Blood Sugar Responses Compared

I asked a friend to be part of an experiment which involved him poking himself with a needle most of the morning. And he agreed. We are both fat adapted (me for 15 months and him for more than 6 months).

We both started fasted from the previous night (no breakfast for myself or my friend). We both ingested 50 g of Whey Protein (IsoPure Zero Carb Protein Powder) at the same time and measured our blood sugar responses over the course of the same morning.

I am a Type 2 Diabetic who has their Blood Sugar “under control” via diet and am no longer on meds. I am 57-years old and do some exercise (CrossFit) five times a week for the past two months.

My fried is a Tri-athlete in his mid-30’s. He’s not a Diabetic and runs frequently.

Here’s the two responses to the same amount of Whey Protein:

 

The results were very interesting.

  1. His fasted (starting) Blood Sugar number was higher than mine. We’ve compared numbers before and noted this same thing. We did not use the same meter since we were looking for relative differences not absolute values.
  2. After ingesting Protein, the Tri-athlete’s blood sugar went down. My blood sugar (the Type 2 Diabetic) went up.
  3. His Blood Sugar returned to normal much more quickly than mine (less than 2 hours. Mine took over three hours to return to normal.

I am not sure if his Blood Sugar went down due to him not having Insulin Resistance. If his Insulin went up in response to the Protein it could have driven his Blood Sugar down. Since I still have some degree of Insulin Resistance my Blood Sugar doesn’t go down nearly as well.

Support for this idea comes from (“Liver Metabolism“):

Overall, gluconeogenesis is stimulated by glucagon and
epinephrine and inhibited by insulin, as observed most
dramatically in insulin-dependent diabetes mellitus, in
which uninhibited gluconeogenesis contributes significantly
to the hyperglycemia.

Insulin favors oxidative decarboxylation of pyruvate and, therefore, also indirectly tends to diminish gluconeogenesis.

Interesting!

 

Explanations for Blood Sugar Rise with Protein Consumption

 

Here’s my questions/comments for the KetoGains thread on this subject.

I’ve been trying for a while to wrap my head around this subject. Here’s what I think at the moment. Would welcome any feedback on where I am missing it.

1 – My blood sugar meter shows that my blood sugar goes up 25 points with Protein (50g of whey) for a couple of hours. Not a bad increase since it’s only from 85 to 110 (US units). I have documented this at: http://land-boards.com/T2D/2017/09/26/blood-sugar-response-to-proteins/ .

2 – My blood sugar drops fairly rapidly at the end of the two hours (makes me hungry) which decreases when the blood sugar levels out. As long as I keep that in mind and keep food out of reach in that time frame I am OK. Otherwise, it seems like my body is telling me that it wants is ready to eat more Protein (or just food).
3 – Blood sugar production proceeds at a constant rate which isn’t all that much affected by Protein consumption. I’ve seen enough studies to believe that is probably the case such as //diabetes.diabetesjournals.org/content/62/5/1435. Also, the demand vs supply GNG argument seems strong. This rules out the idea of GNG being increased by the Protein.
4 – In a non-diabetic blood sugar doesn’t rise as much with ingested Protein as it does in a T2 Diabetic. It may not raise at all. I plan on an experiment with a “healthy” friend to confirm this for myself although the studies say it is “minimal”. But is that difference due to broken Insulin Resistance in the T2 Diabetic? As the Insulin goes up to deal with the Protein does that increase the Insulin Resistance of the cells at the same time and block the glucose from being consumed?
5 – The failure for a T2 Diabetic seems to be able to reduce the production of glucose in response to consumption of Protein (or one of the downstream aspects of the consumption). The Glucose (argued above) is getting “backed up” in the process and not being disposed by Insulin since the Insulin is “busy” dealing with the Amino Acids (all in all a very good use of Insulin).

So although arguably Protein doesn’t turn into glucose directly since Protein does lead to a rise in Blood Sugar (in T2 Diabetics) then what difference does it make if it is increased levels of GNG or an inability to reduce the rate of GNG or due to Insulin Resistance? Either way, the result is the same, Blood Sugar goes up (for T2 Diabetics) with protein consumption.

So then the question for me is whether or not Blood Sugar going up by a relatively small amount in a keto dieter who is eating lots of Protein actually a problem? Normally, us diabetics are trained to do things to minimize their blood sugars. This notion is leading a lot of people to eat a lot of fat and less Protein than they probably should.

Put another way, does the advantage of eating more Protein (maintain or growing Lean Body Mass among others) outweigh the disadvantage (marginally higher blood sugars for short periods of time)?

Survey of the Scientific Literature

From an 20 year old article (Diabetes Educ. 1997 Nov-Dec;23(6):643-6, 648, 650-1. Protein: metabolism and effect on blood glucose levels. Franz MJ):

Insulin is required for carbohydrate, fat, and protein to be metabolized. … Protein has a minimal effect on blood glucose levels with adequate insulin. However, with insulin deficiency, gluconeogenesis proceeds rapidly and contributes to an elevated blood glucose level. With adequate insulin, the blood glucose response in persons with diabetes would be expected to be similar to the blood glucose response in persons without diabetes. The reason why protein does not increase blood glucose levels (sic: in a non-diabetic) is unclear. Several possibilities might explain the response: a slow conversion of protein to glucose, less protein being converted to glucose and released than previously thought, glucose from protein being incorporated into hepatic glycogen stores but not increasing the rate of hepatic glucose release, or because the process of gluconeogenesis from protein occurs over a period of hours and glucose can be disposed of if presented for utilization slowly and evenly over a long time period.

Questions raised by this article:

  1. They don’t define “minimum effect” so is a 20 point rise considered to be a “minimum effect”?
  2. Another study indicates that GNG is much more efficient in a Diabetic. Is that because of an Insulin deficiency (the way it is worded above)? Or is that due more to Insulin Resistance?

Here’s a curve from one paper which shows the body’s Insulin response to Protein vs Carbohydrates which shows that the body has a similar response to Protein as it does to Carbohydrates when it comes to Insulin Levels:

This seems to be a reasonable study (Claire Fromentin1,2, Daniel Tomé1,2, Françoise Nau3, Laurent Flet4, Catherine Luengo1,2, Dalila Azzout-Marniche1,2, Pascal Sanders5, Gilles Fromentin1,2 and Claire Gaudichon1,2. Dietary Proteins Contribute Little to Glucose Production, Even Under Optimal Gluconeogenic Conditions in Healthy Humans. Diabetes 2013 May; 62(5): 1435-1442.) which concludes:

We showed that after a normal intake of protein (20–25 g), the contribution of dietary protein to glucose production was small and did not exceed 10% of the total flux during the 8-h postprandial period, contributing the production of 4 g glucose to 50 g of total glucose production.

While that is true in healthy humans (the subject of this study), is it also true of Diabetic persons?

From one of the comments in this thread

Higher protein intake, which needs insulin response to get it where it needs to be, will increase physiological insulin resistance (adaptive glucose sparing) in order to get the protein into where it needs to go without pushing more glucose into the cells. this will result in seeing a higher fasting blood glucose, and lower circulating ketones, as they replace glucose as a fuel for the tissues that previously used more of it.

Here’s the pieces of the puzzle.

  • Body produces a relatively constant level of blood sugar
  • Non diabetics have little to no rise in Blood Sugar when they eat Protein
  • In a diabetic the down regulation of blood sugar in the presence of Insulin is faulty
    1. Eat Protein
    2. Body begins digesting Protein
    3. Pancreas increases Insulin production to push protein into muscle cells
    4. As Insulin goes up so does Insulin Resistance of the muscle cells to Glucose (difference between a diabetic and a non-diabetic)
    5. Because Glucose is not being disposed by the muscle cells as well, the level of Blood Sugar rises temporarily
    6. After the Protein is processed by the body the Blood Glucose drops

So the theory here is that while the blood sugar rises over the short term it is not being pushed into the cells.

 

Body Recomposition – Part 2

Goals

Proposing to do a test on myself with the following goals:

  1. Improve HbA1C number (HbA1C is a lab test which shows the Blood Sugar over the previous three months)
    July 2017: 5.8 (Low end of Pre-Diabetic level)
    Goal: < 5.6 (Below bottom of Pre-Diabetic levels)
  2. Lose weight to reach 15% Body Fat (Visualize Body Fat percentages)
  3. Barring any injury, be able to do exercise throughout entire test (CrossFit)
    Submaximally is OK (<85% of max level)
  4. Conserve current LBM (Lose Weight but not muscle)
    Possibly add LBM?
  5. Maintain current metabolic levels.
    The same thing as saying not to eat at a net calorie deficit.

Methodology

The means to this end is a form of the Protein Sparing Modified Fast:

A protein-sparing modified fast (PSMF) is a very low calorie diet with some protein, fluids, and vitamin and mineral supplementation.

I don’t plan on doing this using very-low-calories but with an adequate level of calories to not lower my metabolism. The source of calories will come from both body fat and from macro-nutrients consumed.

See also Very-low-carbohydrate diets and preservation of muscle mass.

The Math

Some math is required. Some of this is constants (values which don’t change) and some of it is variables (numbers which you can play with). Part of the variables relate to weights and measurements. Some of the variables change day to day.

Constants and Variables

  • Current Weight (CW) = what the scale told you that you weigh this morning (using lbs for this discussion). My Current Body Weight at the start of this exercise is 205 lbs. This number should decrease over the course of this test or something is really wrong.
  • Lean Body Mass (LBM) = The amount of non-fat in your body. This includes muscle, connective tissues, and everything that is not fat in your body. Without any other value, the US Navy Calculator gives a good estimation of your current LBM. Better values can be found by BodPod or DEXA scans. My LBM is 156 lbs.
  • Pounds of fat is your current weight minus your LBM.  For me, I have 49 lbs of fat left. I can’t lose all of that, but that’s what I have left.
  • Basal Metabolic Rate – The number of calories you burn (per hour) doing nothing. Here’s one on-line calculator for your basal metabolic rate. I am using 11 calories/lb/day for my exercise rest days and 12 calories/lb/day for my exercise days. Better values of your Resting Metabolic Rate can be found by BodPod or DEXA scans.
  • Percent Body Fat – A goal. Use Visualize Body Fat percentages to select your goal number. My own goal is 15% body fat. No point in going any lower.
  • Fat oxidation rate – 31 cal/lb/day (SS, Alpert.A limit on the energy transfer rate from the human fat store in hypophagia. J Theor Biol. 233 (1): 1–13). You can only lose 31 calories worth of fat per lb of your body fat weigh in one day. Since I currently have 49 lbs of fat, I can lose 49 times 31 calories of fat per day or 1519 calories from body fat the first day. This number decreases as you lose weight. (Checking the numbers/units, the article states 290 kJ/kg-day, which is 69.26 kCal/kg-day. With 1 lb = 2.2 kg, that’s 31.5 kCal/lb per day).
  • Calories per pound of fat is 3500 calories/lb.

MacroNutrients to Achieve Goals

There are only three macronutrients in this world (other than alcohol). They are fat, protein, and carbohydrates. Selecting the right mix and amount of each of these three macronutrients is what any diet is about.

Low Carbohydrates

Of the three macronutrients, carbohydrates have the most effect on blood sugar and are the lest important macronutrient for function. It is necessary to stay at a low carbohydrate level to maintain a low blood sugar level.

I plan on sticking with the 20 grams of carbs per day limit. This number will not change over the course of this experiment. The source will continue to be green vegetables.

Protein for LBM preservation and Gainz

The Protein Sparing Modified Fast provides enough protein to maintain LBM and a little extra protein to cover muscle building. Dr Fung has a lower value for this number than most of the other sources (0.61 g/kg/day). KetoGains has a number of 0.8 g/lb/day of LBM.

For my LBM of 156 lbs, that’s 124.8 grams of protein per day. This number will not change over the course of this experiment since I want to maintain my LBM. I don’t want this number to be higher because it will lead to GNG or lower because it will lead to LBM loss.

Fat Level

When I have done long fasts, the lack of fat during the fast put me at a metabolic deficit. I could see this was true from my body temperature which was cold. I had enough energy to walk and function but was quickly tired by any exercise.

What gets left over after carbs and fat are determined is the amount of fat. Rather than High Fat or Moderate Fat of the typical LCHF/Keto diet, dietary fat is only used to make up the difference between the fat oxidation rate and the number of calories needed to not drop the base metabolic rate.

On day 1, that is only 17 grams of fat – about 1/2T of butter a day. That is quite a bit lower than I am currently doing but that’s probably why I am not losing weight. If I go over this number it will decrease my daily deficit and I will lose weight slower.

Intermittent Fasting

In the short term, I plan to do this experiment by continuing to feed one time per day. This is convenient and helps me keep my Insulin levels as long as possible. I may experiment with the timing of this one meal or may split it into a pre and post workout meal.

Testing the Results

Any good experiment requires some evaluation criteria against the goals. For this experiment I will:

Proposing to do a test on myself with the following goals:

Goal: Improve HbA1C number

Measurement: Get test done of HbA1C on Jan 1 for  < 5.6. Surrogate will be 90-day average blood sugar of 110 or less.

Goal: Reach 15% Body Fat

Measurement:  Use Visualize Body Fat percentages to check body fat percentage. Get third party to check from the pictures. Alternately use BodPod or DEXA scan test.

Goal: Be able to do exercise throughout transition

Measurement: Stick with current CrossFit with minimum average attendance record of 3 days per week. Stretch goal of 4 days per week (only open 5 days per week). Submaximal performance is OK although I would like to be able to complete at least 50% of timed WODs in the allowed times.

Goal: Maintain current LBM

Measurement: Same as Body Fat % Goal.

Goal: Maintain current metabolic levels.

Will know if this works if end weight is maintainable.

Best thing is this all could be done by Christmas!

The Cori Cycle – Not a new kind of bicycle

I had an interesting response to intense exercise the other day. I was many days fasted and went to an introductory CrossFit class. I measured my blood sugar after I got home from the class and my blood sugar was around 80 points higher. Did some digging to try and find out why.

My first assumption was that the liver was dumping glycogen and that’s partly true. Turns out that the muscles store around 80% of our glycogen stores and the liver contains the rest. The muscles use the glycogen locally and they don’t dump glucose into the blood stream. All of the glucose does come from the liver which takes it out of stored glycogen. That would account for some of the rise. I usually see a ten point pop with some exercise like bike riding but not like that time. The CrossFit exercise was very hard compared to normal exercise.

Here’s where the the Cori Cycle comes into play. I was fasted during the exercise for more than 20 days. From the Wikipedia article:

The Cori cycle is a much more important source of substrate for gluconeogenesis than food. The contribution of Cori cycle lactate to overall glucose production increases with fasting duration. Specifically, after 12, 20, and 40 hours of fasting by human volunteers, the contribution of Cori cycle lactate to gluconeogenesis is 41%, 71%, and 92%, respectively.

This was a piece of data which I didn’t have before. This makes sense of the experience that I had with intense exercise. The muscles released a lot of lactate which at the end of the exercise gets converted in the liver through gluconeogenesis into glucose. Hence, the large pop in blood sugars.

Here is a great discussion of exercise and the Type 2 Diabetic with Dr Finney.

 

Protein and Gluconeogenesis

A dialog in the 2KetoDudes Facebook group has me thinking more deeply about Gluconeogenesis (GNG). One of the folks there challenged my belief that GNG is a culprit with respect to Protein consumption. The person pointed me to a site which had a couple of articles, but this was the key one to represent his POV (Protein, Gluconeogenesis, and Blood Sugar).

It is the contention of the article that for a Keogenic (LCHF) diet the effects of Gluconeogensis from protein consumption are not significant to blood glucose levels. In fact, the article argues GNG and blood glucose levels are negatively correlated.

We haven’t found any solid evidence to support the idea that excess protein is turned into glucose.

Another interesting quote:

On the input side, blood sugar can come from three sources:
– We can eat carbohydrates, and have sugar enter the blood through digestion.
– We can make glucose out of glycogen (the limited amount of glucose stored in persistent form in the liver). This process is called glycogenolysis.
– Thirdly, we can produce new glucose by GNG.

Here’s where it gets even more interesting:

Even on a keto diet, there is still a substantial proportion of glucose production from glycogenolysis. Ultimately, of course, the glycogen in keto dieters also comes from GNG that happened previously.

Here’s a different article (Effect of long-term dietary protein intake on glucose metabolism in humans).

Glucose-stimulated insulin secretion was increased in the high protein group “516  45 pmol/l vs 305  32,p = 0.012) due to reduced glucose threshold of the endocrine beta cells “4.2  0.5 mmol/l vs 4.9  0.3, p = 0.031). Endogeneous glucose output was increased by 12% “p = 0.009) at 40 pmol/l plasma insulin in the high protein group, but not at higher insulin concentration whereas overall glucose disposal was reduced.

How Much Protein?

Dr Fung has a great article on how much protein a person needs. The recommended amount was determined in a rather distorted manner.

In 1985, the WHO reviewed studies of daily obligatory losses of nitrogen, and found that an average is 0.61 g/kg/day (total). Presumable, the diet should replace (roughly) this 0.61 g/kg/day being lost. In order to make sure everybody was covered, the WHO added 25% (2 standard deviations) above the mean to get 0.75 g/kg/day which sometimes gets rounded up to 0.8 g/kg/day. For a standard 70-kg male this is 52.5 g/day. Remember this is for absolutely healthy adults, not gaining or losing weight and the amount needed to cover the average amino acid losses are only 42 g/day (0.6g/kg/day). Remember, that if you want to lose weight, you should be eating less protein so that you can break some down.

Considering that protein leads to gluconeogenesis in diabetics then excess protein is a bad thing. The Ketocalculator said that I need 100 grams of protein a day. Rerunning my numbers on the Ketocalculator:

  • 1301 kcal Goal, a 40% deficit. (546 min, 2169 max)
  • 25g Carbohydrates
  • 44g Protein (97g min, 160g max)
  • 114g Fat (30g min, 210g max)

 

Daily Status – 2016-08-29

Today is the third day I have been off Metformin. My Blood Glucose numbers have tended up but not horribly. About 10 increase. I am no longer seeing numbers from 95-115 and am now seeing numbers from 105-125 instead. Not too bad really. If the upward trend continues I will add back in Metformin. If it flattens out I will stick with removing Metformin. If Metformin reduces gluconeogensis by 33%, I really don’t see it in my own numbers. I should be seeing numbers that are 33% higher not 10% higher.

Work scale shows I am down 23 lbs since Aug 5th. I started about July 31 (four weeks now). Not sure what my initial weight was but my guess is that I am down about 30 lbs so far.

I am going out for dinner with the kiddos tonight so it will be out to somewhere that I can do LCHF easily. We have done Jimmy John’s (order the lettuce wrap and the JJ Gargantuan) as well as Five Guys Burgers and Fries (skip the fries and order the burger “bunless”). Harder to find suitable choices at places like Applebee’s.

Still doing the Intermittent Fasting (IF). Yesterday I ate from 5 PM to 6:30 PM with a final snack at 8:30 PM of some ParmCrisps.

 

Keto Calculator – Macronutrients

How many macronutrients do you need to do LCHF? There’s an on-line Keto Calculator.

KetoCalc

It projects your rate of weight loss based on the values you selected. You can even download this data as a CSV (EXCEL) file.

Here’s my daily macronutrient goals (yours will vary):

KetoCalc-Numbers

I have been shooting for a higher percentage from fat due to my Diabetes. I am too good at converting protein into glucose.

 

Fat Adapted Athletes

Here’s a great study on fat adapted athletes (Enhanced endurance in trained cyclists during moderate intensity exercise following 2 weeks adaptation to a high fat diet).

The study looked at five cyclists and compared them on a High Carb vs a High Fat diet.

Despite a lower muscle glycogen content at the onset of MIE [32 (SEM 7) vs 73 (SEM 6) mmol · kg −1 wet mass, HIGH-FAT vs HIGH-CHO, P < 0.01], exercise time to exhaustion during subsequent MIE was significantly longer after the HIGH-FAT diet [79.7 (SEM 7.6) vs 42.5 (SEM 6.8) min, HIGH-FAT vs HIGH-CHO, P<0.01]

Looks like they have an almost 2x advantage when it comes to endurance.

How long did it take to convert these athletes from Carb Adapted to Fat Adapted?

These results would suggest that 2 weeks of adaptation to a high-fat diet would result in an enhanced resistance to fatigue and a significant sparing of endogenous carbohydrate during low to moderate intensity exercise in a relatively glycogen-depleted state and unimpaired performance during high intensity exercise.

Only two weeks!

How much Insulin Does the Pancreas Produce?

According to (“Normal” Insulin Secretion: The Goal of Artificial Insulin Delivery Systems?).

In the present study, we have determined prehepatic insulin production in six normal men throughout a day that included three typical 750-cal meals. Total insulin secretion for the 24 h was 45.4 ∪, secreted as 10.6 ∪ with breakfast, 13.4 ∪ with lunch, and 13.8 ∪ with dinner. The remaining 7.6 ∪ was secreted during the 9 h night at a rate of 0.85 ∪/h.

This may be why the transition down from 20 units a day to 8 units a day has been a more stressful one (with a couple of “higher” Blood Glucose levels) than any of the previous steps. I am now down into the range my body needs as a baseline.

If my LC-HF diet is keeping me from needing mealtime insulin then the remaining rate of approx .85 U/h would mean approx 20 U/day are needed for the background rate. I am far from a normal man (in so many ways) but I have to imagine that these were people substantially smaller than myself. Maybe 2/3 my weight so my requirements should be proportionately higher. Not a biologist so who knows?

An interesting additional factor is the question of gluconeogenesis during fasting. There was a study done on this as well (Quantitative contributions of gluconeogenesis to glucose production during fasting in type 2 diabetes mellitus).

Contributions of gluconeogenesis to glucose production were determined between 14 to 22 hours into a fast in type 2 diabetics (n = 9) and age-weight-matched controls (n = 7); ages, 60.4 ± 2.3 versus 55.6 ± 1.2 years and body mass indices (BMI) 28.6 ± 2.3 versus 26.6 ± 0.8 kg/m2.

The results were interesting.

Thus, gluconeogenesis contributed more to glucose production in the diabetic than control subjects. Production and the contribution of gluconeogenesis declined more in the diabetic subjects during the fast.