That hidden epidemic he describes is insulin resistance, sometimes called metabolic syndrome, which raises the risk of a host of diseases, from cardiovascular diseases, to various cancers and even Alzheimer’s.
Dr. Sarah Hallberg, one of my Health Sherpas, says patients who want to reverse type 2 diabetes have three medically proven options, backed by multiple published studies:
Very Low Calorie Diet
Low Carbohydrate Diet
Bariatric Surgery works for many people, with 30% or more able to achieve long-term remission. It also has the obvious downsides of surgical risk and expense. But it should be presented as an option, and some people will find it right for them.
A Very Low Calorie Diet, depending on the study, ranges from 300 to 1,800 calories per day. While these work really well in the short term, there is an issue with weight gain after the period of calorie restriction ends. It’s difficult to maintain the weight loss: the faster you lose weight, the faster you tend to regain it, and progress on diabetes can be lost too.
Low Carbohydrate Diets – Dr. Hallberg points to 22 randomized controlled trials (RCTs), 10 meta-analyses and 10 non-randomized trials, including six studies of two years or longer, including the Virta Health/Indiana University Health study she leads.
I think it’s worth watching the video below in its entirety for context, but if you want to skip ahead, she starts describing her results at about the 16:00 mark:
These results are phenomenal: Half of patients maintaining diabetes reversal at two years.
As she says, can you imagine if a drug had that kind of sustained effectiveness?
Here’s how the methods compare in blood sugar control:
In HbA1c, low carbohydrate is better than sleeve or very low calorie at two years, and equal to bypass.
And here’s how they compare from a weight loss perspective:
As Dr. Hallberg pointed out, the patients in her study (the purple line) started at a higher weight, and the average time with diabetes before the study was 8 years. Shifting the purple line’s starting point down 10 kg would make it pretty similar to either of the surgical options.
I greatly admire Dr. Hallberg and her collaborators, and I think the work Virta Health is doing is outstanding. Their results are great, and I think their intensive coaching intervention is valuable for people adopting this new way of eating.
I would add a fourth approach that I think will be the most effective, however: a combination of a low carbohydrate diet with intermittent fasting.
It conceptually combines the effects of the purple and orange lines in the graphs above.
Dr. Jason Fung calls fasting “medical bariatrics.” It has the benefits of bariatric surgery without the surgical expense and risk. It’s a lot easier to undo, too: You simply resume eating.
In fact, you have unlimited flexibility in adjusting the dosage of fasting. You can start with a 12-hour eating window each day, or you can fast for 16 or 18 hours and only eat from noon to 6 p.m. or noon to 8 p.m.
Low carbohydrate eating makes those fasting periods much less difficult, because fat and protein are more satiating than carbohydrates.
It’s kind of magical how these two strategies work together.
One final observation: At about the 23-minute mark of the video, Dr. Hallberg makes a really important point about the misplaced emphasis on randomized controlled trials in gauging efficacy.
RCTs are important when you have a drug intervention, because you’re typically testing a drug vs. a placebo, and the only thing you’re asking of the patients in the study is to just be sure they take whichever pill is assigned.
Diet is different. Motivation matters.
So does belief. If you’re randomly assigned to a diet for purposes of a study, even if you’re really motivated to change, you may not have really bought into the rationale behind the diet.
More on belief in a bit.
Dr. Hallberg in the U.S. and Dr. David Unwin in the U.K. have each demonstrated that a significant portion of patients under their care (as many as half) are able to reverse type 2 diabetes, going off diabetes medications, through a truly low-carb diet.
They’re just helping patients who are motivated to get healthy and lose weight, and who are willing to try a low-carb approach.
For type 2 diabetes reversal (and prevention) and for weight loss, low-carb works.
I believe low carb + periodic fasting works even better.
I can’t “prove” it by the RCT standard, and the people I’ve mentioned above may not all agree with the combination.
They each have their own emphases: Dr. Fung’s is mainly on fasting, while I think some of the others who promote low-carb think it’s most important to eat healthy fat and moderate protein meals to satiety. They say the key is avoiding hunger, which makes compliance easier.
My experience has been that combining both perspectives has led to the best result for Lisa and me.
Now back to what I said about belief.
There’s plenty of evidence that if you will adopt a low-carb eating pattern you can eat until you’re full, rarely feel hungry, improve your metabolic health and lose weight.
But as long as you toy with the idea instead of taking the plunge, you’ll never really know. As one of the great Christian theologians put it in a different context:
“Understanding is the reward of faith. Therefore, seek not to understand that you may believe, but believe that you may understand.”
St. Augustine of Hippo
Give low carb with periodic fasting a try.
Embrace the journey. Take the plunge.
If it doesn’t work for you, you can always have bariatric surgery later.
In the next few days I’ll have a post describing a new free community we’re setting up to support people in making these changes and swimming against the societal dietary currents. I look forward to telling you about it.
Director/Writer Jennifer Isenhart does an amazing job of summarizing arguments for a low-carbohydrate, high (healthy) fat eating pattern.
And healthy fat isn’t what you might think it is.
Here’s an appetizer through the official trailer:
In writing this post, I just rewatched Fat Fiction to make sure I gave a shout-out to all of my featured Sherpas.
It’s so inspiring to hear the stories of several of Dr. Lenzkes’ patients who reversed their type 2 diabetes and are now off insulin using a low-carb diet.
He had never had a patient on a low-fat diet reverse diabetes.
Dr. Westman and Jennifer Gallagher’s patient stories were amazing, too.
And while I’m generally proud to be a Minnesotan, this documentary highlights why Ancel Keys is not our favorite son, and the scientific fraud in suppression of the Minnesota Coronary Survey’s real findings is absolutely maddening.
If you’ve wondered what’s behind the grassroots surge in popularity of low-carb/ketogenic eating diets, Fat Fiction will tell you that story.
It runs just under 1:45 and is totally worth your time.
It will probably blow your mind, and could change your life significantly for the better.
Lisa, despite her extra challenges being post-menopausal and with thyroid issues, lost 10.
In alternate-day fasting you still eat dinner every evening.
You just skip breakfast and lunch every other day, and so on alternate days you go from dinner one night until dinner the next without eating.
In that time you’ll burn about half a pound of fat because of your sustained low insulin levels.
Do it two or three times a week and you’ll lose at least a pound a week.
It’s a lot easier if you’re limiting carbohydrates and getting plenty of healthy fats. That prevents cravings that could lead to overeating during your feeding windows.
If you want to add some heavy whipping cream (not half-and-half) to your coffee on the fasting days, that’s OK and you may find it easier. It won’t spike your insulin, and you’ll switch pretty seamlessly between burning your stored fat and the fat in the cream, and then back again.
If you start now and just plug away at it week after week, you won’t believe the progress you’ll see by the time the fireworks fly.
Lisa and I felt fantastic in August 2018, after our 10-week experiment, when we left for a three-week driving tour that took us to throughout the western U.S.
We feel even better now; another 15-20 pounds lighter and even more in control of our eating patterns.
If you’re not yet ready to dive into alternate-day fasting, start with the #BodyBabySteps.
The important thing is to start at some level today. Begin building your momentum. Small steps, repeated consistently, will get you there.
Check out My Health Journey for the full story of our health improvements, and my #BodyBabySteps for an approach to how I would do it if I were starting today, based on what I’ve learned.
As I noted in an update the day after my Stepping Off the Wagon post, I was shocked that after eating a whole pizza and more than one gluten-free beer, I was still able to stay in therapeutic ketosis.
Since Lisa and I concluded our #3DayCancerPreventionFast on January 27, in addition to January 31 we have stepped off the wagon two more times: February 11 and last night.
While Lisa has stopped the daily glucose and ketone measurements between our monthly extended fasts, I have kept them up since then. My readings for the 24 hours after the first excursion are above, and below are those for the period after the February 11:
I technically was out of GKI ketosis on the morning of the 12th, but by fasting as I stepped back on the wagon I was back to moderate ketosis by dinner time.
So because we’ve handled our off-wagon ventures with few negative effects, and because Lisa was away most of the day yesterday, we decide to exchange Valentine’s Day presents a day late. Here was hers to me:
Some in the low-carb/ketogenic community believe it’s essential to always rigorously limit carbs to avoid undoing all of the good of ketosis, and that one step off the wagon will undo weeks of effort.
They say it puts you right back to square one.
I cautiously disagree, at least for myself and for Lisa.
One way it could derail us would be if it became a gateway to ravenous, uncontrolled carbohydrate indulgence.
I’m confident that won’t be the case for us today, because it hasn’t led to this in the past.
We will enjoy our black coffee this morning, and fast until dinner.
The other way it theoretically could cause a problem would be if it reversed the fat-adaptation we had achieved. I think the ketone readings above in my post-pizza periods – all of them 0.5 mmol/L or higher – show that the ketone production is continuing.
That’s a secondary benefit of extended fasting, on top of a generally low-carb eating pattern.
In addition to activating autophagy and apoptosis, an extended fast flips the fat-burning switch to high gear.
The fundamental idea behind ketogenic eating and fasting is to restore metabolic flexibility the ability to use both sugar and fat for fuel.
Unfortunately, the typical American diet has so much sugar and starch in their various forms that it destroys fat-burning capability.
As I finish this post before starting work, and having just taken my morning readings, I’ve seen my ketones dip to 0.4 mmol/L, the first time I’ve been below 0.5 in a month.
So it suggests I probably should wait until after the next #3DayCancerPreventionFast for another pizza night.
Update: I tracked my “day after” glucose and ketones three times today, and here were the readings:
With plenty of carbs in my system from a whole pizza and a couple of gluten-free beers, and with the normal morning rise in glucose levels, I wasn’t too surprised that ketones dipped a bit further even at noon. But with only black coffee in the morning and coffee with cream at noon, I’m now solidly back into GKI ketosis.