‘Medical’ Bariatrics – T2D 32

posted in: Diabetes, Health and Nutrition | 80

What happens when a severely obese, diabetic patient undergoes weight loss (bariatric) surgery? If type 2 diabetes is truly a chronic, incurable progressive disease, then surgery will not alter the natural history. According to conventional medical wisdom, long standing type 2 diabetics have very high insulin resistance provoking increased insulin secretion from the pancreas. Over time, the pancreas ‘burns out’ and insulin production falls. As the insulin falls, it is no longer able to compensate for insulin resistance and blood glucose rises, triggering the diagnosis of type 2 diabetes. Once the pancreas burns out, nothing will revive it, meaning that type 2 diabetes is destined to progress and nothing can change that. Since this abnormality is irreversible, the diabetes should continue unabated despite bariatric surgery. Right?

Actually, in virtually all cases, the type 2 diabetes completely disappears!

Type 2 diabetes is entirely reversible, even in patients that weigh 500 pounds. It is reversible even if patients have had their diabetes for twenty or thirty years. Not only is it reversible, but the type 2 diabetes is rapidly reversible. In a matter of weeks, even before any substantial weight loss, the diabetes disappears. Yes. It just goes away.

The 2012 STAMPEDE study was a three-year randomized trial of surgery versus medical therapy. Patients were initially randomized to Roux-en-Y surgery, sleeve gastrectomy, or their usual medications without any surgical treatment. At baseline, the average patient was 48 years old, with a hemoglobin A1C of 9.3% (considered very poor control) and body mass index of 36 (considered obese).

Without surgery, the medical treatment group increased both weight and diabetes medication. Their type 2 diabetes continued worsening, as they required more medication to keep control of their blood sugars.

But the surgical results were stunning. Within 3 months, most patients were off all their diabetic medications and maintaining blood sugars in the normal range. Interestingly, the benefits for diabetes appear long before most of the weight loss. A patient undergoing surgery at 400 pounds would likely still weigh over 350 pounds at 3 months. Nevertheless, the diabetes is completely undetectable despite the fact that they are still morbidly obese.

A full 38% of the Roux-En-Y surgical group maintained a hemoglobin A1C < 6% without any diabetic medications whatsoever. Technically, these patients no longer had diabetes. In other words, type 2 diabetes is reversible – even curable! Even the heaviest, most severe type 2 diabetics had disease that is reversible with treatment, but not with standard medications.

The ramifications are enormous. Type 2 diabetes is not chronic. It is not progressive. It is fully reversible, but our current medical paradigm of treatment is not correct.

Adolescents undergoing bariatric surgery enjoy the same success. In one study, patients starting with an average body mass index of 53, classified as super obese maintained a ninety-pound weight loss after three years. High blood pressure resolved in 74% of patients and 66% of abnormal lipids resolved. And Type 2 diabetes? Glad you asked. A stunning 95% of type 2 diabetes was reversed, with a median hemoglobin A1C of only 5.3% by trial’s end. The point once again is that type 2 diabetes is not chronic, not progressive, and not inevitable. It is fully and quickly reversible.

But surgery carries a heavy price. Complications are common with thirteen percent of the participants requiring surgical re-intervention. The most common problem is esophageal strictures requiring dilatation. The esophagus develops scarring. It gradually narrows resulting in difficulty eating. The treatment is to shove progressively larger sized tubes down the patient’s throats to open things up (lovely). This procedure is often repeated over and over.

That surgery can cure type 2 diabetes has been known since 1992. For ten years after weight loss surgery patients, most patients maintained normal blood glucose without the need for any medications. This treatment for diabetes is both rapid and long lasting. Normal blood sugars were achieved within two months and maintained for ten years. So the problem was not the disease. The problem was our treatment and understanding.

The benefits extended far beyond their body weight. Many metabolic abnormalities reverted back to normal as well. Sky-high insulin levels plummeted to normal levels. Blood glucose dropped in half. Fasting insulin, a marker of insulin resistance dropped 73%.

Despite all their successes, I don’t generally recommend these surgeries for a variety of reasons. The most important, though is that we can derive all the benefits without surgery and all of its complications. However, bariatric surgery studies have a very important lesson to teach. Type 2 diabetes, even in the most severe, long-standing and seemingly recalcitrant patient is an entirely reversible disease.

Surgically Enforced Fasting

Why is bariatric surgery is so successful at reversing diabetes where all the medications and insulins fail? Why does it work? There are many theories.

The foregut hypothesis suggests that the surgical procedure itself provides much of the benefit. Perhaps removing part of the healthy stomach or rewiring normal, healthy intestines into an abnormal, artificial man-made configuration somehow improves things. The normal stomach secretes many hormones, including incretins, peptide YY and ghrelin. Removing the stomach reduces all of these hormones, and perhaps others not yet identified.

Sleeve Gastrectomy

However it soon became obvious that this could not be correct. Gastric banding reverses the type 2 diabetes as effectively as the Roux-En-Y procedure. However, no part of the stomach is removed during lap banding. Reversal of type 2 diabetes did not depend upon surgical removal of any part of the healthy stomach.

The different bariatric procedures do not differ substantially in their ability to reduce insulin resistance. The only variable that matters is how much weight is lost. It did not matter whether you cut the stomach or not. It did not matter if you rewire the intestines or not.

The foregut hypothesis also fails to explain why type 2 diabetes often recurs years later since the stomach does not regenerate the ability to secrete these hormones. This proves what should have been a rather obvious point that the removing healthy stomach (like with the sleeve gastrectomy) doesn’t truly have any benefits.

Another natural assumption is that loss of fat mass, both subcutaneous and visceral, leads to the beneficial effects of surgery. We often imagine that fat cells, as a store of energy, just sit around doing nothing all day long, like a sack of potatoes, but it’s not really true. Adipocytes actively secrete many different types of hormones.

For example, fat cells secrete the hormone leptin, an important regulator of body weight. As fat mass rises, leptin secretion increases, signaling brain receptors to lose weight. In obesity, the body becomes resistant to the leptin’s weight losing effects. Adipocytes also convert testosterone into estrogen, leading to the familiar phenomenon of ‘man boobs’ in obesity. So adipocytes are not metabolically inert, but active hormonal players.

If adipocytes help sustain obesity and type 2 diabetes, then their removal should normalize the hormonal environment. But there are two problems with this theory. First, type 2 diabetes disappears within weeks – long, long before any substantial loss of fat mass. Second, surgical removal of fat does not provide any metabolic benefit.

Liposuction removes subcutaneous fat but not the visceral fat found in and around the organs. One study of liposuction removed 10 kg (22 pounds) of subcutaneous fat, yet failed to provide any metabolic benefit. There was no significant improvement in the blood sugar readings or any measurable metabolic markers. The only benefits were cosmetic.

Visceral fat is a far greater health risk. Unfortunately, this tendency to gain weight around the abdomen is very common. People with this ‘beer belly’ often have skinny arms and legs, but a protuberant abdomen. Bariatric surgery preferentially removes this visceral fat, where liposuction only removes subcutaneous fat. This partially explains why bariatric surgery leads to metabolic improvement even before all of the weight is lost.

There is no real magic here. The mechanism of benefit is the simplest and most obvious. All different types of bariatric surgery work because they have one thing in common – a sudden severe caloric reduction. Simply put – Bariatrics is surgically enforced fasting. All the benefits accrue because of the fasting. A study directly comparing the two shows fasting is actually superior to surgery in both weight loss and blood sugar reduction. Fasting produced almost twice the weight loss of bariatric surgery.

So here’s the crucial question. If all the benefits come from fasting, why not do the fasting and skip the surgery entirely? Fasting can produce results without postoperative complications, cost, or the need for expensive hospitals, equipment or specially trained surgeons. In essence, fasting is ‘bariatric surgery, without the surgery’. Medical Bariatrics.

But my point is not to criticize or praise surgery. There is one essential lesson to be learned from surgical studies. Type 2 diabetes is not a chronic and progressive disease. This is a colossal deception. Instead type 2 diabetes is an entirely preventable and reversible disease. Even the heaviest patients with the most intractable obesity can reverse decades of type 2 diabetes within weeks. Further, the cure does not require invasive surgery, only a deeper knowledge of its root causes. This changes everything. A new hope arises.



80 Responses

  1. Logically speaking, bariatric surgery patients don’t fast much after the surgery – they eat a reduced calorie diet. Which makes bariatric surgery a CRaP intervention, not a fasting intervention. And the whole point of this article and many more like this is to promote fasting and demote CRaP – which is a contradiction.

    But me and other observant people commented several times about this contradiction on these articles and nothing happens.

    • Isabela,

      The people who take these surgeries don’t shift from eating 3,000 calories/day to eating 2,700 calories/day, in my observation. Rather they shift to eating 1,000 calories/day, at first. It’s not total fasting but it’s closer to fasting than to standard CRaP, with doctors typically suggesting 1 lbs of weight loss a week or 500 calories a day in deficit.

      Dr. Fung has never been a fasting purist, for example he openly discusses people eating chia seed pudding and bone broth and cream-in-coffee during fasts. That’s not quite 1,000 calories/day, but it could be 100-300. He cites papers here fasting is defined as 500 calories/day for women, and 600 calories/day for men.

      He actually has a paragraph, in this very blog post, at the end saying that fasting works better. The conclusions are thus clear I think:
      – Shifting from 3,000 calories/day to 2,700 calories/day does nothing, as these patients have already tried it;
      – Shifting to 1,000 calories/day usually works well;
      – Shifting to <~ 200 calories/day (fasting) works even better;

      It took me a while to see the difference as well but I think I get it now. Modest calorie consumption with high insulin just leads to being in "starvation mode". Very severe calorie consumption likely forces insulin to drop, and that's good, you get some of the benefits of fasting, but not as much as a total fast.

      • Further adding to the CRaP or CICO theory – someone who has bariatric is usually over 300lb, I’d almost bet they’re pushing 400 usually. They also need to be in decent health and activity level before surgery, else they don’t do the surgery. They are burning 3000 calories pretending to be a couch at a minimum. Pre and post surgery forced fasting gives them the jump start and the inability to eat takes over after that. Once you start burning fat usually the body reacts well if you didn’t present it with carbs. Cos every night a low carb or a faster after a meal easily drops into fat burning mode.

    • The trick, actually, is how incredibly FAST (pun inteded) is the t2d reverted after bariatric surgery…

      …because the actual surgical pre- and postoperatory FORCES an ABSOLUTE and pretty long fast.

      Most bariatric surgeries implie 3 to 5 days (or even a week) “clear liquid” diet BEFORE the surgery, this being basically a “suboptimal” water fast (some low-fat milk, bone broth or sugar-free jello allowed), followed by a 48 hours post-op and yet another week of “clear liquid” diet before even starting with purees and protein shakes.

      So, even before the radical long-term calorie reduction (people dropping from 4000 to 1000 kcal a day is a almost demi-fast, being that their Basal Metabolic Rate will not be able to adapt), there is a short term extended fast that, actually, reverses in itself the t2d problem (most likely the origin of their obesity to start with)

      As it were, it is the long fast, not the surgery and reduced stomach, that reverses the t2d. And it is the t2d reversal, not the calorie reduction, that causes the severe weight drop.

      Bloody, maiming serendipity, I would say

      Extra idea: if the basis of weight loss due to bariatric surgery WAS the surgery and subsequent forced calorie reduction/malabsorption, how come people don’t “disappear”? Meaning, why don’t they keep on thinning as in Stephen King’s novel?

      My answer would be: because the deficient calorie absorption is not the reason for thinning. The healing of their hormonal weight regulation system is the cause, and once the system is on line, it causes not indiscriminate thinning, but effective weight control

    • Isabela,

      I know personally three persons who had that surgeries and go with them through their first two years after the surgery. And they technical fast. They eat one bite of Food in the morning and are not able to eat more, it´s not Fitting more than 100 ml Food into the tiny stomach. And they are full untill noon or even night and are not able to eat more. At least in the first two-three month. One of them was not able to eat before lunch, so she was fasting from dinner to lunch, a 16-18 hour fast. That is what Dr. Fung was talking about in his article and I really saw that in the three persons I know with that surgery.

    • sten bjorsell

      Most of diabetes 2 disappear during the days of fasting surrounding the surgical procedure. Minimum 1 day before op, day of op and a few days after with no food to heal up. 4-5 days. This is enough to empty the liver from lots of fats which starts to restore most parameters, and cures them when not to bad starting off, depending on how much visceral fats had built up before.
      After 5 days fasting, eat lots of low-carb and high fat for 2 days , and start next week the same. As DrF says, add bone broth at least the two last days of each fasting period. I did 3 such passes a year ago and lost 9 kgs and normalized morning blood sugar, that had started to go up after 3 years of LCHF. A great experience and I am set to repeat at least one such week every year for various other reasons as well, as fasting per se not only cleanses away old cells but also cleans the body inside. Every fast amazingly also increases the number of stem cells, providing vital engineering at subsequent refeeding! Refeeding is important as lots of good food plus stem cells can provide a lot more together than either alone. Buy ecological and GMO and toxic spray free food for the money saved during the fast!
      Google Valter Longo for more about the last!

      • Hi Sten, I posted to you in last several DrF’s blogs but perhaps you had already moved on. Tuesday I finish my first 2 week fast, not the least bit hungry. BS is routinely in the mid 70’s vry low 80s. That, however, is not good enough. Dr Taylor’s diet (he shows test results, I think GTT, look to be identical to category 1, Dr Kraft results.. The main point of this is aren’t you using refeeding out of context? I did research on this and virtually nobody suffers refeeding syndrome unless they have virtually no body fat left. That’s a question, not a stmt.

        I am undersided whether to continue this for a full month or even, perhaps, 2. But thereafter I believe I will WF one week every month. And, to whoever it was that asked if you can go full on carb binge after normalizing you bg via IDF. Yes, you can, so long as you resume fasting after. But, to my recollection after Christmas/New Years my fbs was still normal.

        • sten bjorsell

          Hi Walt, nice to encounter you again!
          After my first 5-day fast I just ate as normal first dinner meal. Awoke later in the night with stomach pains lasting for an hour. Next time I took chicken stock late on 4ft day and on last day. No problems. Agree that serious refeeding problems must come when body fats gone, yet there is likely a gradual transition. FBG of 70 is great,and I agree that one can binge on carbs with good blood sugar control after renewing the liver wiith IF. But regular switching betwer feasting and fasting is then key.
          Keep it up, including posting!

        • At the time I made that stmt I had but one outlier in the data, so to speak. Now it’s two. I had one evening of 60 bg and now another at 63. Again, referring to pg 239, the stmt made is “for a non-diabetic blood sugar levels will drop but stay in the normal range” Low 60’s is not ‘in the normal range’. How should I interpret that? Actually, if you get a chance, look at last two blog entries. tnx

    • Also, many studies that study “fasting” involve eating small (about 500 calorie) meals on the “fasting” days. Technically, not true fasting, but perhaps they can’t get actual fasting through their approval departments.

    • Dr. Anil Kagal

      I am a physician practising in rural India for the past 40 years. Diabetes is very common in my practice. Most of my patients are not obese, eat healthy natural food which they grow in their farms and are engaged in hard physical labour from 5am to 6pm everyday throughout the year. Gross obesity among city dwellers here is uncommon and and surprisingly many of these obese individuals are metabolically normal! Fasting for religious reasons through out the year is common……and still they have diabetes. I think we are missing something here. Genetic factors? Toxins in the food or water? I have read your blogs, seen your videos, bought your books and followed and dispensed your advice for 2 to 3 years now. My feeling is that your observations apply to less than 50% of rural Indian diabetics.

      • Sad and interesting… They are eating what they always have, but don’t they have sugar and processed junk available in a convenience store? Did their stress level increase a lot lately? Maybe the fat city dwellers are metabolically healthy because they store fat under their skin as opposed to their internal organs…

      • Stephen T

        Dr, you present an interesting example. I wonder what that diet really consists of? I understand that parts of India have a very high carbohydrate diet from crops and grains. Is there sugar in the diet? I’d be looking for simple answers before anything more complicated.

      • Maybe look at this research with regards to a plant based diet presented by Dr Michael Greger. I understand that there are many vegetarians in India but that dairy consumption is still high. Perhaps those in the country areas consume even more dairy or other animal products ?

    • Actually they pretty much are fasting, especially right after surgery. My daughter had the gastric sleeve and she hardly ate a thing for several weeks, she could only stand to eat like a bite at a time. That would totally make sense as to why the type 2 diabetes was fixed so fast, before even losing much body fat. Also I was with her at the pre surgery dr appointment, and the way he told her to eat after the surgery was great advice: Don’t ever eat bread or pasta, don’t snack, eat two or three meals a day. This would be hugely beneficial in keeping insulin low.

    • gracielou

      If you’ve ever looked at a post-bariatric surgery diet, most patients are on a liquid diet for first 6-8 weeks, then they move on to pureed food (starting with like a tablespoon of food max per meal) for another few weeks, then soft food (maybe 1/4 to 1/2 cup per meal), and then regular food (working up to a cup of food max per meal). So they are basically fasting for the first 3-4 months, which may be enough time for the body to repair itself and use/react to insulin the right way.

  2. I have a doubt regarding fasting. While fasting , In a diabetic patient the fasting blood glucose is provided by the liver gluconeogenesis, right? But even this high glucose level can constantly trigger the insulin production from the pancreas?. That means a diabetic patients body is never out of insulin attack even under fasting? I am not sure whether my argument is right or not. Please comment ..

    • Hyperglycemia from food and from liver are not the same things.

      Food leads to release of incretins from stomach and they provide more singnificant increase of insulin release. There is an investigation where they compare oral and intravenous administration of glucose. The last one results in much less insulin increase.

    • sten bjorsell

      It is not really gluconeogenesis that creates high morning blood glucose (BG). According to Dr Fung , insulin resistance keeps blood sugar from going into tissues, and also from leaving the liver! (High insulin drives sugar into both tissues and liver, low insulin takes it out of the two way storage organ, the liver) When BG and insulin drops during the night or during a fast, BG therefore rises as the liver sees lower insulin and then EMPTIES out part of its excess sugar, kept inside by high insulin. This can go on for days, something that make many with diabetes-2 fearful as it may take 4-5 fasting days before liver is “empty”. Gluconeogenesis from proteins plays a much inferior role during fasting. Mybe Dr Fung can elaborate further ?

    • This link was posted by SA recently


      While I do not understand all of this
      Not sure whether to be concerned

      “Given the widespread use of KD in the treatment of obesity and the role of NAFLD and hepatic insulin resistance in promoting type 2 diabetes, these results may have important clinical implications, as obese patients on such diets could lose weight but develop NAFLD and hepatic insulin resistance.”

      “Consistent with a recent study (29), elevated FGF21 in KD-fed mice induced PGC-1α expression in liver. The latter plays a crucial role in the adaptive starvation response, leading to an increase in fatty acid oxidation and gluconeogenesis without increasing glycogenolysis”

      • sten bjorsell

        Ketogenig Diet, KD, did at least for me result in annoying raised fasting blood glucose. That disappeared with IF, and fasting insulin dropped at same time. A main benefit of KD is that it makes it much easier to start fasting.

  3. HabeebuRahman

    Vimal, I am on LCHF and IF for the last 7 months. I am having a very low fasting insulin now. Only 2.33 mU/L. But my FBS is now 160mg/ml as I stopped sulfonylureas last month.

  4. Is there any data about average insulin levels if I for example will eat the piece of bread in one meal in compare to if I will divide and eat the same amount of bread in 5 meals during the day every 2 hours? Will it be the same daily levels? ty

    • I can vaguely remember a study where they fed the subjects (either mice or humans), either a couple of teaspoons of sugar every 2 hours or the or the whole amount of sugar at one time (maybe 10 teaspoons). Insulin spiked with every single small sugar snack just as high as the one-time spike after 10 teaspoon of sugar. I know what spike I would rather have…

      • That sounds a lot like a standard glucose tolerance test. Instead of sugar, it would have been liquid glucose. Sugar is 50% fructose.

        • I really failed to make myself clear, if this is what sounds like. I was trying to describe a study testing the effect of ‘small frequent meals’ and ‘one large meal’ on insulin. One large meal won by far, as you know from Jason Fung. Cheers.

  5. “Bariatric surgery preferentially removes this visceral fat, where liposuction only removes subcutaneous fat. ”

    I am confused by what is meant by this statement. I am sure you do not mean surgical removal of visceral fat during the procedure itself (as I know enough about the various procedures to know this is not done). Do you mean that after bariatric surgery, visceral fat is lost in preference to subcutaneous fat? Do you or any of the many informed commenters here have authority for this claim? I certainly hope it’s true in the case of fasting.

    Also, elsewhere in the post (and in other posts), you say that it is not about the weight loss, but the above statement appears to imply it is about visceral fat loss? So perhaps the hypothesis should be that the diabetes reverses when you do lose a certain threshold of visceral fat, but it doesn’t need to be all that much, at least by physical appearances? Were that the case, and this hypothesis seems in line with the work and ideas of Roy Taylor at Newcastle University, then we really shouldn’t say it’s not about weight loss at all. It manifestly is about fat loss, and clearly where (visceral vs subcutaneous) that fat was, and how much likely matters too (my threshold for reversal might be different to yours). It’s very possibly also about the fasting in and of itself too, the two hypotheses not being mutually exclusive

    • Kate Miller

      I was curious about the visceral fat reference as well.

      • Stephen T

        Kate, visceral fat is the worst kind of fat because it builds around the organs. I believe Dr Fung discussed it in a previous post on fructose, if you want to go back.

    • Mark, pls see the below post where I inserted the Taylor presentation “Reversing the Irreversible”. Several points. Dr Taylor concludes with individuals all have a T2D BMI ‘setpoint’, above which they become diabetic, below which they become ‘normal’. This, he posits, is why some will ask or state, All my friends are much heavier than I and none of them are diabetic. Dr Michael Mosley calls this TOFI, Thin on the outside, fat on the inside. I believe there are three classes of fat, subcutaneous (suitable for lipo), visceral, between the organs below that muscle between skin and organs at midsection, and intra-organ. This is far in the organs themselves, be it pancreas, liver, heart etc. It is this fat that must be removed and that can only happen by extended diet. Short of having a CS PhD and Applied Physics PhD to rewrite the code for an MRI machine I don’t know how one can tell that. How Dr Taylor could tell is via the above mentioned PhD’s.

      • Thanks Walt, I am familiar with the Newcastle and came to it long before this website. What I wanted to clarify here was what “remove” means when elsewhere the post claimed the reversal was not about weight “loss”, and then a seeming synonym for loss was substituted. So not weight loss but fat removal is important? I am being pedantic and semantic probably….

        • I, too, came across Professor Taylor long before I came across Dr Fung. I didn’t understand that reference either. Possibly meaning one loses 10lbs of fat but gains 9 lbs in lean muscle? Gaining muscle increases REE whereas losing fat doesn’t beyond simply changing the parameters for Mifflin St Jeor? I do recommend folks view Taylor’s presentation below.

  6. I admire Dr Fung, because thanks him I opened my eyes to fasting as a method to weight control. I live in Spain, and all the info here comes late, so it is difficult to comment this to any doctor.
    I am 45 years old women non diabetic, overweight ( 10 kilos or 20 pounds) .5 kg went away in the last 5 weeks of alternate day fasting (3 days a week only water fasting). PreviousIy, I have been trying IF (with no success ) for more than a year, but with this protocoll I finally succeded.
    I would like to ask Dr Fung to write a post about women and fasting. I have been reading about it, and there is so much grey information regarding the link… Sleep issues ( which I always had) are incresed in the fasting days. But it would be the same if i were in a 1400 kcal day diet anyway). Many thanks! Maru

    • You could start with this post, entitled “Women and Fasting”: https://intensivedietarymanagement.com/women-and-fasting-part-10/

      • Mark _ I have read that article but it doesn’t explain why women get more adrenal fatigue. Dr Fung’s patients are typically older women with type 2 diabetes. What about younger women who are still in child bearing years? Does this impact their fertility? I am passed all that but again I fear adrenal fatigue. I don’t think there is yet enough information available on the overall impact to women’s hormones.

        With that said, I am a huge fan of fasting and I am experimenting on different lengths of fasting. But my hunger pangs NEVER go away. I feel great but why over time does that not dissipate? I’d just like to see more confirmed research that it is good for women. For background information – I have been eating LCHF for about 3 years now (no real weight loss but luckily no gains either).

  7. Raj Kumar

    “If all the benefits come from fasting, why not do the fasting and skip the surgery entirely?” – Because people still don’t understand the benefits of fasting even though fantastic doctors like Jason Fung work tirelessly to educate. Well done Dr Fung, I think you are leading the way to changing human health for ever, you deserve a Nobel Prize.

  8. I wonder if it happens with any surgical procedure that forces the patient to limit calories. In early December an older relative 75+ had a heart attack followed by open heart bypass surgery. Over 20 years T2 but walked an hour a day and was outwardly thin but with a strong family history of metabolic syndrome, T2 controlled (not tightly, not monitored that well) for that time by one of the sulfnyurea drugs, no idea which. He had been following a low/moderate carb diet (no white carbs) for most of the prior year and his A1C had gone from 9 to 5.9 but the attack was from a prior calcification but he still had needed some minor drug intervention to maintain blood sugar. Before last year he ate a decent amount of white carbs while pretending he controlled his sugar.

    During the 3 weeks he was in the hospital (one week before and two weeks after) he was not hungry and although we tried to force feed him with the diabetic version of Glucaerna because we were concerned he needed the energy for tissue repair (it was before we found this blog!) I calculate he was probably eating less than 500 calories a day. He lost about 15 lbs (which he did not need to lose) some of which he has since regained, in a good way.

    Although at times in the hospital he had post meal bg of 170 or so (and was immediately given 1 unit of insulin!) a week after the procedure and was discharged on a low dose of a different Sulfonylurea to be taken only with a carb loaded meal, he really has not needed it. His A1C has gone down more and in fact he recently accidentally took a pill in the morning and he dropped to a bg of 65 (the NEXT day!) He no longer takes it and his morning sugars are under 105 consistently.

    Originally we thought the moderate carb was the reason his morning bg was low, he was following the diet (one we put him on, not the 60 grams of carbs per meal the hospital recommended!) but since finding this blog I wonder if spending nearly 3 weeks in a modified fasting state was what put him into remission?

    He is feeling better and has resumed his normal activities. Note, of late he has been eating a little bit of carbs, eg a slice of toast with his omelette. When he does that, his post meal numbers are 170 without medication. I find this unsettling because I think it means that unless he adheres to his diet strictly his diabetes will return and the underlying heart issues as well.

    I personally hate when an expert claims that a low carb diet or any diet or fasting CURES T2. I do not think it does, it puts it into remission as long as you continue to follow the diet. It does concern me to read post such as Sten’s above where after 3 years of LCHF he found his morning blood sugar up so that he HAD to add IMF in order to control it. Makes me wonder if any of this is really a long term solution. Sure, is it better than amputation and disability, absolutely but given my family history I wonder if anyone who reacts to carbs will ever be able to eat like a NORMAL person? Will I ever be able to eat all fruits, or beans or quinoa? I know pasta and regular pizza is too much to ask

    • For me to describe something as a “cure” for T2 diabetes, it would have to mean that after being “cured”, you could go on an all-out balls to the wall refined carb bender, and your blood glucose levels would return to normal within a normal time frame exactly as a metabolically healthy person’s would.

      If a diet or fasting protocol enables you to maintain normal blood glucose levels and HbA1C only as long as you adhere to it, then this is wonderful to be sure, but it is a remission of your symptoms and not a cure of the underlying disease.

      • Exactly!

        This article calls surgery and fasting a cure and it just is not. It is a solution as long as you stick with it, a T2 will never be able to have a pasta dinner and cake and wake up to an unmedicated 90 BG

        • My view is that insulin resistance is not absolute (yes/no), but gradual (more/less resistant).

          Yet, in order to tag someone as T2D or prediabetic, arbitrary set points in indicators are fixed.

          So, suppose you are seriously resistant to insulin and you start on LCHF and IF: you will partially recover your insulin sensitivity, maybe to the point that your indicators fall below the T2D arbitrary set point.

          Hooray! You’re cured of T2D!

          You forget about T2D, LCHF, IF…
          …and next time you look, IR is acting up again and T2D is back.

          Damnation! Snake oil and phoney witchdoctors!

          No. Because IR is gradual, but the medical definition of T2D is not.
          You were just too close to the limit, and eating “bad” carbs is always pushing you (and everybody else!) towards T2D.

          Is it possible to regain insulin sensitivity to the point that no amount of carb bingeing will make you lose it? ‘course not! Not you, not anybody: enough hyperinsulinemia will turn anyone into a T2D.

          It’s as if you imply that bariatric surgery (or fasting!) is not the cure for obesity, because if after thinning out you systematically stuff yourself time and again, you will gradually get fat…

          Well, of course, because that’s how you get fat, independently of whether you had been cured of obesity or had never actually been obese

          • It is a treatment, NOT A CURE. I have no problem with saying LC etc is a treatment and will control the problem as long as you stay with it. I resent it being called a cure to sell articles or books because it is not, a cure implies you no longer have the ailment. Even if 40% of the USA will be diabetic by 2030 (or whatever the estimate is) and they all go LC, they will still never be able to eat the same diet as the other 60% (some of whom are also obese) even if it is only for a week while on vacation, without changes to their blood sugar.

            It is not as simple as being obese or not. Obesity itself is not as simple as what you eat or how often. There are people who can eat whatever they want and their metabolism compensates and there are some who are not genetically prone to Syndrome X. I have a friend with a BMI of 40 whose doctor was extremely “disappointed” when her A1C came back as 5! OTOH I have a friend who has been hospitalized in her 50s due to T2 complications. Her BMI has never been above 22 and her entire life she never finished what was on her plate because she was never interested in food.

            As for fasting or surgery not being a cure, it is not. It is a treatment that works as long as you stick to it. The article, while a rehash of 4 other previous posts is ok. It is calling a treatment a cure that is the problem.

        • Lori, That is not the case. I can personally attest to that. If you read Obesity Code and/or watch Fung’s video, he is, rightfully, right up front pointing out there are areas of the world with very high carb diets and no instances of T2D. In fact when these populations started getting T2D it was after the adoption of the ‘western’ diet. We’ve done IDF for awhile now and while it is not every Wednesday (Prince Spaghetti Day) we often have spaghetti for dinner. It’s never blown my FBG out of the water. I think Carlos is correct, the issue isn’t carbs, it’s Insulin Resistance. To another point he made the Taylor protocol is 8 weeks likely because it takes that long for the insulin sensitivity tests to normalize. It’s in the video. So for those doing IF or dieting or whatever until they have a good A1C and declare victory, they haven’t. Watch the video.

        • Sorry to come back to this again after such a long time.
          I feel this is merely a semantic problem caused by a different interpretation of what T2D actually is.

          In my view T2D is merely a “yes/no” tag for the ailments of people that have passed a certain level of IR, but IR is not binary, on/off, “yes/no” condition, but a progressive scale.

          So in my view people are not either insulin resistant or insulin sensitive: they are more or less resistant/sensitive to insulin.

          Being that everyone is to some extent insulin resistant (extending my previous metaphor: everyone has weight), but this is normal and not a problem unless you are too resistant (or too overweight), there is no “cure” from being somewhat IR (there is no cure from having weight).

          BUT, and it’s a big but, there IS a cure for excessive IR. There is a way to first lower, then stabilize your IR.

          What there is not, is a way to make IR independent of how you live your life: given enough time and bad habits, everyone ends being T2D.

          You want to call it a treatment, not a cure, because once you revert your excessive IR you must keep good habits to prevent it from escalating? Fine, a treatment it is.

          But in that case, we need a new name for insulin injections, sulphamides, metformin, etc. because those are called treatment when they are merely symptom paliatives.

          So, in short: I’ll call IF and LCHF a cure for T2D not because I “bought the book”, or because I think a couple of months with IF/LCHF will make me immune to any amount of carbs (no one is, on the long run). I’ll call it a cure because it reverses a condition that was believed to be progressive and irreversible with current “treatment”.

          As I said, it’s mere semantics

      • Couldn’t have said it better.

        • Mark, Lori, Mathieu, refer to my below post w/url to Dr Taylor’s presentation, “Reversing the Irreversible”. It’s very illuminating. I think there is much more work to be done. Google Dr Joseph Kraft’s work on ascertaining T2D could be diagnosed upwards of a decade before it currently is if Drs used (the more expensive) Glucose tolerance test rather than FBG. I believe, to answer, your question, what needs to be done is get people’s Glucose Tolerance Test results into the category 1 response, not merely bring FBG or A1C into normal.

          • Further, google the DiRECT study, which is a current study on prolonged remission of T2D.

      • Dr. Fung addresses the cure issue at https://www.dietdoctor.com/eat-wanted-not-gain-weight

        Basically, you can reverse d2 by fasting every other day for 5 or 10 years.

    • You will have better blood glucose control. Don’t confuse short-term high blood sugar (a response due to being physiologically insulin resistant due to very low carbs) with a total lack of control. If you continue to eat a “high” carb diet, you’ll find that your overall blood sugar control is better. Will it be the same as it was when you were 20? Probably not.

      I will occasionally go off my low carb diet, such as when I go on vacation. I’ve found my head does not spin as much as it used to do. I think there is a benefit. On the other hand, I don’t care much about eating things like quinoa, fruits, or beans.

  9. Unbelievable, still not one mention of Dr Roy Taylor who predated the 2012 Stampede study. But, in fact, in his writings, not everyone’s T2D is reversible. It’s a function of how long they’ve had it. However, everyone, regardless of length of time, has dramatic improvement.


    This video is a must view!

    Diabetologia. 2011 Oct; 54(10): 2506–2514.
    Published online 2011 Jun 9. doi: 10.1007/s00125-011-2204-7
    PMCID: PMC3168743
    Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol
    E. L. Lim,1 K. G. Hollingsworth,1 B. S. Aribisala,1 M. J. Chen,1 J. C. Mathers,2 and R. Taylorcorresponding author1
    Author information ► Article notes ► Copyright and License information ►

    • Walt, great mention of the Roy Taylor video. A “must view” indeed! Well done, Sir, and thank you.

      • Doug, what leaves me cold is the difference between Dr Fung and Dr Taylor. In fact, Dr Fung is outstanding as an aggregator of clinical trials whereas Dr Tayloy has been and is an original source of clinical data re: reversal of T2D. Have you seen his “Reversing the Irreversible” vid? I think it’s a must see for anyone with T2D. Thank you, btw, for the warm shout out sir!!

      • DUH! Sorry for the brain lapse. Obviously you’ve seen it.

  10. I have had a nagging disbelief in Fung’s explanation of why CICO doesn’t work. I get the 2 compartment analogy but that presupposes a broken insulin sensitivity. Pg 36 of OC, he describes the Minnesota Starvation experiment. Thirty-six young men, since we’re not given their age, let’s say 25, we fed a 3,200 calorie diet for 3 months. That given a 20% increase for activity would be 1200/day higher than Mifflin St Jeor would predict. Then, for 6 months cut that in half.
    As mentioned about I kinda sorta did this for about a year and was never cold and while I did experience plateaus I was able to adjust and/or work through them. However comparing that to long term water fasting, say 7 days or 14 days, isn’t that a far more severe reduction in calories/day, like 3200 to 0. I am setting something up so bear with me.
    All that I described above and a little bit here was done before crossing paths with Dr Fung’s webinars or books. In fact I think I actually preordered OC. Here’s where I am going. So right now I either eat nothing per day or a salad w/dressing that is around 200 cals. If I go to the gym, as I did over the last year and walk 21mi/wk at a rate of 3.6 mph the machine tells me it burns 700 cal/hour. If my body requires, say, 2300 cal/day according to Mifflin St Jeor if it’s a no food day doesn’t that represent a deficit of 3000 cal/day (2300+700) that MUST be made up, if my metabolism is functioning, by ketosis? If it is a fed day isn’t there still a 2800cal/day deficit that must be made up?
    For the purposes of fasting, isn’t the presence of absence of a 200 cal salad (oil dressing being the bulk of the cals) irrelevant? It doesn’t provide, that I can see, excess glucose as even a instantaneous infusion of 200 calories worth of glucose would be consumed in just about 2 hrs by subtracting out the fiber. I do take weekends off from the gym so that adds back 700 (or 350 if I do only 30mins) for 2 days /wk but I would still be running a, what I would think, starvation mode diet by consuming at most 200cal/day but still expending maybe 2000 cals/day. Generally speaking at night my feet are intermittently either a tad cool or perfectly comfortable and in the morning they are perfectly comfortable.

    Can anyone come up with a functional difference between what I described and and a full on water fast? In fact, wouldn’t the 200 cal be consumed just by virtue of digesting the salad? I guess I specifically would appreciate the thoughts from those having done both a full on water fast as well as a 2-5 fast.

    • 200 calories if from oil and lettuce (assuming only trace carbs) is probably the same as a water fast. Dr. Fung permits coffee with a touch of cream or oil and or bone broth as part of what he considers fasting, although he did caution someone about bulletproof coffee in July 2015 in terms of possibly slowing weight loss. Two hundred calories from toast and jelly would probably mess up your diet and risk a set point reset downward according to how I interpret what I have read. The issue is insulin. How much you produce, how often. Fasting and low carb foods when consumed alone (without carbs) do not impact the insulin set point since without carbs there is no reason to release insulin. Insulin resistance is presumably repaired as you are producing less insulin for a period of time and your liver is depleted of glucose and shifts over to ketosis. Not sure I believe yet and I do worry that after IMF and LC for weeks there is the possibility that I will have an even slower metabolism than previously. Thoughts, corrections and opinions welcome on this issue

    • Terry teh

      Trust your body.

      All research are base on mean or an average and there are many extraneous factors like genes, race, and are subjected to biases no matter how ‘scientific’ it claims to be.

      Everyone body is different. For example by worrying about this point you are experiencing the incretin effect. The CCC confirm that 80% of all human diseases are bcos of stress. This fact has been known to psychologist for decades.

      Personally, I have experimented with different ways including dry fasting and Chinese herbs. I find that at different times the body react differently.

      For example. In the early stages of having recovered from diabetes and metabolic syndrome any consumption of carbo will make my blood sugar spike. Now, Natural carbo has no effect at all. My body now onky react with a bs spike with artificial sugar.
      In the earlier days, alcohol have the same effect on bs. Now after a year, I can even go on drinking binges, and my bs will even reduce slightly the next morning. My bp spike have also lessen considerably compared to earlier days.

      My experience tells me , my body is alive. It is not as dead as a computer software as all these researches presume.

      Just a thought. Feel free to comment.

  11. I thought I’d add something else for people’s education. Specifically, this is a huge study being undertaken in the UK, the DiRECT study. This is yet another follow on study by Dr Roy Taylor et al looking at long term remission of diabetes. This may, in full or in part, answer the question of the true meaning of reversal in the context of diabetes. In the talk I referenced above and prior blogs, Dr Taylor points out that his 8 week protocol caused the remission of diabetes FOR A TIME (this seems to be no facility for bold or italics here). Note, his trials involved a strict dietary regiment requiring 8 weeks of hospitalization for the subjects. That does not scale well to masses of people nor for permanent remission, hence his other on-going study, to be completed in 2018 on whether his earlier protocol could be achieved in a primary care environment. At any rate, I thought the following section from their web page would prove illuminating.

    Why is DiRECT important?

    Some people with Type 2 diabetes can become non-diabetic again, at least for a period. That is called a remission of diabetes. A remission of diabetes will allow the patient to stop taking anti-diabetic drugs. This is important as the drugs are inconvenient and can cause side-effects. Also these drugs cost the NHS around £800million per year. If diabetes remission is long term this would prevent or delay the long-term damage which diabetes causes in different body-organs. The mechanisms underlying the return of normal glucose control will also be examined in the Tyneside cohort. Detailed tests using magnetic resonance scans and insulin secretion tests will be carried out.
    A new treatment programme which helps to produce remissions in type 2 diabetes could therefore be advantageous for people with diabetes, and also save treatment costs. For people who achieve a long term remission, the effect upon their future health and well being could be very great indeed.

  12. The actual reversal of the T2D is ascribed to metabolic alterations rather than fasting, though, particularly bile acid production which is permanently modified during bypass procedures, among other alterations. That’s why the bypass, and duodenal switch, resolve T2D far faster than the sleeve gastrectomy. The alteration of hormones due to the RNY is well-documented.

    As for the lap-band, the lap-band is actually more dangerous in several cases than the sleeve gastrectomy or bypass. I’m not sure where the gastric banding information comes from, as typically the results for T2D and insulin resistance are not present. Most studies delineate a drastic difference, and the lap band is absolutely not coming even close to gastric bypass results: http://www.medscape.com/viewarticle/733691

    In fact, to cure diabetes in Europe without obesity, intestinal bypasses are sometimes done. This has the result of immediately effecting significant change regarding the hormone production of the gut. As you say, the reasons are not all well-understood. However, it’s absolutely due to the altered anatomy, rather than consumption changes.

    By far the best resolution of diabetes from surgery comes from the duodenal switch, however, which has more significant rates of resolution, sometimes 1-2 days after surgery – not weeks. Frequently it’s a matter of days. It is the most drastic of all the procedures, but it absolutely has significant, and often durable, results despite dietary changes. They definitely don’t fast – DS patients need 120g of protein per day minimum to counteract their absorption of protein. This gets started ASAP. First, it’s constant caloric/protein liquids through the day, and then eating through the day.

    It’s a gross misconception that bariatric patients fast. We eat less volume calorie-wise, however we eat more often. The only fasting period is, maybe, a few days after surgery, if the surgeons tout a clear liquid diet. After a few days of liquids only, your sole job is to consume as much protein as possible. Most patients eat 500-700 calories per day through their weight loss phase. While calories are restricted, due to stomach size, eating is done throughout the day. There is no fasting, intermittent, or extended, really. Bariatric patients eat several times a day. In some cases, more frequently than non-patients, to meet the high protein requirements (anywhere from 70-100g of protein depending on your program). This is begun as soon as liquids are tolerated, and continues steadily. I was probably eating or drinking protein or pureed food constantly while I was awake only 3-5 days after surgery.

    Even as an experienced faster pre-op (I am a trained Buddhist, and I did IF for years as well as extended fasting), I never had anywhere close to the degree of positive results surgery got me.

    • Are surgical patients eating low carb / high protein or can they pretty much eat whatever they want a month or 3 down the road? I would imagine they are given a diet that is designed to be nutritionally dense but I would assume it is probably along the lines of the food pyramid? I have no idea.

      The reason I ask is because if surgical patients who were previously T2 are able to maintain good blood sugar without medication 3 months out while eating a moderately high carb diet and sustain weight loss then that is not the same as what happens with IMF or restricting carbs

      • Lori, typically most eat a high protein, and moderate to low fat diet. They still do caloric restriction advice for bariatric patients, and it is, as you suggested, based (unfortunately) on the food pyramid. However, most nutritionists cap carbohydrate at 120-130g. While this isn’t ketogenic or Atkins-esque, it’s still 1/2 to 1/3 of the standard american diet, and so they are still “low carb” after a fashion. Many patients do eat well under that because of sheer practicality – a four ounce stomach and a 70-90g a day requirement of protein doesn’t leave room for veggies or starches, really. You can eat around the sleeve, however, you can also eat around a ketogenic diet or fasting too.

        In truth, as with any habit change, a large percentage of individuals resume their diets, or eat increasingly carby food. Old habits can rear their heads up if vigilance is not engaged in. I see this with ketogenic dieters and clients who haven’t had surgery, too, though, who have been very obese in some cases. A lot of obesity is behavior-driven, not just hormone-driven. It’s the behavior which is the issue, and neither fasting, nor surgery, will fix that. Of course, I admit my bias, as I am a counselor. 😉

        Tangent aside, even with poor dietary habits, it is rare that bariatric patients resume their diabetes medication. I’ve worked with people anywhere from a few to over ten years out. Even ones who had regain were never again diabetic, even on higher carb diets they are supposed to avoid. The study I linked above was after two years, and the introduction of higher carb diets – carb creep, as I call it, happens frequently. Despite that, bypass patients retained their benefits by and large whereas lap band patients did not. (The lab band is also far more problematic in my opinion for a variety of reasons.) Here’s an article on insulin cessation in diabetics post-op: http://care.diabetesjournals.org/content/38/4/659

        Sadly, I fear there is scant data overall, though.

        The sleeve gastrectomy which is currently used for over half of the procedures in the US is another matter. The benefits for having an intestinal bypass are durable to some degree despite diet, and typically last even with higher carb consumption. Of course, diabetic diagnoses are based on glucose, not insulin levels. It’s still safer to maintain lower serum insulin regardless of glucose reading, I’d argue.

        • Donna, Thank you for the response. It is interesting to hear from someone who has experience in this area,

          I agree that if glucose is normal after eating a higher carb diet then surgery definitely sounds like a a cure. I do not believe this is the case after LCHF or IMF even when a normal A1C or weight has been achieved. In those cases where the sense I get is it MAY work as long as you stick to it. With surgery it sounds like it is the mechanical intervention which changes the hormones and not the caloric restriction.

          ” A lot of obesity is behavior-driven, not just hormone-driven. It’s the behavior which is the issue, and neither fasting, nor surgery, will fix that. Of course, I admit my bias, as I am a counselor”

          I have very mixed feelings about that statement, in some ways it is a chicken and egg problem. On the one hand I have felt since doing IMF that there are times when I do not eat when under normal circumstances I would have. Unconscious eating is what I would call it. Automatically grabbing snacks as I pass by the kitchen. As I eat fewer times in the week or the day I am becoming more aware of when I ate in the past when I was not hungry. While this may have contributed to excess insulin periods as mentioned on this blog, in terms of calories I doubt the apple with a teaspoon of peanut butter I ate when I was not hungry was responsible for my weight problem

          Here is the other part though. I do not think it is entirely habitual or emotional. I have been pregnant a number of times. For the first pregnancy I was a more or less normal weight and I gained the most with that one, about 40 lbs. I neither tried to eat nor tried not to eat and had a normal appetite. In subsequent pregnancies I started out obese. By the 3rd or 4th month I completely lost my appetite. I would eat, I enjoyed eating but it was not my focus as it is on a regular Saturday. As I mentioned elsewhere, I have a relative who is an amazing baker. Whenever I go to her house I look forward to dessert (usually after a balanced meal of steak, salad and a starch assuming I am not dieting). I will eat as much dessert as I possibly can. More than once during my pregnancies I would forget to have dessert at her house. I would get caught up and not eat. Normally when not pregnant all I can think about is when I can politely take another helping, I could be talking to my favorite movie star or a Nobel Prize Winner (neither of whom would ever be there) and I would still be thinking about dessert. It is and was absolutely hormonal. Note I was never diagnosed with gestational diabetes despite a very strong T2 family history. Many years ago I had a very thin co worker who had the opposite experience, she never exercised or dieted but was very energetic. If we needed to order food she was never very interested, a true eat to live person. With each of her pregnancies she became huge, gaining 60 or more lbs. She would eat everything in sight. She claimed in the delivery room her appetite would disappear and within a couple of months all the weight would be gone.

          Assuming someone has led a normal life with no unusual traumas I do not believe that most eating is emotional. And while some heavier people eat very little, many enjoy their cookies etc. The question is not why they cannot have more more will power but what mechanism compels them to eat when other people are able to stop after one slice or are not overly interested in eating? Perhaps insulin, perhaps not

          • Hi Lori, I am hopeful you remember the old saying for Lays Potato Chips, “Nobody can eat just one”. For some people it’s true. It’s a simple carb w/salt and for some reason, one leads to two leads to . There is a small local shop not far, it sells cheeses, home made cookies, cakes, pre-made and home made soups and even meals. This one cookie they sell, same as the potato chip, for some reason I cannot eat just one. I don’t know the mechanism but there is one. However, in my case, if I don’t start, I can stay away forever. If you find out what it is, let me know pls.

  13. D. Anil Kagal

    I am a physician practicing in rural India for the past 40 years. I see a lot of diabetics everyday. Most of my patients are not obese, eat healthy natural food which they grow on their farms and work hard on their farms from 5am to 6pm every day of the year.Fasting on certain days of the week for religious reasons is common. And still they have diabetes. Obesity is uncommon and surprisingly most of the obese are metabolically normal! I think we are missing something. Genetic factors? Toxins in the food or water? I have been reading your blogs, watching your videos, buying and reading your books and following and dispensing your advice for 2 to 3 years. I think what you advocate applies to less than 50% of patients in my practice.

    • Dr. Anil Kagal, That is very interesting. Have any of your patients tried either the Ornish diet or the diet followed by those in the so called blue zones, for example Lorma Linda in California? Are either of those similar to what they naturally would eat given their locale? Not suggesting they should but rather curious as to whether those have been considered or did not work. Having been on LCHF for two weeks and IMF for over 5 weeks I can say it seems to be working but I really do worry that I am eating too much fat, that perhaps an Ornish type diet would have better cardiac outcomes given the strong family history of heart disease. Since reading this blog has made me aware of how study outcomes are subjective depending on the bias of the researcher or writer (both for and against LC diets) and tests for blockages are expensive and invasive and are only done if there is a problem, and physicians have no education in nutrition, I feel as if I have to take diet advice as a belief rather than has hard core science so trying to research as much as I possibly can.

      Also, is it possible it is something they are exposed to as you say? I would assume you had some patients that spent significant time in cities and then either moved away or moved back, are those patients identical in outcomes to your rural patients? Would it be worth doing a study, comparing the diets and lab results of those who are successful with those that are not? Comparing them against the obese who are normal? Is there a suspected issue with compliance? You mention that they grow their own food, is that based on wheat, beans, rice, corn, lentils and fruit? All of which will spark insulin. Is it based primarily on leafy greens, good fats, and pastured meat, chicken and wild caught fish from unpolluted water?bolism

      When a new patient comes in with T2 do you have an inkling at the first meeting as to whether this patient will be able to repair their metabolism

      • Stephen T

        Lori, after forty years of bad advice on fat it’s not surprising that you still worry about eating it. I don’t think you need have any concern.

        In March 2014, Meta-analysis by both Harvard and Cambridge Universities found no link between saturated fat and heart disease. In February 2015, the BMJ’s Open Heart published research showing that the low-fat dietary guidelines, first issued in 1983, did not have any scientific foundation. As NHS cardiologist Aseem Malhotra recently stated, “Evidence does not show a link between natural saturated fat and heart disease.”

        Some World Health Organisation facts that they don’t shout about.

        • France has the highest rate of saturated fat consumption in the world and a heart disease rate one third of the UK’s. Many other countries show similar results, including Switzerland, Sweden, Norway, Holland, Belgium, Germany, Spain and Iceland.
        • Switzerland has the second highest rate of saturated fat consumption in the world and the second lowest rate of heart disease.
        • Lithuania’s population consumes half France’s level of saturated fat, yet has a rate of CHD nine times higher. This is one of many similar examples. The WHO figures in Europe show a clear relationship between higher saturated fat and lower heart disease.
        • In America of 137,000 people, in 541 hospitals, who’d had a heart attack, 78% had below average cholesterol. (American Heart Journal, 2009.)

        The fat causes heart theory can’t be made to fit these facts. If it didn’t generate billions for pharma, it would have been ditched years ago.

    • As someone who is familiar with life in an African rural setting, the problem I see is the consumption of incredibly large quantities of grain-based or starchy foods at a seating. They may come back from the farm late in the evening and eat large quantities of grain-based or starchy tuber-based foods with very little protein after hours of not eating much. They go to bed soon after the big meal. I’m not sure this is what happens in your rural Indian setting but I suspect there are some practices responsible. Study what they eat and when they eat it.

    • My heart goes out to your patients. While things like diet and physical labor certainly influence our lives I wonder about happiness, contentment, joy and hope. I understand that many rural farmers in India have suffered a great deal, emotionally. In the U.S., in the mid 1980’s there were unprecedented levels of suicide and depression in the farming communities. The stress of family farming become unbearable for many. The statistics are staggering. Some journalists have suggested that the same thing is happening in other parts of the world today. Little joy, a desire for sweetness in life, can make a person heart sick, no?

  14. I have a fundamental confusion about insulin resistance.

    If one has T2, doesn’t the pancreas keep pumping out insulin to address the high blood sugar, until the pancreas “burns out”? When the pancreas burns out, shouldn’t insulin levels fall, and the person become T1diabetic?

    Is insulin resistance measured by too much insulin, or too little insulin?

    I thought humans can’t live without insulin. If the pancreas is burned out, how can diabetics survive without taking insulin?

    • https://campus.recap.ncl.ac.uk/Panopto/Pages/Embed.aspx?id=c3bef819-e5f4-4a55-876f-0a23436988ed

      This video is a must view!

      The pancreas doesn’t die, Beta cells don’t die, they get clogged with intra-organ fat.

      Watch the video.

      • Thank you for this link. Not sure all of my questions are answered in it. I will have to listen to it multiple times before I fully understand it. Thanks, again.

      • Deb, I completely concur with your comment about listening to it multiple times. I did as well. This is pretty densely packed information.

      • Deb, insulin resistance is caused by a persistently high insulin level. As your cells become more resistant to the insulin your body produces yet more insulin. By breaking the persistent part of the persistent high pairing, over time cells become more sensitive. Now, what I’ve not seen in print from anywhere is cells don’t live forever, they split or otherwise get replaced. Are the new cells ‘born’ resistant or do they become resistant?

  15. Dr Shivanand Nelogal

    Probably insulin never touches zero in T2DM that is why ketosis is rare.You may have low insulin when pancreas burns out but not zero.
    Insulin resistance is suggested by high insulin levels.low insulin with high sugar is suggestive beta cell secretory defect in addition to IR.

    • Dr Nekigal, if you look at my above referenced webinar from Dr Taylor, specifically at the 26min mark forward, there are a series of three slides for insulin secretion rate, first the control group.
      1) pre bolus insulin appears to be just above 0.
      2) phase 1 reaction appears to be .6
      3) from mins 20-60 reaction drops to just above 0
      4) phase 2? rate is about 1.2

      In the diabetic baseline rates
      1) prebolus insulin just above 0, perhaps .1
      2) virtually no phase 1 response, perhaps .2
      3) from mins 20-60 perhaps .2
      4) phase 2 rate about .7 to .8

      After 1 week (just the deltas)
      2) stronger phase 1 rate .3
      4) phase 2 rate .9 to 1.0

      At 8 weeks
      2) phase 1 rate .5 and up
      4) phase 2 rate 1.4 peaking to 1.7 which is better than control group.

      The point of this and much of Dr Taylor’s research is that for most T2D (its duration dependent) the pancreas does NOT burn out or suffer from a secretory defect.

      What I think is interesting, and this would mean more to you, being a physician, than me, is Dr Taylor’s approach to these results and conclusions did not come after an 8 week IDF or LCHF diet, merely a 700kcal diet via Optifast meal replacement w/salad while in a hospital setting for 8 wks. I would certainly encourage you to view the entire video.

      I think Dr Taylor’s work is hugely consequential to T2D patients. As Dr Fung admits up front, even after his medical school, internship, residency, fellowship work, he recommended and subscribed to the prior conventional wisdom that T2D was a chronic and progressive disease, as did Dr Taylor acknowledge, until they realized that notion was incorrect.

  16. I am a board certified medical bariatrician. I appreciate the post and (most of) the comments. I have just birthed a new category on my blog dedicated to this topic. Just go to auditusdei.wordpress.com and click on the category “Weight Wise”. I would appreciate learning and sharing with everyone.

  17. What can I expect in 6 months in terms of weight loss with an alternate day water fast? I am 68 and weigh 74kilos. I am not diabetic. I should weigh 66kilos max.

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