Wednesday, June 3, 2020

Retrospective #473: IT’S THE VISCERAL FAT, STUPID!

What if you’re a type 2 diabetic who doesn’t need to lose a lot of weight but is very motivated to get off daily basal insulin injections? You’ve been recently diagnosed a type 2 but weren’t able to tolerate Metformin or a DPP-4 inhibitor (Januvia) and a SGLT2 is counter-indicated.  I am interested in this question since, at the moment, I am mentoring such a person.
Only about 80% of type 2 diabetics are seriously overweight or obese. If you’re overweight or obese and a type 2, success in remediating both conditions can be achieved by eating Very Low Carb (VLC). If you eat VLC (+/-20g of carbs a day), you will lower your blood glucose to non-diabetic levels, and you will enable your body to burn fat when your blood insulin level also drops. Your body will naturally switch to burning stored fat for energy.
But my mentee has a concern, since he’s not really fat to begin with, that his body will turn to breaking down muscle for energy (in true starvation mode). Not a problem, I told him, so long as he continues to eat protein (with fat) every day. While he’s a non-obese type 2, he definitely has a “pot” belly to lose.
But, my mentee wants to know, since he’s not seriously overweight, what accounts for his being a diagnosed type 2 diabetic? Clinically speaking, it’s the convenient symptom, a high blood sugar! If your fasting blood glucose (FBG) is ≥ 126mg/dl or your A1c is ≥6.5%, you definitely are a type 2. And if your A1c is ≥5.7% and <6.5%, or your FBG is between ≥100 and <126mg/dl, you’re pre-diabetic! But the cause of type 2 diabetes is Insulin Resistance.
But WHY does VLC work, he asks?  The answer is that by losing weight in this very specific way – Very Low Carb – while maintaining your energy level at a high metabolic rate, you burn body fat in a way that repairs your impaired, dysfunctional glucose metabolism. Your insulin receptors (which had become Insulin Resistant) become more insulin sensitive and you slowly restore insulin production by your pancreatic beta cells. How?
By burning VISCERAL fat – that not-so-little “pot” belly which is really the INTERNAL fat around your organs.
I first read about this etiological hypothesis a while ago in the blog of Dr. Jason Fung, a cutting-edge Canadian nephrologist. In the opinion of many (including me), he is the leading “non-establishment” thinker in the field of obesity and type 2 diabetes. He blogs weekly and is co-founder, with Megan Ramos, of the Intensive Dietary Management (IDM) program. He is now also the author of 3 books, including my favorite, “The Obesity Code.”
There are basically two types of white body fat: 1) subcutaneous fat, fat just below the skin, generally everywhere but especially in women around the butt, thighs and midriff, and 2) visceral fat, internal body fat within the peritoneal cavity and around and within the organs, especially the liver and pancreas. It is also referred to as “central obesity” and (by me) as “omental adiposity.” In a man, it’s his high, hard pot belly.
Fatty liver, or Non-alcoholic Fatty Liver Disease (NAFLD), is a serious inflammatory condition that is increasing at alarming rates. Fatty pancreas is much less studied and understood, but it is Dr. Fung’s hypothesis that fat around and within the pancreas interferes with the function of beta cells in secreting the hormone insulin. And that eating Very Low Carb, with Intermittent Fasting (IF), forces the body to burn body fat for energy. As the fat within the pancreas dissolves to be used for energy, normal function of beta cells is restored.
Thus, the body restores its ability to produce (secrete) sufficient insulin when needed. And by eating a Very Low Carb diet, with Intermittent Fasting, the body will need less insulin to transport and facilitate glucose uptake and will become less resistant and more sensitive to insulin at the cellular uptake level.
Thus, the two joint and related dysfunctions of type 2 diabetes – 1) insulin resistance, interfering with glucose uptake, and 2) insulin production, in the pancreatic beta cells – are resolved. IT’S THE VISCERAL FAT, STUPID!

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