weight chart for this past almost eight years since I started eating low carb high fat (LCHF) and nutritional ketosis.

Each time I lost weight and stopped tracking and weighing myself, I gradually put most of the weight back on again. As you can see by the chart, this happened several times, and the last few times it happened, my weight was going up a little higher each time.

On January 1, 2016, I developed and started using my Protocol. Since starting the Protocol, I took two breaks, once in May 2016 when my husband had a heart attack and I was too concerned with his health to care about my own, but I got back on the Protocol within a couple of weeks and started seeing success again.

The next time I took a break was in July 2016, when I had to eat high carb and not fast for a week in preparation for some metabolic testing. As soon as the testing was over, I was back on the Protocol and started losing again. I have been going strong ever since, with small gains here and there brought on by restaurant meals and Thanksgiving.

I have now I reached my ultimate goal for scale weight, weighing in at 122.4 pounds with a body fat percentage of 25.7%, which means that I have lost approximately 37.5 pounds of body fat. The Protocol is the only thing that has brought me sustained weight loss, and I plan to follow it for the rest of my life!

Many people have a love/hate or even just a hate/hate relationship with their bathroom scale. It would be nice if low carb or nutrient dense achieved optimal health outcomes without any restriction for everyone. However, unfortunately, sustaining weight loss in the long term often takes discipline, some form of accountability and some level of restriction for most of us.

While weighing yourself every day isn’t much fun, the national weight control registry data indicates that people who have successfully lost weight and kept it off weigh themselves regularly.[3] [4] [5] Rebecca’s intended long term maintenance plan will likely be to weigh herself regularly and fast again once her weight goes outside her target range.

Better than calorie counting?

Some people who first try low carb or keto find that they initially lose a lot of weight eating to satiety as their blood glucose and insulin levels drop to healthier levels. However, in the long term, many people find that they need to be more disciplined and mindful of how much and/or how often they are eating to reach their optimal level of body composition.

The great thing about combining fasting with working to a goal like this is that it makes sure you don’t overdo the feasting days. I’ve found personally that it can be hard to know how much to eat after a fast. A quantitative system like this helps to manage and calibrate your appetite when you’re feasting.

If you eat to satiety, and not beyond, then you won’t have to fast again as soon as compared to if you binge after your fast. Eating to satiety on a regular basis means that your body’s metabolism doesn’t slow and adjust in the same way that it would if you maintained a constant caloric restriction.[6]

Life extension benefits

There are a number of benefits to fasting:

You can reduce your insulin levels more than if eating small but regular meals which keeps your insulin levels consistently elevated.
Fasting gives your body a chance to repair through a process called autophagy which is where the old cells are cleaned up which allow space for the fresh new cells to grow.
Fasting trains your body to become ‘metabolically flexible’ so you can use your body fat stores for and your food for fuel.
There is less need to focus on the quantity of food eaten at every single meal.
It’s not ideal to always be in growth mode with mTOR switched on. Alternating periods of growth and repair appear to be more beneficial in the long term.[7]
Fasting makes sense from an ancestral point of view when we wouldn’t have had constant access to plentiful food the way we do now. Periods of intentional restriction mimic what we have become adapted to and follow the seasons of the past.

Fasting also seems to have some special anti-aging effects. When food is scarce 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 to a time when food is more plentiful and you can reproduce and pass on your genes. Unfortunately, this emergency repair function doesn’t happen when food is plentiful.

Fasting and blood glucose levels

During the first three months following her protocol, Rebecca added a blood glucose target to also bring her blood sugar down by 0.25 mg/dL per day. As you can see in the chart below her blood glucose levels have dropped pretty much in parallel with her weight loss during this time.

More recently, she tested her blood glucose levels and found that they were consistently great so she ended up discontinuing the testing because it was becoming monotonous and not helping her make useful decisions.

While it’s useful to track a few things, it can be overwhelming and time-consuming to keep track of too many things at once and lead to analysis paralysis. It’s good to find a handful of things to track that will help you make useful decisions.

Do we lose fat or muscle during fasting?

One hot topic of discussion is the amount of lean mass (i.e. or muscle) that one may lose in long term fasting.

The reality is that any weight loss is going to consist of a combination of water, fat and muscle (or lean muscle mass). The chart below from Kevin Hall’s model shows that we initially lose a lot of carbohydrate (glycogen) and with it a lot of water.

Protein / muscle loss is the smallest component of loss from the body and this decreases as we adapt more to using fat and ketones rather than relying on glucose. It takes a few days to adapt to using fat and ketones, but in the long run they are by far the greatest proportion of energy used during fasting.

Rebecca’s experience aligns with this. She didn’t get a DEXA scan, but she does take regular body measurements which she uses to calculate her body fat percentage (see US Navy Circumference Method). Based on these measurements she lost 28.6 lbs of fat and 3.0 lbs of lean mass. So, more than 90% of her weight loss over the past year was fat.

“Problems” with fasting

Jason Fung has recently popularised the concept of fasting in the low carb community via his blog and videos and published The Complete Guide to Fasting. There is a ton of convincing evidence on the benefits of fasting which is an age old practice for a variety of reasons.

However, Dr Steve Phinney has come out highlighting his concerns with long term fasting with respect to loss of lean tissues as well as vitamins and minerals. A number of others have expressed concerns that fasting without due care and attention to refeeding will not be beneficial in the long term.

One way to reconcile the differences is to see these concerns as two ends of the spectrum. Jason’s focus is very sick people who come to him with major kidney issues due to their advanced Type 2 Diabetes, while Steve’s focus is more around maximising athletic performance for those whom maintaining muscle mass is critical to performance.

As you can see in the chart below from Differences in fat, carbohydrate, and protein metabolism between lean and obese subjects undergoing total starvation the proportion of energy from lean body mass increases as our level of available level of body fat decreases.

Also, if you are more fat adapted your body will be able to more easily draw energy from stored body fat rather than requiring glucose which can be drawn from the protein in your body via gluconeogenesis.

Most people don’t fit neatly into either of the extremes, so how do you refine the approach to suit your current situation? That is where optimising your food choices to suit your current situation comes in.

How much to eat after your fast?

Personally, one challenge I find with fasting is that it’s easy to overdo it when you get to eat again. I think some people experience this more than others. Dr Phinney made the analogy that telling someone not to binge at the end of a fast is like telling someone to hold their breath but then not to take too big a breath when they come up for air.

While some people can eat normally the next day after a fast, personally I find that it’s easy to reach for the energy dense lower nutrient dense foods or to give yourself liberty to eat foods that you may not normally eat if you were being disciplined all the time. By doing this, I’ve found it’s still possible to maintain or gain weight when fasting more days that you eat if you’re not disciplined with what you eat on your feasting days.

If you find yourself reaching for energy dense low nutrient density foods like processed carbs, a block of chocolate or litre of cream after your fast then you could take that as a sign that you need to revert to shorter fasting periods until you’re more fat adapted.

Another challenge with fasting is that it will deplete your system of vital nutrients in the long term meaning that you may be more inclined to binge when you do eat unless you’ve focusing on maximising nutrient density in your feasting periods.[8]

What to eat after you fast

One of the unique things about fasting is that it forces your body into the cleansing process of autophagy and primes the body to rebuild. Hence, it’s especially important to feed the parts of the body you want to grow (lean muscle mass is critical for long term health[9]) and maximise the nutrient density during the initial refeed.

In some ways, a fast is only as good as the feast afterwards that your body is highly primed to absorb. For me that means trying to plan some nutrient dense greens and a solid amount of protein for my first meal so I don’t end up reaching for the energy dense cream, butter or peanut butter or indulge in some junk carbage because I feel like I’ve earned it.

If your goal is to lose fat during the fast then it’s important to build back the essential vitamins, minerals and amino acids during the feeding period. The body will fight to get what it needs in the long run and I think you’ll have a better chance of avoiding cravings and involuntary binging if you maximise the essential nutrients of your food when you do this. And if you are using fasting to achieve long term weight loss I think it makes sense to try to get the maximum number of nutrients with the least amount of energy (a.k.a. avoiding empty calories and maximising nutrient density).

People looking to use fasting for long term weight loss may benefit from starting out with a higher fat dietary approach if they are very insulin resistant. However, as blood glucose levels progressively improve you should be able to transition to a more nutrient dense nutritional approach which will allow you to get your required nutrients with less energy.

I see a lot of arguments online regarding whether high fat keto or high protein is optimal. I think these arguments come down to context. The table below gives some guidance as to which approach might be right for you initially based on:

your blood glucose levels (if your glucose levels are high you will likely benefit from a higher fat keto approach, at least initially until your glucose levels start to normalise),
ketones (some is better than none, but there’s no need to chase high ketones with heaps of extra dietary fat, especially if you are trying to lose body fat), and
waist to height ratio (this is going to be more useful than the BMI chart to tell you if you still need to lose a bit of weight).

approach	average glucose		ketones (mmol/L)	waist : height
approach	(mg/dL)	(mmol/L)	ketones (mmol/L)	waist : height
therapeutic ketosis	> 140	> 7.8	< 0.3
diabetes and nutritional ketosis	108 to 140	6.0 to 7.8	< 0.3
weight loss (insulin resistant)	97 to 108	5.4 to 6.0	< 0.3	> 0.5
weight loss (insulin sensitive)	< 97	< 5.4	> 0.2	> 0.5
nutrient dense maintenance	< 97	< 5.4	> 0.2	< 0.5

This graphic from Dr Ted Naiman demonstrates how foods are all somewhere on the sliding scale between maximum energy density and maximum nutrient density. If we are aiming for long term weight loss, we want to maximise nutrient density as much as we can while keeping blood glucose levels and insulin levels low. Then as we improve blood glucose levels and insulin sensitivity we will be able continue to move towards the right to more nutrient dense approaches which will help to provide satiety and adequate nutrition with less energy.[10]

If / when we reach our ideal weight or level of body fat, we can afford to add back in some more energy dense foods because we are no longer trying to use the glucose in our liver (glycogen) and body fat from our belly.[11] [12]

Rebecca says:

I originally started eating ketogenically a few years ago by eating very high fat, lower protein, and very low (sometimes zero) carbs. That worked for a while, and I lost weight, but as time went on, I found that I was eating so much fat and so little protein that I was getting hungry all the time.

I now get plenty of protein on my eating days. I am 5’3″ and eat 125g on the days that I feast. I find with this approach I am less hungry and my Protocol requires me to fast less often.[13] [14]

Losing lean muscle mass is bad news whether you’re a bodybuilder, a diabetic or an older person battling sarcopenia.[15] Not only will losing muscle decrease your metabolic health, glucose disposal and metabolic rate, your body will also increase appetite to regain the muscle, making it harder to keep on losing the fat.[16]

It’s not just about looking buff and building muscles, amino acids are critical to fueling mitochondrial function and creating neurotransmitters that assist in staying happy and sleeping well. For example, the amino acid tryptophan produces serotonin which makes us happy and melatonin which helps us sleep.[17]

For reference, Rebecca’s 125g of protein per day ends up being 3g/kg LMB. This equates to 2g/kg LBM per day on average if you factor in the fact that she fasts every third day. This aligns with Volek and Phinney’s recommendations in the Art and Science of Low Carb Living (i.e. 1.5 – 2g/kg reference body weight) which equates to 1.7 to 2.2g/kg LBM . In Lyle McDondald’s Rapid Fat Loss Handbook he recommends between 1.8 to 4.4g/kg LBM protein, with a higher level of protein if you are lean and more active, and less if you are obese and inactive, to prevent muscle loss during a protein sparing modified fast.

The optimal food lists have been designed to help maximise nutrient density (including ensuring adequate amino acids) ideally without needing to rely on tracking calories. Rebecca does track what she eats, but mainly to make sure she is getting adequate protein on her feasting days.

The Protocol does not *require* tracking food intake, but I strongly recommend it. I found, for myself, that if I did not track on feast days, I ate too much fat and not enough protein, and I was having to fast a lot more to make my daily goals. Starting in April, I did start using the OKL macros and recommending the same to others.[18]

Rebecca also practices early time restricted feeding (eTRF) which means she eats earlier in the day due to better insulin sensitivity which seems to be producing good results for a lot of people. I have heard a lot of reports from people that have found that eating earlier rather than later helps with sleep, appetite and blood sugar.

Variations

I encourage you to check out Rebecca’s Facebook group where she has documented her daily progress and learnings and supports others using the Protocol. You can download a spreadsheet and start tracking and sharing your own progress. Public accountability and a supportive community are always going to be helpful in achieving such a long-term goal.

Rebecca has ‘stacked’ several different techniques from her learnings to ensure her long term success this time around to fight her genetics and tendency to regain her weight.

Before launching in, there are several considerations to tailor Rebecca’s approach to suit your situation and goals such as:

Target rate of weight loss. Rebecca recommends that people aim for a maximum weight loss of 0.2lbs or 0.1kg per day. Anything more is typically hard to sustain in the long term. You might be feeling ambitious and this level might be easy to achieve when things are going well but it may be hard to sustain in the longer term, especially if you have a few social gatherings or parties that leave you with some catching up to do. As you approach your goal weight you may be glad you chose a less aggressive goal as the weight loss becomes a little harder to achieve.

Social context. This type of approach can be hard to work around family or social commitments. I like to enjoy good food with my family on the weekends and save my fasting for work days when it’s easier to skip food. When I’ve followed this protocol, it leaves me fasting Monday and Tuesday and eating dinner Tuesday night with the family or ideally a hearty breakfast Wednesday morning. Based on my scale weight I may end up fasting another day or two on Thursday and / or Friday.
What’s your maximum fasting tolerance? Fasting gets easier with practice. You might want to start with just skipping a couple of meals, then going for 36 hours, then a couple of days. If you find your cravings are leading you to binge or sacrifice food quality, then you may want to stick with shorter fasting periods or aim for a less aggressive target rate of weight loss.
What else do you want to measure? The good thing about measuring weight is that it’s easy. It can however be problematic in that there are a ton of things that influence your weight other than fat gain or loss (e.g. muscle, water, how full is your gut, when did you go to the toilet etc); it’s an easy way to measure your progress day to day. In the long term, you want to see a trend in the right direction. If you have diabetes, then you may also want to track your glucose and even your ketone levels. It will also be useful to track your waist measurement periodically to see whether you’re getting closer to your optimum waist to height ratio of 0.5, particularly if you are building muscle and hence the BMI chart categories won’t mean much for you. For reference, during 2016 Rebecca’s waist to height ratio went from 0.54 to 0.44.

How full is your stress bucket?

A word of warning, again from personal experience, is that this approach is simple, but it’s not necessarily easy. Wondering what number you will see on the scale each day can be exciting but a bit stressful. It can be frustrating when you see the number going in the wrong direction or not keeping up with your target rate of weight loss.

Chris Masterjohn recently did an excellent podcast How I Lost 30 Pounds in Four Months and How I Knew It Was Time which I highly recommend if you’re hoping to lose some serious weight.

A regular fasting routine is another thing that you will add to your “stress bucket” and if you don’t already have your sleep, nutrition, relationships, stress, circadian rhythm and regular activity in check then the cortisol and related insulin spikes may make achieving long term success with this approach harder than it would otherwise be.

If you do have these things ticked off and you’re feeling relaxed after a Christmas holidays but may have overdone the celebratory food then you can download a copy of the spreadsheet from My Low Carb Road – Fasting Support and give it a go.

references

[1] http://www.why-low-carb-diets-work.com/atkins-forum.html

[2] https://www.carbsmart.com/low-carb-success-story-rebecca-latham.html

[3] https://www.ncbi.nlm.nih.gov/pubmed/24355667

[4] https://www.ncbi.nlm.nih.gov/pubmed/18198319

[5] https://www.ncbi.nlm.nih.gov/pubmed/14668267

[6] https://www.ncbi.nlm.nih.gov/pubmed/20921964

[7] https://optimisingnutrition.com/2016/10/29/the-complete-guide-to-fasting-book-review/

[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988700/

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

[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2988700/

[11] http://livinlavidalowcarb.com/blog/the-llvlc-show-episode-1161-qa-medical-panel-2016-low-carb-cruise/26797

[12] https://www.youtube.com/watch?v=2KYYnEAYCGk

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

[14] http://www.ketoisland.com/blog/is-keto-high-fat-or-low-fat/

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

[16] http://www.nature.com/ejcn/journal/vaop/ncurrent/full/ejcn2016256a.html?platform=hootsuite

[17] https://optimisingnutrition.com/2016/12/03/finding-your-optimal-insulin-load/

[18] https://www.facebook.com/groups/MyLowCarbRoadFastingSupport/permalink/147072942381538/

post last updated July 2017

fasting, recipies, weight loss

eggs florentine with chicken livers and bacon

December 26, 2016 Marty Kendall Leave a comment

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

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

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

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

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

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

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

Rebecca’s recipe is:

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

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

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

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

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

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

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

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

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

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

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

blood sugar, diabetes, fasting, fat, healthy foods, insulin index, insulin resistance, ketones

the complete guide to fasting (review)

October 29, 2016 Marty Kendall 14 Comments

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

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

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

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

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

Essentially, Jason’s key points are that:

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

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

my experience with fasting

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

Complete abstinence is easier than perfect moderation.

St Augustine

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

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

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

My key fasting takeaways are:

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

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

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

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

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

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

context

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

Desperate times call for desperate measures!

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

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

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

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

the Complete Guide to Fasting

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

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

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

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

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

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

The book covers:

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

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

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

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

my additional 2c…

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

target glucose levels

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

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

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

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

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

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

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

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

fasting to optimise blood glucose levels

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

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

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

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

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

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

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

fasting frequency

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

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

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

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

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

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

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

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

FAST WELL, FEED WELL

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

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

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

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

“Fasting without proper refeeding is called anorexia.”

Mike Julian

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

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

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

optimising insulin levels AND nutrient density

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

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

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

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

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

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

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

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

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

protein

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

are you really insulin resistant?

Insulin resistance and obesity is a continuum.

Not everyone who is obese is necessarily insulin resistant.

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

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

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

optimal ketone levels

Measuring ketones is really fascinating but confusing as well.

“Don’t be a purple peetone chaser.”

Carrie Brown, The Ketovangelist Podcast Ep 78

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

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

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

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

the root cause of insulin resistance is…

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

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

But what is the root cause of insulin resistance?

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

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

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

summary

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

references

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

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

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

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

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

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

athletes, calorie density, carbohydrates, cheat sheets, diabetes, insulin index, insulin load, insulin resistance, nutrient density, therapeutic ketosis

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

October 23, 2016 Marty Kendall 4 Comments

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

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

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

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

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

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

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

OFT in the wild

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

… gone to extraordinary lengths to obtain energy dense honey …

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

OFT in captivity

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

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

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

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

sweet = good = energy to survive winter

But now we have entered a brave new world.

We are now surrounded by energy dense hyperpalatable foods that are designed to taste good without providing substantial levels of nutrients.

Our primal programming is defenceless to these foods. Our willpower or our calorie counting apps are no match for engineered foods optimised for bliss point.

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

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

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

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

what happens when we go low fat?

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

Sounds logical, right?

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

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

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

Maybe a little too well.

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

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

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

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

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

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

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

what happens when we go low carb?

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

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

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

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

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

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

what happens when we go paleo?

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

Well, maybe. Maybe not.

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

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

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

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

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

enter nutrient density

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

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

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

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

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

optimal rehabilitation plan?

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

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

the solution

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

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

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

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

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

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

I hope this helps. Good luck out there!

post last updated May 2017

references

^[1] http://ketosummit.com/

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

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

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

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

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

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

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

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

articles, foods, insulin load, insulin resisatnce, insulin resistance, weight loss

nutrient dense foods for weight loss and insulin resistance

October 10, 2016 Marty Kendall 77 Comments

I found a number of people that were using a combination of the optimal foods for diabetes and nutritional ketosis and the optimal foods for weight loss lists. So I thought it would be useful to combine the two approaches into a single list of foods for people who want to lose weight but who were still somewhat insulin resistant.

optimal foods for diabetes and nutritional ketosis

The food ranking system revolves around manipulating these three parameters to suit different goals:

The optimal foods for diabetes and nutritional ketosis list has a low insulin load, is fairly low in non-fibre carbs and moderately high fat while still being as nutrient dense as possible.

This approach suits someone who has Type 1 Diabetes or is lean and looking to achieve nutritional ketosis. People who are at their goal weight can afford to eat a little more added dietary fat.

While most people looking to manage their blood glucose levels limit their carbohydrates to some arbitrary number that works for them, maximising nutrient density as well will help you to improve your mitochondrial function and increase your energy levels to ideally overcome your insulin resistance. Maximising nutrient density also means that your body won’t keep on seeking out more and more food to obtain the nutrients it requires.

People who are very insulin resistant often do well on a higher fat dietary approach initially to let the insulin levels drop, however they often find further success in the long term if they drop their dietary fat to let more fat come from their body.

optimal foods for weight loss

The optimal foods for weight loss list are fairly low in dietary fat to allow for to come from the body during weight loss. It’s heavy in lean proteins and non-starchy veggies and is VERY nutrient dense. The chart below shows a comparison of a range of dietary approaches with the insulin sensitive weight loss approach being having the highest nutrient density while diabetes and nutritional ketosis approach comes in at #8 of thirteen.

This list of foods may look like a low-fat dietary approach, but it’s not really low fat once you factor in your body fat. The chart from Steve Phinney illustrates how your body fat makes a contribution to the weight loss phase of a well formulated ketogenic diet.

The weight loss list of foods is also quite bulky (i.e. lots of fibre and water) so they would be very hard to overeat if you stick to just these foods. The chart below shows a comparison of the various approaches with the weight loss approach having the lowest energy density.

Eating from the weight loss foods basically equates to a protein sparing modified fast (which is widely held to be the most effect way to lose weight in the long term) meaning that will fill you up so much you won’t be above to overeat while at the same time providing enough protein to preserve lean muscle mass during the weight loss phase.

The “problem” with the aggressive weight loss approach is that it is very low in energy dense comfort foods and it is higher in carbohydrates and protein than most low carbers might be used to, so it might be harder to stick to. It may also raise your blood glucose levels if you’re still somewhat insulin resistant.

finding the optimal balance between the extremes

I have designed this list of foods for people who are insulin resistant and also looking to lose weight provides a balance between both extremes – high nutrient density, lowish levels of dietary fat and lower energy density.

The foods listed below represent the top 10% of the USDA food database using this ranking system. I’ve included the nutrient density score, percentage of insulinogenic calories, insulin load (per 100g), energy density (per 100g) and the multicriteria analysis score (MCA) that combines all these factors.

The chart below shows the amount of each nutrient provided by the more balanced approach compared to the average of all the foods in the USDA food database. As you can see you will still be able to obtain heaps of nutrients while the fat comes from your body.

vegetables

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
broccoli	23	36%	3	22	2.07
endive	15	23%	1	17	1.84
coriander	16	30%	2	23	1.79
zucchini	18	40%	2	17	1.75
chicory greens	14	23%	2	23	1.74
spinach	20	49%	4	23	1.66
escarole	11	24%	1	19	1.58
basil	17	47%	3	23	1.55
alfalfa	9	19%	1	23	1.51
watercress	22	65%	2	11	1.51
beet greens	13	35%	2	22	1.49
asparagus	16	50%	3	22	1.44
lettuce	14	50%	2	15	1.33
Chinese cabbage	15	54%	2	12	1.29
summer squash	12	45%	2	19	1.26
okra	13	50%	3	22	1.26
parsley	13	48%	5	36	1.25
cauliflower	13	50%	4	25	1.23
chard	13	51%	3	19	1.22
portabella mushrooms	14	55%	5	29	1.20
mustard greens	9	36%	3	27	1.20
arugula	11	45%	3	25	1.17
turnip greens	10	44%	4	29	1.17
chives	11	48%	4	30	1.14
banana pepper	8	36%	3	27	1.13
paprika	9	27%	26	282	1.11
cucumber	7	39%	1	12	1.08
pickles	7	39%	1	12	1.08
collards	7	37%	4	33	1.07
celery	10	50%	3	18	1.03
brown mushrooms	16	73%	5	22	1.01
avocado	-0	8%	3	160	0.99
white mushroom	13	65%	5	22	0.99
shitake mushroom	12	58%	7	39	0.98
red peppers	6	40%	3	31	0.98
dandelion greens	10	54%	7	45	0.97
sauerkraut	5	39%	2	19	0.96
dill	11	59%	8	43	0.96
eggplant	4	35%	3	25	0.95
cloves	9	35%	35	274	0.95
radishes	6	43%	2	16	0.94
sage	7	26%	26	315	0.93
jalapeno peppers	5	37%	3	27	0.93
curry powder	3	13%	14	325	0.92
edamame	7	41%	13	121	0.89
chayote	5	40%	3	24	0.88
olives	-5	3%	1	145	0.80
Brussel sprouts	6	50%	6	42	0.78
spirulina	11	70%	6	26	0.76
soybeans (sprouted)	6	49%	12	81	0.76
cabbage	7	55%	4	23	0.75
blackberries	-1	27%	3	43	0.71
artichokes	5	49%	7	47	0.71

seafood

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
fish roe	18	47%	18	143	1.45
salmon	19	52%	20	156	1.44
trout	16	45%	18	168	1.36
caviar	13	33%	23	264	1.25
oyster	16	59%	14	102	1.19
cisco	9	29%	13	177	1.17
sturgeon	13	49%	16	135	1.13
mackerel	6	14%	10	305	1.08
anchovy	12	44%	22	210	1.08
crab	17	71%	14	83	1.01
sardines	9	36%	16	185	1.01
flounder	13	57%	12	86	1.01
herring	9	36%	19	217	0.97
sardine	9	37%	19	208	1.0
halibut	15	66%	17	111	0.96
tuna	12	52%	23	184	0.91
rockfish	13	66%	17	109	0.86
lobster	14	71%	15	89	0.85
crayfish	12	67%	13	82	0.82
shrimp	13	69%	19	119	0.81
pollock	13	69%	18	111	0.79
perch	10	62%	14	96	0.73

animal products

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
lamb liver	19	48%	20	168	1.47
lamb kidney	19	52%	15	112	1.45
turkey liver	16	47%	21	189	1.25
beef brains	8	22%	8	151	1.24
veal liver	17	55%	26	192	1.20
beef liver	17	59%	25	175	1.14
chicken liver	14	50%	20	172	1.13
beef kidney	14	52%	20	157	1.10
lamb brains	6	27%	10	154	1.05
chicken liver pate	7	34%	17	201	0.91
lamb heart	10	48%	19	161	0.90
ham	12	59%	17	113	0.88
ground turkey	6	30%	19	258	0.88
turkey heart	9	47%	20	174	0.85
rib eye steak	8	41%	21	210	0.84
roast pork	7	41%	20	199	0.83
roast beef	7	38%	21	219	0.83
beef tongue	1	16%	11	284	0.81
lamb sweetbread	6	43%	15	144	0.79
lamb chop	8	42%	25	234	0.79
lean beef	11	61%	23	149	0.78
beef heart	9	52%	23	179	0.78
park sausage	2	25%	13	217	0.78
pork liver	11	59%	23	165	0.77
turkey meat	8	52%	21	158	0.74
turkey drumstick	8	52%	21	158	0.74
chicken	10	60%	22	148	0.73

dairy and egg

food	ND	% insulinogenic	insulin load (g/100g)	calories/100g	MCA
whole egg	9	30%	10	143	1.20
egg yolk	8	18%	12	275	1.15
sour cream	2	13%	6	198	1.02
cream	2	6%	5	340	0.93
cream cheese	2	11%	10	350	0.84
Swiss cheese	5	22%	22	393	0.80
cheddar cheese	5	20%	20	410	0.78
Greek yogurt	3	37%	9	97	0.74

other dietary approaches

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

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

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

Post last updated July 2017

athletes, nutrient density, recipes

Dom D’Agostino’s breakfast – sardines, oysters, eggs and broccoli

August 15, 2016 Marty Kendall 19 Comments

At first it sounds like a bizarre combination, but when the smartest guy in keto says that he has sardines, oysters, eggs and broccoli as his regular breakfast I wasn’t surprised to find this diet scored highly in the nutritional analysis.

Before he started saving the world by developing Warburg’s mitochondrial theory of cancer and oxygen toxicity seizures for DARPA Dominic D’Agostino studied nutrition and is rumoured to be able to do a 500-pound deadlift for 10 reps after a week of fasting.

Both physical and mental performance are undoubtedly critical to Dom, so it’s not surprising that he is very intentional about his diet and what he puts in his mouth to start each day.

As you can see in the plot from Nutrition Data below Dom’s breakfast scores a very high 93 in the vitamins and minerals score and a very solid 139 in the protein score.

You could say this meal was high protein (44%), low carb (10%) and moderate fat (46%), although his fatty coffee and high-fat desserts would boost the fat content to make it more “ketogenic”.

Dom’s breakfast scores well against the 250 meals analysed to date in the meal rankings for different goals coming in at:

therapeutic ketosis – 176
diabetes and nutritional ketosis – 87
nutrient density – 9
weight loss – 16

I’ve heard Dom say that he aims for a ‘modified Atkins’ approach with higher protein levels rather than a classical therapeutic ketogenic diet which is harder to stick to and might be used for people with epilepsy, cancer, dementia, etc. It was intriguing to see that Dom’s standard breakfast ranks the highest in nutrient density rather than therapeutic or nutritional ketosis.

Dom first mentioned his favourite breakfast concoction in his first interview with Tim Ferriss (check out the excellent three-hour podcast here). You can hear the shock and slight repulsion in Tim’s voice in the sound check as he responds with

“Do you blend that up in the Vitamix?”

But now Tim, rather than following his own slow carb approach, has made sardines and oysters a regular breakfast staple and mentions it as one of the top 25 great things he learned from podcasts guests in 2015.

The stats for a 500 calorie serve of Dom’s breakfast are shown in the table below.

net carbs	insulin load	carb insulin	fat	protein	fibre
6g	38g	18%	46%	44%	6g

I was aware that broccoli, eggs and sardines are nutritionally amazing, but then the oysters fill out the vitamin and mineral score to take it a little bit higher. Dom obviously understands the importance of Omega 3s which are hard to get in significant quantities from anything other than seafood.

I was surprised to see that oysters can be ‘carby’ (at 23% carbs) which is apparently due to their glucose pouch which varies in size depending on when they’re harvested.

If you wanted to skip the oysters due to taste or cost considerations, the combination of sardines, egg and broccoli still does pretty well. This option gives fewer carbs, a slight decrease in the vitamin and mineral score with a small increase in the amino acid score.

The ranking for the sans-oyster option is:

therapeutic ketosis – 159
diabetes and nutritional ketosis – 67
nutrient density – 11
weight loss – 20

The stats for a 500 calorie serving are:

net carbs	insulin load	carb insulin	fat	protein	fibre
3g	30g	10%	48%	44%	6g

The combination of nutrient dense seafood with nutrient dense vegetables is hard to beat. The chart below shows my comparison of the nutrients in the various food groups in terms the proportion of the Daily Recommended Intake (DRI) from 2000 calories (click to enlarge).

I couldn’t get any photos of Dom’s breakfast, but I did get a picture of my current go to lunch. Each weekend I get a bunch of quality celery and chop it up into tubs to take to work each day. I have cans of mackerel and sardines in my drawer at work.

Celery does really well in terms of nutrient density per calorie and sardines and mackerel are high on the nutrient density lists without being outrageously expensive (e.g. caviar, anchovy, swordfish, trout).

When I feel hungry, I might start munching on the celery which is pretty filling and hard to binge on. Then if I’m still hungry, I’ll have as many cans of mackerel or sardines as it takes to fill me up (which is usually 2 to 4).

At around 2 pm this is my first meal of the day (other than espresso shots with cream) at around 2 pm. If I start to feel hungry before then I might check my blood glucose to see if I really need to refuel or if I think I’m hungry because I’m bored. I’ll then go home and have an early dinner with the family around 6 pm.

I’ve been known to indulge in some peanut butter with, cream, Greek yoghurt or even butter if I’m still hungry (e.g. if I’ve ridden to work) but I try to not overdo it as I’m not as shredded as Dom yet.

The simple combination of celery and mackerel also does pretty well in the ranking of 250 meals and aligns well with my current goal of maximising nutrient density and ongoing weight loss now that I’ve been able to stabilise my blood glucose levels.

therapeutic ketosis – 137
diabetes and nutritional ketosis – 36
nutrient density – 16
weight loss – 8

net carbs	insulin load	carb insulin	fat	protein	fibre
8g	33g	25%	51%	35%	6g

articles, blood sugar, diabetes, exogenous ketones, insulin load, ketones, ketosis, nutrient density, protein, therapeutic ketosis

are exogenous ketones right for you?

August 8, 2016 Marty Kendall 56 Comments

I’ve spent a lot of time lately analysing three thousand ketone vs. glucose data points trying to determine the optimal ketone and blood sugar levels for weight loss, diabetes management, athletic performance and longevity.

In this article, I share my insights and learnings on the benefits, side effects and risks of endogenous and endogenous ketosis.

Exogenous vs. endogenous ketosis

But first, I think it’s important to understand the difference between exogenous and endogenous ketosis:

Endogenous ketosis occurs when we go without food for a significant period. Our insulin levels drop, and we transition to burning body fat and ketones in our blood rise.
Exogenous ketosis occurs when we drink exogenous ketones or consume a ketogenic diet.

Ketones vs glucose

Ketones are important. As blood glucose decreases, the ketones in your blood increase to keep our energy levels stable.

The chart below shows three thousand blood glucose vs ketone values measured at the same time from a range of people following a low carbohydrate or ketogenic diet.

While there is generally a linear relationship between glucose and ketones, each person has a unique relationship between their blood glucose and ketone values that provide a unique insight into a particular person’s metabolic health.

Some people produce more ketones than others. Some people have higher blood glucose levels.

What our ketone and glucose values tell us about our metabolic health

Hyperinsulinemia has been called as the “unifying theory of chronic disease” [1] [2] [3] [4] [5]. It’s beneficial to understand where you stand on the spectrum of metabolic health and insulin sensitivity.

The chart below shows the typical relationship between blood glucose and blood ketone for a range of different degrees of insulin resistance/sensitivity.

If your blood glucose levels are consistently high it’s likely you are not metabolising carbohydrate well. When you go without food, endogenous ketones are slow to kick in because your insulin levels are also high. You feel tired and hungry, and you are likely to eat again sooner and not stop until you feel good.

By contrast, if you are insulin sensitive you may be able to go longer between meals naturally and you will not feel as compelled to eat as much or as often. If someone is insulin resistant, a lower insulin load dietary approach will help with satiety and carb cravings while keeping blood glucose levels and insulin under control.

hyperinsulinemia and metabolic disorders

Exciting research is coming out underway looking at the use of EXOGENOUS ketones as an adjunct treatment for cancer or to provide energy directly to the mitochondria for people with epilepsy, dementia, Alzheimer’s and the like.^[6] ^[7]

EXOGENOUS ketones may help to relieve the debilitating symptoms and side effects of acute hyperinsulinemia, Alzheimer’s, dementia, epilepsy or other conditions where glucose is not used well.

exogenous ketones and the low carb flu

Patrick Arnold, who worked with Dr Dominic D’Agostino to develop the first ketone esters and ketone salts, has noted that exogenous ketones may help alleviate the symptoms of the ‘keto flu’ during the transition from a high carb to a low carb dietary approach.

However, once you have successfully transitioned to a lower carb eating style it may be wise to reduce or eliminate the exogenous ketones to enable your body to fully up-regulate lipolysis (fat burning), maximise ENDOGENOUS ketone production and access your body fat stores.

As discussed in the article Are ketones insulinogenic and does it matter? it exogenous ketones require about half as much insulin as carbohydrate to metabolise (or about the same amount as protein). Hence the continual use of exogenous ketones will limit how much our insulin levels are able to decrease.

Someone with diabetes who follows with a nutrient dense low insulin load dietary approach may be able to successfully normalise their blood glucose and insulin levels. When this happens, your liver will be able to more easily produce ENDOGENOUS ketones which will help improve satiety between meals and decrease appetite which will, in turn, lead to weight loss.

Exercising to train your body to do more with less is also helpful.

my experience with exogenous ketones

The light blue “mild insulin resistance” line is based on my ketone and glucose tests when I started trying to wrap my head around low carb/keto.

I enthusiastically started adding generous amounts of fat from all the yummy stuff (cheese, butter, cream, peanut butter, BPC etc) in the hope of achieving higher ketone levels and therefore weight loss, but I just got fatter and more inflamed as you can see in the photo on the left.

My blood tests suggested I was developing fatty liver in my mid-30s! And I thought I was doing it right with lots of bacon and BPC?!?!?

The photo on the right is after I worked out how to decrease the insulin load of my diet and learning about intermittent fasting. I realised that ENDOGENOUS ketosis and weight loss is caused by a lower dietary insulin load, not more EXOGENOUS fat on your plate or in your coffee cup.

I recently had my HbA1c tested at 4.9%. It’s getting there. But knowing what I know now about the importance of glucose control, I would love to lose a bit more weight and see my HbA1c even lower.

I initially purchased a couple of bottles of KetoCaNa after hearing a number of podcast interviews with Dominic D’Agostino and Patrick Arnold.^{^[8]} ^{^[9]}

Part of the reasons shelling out the money for the exogenous ketones was to see if it would provide a fuel source that didn’t need insulin for my wife Monica who has Type 1 Diabetes.

This metabolic jet fuel is definitely fascinating stuff! My experience is that it gave me a buzz like a BPC but also has an acute diuretic effect.

I had hoped it would have a weight loss effect like some people seemed to be saying it would.

I did find it had an amazing impact on my appetite. While it was in my system I didn’t care as much about food. However, once the ketones were used up my appetite came flooding back.

Unfortunately, my hunger and subsequent binge eating seemed to more than offset the short term appetite suppression that had occurred while the exogenous ketones were in my system. And it was not going to be financially viable for me to maintain a constant level of artificially elevated ketone levels which return to normal levels after a couple of hours.

do exogenous ketones help with weight loss?

I asked around to see if anyone had come across studies demonstrating long term weight loss effects of exogenous ketones.^{^[11]}It was a VERY enlightening discussion if you want to check it out here.

The Pruvit FAQ says that one of the benefits of Keto//OS is weight loss. However, no reference to the research studies was provided to prove his claim.

Also, the studies that were referenced in the Pruvit FAQ all appeared to relate to the benefits of ENDOGENOUS or nutritional ketosis rather than EXOGENOUS ketone supplementation.

According to Dominic D’Agostino in a Pruvit teleseminar, the EXOGENOUS ketone salts were not designed to be a weight loss product and hence have not been studied for weight loss after all!

The only studies that we could find that mentioned EXOGENOUS ketone supplementation and weight loss were on rats and they found that there was no long term effect on weight loss.^{^[12]}

So in spite of my hopeful $250 outlay, it seems that exogenous ketones ARE just a fuel source after all.

Even the experts don’t seem to think exogenous ketones help with fat loss.

^{^[13]}

Confused?

I don’t blame you.

Metabolically healthy

The “metabolically healthy” line in the chart above is based on RD Dikeman’s ketone and glucose data when he fasted for 21 days.

Due to his hard-earned metabolic health and improved insulin resistance RD has developed the ability to fairly easily release ketones when he doesn’t eat for a while. RD still doesn’t find going without food effortless, but it is easier than when his insulin levels were much higher which prevented his body from accessing his body fat stores.

Through a disciplined diet and exercise habits RD has achieved a spectacular HbA1c of 4.4%.

Perhaps a two or three day water only fast testing blood glucose and ketones with no exercise would be a useful test of your insulin status? You could use RD’s glucose : ketone gradient as the gold standard.

RD also told me that when he is not fasting and is eating his regular nutrient dense higher protein meals his ketone levels are not particularly high. While RD fairly easily produces ketones when fasting, it seems they are also quickly metabolised so they do not build up in his bloodstream.

I know Luis Villasenor from Ketogains finds the same thing.

total energy = ketones + glucose

Where this gets even more interesting is when we look at the glucose and ketone data in terms of TOTAL ENERGY. That is, the energy coming from both glucose and ketones.

The average TOTAL ENERGY of the three thousand data points from these healthy people working hard to achieve nutritional ketosis is around 6.0mmol/L. It seems the body works to maintain homoeostasis around this level.

When the TOTAL ENERGY in our bloodstream increases outside of the normal range it the body raises insulin to store the excess energy. That is, unless you have untreated type 1 diabetes, in which case you end up in diabetic ketoacidosis with high blood glucose and high ketones due to the lack of insulin available to keep your energy in storage.

Regardless of whether your energy takes the form of glucose, ketones or free fatty acids, they all contribute to acetyl-coA which is oxidised to produce energy. Forcing excess unused energy to build up in the bloodstream is typically desirable and can lead to long term issues (e.g. glycation, oxidised LDL etc).

I’m not sure if ketones can be converted to glucose or body fat, but it makes sense that excess glucose would be converted to body fat via de novo lipogenesis to decrease the TOTAL ENERGY in the blood stream to normal levels.

A number of studies seem to support this view including Roger Unger’s 1964 paper the Hypoglycemic Action of Ketones. Evidence for a Stimulatory Feedback of Ketones on the Pancreatic Beta Cells.^{^[14]}

Ketone bodies have effects on insulin and glucagon secretions that potentially contribute to the control of the rate of their own formation because of antilipolytic and lipolytic hormones, respectively. Ketones also have a direct inhibitory effect on lipolysis in adipose tissue.^{^[15]}

^[16]^[17]^[18]

Looking at the glucose and ketones together in terms of TOTAL ENERGY was a bit of an ‘ah ha’ moment for me. It helped me to understand why people like Thomas Seyfried and Dominic D’Agostino always talk about the therapeutic benefits and the insulin lowering effects of a calorie restricted ketogenic diet. ^{^[19]} ^{^[20]} ^{^[21]} ^{^[22]}

Dealing with high ketones and high glucose is typically not a concern because it doesn’t happen in nature or when eating whole foods. But now we have refined grains, HFCS, processed fats and exogenous ketones to ‘bio hack’ our metabolism and send it into overdrive.

While fat doesn’t normally trigger an insulin response, it seems that excess unused energy, regardless of the source, will trigger an increase in insulin to reduce the TOTAL ENERGY in the blood stream.

I am concerned that if people continue to enthusiastically zealously focus on pursuing higher blood ketones “through whatever means you can”^{^[24]} in an effort to amplify fat loss they will promote excess energy in the bloodstream which will lead to insulin resistance and hyperinsulinemia.

Using multi-level marketing tactics to distribute therapeutic supplements to the uneducated masses who are desperate to lose weight with a ‘more is better’ approach also troubles me deeply.

My heart sank when I saw this video.

MORE investigation required?

There are anecdotal reports that exogenous ketones provide mental clarity, enhanced focus and athletic performance benefits. At the same time, there are also people who have been taking these products for a while that don’t appear to be doing so well.

A July 2016 study Ketone Bodies and Exercise Performance: The Next Magic Bullet or Merely Hype? didn’t find that EXOGENOUS ketones to be very exciting.

Recently, ketone body supplements (ketone salts and esters) have emerged and may be used to rapidly increase ketone body availability, without the need to first adapt to a ketogenic diet. However, the extent to which ketone bodies regulate skeletal muscle bioenergetics and substrate metabolism during prolonged endurance-type exercise of varying intensity and duration remains unknown. Therefore, at present there are no data available to suggest that ingestion of ketone bodies during exercise improves athletes’ performance under conditions where evidence-based nutritional strategies are applied appropriately.

However, another study by Veech et al (who is trying to bring his own ketone ester to market) from August 2016 Nutritional Ketosis Alters Fuel Preference and Thereby Endurance Performance in Athletes found in favour of ketones.

Ketosis decreased muscle glycolysis and plasma lactate concentrations, while providing an alternative substrate for oxidative phosphorylation. Ketosis increased intramuscular triacylglycerol oxidation during exercise, even in the presence of normal muscle glycogen, co-ingested carbohydrate and elevated insulin. These findings may hold clues to greater human potential and a better understanding of fuel metabolism in health and disease.

I can understand how exogenous ketones could be beneficial for someone who is metabolically healthy and consuming a disciplined hypo-caloric nutrient dense diet. They would likely be able to auto regulate their appetite to easily offset the energy from the EXOGENOUS ketones with less food intake.

While it seems that EXOGENOUS ketones assist in relieving the symptoms of metabolic disorders I’m yet to be convinced that a someone who is obese and / or has Type 2 Diabetes would do as well in the long term, especially if they were hammering both more fat and exogenous ketones (along with maybe some sneaky processed carbs on the side) in an effort to get their blood ketones as higher in the hope of losing body fat.

Some questions that I couldn’t find addressed in the Pruvit FAQ that I think would be interesting to answer through a controlled study in the future are:

What is the safe dose limit of EXOGENOUS ketones for a young child? How would you adjust their maximum intake based on age and weight?
IF EXOGENOUS ketones do have a long term weight loss effect what is the upper limit of intake of EXOGENOUS ketones to avoid stunting a child’s growth?
Is there a difference in the way EXOGENOUS ketones are processed in someone is metabolically healthy versus someone who is very insulin resistant?
Does the effect on appetite continue beyond the point that the ketones are out of your system?
Do you need to take EXOGENOUS ketones continuously to maintain appetite suppression? Does the effect of ENDOGENOUS wear off as your own ENDOGENOUS ketone production down regulates? Do you need to keep taking more and more EXOGENOUS ketones to maintain healthy appetite control?
How should someone with Type 2 Diabetes adjust their medication and insulin dose based on their dose of EXOGENOUS ketones? Should they be under medical supervision during this period?
Is there a difference in health outcome if you are taking EXOGENOUS ketones in the context of a hypocaloric ketogenic diet versus a hypercaloric ketogenic diet? What about a diet high in processed carbs?
Is there a minimum effective dose to achieve optimal long term benefits to your metabolic health or is MORE better?
Are the long term health benefits of EXOGENOUS ketones equivalent to a calorie restricted ketogenic diet?

Unfortunately, I think we will find the answers to these questions sooner rather than later with the large scale experiment that now seems to be well underway.

Perhaps the burden of proof is actually on Pruvit to prove it rather getting their Pruvers to demonstrate that within 59 minutes they are successfully peeing out the product they’ve just paid some serious money for!

The lower the better?

Alessandro Ferretti recently made the observation that metabolically healthy people tend to have lower TOTAL ENERGY levels at rest (and hence have a lower HbA1c), but are able to quickly mobilize glycogen and fat easily when required (e.g. when fasting or a sprint).

Metabolically healthy people are both metabolically flexible^{^[25]} and metabolically efficient.^{^[26]}These people would have been able to both conserve energy during a famine and run away from a tiger and live to become our ancestors, while the ones who couldn’t didn’t.

Similar to RD Dikeman, John Halloran is an interesting case. He has been putting a lot of effort into eating nutrient dense foods, intermittent fasting and high-intensity exercise.

He is also committed to improving his metabolic fitness to be more competitive in ice hockey. His resting heart rate is now a spectacular 45 bpm!

And he’s been able to lose 10kg (22lb) in one month!

At 5.2mmol/L (i.e. glucose of 4.0mmol/L plus ketones of 1.2mmol/L) John’s TOTAL ENERGY is well below the average of the 26 people shown in the glucose + ketone chart above. It seems excellent metabolic health is actually characterised by lower TOTAL ENERGY.

MORE is not necessarily BETTER when it comes to health.

Fast well, feed well

To clean up the data a little I removed the ketones vs glucose data points for a couple of people who I thought might be suffering from pancreatic beta cell burnout and one person that was taking exogenous ketones during their fast that had a higher TOTAL ENERGY. I also removed the top 30% of points that I thought were likely high due to measuring after high-fat meals or coffee.

So now the chart below represents the glucose and ketone values for a group of reasonably metabolically healthy people following a strict ketogenic dietary approach, excluding for the effect of high-fat meals, BPC, fat bombs and the like.

The average ketone value for this group of healthy people trying to live a ketogenic lifestyle is 0.7mmol/L. Their average glucose is 4.8mmol/L (or 87mg/dL). The average TOTAL ENERGY is 5.5mmol/L or 99mg/dL.

	ketones (mmol/L)	blood glucose (mmol/L)	total energy (mmol/L)
average	0.7	4.8	5.5
30th percentile	0.4	4.6	5.2
70th percentile	0.9	5.1	5.8

The table below shows this in US units (mg/dL).

	ketones (mmol/L)	blood glucose (mg/dL)	total energy (mg/dL)
average	0.7	86	99
30th percentile	0.4	83	94
70th percentile	0.9	92	104

It seems we may not necessarily see really high ketone levels in our blood even if we follow a strict ketogenic diet, particularly if we are metabolically healthy and our body is using to ketones efficiently.

the real magic of ketones

When we deplete glucose we train our body to produce ketones.

This is where autophagy, increased NAD+ and SIRT1 kicks in to trigger mitochondrial biogenesis and ENDOGENOUS ketone production (i.e. the free ones).^{^[27]}The REAL magic of ketosis happens when all these things happen and ketones are released as a byproduct.

I do not believe that simply adding EXOGENOUS ketones will have nearly as much benefit to your mitochondria, metabolism and insulin resistance as training your body to produce ENDOGENOUS ketones in a low energy state.

Everything improves when we train our bodies to do more with less (e.g. fasting, high-intensity exercise, or even better fasted HIIT). Resistance to insulin will improve as your insulin receptors are no longer flooded with insulin caused by high TOTAL ENERGY building up in your bloodstream (i.e. from glucose, ketones and even free fatty acids).

Driving up ketones artificially through EXOGENOUS inputs (treating the symptom) does NOT lead to increased metabolic health or mitochondrial biogenesis (cure) particularly if you are driving them higher than normal levels and not using them up with activity.

You may be able to artificially mimic the buzz that you would get when the body produces ketones ENDOGENOUSLY, however, it seems you may just be driving insulin resistance and hyperinsulinemia if you follow a “MORE is better” approach.

Simply managing symptoms with patented products for profit without addressing the underlying cause often doesn’t end well.

Perhaps as more exogenous products come to market without the marketing hype that that comes with multi level marketing (e.g. Julian Baker’s Insta Ketone which are a sixth of the price of the Pruvit products) people will get to see if they really do anything useful.

Just like having low blood glucose is not necessarily good if it is primarily caused by high levels of EXOGENOUS insulin coupled with a poor diet or having lower cholesterol due to statins, having high blood ketone values is not necessarily a good thing if it is achieved it by driving up the TOTAL ENERGY in your blood stream with high levels of purified fat and/or EXOGENOUS ketones.

nutrient density

When we feed our body with quality nutrients we maximise ATP production which will make us feel energised and satisfied. Nutrient dense foods will nourish our mitochondria and reduce our drive to keep on seeking out nutrients from more food.

Greater metabolic efficiency will lead to higher satiety, which leads to less food intake, which leads to a lower TOTAL ENERGY, increased mitochondrial biogenesis, improved insulin sensitivity and lower blood glucose levels.

Prioritising nutrient dense real food is even more important in a ketogenic context.^{^[28]}While we can always take supplements, separating nutrients from our energy source is never a great idea, whether it be soda, processed grains, sugar, glucose gels, HFCS, protein powders, processed oils or exogenous ketones.

the best exogenous ketone supplement

If your goal is metabolic health, weight loss and improving your ability to produce ENDOGENOUS ketones, then developing a practice of FEASTING and FASTING is important.

To start out, experiment by extending your fasting periods until your TOTAL ENERGY is decreasing over time. This will cause your circulating insulin levels to decrease which will force your body to produce ENDOGENOUS ketones from your ENDOGENOUS fat stores.

Check out the how to use your glucose meter as a fuel gauge article or how to use your bathroom scale as a fuel gauge for some more ideas on how to get started with fasting.

If you want to measure something, see how low you can get your glucose levels before your next meal. Then when you do eat, make sure you choose the most nutrient dense foods you possibly can to build your metabolic machinery and give your mitochondria the best chance of supporting a vibrant, active and happy life.

As my wise friend Raymund Edwards keeps reminding me, FAST WELL, FEED WELL.