Retrospective #446: “Docs’ Beliefs” prevail…

Thank goodness for the headline in this Medscape Medical News story by Miriam E. Tucker: “Docs’ Beliefs Guide Prescribing of Glucose Monitoring in Type 2 Diabetes.” It means they still prescribe routine self-monitoring of blood glucose (SMBG) in patients who aren’t treated with insulin (or a sulfonylurea). The danger from insulin or a sulfonylurea (e.g.: micronase, glyburide, glipizide) is hypoglycemia (low blood sugar), so a CGM would be better.

That doctors still do this is enormously encouraging to me, a type 2 for 34 years who takes a fasting reading every day, for motivation, and recently had an A1c of 5.0%. It is troubling to me, however, that several doctors said that they prescribe SMBG less than they did 10 years ago, when their professional societies were encouraging the practice.

The evidence to stop prescribing SMBG, described as “qualitative data,” was presented here in The Annals of Family Medicine by a medical student at the Cleveland Clinic. The student told Medscape that “for patients who do not take insulin, the preponderance of evidence shows it increases cost without improving HbA1c.” Talk about “out of touch.”

Patients need awareness and motivation. You need to do something with the information. You need to make wise choices about what to eat. You need to not rely solely on your doctor to treat T2D with drugs. Self-monitoring of blood glucose provide information and have aspirational and motivational value. The medical student seems to acknowledge this, though. He does say “our study addresses the physician perspective, but there’s also the patient perspective.” Her team’s next step will be to assess patient’s perspectives. Brava, I say. There’s hope for this future clinician.

But the abstract, co-authored by half a dozen MD/MPHs at the Cleveland Clinic, make it clear where this study is going. It states, “The majority [of primary care physicians] continue to recommend routine self-monitoring of blood glucose due to a compelling belief in its ability to promote the lifestyle changes needed for glycemic control. Targeting physician beliefs about the effectiveness of self-monitoring of blood glucose, and designing robust interventions accordingly, may help reduce this practice.” This is what medical students are being taught today. They’re myopic and, worse, narcissistic. One physician said, “I try to steer non-insulin dependent patients away from testing at home, mainly because it doesn’t change WHAT I DO. I monitor their diabetes based on the HbA_1c and occasional sugar checks.” It’s me, me, me, me… No thought or consideration to what the patient can do to control their blood sugars.

Okay. There can be exceptions; if you believe that your patient has “low health literacy or physical or cognitive impairment,” then it goes without saying the patient’s diabetes care should be solely in the hands of a health care provider. This may include those who have daily home health care, are hospitalized or institutionalized. But for the rest of us? Are we not capable of participating in the management of our own health care, especially with a condition that is entirely dependent on what we eat for optimized management? But therein lies most of the problem…

Most physicians seem to not accept that type 2 diabetes is a dietary disease. Nor do most patients. Doctors know it, or should know it, given their training in human biology and physiology, but to admit it would require that they repudiate everything they have been telling their patients about nutrition for over 40 years. I don’t blame them for following the guidelines of their medical associations and the prescribed Standards of Practice. It would be hard to look the patient in the eye and say, “I've been wrong all along. It's all been a big fat lie.” (apologies to Gary Taubes)

But that isn’t necessary. A doctor who believes in “patient-centered care” has the option of leaving the daily management of patient’s blood sugar control up to the patient. After all, the clinician only sees the patient a few times a year to monitor their T2D condition, and modify their medical therapy. But the patient has the opportunity multiple times every day, at every meal and in between, to make wise choices that will improve their condition. Take your medication (if you still need it), and make wise choices about what you eat! Hint: eat fewer processed carbs and simple sugars.

Self-Management of Blood Glucose (SMBG) is thus the best way for patients to educate and motivate themselves. If by prescribing SMBG the doctor’s beliefs contribute to the patient’s self-care, that’s a good workaround! Bravo!

Retrospective #445: Are doctors in denial?

When a doctor tells me that I am “no longer diabetic” – as a few have, informally – are they misinformed about what causes type 2 diabetes, or are they just small business men or women in denial and following the government’s definition which dictates a clinical diagnosis? Because they want to get paid and move on…

I mean no offense, honestly. If I seem disrespectful, well…maybe I am, but as Dr. Michael Eades said, at the end of Retrospective #406, it’s sometimes necessary for “you” (his readers) to “educate your trained professional.”

For example, at a cocktail party recently I was having a tête-à-tête with a friend, a retired MD, when a tray of shrimp was passed around. I took one, but when the doctor declined, I asked him, “Why?” He answered, “Cholesterol.” He apparently hadn’t heard that, back in 2014, the Dietary Guidelines Advisory Committee had declared that “cholesterol [was] no longer a nutrient of concern for overconsumption.” Or that Ancel Keys, the infamous creator of the “diet-heart hypothesis,” was quoted later in his life as saying, “And we've known that all along. Cholesterol in the diet doesn't matter at all unless you happen to be a chicken or a rabbit.”

With respect to the “misinformed” possibility, and the “denial” question, we know that type 2 diabetes is caused by a metabolic dysfunction in which the body is no longer able to handle a diet high in refined carbs and simple sugars due to Insulin Resistance. The hormone insulin, secreted by the pancreas, carries glucose from digested carbs in the blood stream and, in a normal metabolism, “opens the door” by connecting to receptor cells where the glucose is supposed to be taken up for energy. When the connection doesn’t work, the glucose continues to circulate and the pancreas secretes more insulin to help out, eventually wearing itself out.

Most doctors rely on the A1c test or a fasting blood glucose to diagnose type 2 diabetes and begin a course of treatment (“diet and exercise”, and 3 months later, when this fails, prescription meds). These simple blood tests show the symptoms of a disregulated glucose metabolism and are cheap and effective as screening methods. Most people who present with an elevated FBG or A1c are pre-diabetic or frank type 2s. And the meds that a doctor prescribes to treat these symptoms will lower your FBG or A1c somewhat, at least temporarily. But your type 2 diabetes will continue to progress, because the clinician is treating a symptom, not the cause, of type 2.

The cause of type 2 diabetes is Insulin Resistance (IR). The best test for IR is the Oral Glucose Tolerance Test (OGTT). In this test, the patient drinks 75g of a glucose solution, and their blood is tested before and at half hour intervals afterwards for 2 hours. It is usually performed by an Endocrinologist and/or in a hospital outpatient setting, so it’s expensive, BUT THE OGTT WILL REVEAL DEFINITIVELY IF THE PATIENT HAS INSULIN RESISTANCE.

But the GOVERNMENT, and therefore your doctor, is only interested in treating your symptom, an elevated blood glucose (A1c). If your A1c is ≥6.5%, you are clinically designated a “type 2 diabetic.” If it is <6.5% but ≥5.7%, you are clinically designated “pre-diabetic.” If your A1c is <5.7%, you are clinically designated “non-diabetic.” If your A1c was previously ≥5.7%, but somehow is lower now, your doctor will declare you “non-diabetic” or “cured,” and by the established Standard of Care, the insurance “system” will reward the doctor financially for this favorable outcome. This totally ignores your INSULIN RESISTANCE. YOU ARE STILL INSULIN RESISTANT, and therefore STILL TYPE 2 DIABETIC. If you don’t change your diet, YOUR DISEASE WILL PROGRESSIVELY WORSEN.

So, is your doctor misinformed, in denial, or just focused on the bottom line? He or she is, after all, in business and just following government rules for treatment and payment. As far as keeping your INSULIN RESISTANCE in check, or even putting your type 2 diabetes IN REMISSION while losing weight easily and without hunger, that’s up to YOU. YOU decide what foods you eat. But don’t expect your doctor or the government to know how to “eat healthy.” FOLLOWING THEIR ADVICE IS HOW YOU GAINED WEIGHT AND GOT SICK IN THE FIRST PLACE.

If you are Insulin Resistant, your doctor can only write scripts to “control” your A1c. Eating right is up to you.

Retrospective #444: “Symptoms are too late!”

A while back on Maria Bartiromo’s “Mornings with Maria” show on television, a doctor was asked, “What are the symptoms of pre-diabetes?” To which the doctor exclaimed, “SYMPTOMS ARE TOO LATE!” Ignoring the answer, the questioner, following a script, continued, “But can’t pre-diabetes be reversed?” The doctor fell into line and answered, correctly, “Once you are diagnosed diabetic, you are diabetic for life, but you CAN manage your condition.”

The doctor, however, didn’t have time to answer. He only had time to mention that pre-diabetes, or even clinically diagnosed type 2 diabetes, can be “reversed,” but only by and with a permanent lifestyle change.

The interview, however, was introduced with a recorded “teaser” from the popular singer Patti LaBelle. She told how her family had suffered terribly from type 2 diabetes and how she, who was now a diagnosed type 2, was determined to avoid those “complications.” She said she had changed her “way of living, eating and thinking.” She’s right, of course, but of the three, Patti just talked about what she eats.

Ways of eating, however, are still open to many interpretations, including ways of eating to lose weight. Arguably, there are countless ways to lose weight, albeit not permanently. As all dieters know, weight loss is usually followed – often quickly – by weight gain. The reason is that the dieter is hungry. The dieter’s body demands more energy (food in some form) to return to energy balance. This condition, homeostasis, is metabolic and beyond control of the dieter.

There is a way of eating, however, if adopted permanently, that will both manage pre-diabetes and type 2 diabetes AND produce permanent weight loss. That way is Very Low Carb (VLC). Eating VLC both enables the “dieter” to either reverse pre-diabetes or manage type 2 diabetes and lose weight easily and permanently…so long as you continue to eat Very Low Carb. That’s the condition. It’s a trade-off. You get to permanently keep the weight off, and reverse your prediabetes, that is to say, put it in “clinical remission.” Based on the medical Standard of Care for diagnosis and treatment, a doctor will declare you clinically “non-diabetic.” Really! Seriously! (See Retrospective #441).

Another huge benefit of this “win-win” outcome is that it will cut in half your risk of cardiovascular disease (CVD), and dying from a heart condition or stroke. These macrovascular complications are in addition to the usual microvascular complications associated with type 2 diabetes: blindness, amputation and end-stage kidney disease (with dialysis). Other “Diseases of Civilization” associated with the high-processed-high-carb diet are Alzheimer’s (type 3 diabetes) and various cancers, particularly liver, pancreas, endometrial, colon and rectum, breast, and bladder cancers.

The doctor on Bartiromo’s program made another good point: He declared type 2 diabetes to be a scourge of our modern lifestyle that is “self-caused.” He said 1) we overeat, 2) we don’t eat properly, and 3) we don’t exercise. The first two are interrelated, with the 2^nd being the cause of the 1^st. But to his point: “WE” IS THE PATIENT. “SELF-CAUSED” means that WE can do something about it, without intercession by our doctors.

The doctor then lost his way on the eating part. He advocated “fruits and vegetables and lean meat” and avoiding “saturated fat and sugary drinks.” It was essentially, the Mediterranean Diet: Eat processed vegetable oils (PUFAs) and avoid fatty red meat (saturated fat). That’s the government’s pitch. Sad, really sad, and too bad, but that’s still the wrong-headed position of the medical, public health and agri-business, big pharma industrial-agricultural complex.

For perspective, just remember that too many processed carbs and simple sugars, and wheat, excessive fructose and excessive linoleic acid (Omega 6s in the polyunsaturated vegetable oils), is how we got sick and fat in the first place.

Note that, as of the 2015, THE GOVERNMENT’S DIETARY GUIDELINES FOR AMERICANS NO LONGER LIMIT DIETARY CHOLESTEROL OR TOTAL FATS. Did you know that? I’ll bet you don’t. They KNOW they got it wrong from the 1960s and now they’re slowly turning it around and hoping you don’t notice. But THEY KNOW you can eat high-cholesterol foods and full-fat dairy and not only do-no-harm but actually improve your health and not gain weight. Do you know it?

Retrospective #443: The 1-percenters

Major “lifestyle changes” are difficult. People are generally unwilling to accept the radical changes that are necessary and usually rationalize it by saying something like “everyone is different.” That’s a convenient scapegoat.

A while back, on a link suggested by a member on a nutrition website, I watched a TED talk. The talk was said to “help you find your ideal diet,” a “personalized program just for you.” It turned out to just be a businessman’s pitch for his startup’s service to for an “individualized” diet for you, for a fee. It was a sham, intended to appeal to a nutritionally naïve audience. This, unfortunately, would be 99% of the public, but I expected better from this nutrition site.

The truth is we are all human and our biological processes for digesting and absorbing the basic components of food –protein, fat and carbohydrates – are virtually identical. The only difference is the degree that a bundle of glucogenic genes have, to a lesser or greater extent, been “modified,” over many years, by overindulging, unnaturally, in a diet composed of a very high percentage of processed carbs and simple sugars. That will vary from person to person.

These “over-indulgers” have developed a dysfunctional glucose metabolism. Once “modified,” these genes continue to express this Carbohydrate Intolerance on a continuum. It is a path which will lead most people, over a period of years, to develop Type 2 diabetes and, for most, to become overweight or obese. The condition is called Insulin Resistance.

Insulin Resistance is thus a genetic expression of a bundle of genes, in those genetically predisposed, such that the insulin receptors on cells that ordinarily open up to allow glucose energy to enter and nourish them, no longer function properly. When these insulin receptor cells “resist,” and the uptake of glucose is impaired, the pancreas secretes more insulin to help out. Type 2 diabetes is thus a disease of too much INSULIN in the blood stream. Characteristically, TYPE 2S HAVE CONTINUOUSLY ELEVATED BLOOD GLUCOSE AND ELEVATED BLOOD INSULIN.

The elevated blood glucose is what clinicians use to detect the presence of incipient pre-diabetes or frank Type 2 diabetes. Today the hemoglobin A1c (HbA1c) is the blood test used to make this diagnosis. Previously, an elevated fasting blood glucose (FBG) was used. The gold standard, however, still used by endocrinologists, is the Oral Glucose Tolerance Test (OGTT). It takes 2 hours and is more expensive, but nevertheless, still the best.

The elevated blood INSULIN is what causes obesity (in about 80% of Type 2s). While insulin is elevated in the blood stream, to avert hunger the body must rely on food BY MOUTH for energy. Most people eat carbs at every meal and often between meals. The net result is that they are always hungry. Then, when they eat more and more often, they get fat. And, with INSULIN RESISTANCE, you’re the INSULIN level in your blood stays high. It’s only when your BLOOD INSULIN level drops that the liver switches to breaking down body fat (the food you’ve previously eaten) for energy.

The 1-percenters – those I call the cognoscenti – know this. Now, you do too. But knowing it and doing something about it are very different. It is hard to change one’s lifestyle and in particular one’s eating habits, which are both cultural and very personal. Incipient pre-diabetes and frank Type 2 diabetes are symptomless conditions.  And it takes decades to kill us, most often indirectly by heart attack, stroke, or Alzheimer’s (aka type 3 diabetes) and many cancers. These days, with better care, blindness, amputation and end-stage kidney disease are less common morbidities.

So, what would motivate a person to make a “lifestyle change” this drastic? Well, how would you like to “kill two birds with one stone”? Lose lots of weight and reverse your slow but indubitable slide into full-blown Type 2 diabetes? You can do both, but you will either have to eat Very Low Carb most of the time, or fast for a day or two a week, or both.

Sounds tough? What if you could eat this way without hunger? That’s what happens when your blood insulin level drops. When your body switches to body fat for energy, it is being fed so you don’t have to eat to stave off hunger pangs. A few days after you make the switch, your metabolism just runs on high test as long as you have fat to burn.

That’s what I did. I started eating Very Low Carb in 2002 and lost 170 pounds. When I plateaued a few times and gained 45 back, I added fasting. I lost 60+ pounds. I maintain my weight loss by eating Very Low Carb and fasting.

Retrospective #442: Stepping into my new trousers…

A few years ago, I took several pairs of trousers to a local tailor to have them altered. In the previous 6 months I’d lost a lot of additional weight (60+ pounds, 188 total since 2002) while fasting 2 or 3 days a week, and there were very few pants in my closet that didn’t bunch up at the waist when I cinched them in. The tailor took a look and told me, “I can take them in, but you’ll always have a big baggy seat. You really should buy some new pants.” So, that’s what I did.

My wife cautioned me not to rush into it though. She said, “Buy one pair to see how it fits. Then you’ll know what size to order going forward.” That sounded prudent. But first, so there would be no going back, I went through all my clothes in the closet and the bureau and prepared to take them to the church thrift shop and the Salvation Army. With the previous year’s tax reform, who knew if I would ever have a chance to deduct them again!

Then I took a bold step: I ordered a pair of trousers with a waist size smaller than I have bought in over half a century. Fact is, I have no idea when I last ordered pants that small. I had nothing in my closet or bureau that small and some of the clothes there were ancient! So, I placed the order and anxiously awaited its arrival.

In the meantime, I tried on a few sports jackets. One was a Magee handwoven Irish tweed that I bought in ’04 in Donegal, Ireland, and had worn only a few times. It was much too large. Then I found another tweed that I bought at Harrods in London in 1969 and that now fit perfectly! It had been relined ages ago and still looks great!

Then I went through my bureau and found a few things that now fit that I hadn’t worn in maybe 40 years. I also found a few things that I had never worn and that now would never fit. They were much too large!

Finally, I went to the front hall closet where we keep our winter clothes. A Woolrich heavy winter car coat that I had hardly ever worn was much too big, but my favorite, a 50-year old, cherry-red ski parka now fit perfectly.

The exercise of “cleaning house” was cathartic. It brought back many fond memories of times and places that I have been and things I have done: shorts and knit shirts from a long-ago vacation in Bermuda, an embroidered knit shirt that my brother gave me when I skippered his 45-foot Bristol sailboat for a week. I took my wife and her 3 daughters and their husbands for a sail out in the Bahamas. And the 2-week golf vacation to Ireland, with the “Fat Boys,” where we played 12 rounds in 12 days, more than 1 in the rain without a cart.

And all the tee shirts from everywhere, especially those that I wore when I fished for 12 years from my kayak in the ocean and in the Indian River in Florida. Everything that no longer fit went to the thrift shop or the Salvation Army store. It was very “Jungian” to clear out the past with an eye to “making room” for the future.

I was also eager to secure the weight loss in my mind and close this “fat period” from my past. I decided I wasn’t going to take out any “insurance policy” that the weight loss would be temporary and that one day I might regain the weight that I had lost. I was confident that once “there,” my weight loss would now be permanent. And I was confident that I knew how to do it, and that I would put that knowledge into practice.

This step may have been the boldest of all. Most people who lose a lot of weight, including me, have put some of it back on. But I knew now that I had found the secret: Very Low Carb all the time, mostly 1-meal a day (OMAD), with sometimes a light, all-protein-and-fat lunch, and 1 or 2 300kcal/full day fasts each week (as needed) to keep my weight within a narrow range. My program includes a glass or two of wine daily, and an occasional cocktail.

A few days later the box with the trousers arrived and, with great anticipation, I opened it and took them out of the plastic bag. I then “stood them up,” opened the waist and held them in front of me with both hands, as though I was preparing to step into them. And…the “hole,” into which I imagined I would step – right leg first – was TINY! How would I…how could I step into such a SMALL OPENING! I smiled to myself as I came to this realization. If I was going to step into my new trousers successfully, it was going to take a little practice. I would have to focus on it – pay full attention. At my age I can’t afford to break a hip! 

Retrospective #441: Have I cured my Type 2 diabetes?

“You’re cured,” the clinician told me. “You no longer have Type 2 diabetes.” You’d think I would greet this news with a sigh of relief since years ago I had an A1c as high as 8.9%; but I did not, because I knew it simply wasn’t true.

I was not, however, surprised with that doctor’s response. I had just told her that, although I had been diagnosed a Type 2 34 years ago, my A1c was now 5.0% and my average FBG was in the mid-80s. From the clinician’s point of view, as one who treats patients according to the ADA’s Standards of Medical Care, her goal was for her to manage my diabetes to get my A1c to ≤7.0%, or even ≤6.5%, the diabetes diagnosis threshold. Thus, to her, clinically speaking, I was “cured.” I asked her, “Would you then write on my chart that I no longer had diabetes?” She replied, “Yes.”

When I shook my head in dismay, she asked me why I wouldn’t accept this “good news.” I replied, “Because I will always have Insulin Resistance and therefore will always be diabetic.”  She just smirked, not wishing to get into an argument. We were, after all, just chatting in a social setting after a panel discussion in NYC with Gary Taubes. Nevertheless, she said dismissively, and with medical authority, that what I said was untrue. I left it at that. The divide between us was too great. In her view, unlettered dotards like me shouldn’t be taken seriously.

This doctor wasn’t my doctor and wasn’t going to be. Except for my MD friends who read this blog – and there are a few – I leave the one-on-one re-education of the trained professional to others. But, as the Dr. Eric Westman sadly said to me a few years ago, in Retrospective #402 here, “Ignorance is the biggest problem.” Gary Taubes expressed a corollary sentiment to me that night. He said the Low Carb “movement” has increased 100 fold in just a few years from 1/100^th percent to 1 percent. That’s a huge relative improvement…yet still an abysmal state of affairs. There is yet so much work to be done to overcome the entrenched positions in the political, agribusiness, big pharma, public health, medical, and other special interest establishments.

But I digress. Insulin Resistance is a dysfunction of a biological process, in those genetically predisposed, such that the insulin receptors on cells that ordinarily open to allow glucose energy to enter and nourish them, no longer function properly. When these insulin receptor cells “resist” opening, and the uptake of glucose is impaired, the pancreas secretes more insulin to help out. Type 2 diabetes is thus a disease of too much insulin in the blood stream. Characteristically, Type 2s have both an elevated blood glucose and an elevated blood insulin.

The elevated blood glucose is what clinicians use to detect the presence of incipient pre-diabetes or Type 2 diabetes. Today the hemoglobin A1c (HbA1c) blood test is used for diagnosis. Previously, an elevated fasting blood glucose (FBG) was used. The gold standard, still used by most endocrinologists, is the Oral Glucose Tolerance Test (OGTT). It takes at least 2 hours (mine was in a hospital outpatient department) and is thus more expensive. The easiest test is to measure your waist/hip ratio (for visceral adiposity); anything over 1.0 (male) or .8 (female) signals insulin resistance.

The elevated blood INSULIN causes OBESITY. While insulin is elevated, the body must rely on food by mouth for energy. Most people eat carbohydrates in every meal and frequently between meals. So, if you have a little Insulin Resistance, your blood INSULIN level stays high ALL THE TIME. That’s why you are always hungry and why, when we eat more and more often, extra calories, whether carbohydrates or fat, are stored as fat. Only when your blood INSULIN level drops will the liver look for an alternate energy source. It will first use glycogen (stored glucose in the liver) and then, after a day or two, turn to breaking down body fat for energy. But to do this, a person either must eat VERY LOW CARB at virtually every meal, and not snack, or FAST for a day or two, or BOTH.

So, while I have no clinical signs of Type 2 diabetes, because of my low A1c and average FBG, and doctors in a clinical setting may regard me as “cured,” I know that I am still Insulin Resistant. I know that it is only because I eat Very Low Carb most of the time, and fast a few days most weeks, that MY INSULIN RESISTANCE IS NOT EXPRESSED. But my Insulin Resistance will always be there, albeit somewhat less dysfunctional because it is less stressed, and that is why I will always be a Type 2 diabetic – A (THIN) TYPE 2 DIABETIC, IN REMISSION, BUT ONLY BECAUSE OF THE WAY I EAT.

Retrospective #440: The Drinking Man’s Fasting Diet

As a drinking man, this post is my approach to drinking while fasting. Yesterday’s Retrospective #439, describes the original 1964, “The Drinking Man's Diet.” The premise of both links is that, as Robert Cameron wrote in 1964, “Most everyone has a drink now and then.” My contention is that it is not necessary, when either dieting or fasting, to give up alcohol altogether. I hope this allays the fear, or excuse of some, for not trying full-day “fasting.”

In this 2004 Forbes Magazine piece, commemorating the 40^th anniversary of its original publication, Cameron was described as a bon vivant. It’s hard to know at this point whether he was or not, but his little pamphlet is replete with humorous references to various spirits in conjunction with the “high-life.” Reading it today it sounds more like a parody of the ‘50s, but in context, it could very well have been the way some people lived.

In any case, while few of today’s business man or woman indulge in a 2-martini lunch, it is fair to say that “most everyone has a drink now and then,” many of us at home, before or with dinner. It has been justified or rationalized as a way to relax and relieve stress. And there’s the social aspect to it: a chance to sit down with one’s spouse and “communicate” (LOL). As a result, perhaps based on today’s mores, medical advice websites tout the “health benefits” of “light drinking,” usually defined as 1 alcoholic drink per day for women and 2 for men.

Okay, so that’s my set-up. I like a drink. I consider myself a light drinker, fitting squarely in the guideline above. I drink spirits (scotch, bourbon, vodka, etc) on special occasions. We go out for dinner on average once a week. In a restaurant I will often have one or sometimes two cocktails, depending on the generosity of the bartender’s “pour.” We entertain at home much less often these days, but if we have people over for dinner, I will make a drink for me and for any guests who will join me. When I make the drink, one is always enough. LOL

On a daily basis at home, I drink wine. When I am NOT fasting, my Way of Eating is generally to eat Very Low Carb: to have just coffee with cream for “breakfast”; then, if I have lunch – a very light lunch, usually a can of kippered herring with iced tea sweetened with pure liquid stevia. And then, a small supper. Supper is one small portion of protein with a low-glycemic vegetable, the vegetable either roasted in olive oil or tossed in butter

My non-fasting daily eating routine is thus Very Low Carb. Daily food intake is about 1,200 kcal: 100g fat, 60g protein, and 15g carbs. In addition, I have two 5-ounce pours of red wine, the glass then filled with seltzer, aka a “spritzer.”

When I am “fasting,” I have the same “breakfast,” I skip lunch, and for “supper” I have just one red-wine spritzer.

If I am working at “hard labor” (in the garden), I will drink more diet ice tea sweetened with liquid stevia. For electrolyte balance, I will supplement it with pickle juice, or a large cup of bouillon.  For any oral fixation impulses, especially after supper, I will make a “cocktail” of 1 Tbs of Bragg’s Apple Cider Vinegar (ACV), a few dashes of bitters, and 5 drops of liquid stevia, stirred (not shaken), the glass filled with ice and then seltzer.

The ACV cocktail is satisfying and is said to be good for blood glucose control too. Who knows? I’ve been a Type 2 for 34 years and, when I wrote this in 2018, my A1c was 5.0%, so I would say that I have my “progressive” disease under control. I do it with just a Very Low CARB diet, 3 42-hour fasts a week, red wine and Metformin (750mg twice a day).

My “Drinking Man’s Fasting Diet” is about 300 kcal/day, equally divided between “breakfast” and “supper.” Macronutrient Distribution is detailed in Retrospective #410, My 300kcal Fasting Diet. It is Protein: 1.2g; Fat: 16g; Carbs: 5.7g and ethyl alcohol: 18g. Last year, I lost about 60 pounds following this “Drinking Man’s Fasting Diet.”

I have been losing weight eating Very Low Carb since 2002. At the start, I weighed 375 pounds. I twice got down to 205, then stalled and regained some. In early 2017 I started my “Drinking Man’s Fasting Diet” to break the log jam. It worked. I got my weight down to 188 pounds, half the man I once was. It was not a “water-only” fast, though. It was this “Drinking Man’s Fasting Diet,” as described. I generally ate 4 days (Tues-Thurs-Sat-Sun) and fasted for 42-hours 3 days a week (Mon-Wed-Fri). So, it turns out you can eat VLC, drink moderately, fast and still lose weight. Cheers!