Type 2 Diabetes, a Dietary Disease #382: Can fasting “wake-up” the pancreas?

“Fasting Diet for Diabetes ‘Could Repair Pancreas’” is the full title of a WebMD Health piece by Peter Russell in Medscape Medical News. Note that the ‘could repair pancreas’ is within single quotation marks. Still, the headline is provocative and got my attention.  After all, you only get one pancreas, and by the time most people are diagnosed as Type 2 diabetics, a substantial part (up to 80%) of the insulin producing cells in the pancreas have been destroyed. And the evidence is scant that the pancreas can or does create new beta cells.

Thus, as the lede states, “‘Rebooting’ the organ in this way could help [these] insulin-producing cells to repair themselves and start producing the hormone.” “This way” refers to a diet of “a very limited number of high-fat calories.” The researchers compared this restricted-calorie, high-fat diet with biomarkers associated with a water-only diet and found it had “the same physiological effects on the body as more extreme fasting.” Thus, they called the restricted-calorie, high-fat diet a “fasting–mimicking diet.” Alas, the study was done on mice.

Nevertheless, the study, published in the journal Cell, said that “during periods of fasting, the cells go into ‘standby’ mode. Then when feeding begins again, new cells are produced that have the potential to become insulin-producing.” “New cells” is hopeful; “potential” a lot less so…but it is still worth further investigation.

Medscape also reported: “The research team, led by the University of Southern California, says that laboratory tests on tissue samples from people with type 1 diabetes produced similar effects.” Now that IS promising. But this piece, “intended for a consumer audience,” was pretty thin, so I referred to the full article in Cell. Quote:

“In consideration of the challenges and side effects associated with prolonged fasting in humans, we developed a low-calorie, low-protein and low-carbohydrate but high-fat 4-day fasting mimicking diet (FMD) that causes changes in the levels of specific growth factors, glucose, and ketone bodies similar to those caused by water-only fasting. Here, we examine whether cycles of the FMD are able to promote the generation of insulin-producing β cells and investigate the mechanisms responsible for these effects,” the researchers say.

The diet: “…a low-calorie, low-protein and low-carbohydrate but high-fat 4-day fasting mimicking diet…”

Well, the rest of the article in Cell is way over my head, but some aspects of the premise, the findings, and the discussion were comprehensible to me, so I will try to convey a bit of the essence in these excerpted quotes:

“The ability of animals to survive food deprivation is an adaptive response accompanied by the atrophy of many tissues and organs to minimize energy expenditure.” This is related to autophagy, a well known process.

“Stem-cell-based therapies can potentially reverse organ dysfunction and diseases, but the removal of impaired tissue and activation of a program leading to organ regeneration pose major challenges.”

“In mice, a 4-day fasting mimicking diet (FMD) induces a stepwise expression of [certain genes], followed by [another gene]-driven generation of insulin producing ß [beta] cells, resembling that observed during pancreatic development.” The researchers focused on fetal pancreatic development in both mice and humans.

“FMD cycles restore insulin secretion and glucose homeostasis in both T1 and T2 diabetes in mouse models.”

“Fasting conditions reduce [certain intracellular signaling pathways that are central regulators of cell metabolism] and induce [gene] expression and insulin production”

“These results indicate that a FMD promotes the reprogramming of pancreatic cells to restore insulin generation in islets from T1D patients and reverse both T1D and T2D phenotypes in mouse models.”

So far I’m up to fasting 2 and at times 3 days a week. It’s easy. So, I’m not averse to trying a fasting-mimicking-diet (FMD) cycle that “entails [a] 4-day FMD cycle and up to 10 days of re-feeding.” That’s like every 2-weeks!

Type 2 Diabetes, a Dietary Disease #381: My Next 30-lb Challenge: 4 weeks in…

After losing 31 pounds in 10 weeks this winter, and learning how easy it is to do a full-day (300 kcal/d) “fast,” without hunger, I relaxed a bit, and I immediately regained 4 pounds in the first week. So, I decided the best way to preserve the weight loss (and A1c benefit: -0.5% from 5.8% to 5.3%), was to start a new challenge: to lose 34 pounds (30 + 4) over 16 weeks, leading up to my next doctor’s visit. For the Design Protocol, see #378.

Week 1: That “first week,” in which I regained 4 pounds after my doctor visit, I let my guard down a bit – not much really – okay, I had a milk shake after seeing the doctor. I deserved it, right? But I paid for it. Even my fasting blood sugars (FBG) were elevated (93 average) with a couple as high as 105mg/dl (5.9mmol/L). Gone were the days of the 60s and 70s. My body stubbornly refuses to take up sugar after such transgressions. I lose insulin sensitivity; my insulin resistance is elevated, at times for many days, even with Metformin. Go figure.

Week 2: I started Week 2 behind the 8-ball. Besides the 4 pound gain in Week 1, my Sunday main meal was a shrimp cocktail and a large bowl of salted peanuts, plus 2 cocktails. See, my body shouldn’t trust me. I gained another 2 pounds (from the salt). The next day I dropped the water weight but was still deep in the hole. And then on Tuesday we ate out before theatre…which didn’t go well. You don’t want to know the details; suffice to say my FBG on Wednesday was 111. So, to start both a FBG drop and weight loss, I began a 2-consecutive day fast. The result: after 1 day, while forgetting my spritzer and my pills (including Metformin and a diuretic), my FBG on Thursday was 94 and I dropped 4 pounds! By Friday, I’d lost 3 more and my FBG was 82. I ended the week with a 5 pound weight loss and a 91mg/dl FBG average. Back on track!

Week 3: Two weeks into this new 30 (34 really) pound challenge, I was down 1, leaving 33 more to lose in 14 weeks. I knew that was doable, so long as I continued with at least 2 days of fasting a week, with perhaps a boost from a 3-consecutive-day fast, or two, if required “by circumstances.” Well, “circumstances” happened. (I love the passive voice; it’s so useful at times.) Monday night we went out to dinner, and I had 3 slices of really good crusty bread, slathered in butter, while waiting for my entrée…and I paid for it. After 4 days in the low 80s, next morning my FBG jumped to 102mg/dl. So, I decided that instead of alternate day fasting this week (Tuesday and Thursday), I would do a 3-consecutive-day fast. I need to protect that new 5.3% A1c!!! Result: The 3-day fast was easy. For the week I lost 4 pounds and posted an 83mg/dl FBG average. Not bad.

Week 4: This week I’m just doing alternate day (Tuesday +Thursday) 300kcal “fasting.” I’m on track to achieve my 4-wek goal, and Wednesday is my birthday. Oops, a premature expectation. I cheated on Tuesday (some junk food in the pantry), and well, Wednesday was my birthday. Okay, so I’m human. My weekly FBG average climbed to 91mg/dl with no day over 100…but the trend line was not good. I also gained 4 pounds (largely water), putting me 6 pounds behind schedule. Clearly, I’m off-message, and I need to do another 3-day fast.

Discussion: My 4-Week goal was to get to 210 (8 weeks to 202, 16 weeks to 187), and I missed it big time. At my August doctor’s appointment, my goal is to rack up another 5.3% A1c and reach 187 lbs. So, I will soon be entering “new territory” here, and we’ll see what’s possible. I remember writing several years ago ("My Goal Weight and the BMI Table") and ("How much Protein Should I Eat?"), that “goal” or “ideal” weights were subjective and basically unattainable for people who have been eating the Standard American or Western Diet for their entire lives. “Lean Body Weight,” on the other hand, was the weight that should be used to compute the body’s protein requirement because overeating protein just puts amino acid stores in the liver which become the building blocks for glucose via gluconeogenesis. That’s a major reason we take Metformin, to suppress this gluconeogenesis. I am now trying to eat just 60 grams of protein a day, and a “lean body weight” of 187 for me, while still “overweight,” now seems achievable:  BMI of 27, vs. BMI of 54, 15 years ago.

Type 2 Diabetes, a Dietary Disease #380: Newcastle Diet (“Counterpoint Study”)

The “Newcastle Diet,” as it seemingly is practiced today, is not the same as the original diet developed at Newcastle University for their “Counterpoint Study,” conducted in 2009 and published in 2011. I wrote about this study four years ago in "Reversal of Type 2 Diabetes" (#88) and "'Reversal of Type 2 Diabetes' Revisited"  (#89). Column #88 garnered the most page views of any column I have ever published due to the appealing but misleading title. Note: My column titles were in quotes because they are the paper’s authors,’ not mine.

The author’s use of “reversal” in the title is misleading because of their definition of “reversal”: “Reversal of diabetes” was defined by them as “achieving fasting capillary blood glucose < 6.1mmol/l [110mg/dl] and/or, if available, HbA1c less than 43 mmol/mol (6.1%) off treatment.” In my book, that is neither a “reversal” nor a “cure,” as some would claim. A FBG of 110 is smack in the middle of “pre-diabetic” (which begins at 100mg/dl (5.6mmol/L) in the U.S). By way of reference, many doctors consider an A1c of 5.7% (39 mmol/mol) – the threshold for “pre-diabetes” – to be incipient type 2 diabetes. That’s because it’s manifest evidence of Insulin Resistance (IR), the cause of type 2 diabetes. “Pre-diabetes” is simply an arbitrary point on the IR continuum.

Why is the Newcastle Diet called the “600 kcal diet”? Quoting from the Newcastle University 2011 paper, the dietary protocol of the “Counterpoint Study,” “consisted of a liquid diet formula (46.4% carbohydrate, 32.5% protein and 20.1% fat; vitamins, minerals and trace elements; 2.1 MJ/day [510 kcal/day]; Optifast; Nestlé Nutrition, Croydon, UK). This was supplemented with three portions of non-starchy vegetables such that total energy intake was about 2.5 MJ (600 kcal)/day.” That’s why the Newcastle Diet is called the “600 calorie diet.”

However, Diabetes.co.uk, which funded the study and has the only official description of it on the web, now says it is 800 kcal diet, comprised of “Optifast meal replacement sachets, which provided 75% of the calories (600 calories). The other 200 calories came from non-starchy vegetables.” Then, “Note: The diet is referred to as the 600 calorie diet (rather than 800) due to the meal replacement aspect of the diet totaling 600 calories.” Wrong! The Optifast portion is 510 kcal, but I guess NHS doesn’t want Brits trying such a “drastic” (600k cal total) diet, and certainly not “without the help and approval of a dietitian or doctor.” Good luck with that!

Note also the macronutrient composition of the Optifast part of the original Newcastle Diet: 46.4% carbs, 32.5% protein, and 20.1% fat. That’s high carb, very high protein and low fat. And that’s not counting the 3 servings of “non-starchy vegetables,” which if you ate them would boost the carb content higher, to 55% of the 600 kcal diet and 66% carbs in the 800 kcal diet. That is how you developed diabetes in the first place!

In addition, the 32.5% protein is much too high. Virtually no one recommends more than 30%, and hardly anyone eats more than 20%. Americans eat 15% on average, and the Nutrition Facts panel on packaged and processed foods is based on 10% protein. Any protein that your body does not take up in 4 or 5 hours is stored in the liver and is used to make glucose (or fat!). In T2s, suppressing this unwanted gluconeogenesis is one of the things that Metformin does. So, basically, Newcastle is a low-dietary-fat diet, but since your body has access to its own fat for fuel, if you burn a pound a week, it’s a pretty HIGH-FAT diet AT THE CELLULAR LEVEL.

Okay, so why does this diet work? The answer is that it is fundamentally a very low CALORIE diet. On this the authors agree. They conclude, “Normalization of both beta cell function and hepatic insulin sensitivity in type 2 diabetes was achieved by dietary energy restriction alone” (my emphasis). Makes sense. You eat less. You lose weight. In this respect the Newcastle diet is similar, both in mode and outcomes, to bariatric surgery…but tremendously safer. And in lieu of the 300g of carbohydrates that the typical Western 2,000 kcal diet includes, the original Counterpoint Study (600 kcal) version would have 59g of carbs from Optifast and 23.5g added for “non-starchy vegetables” = 82.5g total. So, in addition to being very low in DIETARY fat, the original Newcastle is low carb! In the higher-fiber 800 kcal version recommended by Diabetes.co.uk, the carb count climbs to 132 grams, no longer considered “low-carb,” but it’s still pretty low compared to 300 or 375! Good for the gut too.

300g of carbs is the RDA in a 2,000kcal diet; 375g in 2,500kcal (for men). Surely everyone knows, even if the NHS and the ADA and the public health establishment won’t admit it, TYPE 2 DIABETES IS A DIETARY DISEASE. As such, the best treatment for type 2 diabetes is a HIGH fat, moderate protein, LOW carbohydrate diet.

Type 2 Diabetes, a Dietary Disease #379: “Man-up, guys!”

Okay, I have been, or should have been, saying this to myself for years, but…let’s face it: straight talk like this is too confrontational when addressed to oneself. And it’s condescending when addressed to others, so it’s usually left unsaid…but not “unthought.” It’s subtext for the way we think of ourselves and others think of us.

In this instance, the context for this exclamation is eating strictly Very Low Carb (VLC). The benefits, which I have realized for 15 years and espoused since I started writing this blog in 2010, are manifest. Besides losing weight easily (my original motivation), and doing it without hunger, I am so very much healthier by every measure my doctor uses…and I feel so much better and am totally energized.

But eating strictly Very Low Carb is difficult… because it requires change. I have for these 15 years considered it my goal, and, it must be said, have adhered to the protocol at times better than at others. As regular readers know, over a few years in the beginning, following first Atkins Induction (20g of carbs/day), then Bernstein’s 30g/day program for diabetics, I lost 170 pounds. Of course, my blood pressure and cholesterol improved dramatically. My triglycerides dropped to <50mg/dl (<2.8mmol/L), and my HDL doubled to the 80s (high 4s).

While I have kept most of the weight off, and my blood lipids continue to be stellar, my A1c has been disappointing, at least to me. In this respect I get no acknowledgment or agreement from my doctor. He is in the business of treating the sick and those whose health and diabetes are poorly managed. He dispenses pills. And most doctors (not mine) dispense bad dietary advice. I don’t blame them. They’re expected to follow the medical establishment’s Standards of Practice and the Medicare and insurance company guidelines.

My A1c has been in the high 5s/low 6s (38-48mmol/mol) for more than 8 years. Of course, from a physician or RD or CDE, this result elicits praise. The ADA considers an A1c of <7.0% “optimal.” They believe that my A1c is proof that my type 2 diabetes is “well managed,” i.e.  “I don’t yet need progressively more medications!”

The high A1c level that the medical establishment has set for the care of type 2 diabetics  -- ≤7% for the general population and ≤ 8% for persons over 75 years – is a disgrace because of the increased health risk associated with it. BUT this low bar is the result of 1) limited success in using drugs to manage the disease, 2) ignoring the fact that type 2 diabetes is a dietary disease and is thus best managed by the patient and 3) the dietary advice given by doctors to the diabetic or pre-diabetic patient is JUST PLAIN WRONG – in fact, it is the polar opposite of what “healthy eating” should be for type 2s: to wit, to restrict carbohydrates.

So, why do I now say, “Man-up, guys”? Because I finally did it! Ergo, this is as much addressed to me as to others. Please don’t view it as condescending. It is not meant to be. It is meant to be just a statement of fact. I finally did it, and two weeks ago, here in #377, I published the result: a greatly improved A1c. My previous A1c was 5.8%, eliciting nothing but satisfaction from all who heard it.  I was hoping to see an A1c ≤5.5%, with an emphasis on the “less than,” and I wasn’t disappointed. My A1c dropped 0.5% from 5.8 to 5.3 (34mmol/mol).

Comment: This result was the outcome of eating strictly Very Low Carb for 10 weeks. I also fasted on two alternate days a week, and a few times on 3 consecutive days. For most of the 10 weeks I prepared my own meals: just a 12oz coffee with 1½ oz of cream for breakfast, and on non-fasting days, usually a “light” lunch, and then supper (including about 6oz of protein: fish, veal, lamb, or offal), in a stove top preparation cooked with vegetables. Sometimes I grilled meat and had a big salad. All suppers were accompanied by 10-12 oz of red wine (in 2 spritzers); on fasting days, just one spritzer. I hardly ever ate out until the last 2 weeks, when I rejoined my wife and we were travelling, but I continued my fasting routine. Altogether, I lost 31 pounds.