This evidence suggests that type 2 diabetes does not have to be a progressive

[Pegasus]

Again the assumption that I did not allow for confounders .
This experiment was to clarify an already observed effect .

 

[Johnny D]

I'm not really sure what you mean by the "keto ideology." I think you were saying that means keep protein lower in order to remain in ketosis? Please clarify.

Ya. Primarily I mean that I don't subscribe to the notion that it's healthy and proper to be in a constant state of ketosis. I believe ketosis is a good and natural state for people but that it's healthy to come out of it once a day. And then there are a few other facets of keto that I don't agree with, such as the belief that eating high fat will keep one in that state. And, since eating low protein with high fat will inhibit insulin sensitivity over time, I prefer the daily spike in BG from a single large meal of protein

I need to do more research, but my understanding is that dietary fat slows the emptying of the stomach, which can delay delivery of proteins and carbs to the rest of the body, thus blunting (or spreading out) any increase in blood sugar. It's also my understanding the gluconeogenesis is mostly a response to energy demand and not so much a direct, immediate result of dietary intake of protein. That said, my research is limited at this point, so I'd need to do more to argue with confidence.

The body's demand does set the "baseline" for gluconeogenesis, as I understand it. But protein intake size influences the the metabolic and hormonal response, signaling a release of more glucagon with a large bolus. So you get a dose-dependent glucose rises without violating demand-driven regulation principles. This is why my BG won't change much if I eat, say 25 grams of protein, but then spikes pretty high after a meal of 160 grams.

 

[madyogi]

Ya. Primarily I mean that I don't subscribe to the notion that it's healthy and proper to be in a constant state of ketosis. I believe ketosis is a good and natural state for people but that it's healthy to come out of it once a day.

I have no reason to disagree with this. I don't really have evidence as to why the glucose spike once a day is of particular health benefit either, so it's like, meh ... Can you provide some specific evidence that the spike is of particular benefit? If ketosis is a good and natural state, why come out of it once a day? Why not once every other day, or every weekend, or whatever? My general goal is to be metabolically flexible, so I want my body to be able to utilize fat for fuel or sugar for fuel and switch back and forth without being "confused" for a while. I guess you could make the argument this daily glucose spike from a large bolus of protein accomplishes that with introducing dietary carbs. That starts to make good sense in my mind, but I guess I think of true flexibility as being able to tolerate and utilize dietary carbs just as easily as tolerating and utilizing ketones in the context of a near-zero carb, high-fat, med-protein diet. For that goal, cycling dietary carbs makes more sense than this daily insulin/BG spike you're aiming for.

And then there are a few other facets of keto that I don't agree with, such as the belief that eating high fat will keep one in that state. And, since eating low protein with high fat will inhibit insulin sensitivity over time, I prefer the daily spike in BG from a single large meal of protein.

First of all, the notion that eating high fat will keep one in ketosis isn't a "belief." It's a strategy that works. Eating a diet that is calorically derived from mostly fat (60% or more) is highly satiating and in my experience (along with many others I've known) can absolutely allow a human being to maintain blood ketone levels above 0.5 for as long as they like. So, that's just kind of a fact, or at least it's the way my body works. Whether that's good or bad for a body is up for debate, and perhaps a matter of "belief."

Now, let's analyze what a diet like this actually looks like. Let's just use a maintenance calorie level of 2000. My maintenance level is higher than this, but it's an easy standard to work with. Let's say we're going to do the kind of diet that has historically kept me in ketosis for weeks at a time. That would be 65% fat, 30% protein, and 5% carbs. So, calorically speaking, that's 1300 from fat, 600 from protein, and 100 from carbs. If we translate that to grams, that's 145 g fat, 150 g protein, and 25 g carbs. So while the relative caloric intake of protein to fat is low on this diet, in absolute terms, this not a low protein diet. The average person in the Western World is not eating 150 g of protein daily. So, maybe I'm not your average keto guy, but you definitely don't need to eat a "low protein" diet to eat enough fat to maintain a state of ketosis over time.

The body's demand does set the "baseline" for gluconeogenesis, as I understand it. But protein intake size influences the the metabolic and hormonal response, signaling a release of more glucagon with a large bolus. So you get a dose-dependent glucose rises without violating demand-driven regulation principles. This is why my BG won't change much if I eat, say 25 grams of protein, but then spikes pretty high after a meal of 160 grams.

I'd have to do more research on this one to say anything with confidence. It just sounds like you have a belief that spiking your insulin/BG once daily is beneficial (which could be accurate, I'm just not sure), and you prefer to do that with a bolus of protein over adding some carbs into the mix. I've often thought of doing OMAD. My daily maintenance caloric intake is generally 2500-3000 at this point. So for me to get my desired percentage of protein I'd need to eat something like 180 g in one meal, but of course that would come with a considerable amount of fat. I'm sure I could actually sit and eat 2500 calories in one meal with the kind of ratios I try to hit during a ketosis phase. Could be an interesting experiment.

 

[madyogi]

Again the assumption that I did not allow for confounders .
This experiment was to clarify an already observed effect .

Fair enough.

 

[Johnny D]

I have no reason to disagree with this. I don't really have evidence as to why the glucose spike once a day is of particular health benefit either, so it's like, meh ... Can you provide some specific evidence that the spike is of particular benefit? If ketosis is a good and natural state, why come out of it once a day?

I don't have anything more than what I said earlier, which was:
The occasional insulin spike is good for the hormones - thyroid conversion, IGF-1, and testosterone - and if you're in constant ketosis you're probably suppressing those pathways. You also get a sort of "rehydration" effect when the insulin spike reduces sodium excretion. Constant ketosis and low insulin will lead to the kidneys dumping more sodium, with potassium and magnesium being wasted, too ("keto flu").
Some also believe that insulin going up and down helps us to be more insulin sensitive but I'm not sure there's enough evidence for that. I think it's plausible and it's very likely we evolved that way, rather than by eating smaller meals throughout the day. I do know that my insulin sensitivity (assuming that's a thing) is pretty good based how quickly my BG will go down to normal, but I don't know that I can attribute that to how I eat rather than what I eat just yet.

Why not once every other day, or every weekend, or whatever?

Yep. Good question, and not one that I have an answer for. Perhaps any of those strategies is sufficient. Daily is simple because I eat daily. Perhaps remaining in ketosis for a longer period of time might be more beneficial. Maybe it's better for full ketone metabolism adaptation. Dunno. I know many people use a cycling strategy of something like ever 5 or 6 days, etc. but I haven't gone deep enough on that topic, myself.

My general goal is to be metabolically flexible, so I want my body to be able to utilize fat for fuel or sugar for fuel and switch back and forth without being "confused" for a while. I guess you could make the argument this daily glucose spike from a large bolus of protein accomplishes that with introducing dietary carbs. That starts to make good sense in my mind, but I guess I think of true flexibility as being able to tolerate and utilize dietary carbs just as easily as tolerating and utilizing ketones in the context of a near-zero carb, high-fat, med-protein diet. For that goal, cycling dietary carbs makes more sense than this daily insulin/BG spike you're aiming for.

Maybe. I'm not convinced that metabolic flexibility is actually a thing. I think that in the abscence of fat and the introduction of carbs, my metabolic system would use the exogenous carbs/glucose for fuel even if it hasn't seen any for a while. And since I think carbs are generally contraindicated as proper nutrition, I just stick with protein for the "cycling".

First of all, the notion that eating high fat will keep one in ketosis isn't a "belief." It's a strategy that works.

Even with a large bolus of protein? I'm considered doing my own ketone tests but since I'm not really into ketogenic stuff, I haven't. But I'd definitely want to see what happens to BG and ketone levels with and without. I know that when I eat 160 grams of protein at the same time as 160 grams of fat, by BG spikes.

For clarity... What I meant by the original comment was that it's not because of the fat. Ketones are created from fatty acids (dietary or stored) when insulin and glucose is low(which I believe is a natural and indicated metabolic state for people). It's the absence of dietary carbohydrates that causes it, not the consumption of fat.

Now, let's analyze what a diet like this actually looks like. Let's just use a maintenance calorie level of 2000. My maintenance level is higher than this, but it's an easy standard to work with. Let's say we're going to do the kind of diet that has historically kept me in ketosis for weeks at a time. That would be 65% fat, 30% protein, and 5% carbs. So, calorically speaking, that's 1300 from fat, 600 from protein, and 100 from carbs. If we translate that to grams, that's 145 g fat, 150 g protein, and 25 g carbs. So while the relative caloric intake of protein to fat is low on this diet, in absolute terms, this not a low protein diet. The average person in the Western World is not eating 150 g of protein daily. So, maybe I'm not your average keto guy, but you definitely don't need to eat a "low protein" diet to eat enough fat to maintain a state of ketosis over time.

Agree. But you're spreading that protein out. That's the keto strategy, right? Avoid a large amount at once to avoid kicking out of ketosis?

I've often thought of doing OMAD. My daily maintenance caloric intake is generally 2500-3000 at this point. So for me to get my desired percentage of protein I'd need to eat something like 180 g in one meal, but of course that would come with a considerable amount of fat. I'm sure I could actually sit and eat 2500 calories in one meal with the kind of ratios I try to hit during a ketosis phase. Could be an interesting experiment.

Ya. That's how I do it. It's 160 grams of each in one sitting, but that's the strategy and how I've been operating for the last 4 or 5 years.

 

[not2big]

my Medtronic teacher and leader of a local diabetes support group advised that calories are not very important to limit but rather carbohydrates are what need to be controlled.

 

[Pegasus]

Yes not2big that is a standard view but nI have sparked a debate on protein effect on blood sugar etc . There is no doubt protein can move blood sugar and it's relevance is being discussed .

My thought here is that it would be relevant to a disbetic or even pre diabetic .

 

[Johnny D]

Though I think it depends very much on dietary carbohydrates - at least for T2D, anyway. In the absence of those, BG is maintained at low levels quite well throughout the day and might spike briefly with a large amount of protein. And I know there are some who also manage T1D with zero carb but that's venturing into an area of health that I'm not qualified to opine on, really.

 

[madyogi]

I'm not convinced that metabolic flexibility is actually a thing.

I agree it's questionable. It is certain that in the presence of dietary carbs, fat metabolism virtually stops. I think evidence also shows people have trouble adjusting to a sudden dramatic reduction in dietary carbs. It might have nothing to do with "metabolic inflexibility," and it might not the case the other way around, meaning going back to eating a fair amount of carbs after a long stint with none might not mean your cells can't jup back quickly to using glucose derived from dietary carbs for energy.

But you're spreading that protein out. That's the keto strategy, right? Avoid a large amount at once to avoid kicking out of ketosis?

Meh, there are plenty of Keto/Carnivore influencers who do OMAD and don't really prescribe spreading out protein specifically to stay in ketosis. The emphasis is typically on the inclusion of plenty of fat, along with <20g carbs daily. There's also the possibility that such a meal (160 g protein, 160 g fat, with whatever negligible carbs come with it) could cause a blood sugar spike, but not actually kick one out of ketosis. It would depend on your baseline level of ketones, obviously. But again, if it doesn't really matter to you and you feel good throughout the day, it's probably not worth paying that much attention to. I just like to nerd out on such things within my own biohacking journey.

Ya. That's how I do it. It's 160 grams of each in one sitting, but that's the strategy and how I've been operating for the last 4 or 5 years.

I'm going to try this one day in the next week or two for sure.

 

[madyogi]

Yes not2big that is a standard view but nI have sparked a debate on protein effect on blood sugar etc . There is no doubt protein can move blood sugar and it's relevance is being discussed .

My thought here is that it would be relevant to a disbetic or even pre diabetic .

This is a good point. If, as a diabetic or pre-diabetic, your primary goal is to maintain low BG and improve insulin sensitivity, spiking BG with a bolus of protein (even in the virtual absence of carbohydrates) should be avoided.

 

[not2big]

From what I have read, protein included in a meal ingested by non diabetics or T2Ds will tend to reduce BG levels because protein tends to increase insulin production and slows down digestion. In the case of T1Ds, there is no increase in endogenous insulin so BGs tend to increase.

 

[madyogi]

From what I have read, protein included in a meal ingested by non diabetics or T2Ds will tend to reduce BG levels because protein tends to increase insulin production and slows down digestion. In the case of T1Ds, there is no increase in endogenous insulin so BGs tend to increase.

The amount of protein probably matters quite a bit. Johnny D and Peg are talking about "boluses" of well over 100 g in one meal. I doubt most folks having that much protein in one sitting.

 

[Pegasus]

It is well established that protein moves bg ,it just does it less than carbs and thus has got no attention . So here is me saying I have tested it and it does happen .
When I first started geting anomolus high next morn readings I couldn't work it out because carbs get all the attention . The super size steak with a single potato hell am I super sensitive to potato I never noticed it before ???? The korean bbq where I piged out on a ton of meat but limited carbs .
I wish I had tested this morn I had the mixed grill at a local pub and that could have done it . I do wonder how much the amount of fat matters .

 

[Johnny D]

I agree it's questionable. It is certain that in the presence of dietary carbs, fat metabolism virtually stops.

The body will prioritize glucose oxidation as a means to mitigate the adverse effects of glucose in the system. A baseline level of fat oxidation continues, but the amount will depend on metabolic conditions, energy intake, and, especially, insulin level.

I think evidence also shows people have trouble adjusting to a sudden dramatic reduction in dietary carbs. It might have nothing to do with "metabolic inflexibility," and it might not the case the other way around, meaning going back to eating a fair amount of carbs after a long stint with none might not mean your cells can't jup back quickly to using glucose derived from dietary carbs for energy.

I think it's very much a factor of the body then having to up-regulate the enzymes necessary for fat oxidation. Since glucose oxidation is prioritized on a carb-rich diet, the system is down-regulated for fat oxidation. That's also why when people try to go high-fat overnight, they get diarrhea. The production of bile acid was down-regulated and requires some time to get back up to normal levels. There's also the other issues of electrolyte wasting, etc that make it hard to people to adjust suddenly. That's why I kind of eschew the notion of "metabolic flexibility".

Meh, there are plenty of Keto/Carnivore influencers who do OMAD and don't really prescribe spreading out protein specifically to stay in ketosis. The emphasis is typically on the inclusion of plenty of fat, along with <20g carbs daily. There's also the possibility that such a meal (160 g protein, 160 g fat, with whatever negligible carbs come with it) could cause a blood sugar spike, but not actually kick one out of ketosis. It would depend on your baseline level of ketones, obviously.

Ahh... Didn't know that. It's why I've often thought of using a ketone monitor, similar to my experiments with BG monitoring. I'd be super curious to know what your results are if you do!

 

[not2big]

Carbs are digested more quickly than proteins so carb induced BGs can mostly be reduced by insulin in 2 to 2.5 hours whereas proteins require more than 3 to 3.5 hours to be neutralized by insulin.

 

[madyogi]

The body will prioritize glucose oxidation as a means to mitigate the adverse effects of glucose in the system. A baseline level of fat oxidation continues, but the amount will depend on metabolic conditions, energy intake, and, especially, insulin level.

Right. My understanding is that a baseline level is always maintained in the liver, for example. My point is that the utilization of fat as a fuel (ketones) is virtually nil at the cellular level in the presence of blood glucose, mostly because of insulin. There's also another switch in the cell that I can't recall or find a reference to at the moment, that essentially forces an either/or condition between utilizing glucose or utilizing ketones to produce ATP. I'm pissed I can't find the video I watched 2 years ago ... lol.

Ahh... Didn't know that. It's why I've often thought of using a ketone monitor, similar to my experiments with BG monitoring. I'd be super curious to know what your results are if you do!

I have this planned for this week or next week for sure. I'll update when it goes down.

 

[not2big]

Over the past two days my BGs averaged about 100. This evening my wife prepares a large hamburger and even though I bolused for my usual 85 gr of carbs for my usual evening meal, my BGs increased quickly to over 210. I used corrective boluses for 25 gr of carbs over next two hours and reduced my BGs to 165.

 

[Johnny D]

Right. My understanding is that a baseline level is always maintained in the liver, for example. My point is that the utilization of fat as a fuel (ketones) is virtually nil at the cellular level in the presence of blood glucose, mostly because of insulin.

Gotcha. Agreed.

There's also another switch in the cell that I can't recall or find a reference to at the moment, that essentially forces an either/or condition between utilizing glucose or utilizing ketones to produce ATP. I'm pissed I can't find the video I watched 2 years ago ... lol.

Perhaps you're referring to GLUT4?? When insulin production increases, it triggers the GLUT4 receptor for rapid glucose uptake which outcompetes the ketones.

 

[madyogi]

Gotcha. Agreed.

Perhaps you're referring to GLUT4?? When insulin production increases, it triggers the GLUT4 receptor for rapid glucose uptake which outcompetes the ketones.

So, I found the "switch" I was thinking of, finally. It's actually more like a slider, not so much an either/or switch, and it "happens" inside the mitochondria, not at the cellular membrane, so it's below the level of the GLUT4 receptor. It's called the Randle Cycle. After discovering it again, I understand a bit more about GLUT4 receptors, insulin resistance, and fat adaptation.

First off, GLUT4 receptors aren't always sitting around on the cell membrane, waiting for insulin. They are apparently "swimming" in the cytoplasm and need to be triggered to migrate toward the cell membrane and open up a channel. This migration is largely triggered by a lack of a variety of fat oxidation metabolites. So, as fat metabolism slows "inside" the Randle Cycle (inside the mitochondria), fewer of these metabolites are released into the cytoplasm, and more GLUT4 receptors are "sent" to the cell membrane.

If I have this right, insulin resistance isn't so much a matter of the cells being bombarded with elevated insulin because of chronically elevated blood sugars, and subsequently becoming "tired" or "desensitized" to the insulin docking with the GLUT4 receptors. It looks like this is more a result of a "mixed" diet containing high fat in combination with high carbohydrates. Further, insulin resistance appears to be driven by whether or not the Randle Cycle is primarily invested in oxidizing fat for energy at the mitochondrial level.

Finally, there seems to be an "inertia" to this cycle, so it takes a period of time for the slider to move, ostensibly because the metabolites are a lagging indicator, making the mitochondria more apt to continue oxidizing fat for fuel as long as it can, assuming that's the "mode" it has primarily been in. Of course, the inverse is also true (it takes a bit to move off of glucose oxidation, if that has been the primary mode). This makes me think there is more to this idea of "fat adaptation" than I previously believed.

This is of interest to Type 1 Diabetics because it might explain why additional insulin doesn't necessarily reduce BG if you're currently in a general "fat burning mode." For Type 2 Diabetes, it's further evidence for leaning into a VLCD (very low carb diet) as a treatment for insulin resistance.

Here are some links the true nerds around here might find interesting:

 

[Johnny D]

Yep. I'm familiar with the Randle Cycle and I see what you're saying. However, even without the fat, a high-carb or sugar-heavy diet can still lead to insulin resistance (which is more of a construct than a diagnosis, TBH) and eventually T2D. It’s just that the way it happens might be a little different compared to when carbs and fats are both in play. The Randle Cycle is definitely a big deal when both glucose and fat are around, but if you're constantly eating sugar, that’s still going to keep insulin levels high, which over time can make your cells less responsive to it. It’s really the constant high blood sugar that causes the issue, not just having fat in the mix.