Dear Mark: Choline Supplementing, Too Many Almonds, Keto and Insulin Resistance, and How to Drink

For today’s edition of Dear Mark, I’m responding to four reader comments. First up, if a person can’t eat eggs, doesn’t like liver, but really wants choline, can they just supplement? Second, are a couple handfuls of almonds too much omega-6 for the average person? What if they eat fish? Third, a new study claims to show that keto dieting tanks hepatic insulin sensitivity. What should we make of it? Are we giving ourselves type 2 diabetes by going keto? And fourth, I highlight a great approach to drinking alcohol (and living in general) from one of our readers.

Let’s go:

If I can’t eat eggs, and don’t like liver, can I supplement with choline? What would be a good dose?

Yes, you can supplement with choline. Men need around 550 mg per day. Women, 425 mg. Those requirements go up if you’re pregnant or nursing, and they very likely go up if you’re drinking.

It’s very possible that those are good levels for the average person eating a low-moderate fat diet. If you’re eating a high-fat diet or engaging in cognitively-demanding work, you may benefit from higher doses.

What jumped out at me was high O6 from snacking on almonds…this was in the fish oil post too, and it’s got me looking twice at how much is too much. I have a handful or two almost every day, and not supplementing with O3 ( although just started an experiment with daily supplements or fish). Too much?
Thanks as always for the excellent post—I’ve been wondering about alcohol too!

Don’t get me wrong. Almonds are a nutrient-dense whole food. They’ve got tons of magnesium, prebiotic fiber, polyphenols. Their health effect profile is impressive:

But they are high in linoleic acid. Absent fish, two handfuls a day is probably excessive. Having some fish fat will balance it nicely.

Try this: Replace one of your handfuls of almonds with a can of sardines or smoked oysters.

Does keto cause liver insulin resistance? Just saw this study and don’t want type 2 diabetes…

First of all, it’s a mouse study.

Second of all, it was a three-day study designed to look at the short-term transitory effects of going keto. Anyone who’s gone keto knows that the early days are a bit rough. Your mitochondria aren’t good at burning fat or ketones yet. You haven’t built the metabolic machinery required to extract the energy you need from the new balance of macronutrients. This period of transition coincides with the “keto flu”—that period of fatigue, listlessness, and headaches.

If you stick with the diet and make it through to the point where you can crank out and utilize ketones, everything changes. You can suddenly start making ATP from all that body fat you’re burning off, giving you a virtually limitless supply of energy at all times. It’s great.

But in the meantime, for that early period it’s rough. You’re insulin resistant, yet unable to burn much fat. Your liver is perpetually overloaded with energy, making insulin resistance almost unavoidable (if transitory).

Third, the composition of this study’s “keto” diet was about as bad as you could get (PDF). The fat came from Crisco—the classic trans-fat laden version—rounded out with a bit of corn oil. Trans-fats and omega-6 linoleic acid. Does this look like the diet you’re eating? Does this look like the keto diet anyone is eating? If the researchers set out to get the worst possible results for the keto group, it wouldn’t have looked any different. almost looks like they were trying to get the worst possible results.

Alcohol in ketosis is just one aspect of alcohol use in a healthy lifestyle. For me personally I perceive alcohol to play not a vital but an extremely useful role.

I drink about 40 gm of ethanol just about every day in the form of a classic gin martini made with 3.5 oz of premium gin (healthy fats in that olive, brother). I consider gin to be a very special spirit because it is comprised of water, ethanol, and botanical substances like the l-terpenes from juniper berries which are known to have a tonic effect on the human organism – and none of the hundreds of dubious organic chemicals (referred to as “cogeners”) contained in whisky or tequila. I always consume this martini between 5:00 and 7:00pm, and I very rarely drink anything else at any time of day or night. I have this drink immediately before and with the evening meal which I personally prepare from scratch with fresh ingredients and consume with my wife of 51 years.

The martini seems to me to punctuate and enhance the transition from “doing” – being responsible, making things happen, solving problems, exerting myself – to “not doing” – resting, refreshing, nourishing, regenerating. Subjectively, I feel like this one drink, consumed with food, stimulates the parasympathetic nervous system. The alcohol research, so-called, tends to produce the opposite result, but in my opinion, virtually all of the alcohol effects research is dreadful – just about the junkiest junk science you can find anywhere.

I will be 80 on my next birthday, my resting heart rate, measured with a Polar FT7 heart rate monitor as an average over 3-5 minutes is 51-52. I ride a mountain bike on intermediate level trails – often in a fasted state – and recently recorded a maximum heart rate of 167. This is considerably higher than the HRmax predicted by any of the recently validated formulas. My GGT level is 16, so I have to conclude that my liver thrives on classic gin martinis. I take no prescription medications and no over-the-counter medications. I am not trying to brag here, I am just trying to document that by just about any measure my health and physical condition is exceptional for a person my age.

My personal belief is that alcohol in the right form and used properly is a health food. This conclusion is based on my personal experience, but I dearly wish that some enterprising biochemists, neurologists, and social psychologists would get together and design a quality research program to examine alcohol’s health effects under various real-world conditions. People like to drink, but a lot of what they drink is full of cogeners and sugar and genuinely toxic crap. Almost nobody has a clue what is in what they are drinking and what its health effects – positive or negative – might be. Millennials are currently destroying their livers in droves and even killing themselves with booze at distressingly early ages. Beliefs about alcohol and drinking in our culture are pathetically primitive.

I think I’ve got it figured out for me, but I think it would wonderful for the rest of the world to know the score.

I’m highlighting Daniel’s words even though he wasn’t asking a question. This man gets it. This is how to approach, appreciate, and consume alcohol. He’s drinking with complete lucidity, total awareness, and mindfulness. Alcohol isn’t “just” something you use to get loaded. It’s a sacred chemical that marks the transition from “doing” to “being.”

Many people blur the lines, drinking for the hell of it. Make it more of a special occasion, consume it mindfully and purposefully. Having a couple glasses of wine at night because I’m bored will ruin my sleep and throw off my tomorrow. Having those same two glasses of wine and some conversation with my wife or dear friends over cheese and olives has an entirely different physiological—not just psychological—effect. My liver actually processes the wine consumed with mindfulness differently.

That’s it for this week, everyone. Thanks for reading and be sure to chime in down below with your own comments, answers, or concerns.

Take care!

About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.

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31 thoughts on “Dear Mark: Choline Supplementing, Too Many Almonds, Keto and Insulin Resistance, and How to Drink”

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  1. Around here we drink about a tablespoon of gin with lemon or lime juice in fizzy water. That’s enough gin to get the flavor of the botanicals but it doesn’t interfere with husband’s muscle control which is diminished due to cerebral palsy. He can even have two occasionally.

    I mindfully had a bottle of wine and a bottle of sour beer at our family bbq the day of my father’s funeral. Does that count?

  2. Love me some choline. Pro tip: find out how much choline is actually in the capsule and how much of that “other stuff” is mixed in with it. You may find that you’re actually getting a whole lotta magnesium stearate and a pinch of actual choline.

    Choline has a stickyish consistency that requires flow agents to make these guys flow through the encapsulation machines. If you’re not gonna devour egg yolks, love on the fresh liver, or get down on the wild fish eggs, ask the choline supplement co. exactly how much choline is in each capsule… the rest is flow. And now ya know!

    1. Just want to remind everyone that you can cut liver into pill shapes and freeze them. Swallow whole like a pill in the morning or dump into your smoothie and you won’t taste it.

      1. This is a really interesting idea, Karen! I’m curious: I’ve always read that digestion starts in the mouth with the saliva enzymes and the act of chewing. I wonder if swallowing liver whole interferes with its digestion…? I will have to Google it!

  3. Great article!

    I’d be really interested in you researching and writing about the jobs/careers that yield the healthiest employees. I (like a lot of people, I’m sure) have been thinking about making a job change in the near future. I’m currently a pastry chef at a pizzeria and brewpub on a college campus… which definitely isn’t helping my efforts to get healthier. I’d love to have a job that I can go to and not feel constantly tempted by unhealthy choices (and surrounded by other unhealthy people).

    Anyway, I think that could make a great post 🙂

    1. I too would love to hear ideas. Probably get lots of good feedback to add to the mix.

  4. I would love to submit a question for the next round. I am traveling to Patagonia in November for 2 weeks and would love a post about what to pack and try to eat there. It is such a remote place and I’ve heard it’s very hard to come by vegetables. I was thinking of bringing some things like primal bars but not much else since I am afraid it won’t get past customs. Would love advice!

    1. Pemmican! Make it yourself with just a little salt and chipotle pepper. Just did a week with only the above in the Swedish mountains and it worked great. Tip: fill your mug with pemmican, eat it and then have some coffee from the same mug – great food, great drink and easy cleaning of your utensils.

      1. I’ll have to look that up! I’ve honestly never heard of that before – thanks for the tip!

    2. hi Tara, Patagonia in Argentine? I dont think you are going to find difficult here. Paleo is arriving here too.

      1. Oh fantastic! And we’ll be visiting both Argentina and Chile. I am big on vegetables as well – I’ve heard that can be hard to come by? I am not too worried about the meat – really looking forward to the lamb there!

  5. Mark: Your blog is the best. Thanks so much for taking the time to share this with all of us.

  6. I’ve been wondering about the omega-6s in all the nut and seed crackers I make from scratch and eat. Should I add sardine pate to the top or maybe just take a fish oil supplement every time I have those crackers? My ratios are one thing I haven’t paid attention to until recently.

  7. What makes a food a health food?

    If exercise is damaging stress for muscles that is ultimately beneficial, would occasionally eating *bad* foods be a good stress for your body or are some things simply always bad for us?

  8. I keep seeing canned smoked oysters come up. While I do love them, I’ve been avoiding them because every brand I can get conveniently is packed in either sunflower or “vegetable” oil.
    Any brand tips? Or thoughts on the sunflower oil, does the oyster reward outweigh the bad from the oil?

    1. Rinse them, they’re good enough for Robb Wolf, you’ll be fine.

    2. The Crown Prince brand label claims that they are “packed in pure olive oil”.

      1. That’s Crown Prince Natural. The standard Crown Prince line that’s easiest to find is packed in cottonseed oil.

        If you want the Crown Prince Natural line you will have to look at an upmarket grocery store that has a natural foods section or your local co-op grocery or a health food store or a store like Fresh Thyme or Sprouts or Lucky’s or Whole Foods.

        Or you can get them on Amazon but they are over four buck per can there which is at least $1 more than I buy them for in my local co-op.

  9. I have a question for you, Mark! I eat primal food most of the time, but am comfortable occasionally enjoying a little other foods now and again. I had a work lunch today and ate more non-primal than usual (wheat and sugar), and immediately suffered from a stomach ache, and then felt foggy, exhausted, and my heart started racing, jumping up to 120 beats a minute. I think this was a reaction to wheat/sugar.

    My question is this: before changing my eating habits, a little wheat or sugar would not have made me feel sick like it did today. Why does it now? Why does it seem that the cleaner I eat, the bigger the reaction when I eat non-primal foods?


  10. What a breath of fresh air the alcohol comments were. This man is a Jedi. Would be curious to hear more from him on his lifestyle and the net positive alcohol has provided him. I am certainly in his camp but choose dry farm wines as my weapon of choice

  11. Eating almonds (especially too many) can contribute to kidney stone formation. True story

    1. I hear you should eat nuts with dairy or other high calcium food to bind the oxalates before they get to the kidneys.

  12. I’m pretty sure they designed the study to make keto look bad. Low carb — keto threaten many large industries and they will pay big bucks to researchers to come up with dirt on them.

    The dialysis bussiness alone. Does Coke® pay nutrition advisory companies out of the goodness of their hearts?

  13. I always love to read your Q/A session as it clears various doubts and gets answers to many questions that are beneficial for health and fitness. I loved reading this article. It defined how one can get choline through the supplement if someone can’t eat eggs and don’t like liver, impressive health effects of almonds on our body. And the most important thing that I took note of from this blog is that keto cause liver insulin resistance. So thanks Mark, for sharing your thoughts and research information on these topics.

  14. fact check: millenials actually drink less than the baby boomers.

  15. I haven’t been able to find the macros on homemade almond milk (just almonds and water). I use the almond pulp for crackers, etc… So how do I split the macros between the milk and the pulp? As a keto newbie, it’s suddenly become important for me to know! Thanks!