Paging Dr. Hive - questions re: diabetes, intermittent fasting, and calorie restrictions

[Hoggirl]

I’m worried about my cousin.  She is morbidly obese and on Metformin for (pre?) diabetes.  She’s been on it probably two to two and half years.  At her last doctor visit, she was told that if her A1C hit a certain number, she would have to go on insulin.  Apparently, it’s been creeping up?? I think the number was “7” that would put her on insulin?? I know nothing about this..  Anyway, the thought of being insulin-dependent put the fear of god in her, so she is working on losing weight.  Side note - she previously lost approx 150 lbs several years ago using Medifast.  Then gained all of it back.  She is 5’3” tall and started at 303 lbs.  She is down to 260 lbs after about two months, which is great, but I am worried about her approach. 

She discovered Dr. Fung and has started doing intermittent fasting.  This seems reasonable to me, but she is also severely restricting her calories.  She is doing two 24-hour fasts a week and one 16-hour fast a week, I believe.  She did NOT clear starting this with her personal medical doctor.  Her doctor has been after her to lose weight for a long time and told her to keep her caloric intake to approx. 300 calories per meal. This also (sort of??) seems reasonable to me, but I am worried because she is combining these two approaches.  I am worried she is not getting the proper nutrients that she needs and that she may be messing up her metabolism as well (going into starvation mode).  I asked her a bit about this today, I know she is eating those little pretty-made salads from Walmart for lunch.  There isn’t much too them - usually romaine and sometimes spinach.  She has lean protein and veggies for dinner.  Sometimes oatmeal for breakfast, I think.  She is avoiding carbs for the most part.  She has also started walking a bit.  She was extremely sedentary before.  

I completely understand that the concept of intermittent fasting does not mean eating during non-fasting times becomes a free-for-all.  I suggested she make her own salads - load them up with tons of fresh veggies.  She is not eating much fat at all. When I ask questions she gets frustrated and reverts back to Dr. Fung’s videos where she tries to explain it but eventually says, “It’s very complicated.”   I guess my overarching issue is that she was on a medication for pre-diabetes/diabetes but didn’t clear this fasting idea with her doctor before she started..  She does go back next week for her quarterly blood draw.  I have no doubt her numbers will have improved.  However, she complained today that her weight loss has now somewhat stalled which is why I am wondering if she has whacked out her metabolism. 

I am not even sure what my question is.  I’m just wondering what folks think/know in general about doing long fasts in combination with pretty severe caloric restrictions. 

[Jean in Newcastle]

Good for her!  As before, you seem way too invested in what your cousin is doing. If she stalls, she will research as she has done before and will work it out. 

[City Mouse]

Her metabolism is probably messed up anyway from being morbidly obese. Being that overweight is just as dangerous as the rapid weight loss. It is kind of a “pick your poison” situation. 

Being that heaven makes physical activity extremely difficult, so losing weight before adding in additional activity can be a motivator. If activity is easier than it is more likely to happen.

But I agree with Jean. It really isn’t any of your concern how she chooses to loose weight. I would stay completely away from it unless she directly asks you for advice, and even then I would keep the advice to a minimum. “Have you talked to your doctor about your weight loss plan?”

i spent many years obese in a family of obese adults before I chose to really lose weight, and no one’s advice ever did anything more than piss me off. My own Adult DD is probably in the obese category. All I have said to her is that if she ever wants me to help her with losing weight that I would be glad to offer suggestions, but until then I will not bother her. 

[Hoggirl]

32 minutes ago, Jean in Newcastle said:

Good for her!  As before, you seem way too invested in what your cousin is doing. If she stalls, she will research as she has done before and will work it out. 

 

I’m sorry you see my concern as “way too invested.”   Other than my immediate family of dh and ds (and an uncle I barely know) she is the only living family member I have left.  Neither one of us has siblings.  I care about her and want her to be healthy. 

[Hoggirl]

32 minutes ago, Margaret in CO said:

Actually, if it's her A1C that's down to 7, that's pretty good. That means the Metformin is working. I hit a 12.2 when I found out I was diabetic, and ecstatic to get down to 7. At 4.9 now, I'm off Metformin. Quite possibly, she has whacked out her metabolism. I lost 47 lbs walking 10 miles a day. Now, I have to walk 12-13 in order to maintain or lose. Her body has said, "I'm starving! Hang to every bit I've got!" Stalls are quite common, but she's be way better off with more exercise. 

 

I think that number (which I may be wrong about) has been creeping upward while on the Metformin.  I know her doc has adjusted her dose and she currently takes the max she can.  

She had worked her way up to walking a mile but hurt her back and had to stop for awhile.  She’s working back up to one mile. 

This is what I fear her body is doing as well. It’s mostly that I think she is not getting proper nutrients. Idk if she takes a daily vitamin or other supplements. 

[EKS]

A 16 hour fast isn't really a fast IMO.  It's just a late breakfast.

A 24 hour fast also isn't that big of a deal once you get used to it.  It certainly isn't dangerous.  

The biggest problem with what you've said here is that she is essentially subsisting on protein.  It would be much better if she were to eat a normal amount of protein and make up the balance with fat.  

[Hoggirl]

8 minutes ago, City Mouse said:

Her metabolism is probably messed up anyway from being morbidly obese. Being that overweight is just as dangerous as the rapid weight loss. It is kind of a “pick your poison” situation. 

Being that heaven makes physical activity extremely difficult, so losing weight before adding in additional activity can be a motivator. If activity is easier than it is more likely to happen.

But I agree with Jean. It really isn’t any of your concern how she chooses to loose weight. I would stay completely away from it unless she directly asks you for advice, and even then I would keep the advice to a minimum. “Have you talked to your doctor about your weight loss plan?”

i spent many years obese in a family of obese adults before I chose to really lose weight, and no one’s advice ever did anything more than piss me off. My own Adult DD is probably in the obese category. All I have said to her is that if she ever wants me to help her with losing weight that I would be glad to offer suggestions, but until then I will not bother her. 

 

That is good advice, except she brings it up every time we talk on the phone (usually once a week).  She gives me specific details about how much she’s lost, what she is eating, how much she is walking, how often she fasts.  It’s pretty much all she talks about. I don't’ bring it up - she does.  Obviously I encourage her and tell her I am proud of her. 

[Hoggirl]

2 minutes ago, EKS said:

A 16 hour fast isn't really a fast IMO.  It's just a late breakfast.

A 24 hour fast also isn't that big of a deal once you get used to it.  It certainly isn't dangerous.  

The biggest problem with what you've said here is that she is essentially subsisting on protein.  It would be much better if she were to eat a normal amount of protein and make up the balance with fat.  

 

She watches carbs, sugar, and fat.  She is anti-keto diet.  I don’t know why. 

[EKS]

2 minutes ago, Hoggirl said:

She watches carbs, sugar, and fat.  She is anti-keto diet.  I don’t know why. 

The problem is that there are two conflicting messages about the best way to lose weight--carbs are bad and fat is bad.  But you need to choose one or the other, otherwise, all you're eating is protein.

[BeachGal]

Her doctor will probably know very little about Dr. Fung's work so there likely won't be much to discuss.

Fasting is not at all the same as starvation. They affect the body differently.

My A1C is very good (in the 4s) but I still fast usually 4 days per month (2 days every 2 weeks) for the benefit of autophagy, which is the way our bodies clear out or reuse pro-inflammatory cellular debris. Most people in the US have way too much of this in their bodies wreaking havoc on their health. Some of the first bits to get cleared out are skin, so people who fast can sometimes not have the saggy skin problem that others get with doing just calorie reduction.  I used to belong to one of Fung's fasting groups and a number of people did experience this even after very large losses. 

More importantly, a 5-day fast eliminates about 40% immune cells, many of which are damaged and pro-inflammatory. Upon refeeding, new stem cells will sprout which can be used throughout the body to rebuild. So fasting is a way to rebuild the immune system. Valter Longo at USC is doing a lot of research using fasting or the fast-mimicking diet to treat both cancer and autoimmune conditions. (It is also important long-term to keep protein intake to just what your body needs, probably on the low end. Longo's also done work on this.) Longo has a book that explains all this.

Fasting also improves the microbiome.

I use the Glucose Ketone Index to monitor how a fast is going. It's just blood glucose divided by blood ketones. I aim to get that ratio close to 1.0 and am often below 1.0 around day 2 in the afternoon. I use the True Metrix blood meter for measuring glucose and the Precision Xtra for ketones. Ketones are often higher in late afternoon/evening and that's when I measure those along with glucose when I'm fasting. It's a little finger prick of blood.

When I eat, I avoid sugar and simple carbs (avoid, not eliminate) and eat until I'm full. I also eat a wide variety of veggies and fruit, probably 15-20 different things, just a bit of some and more of others. I make almond/coconut flour/low-sugar cookies and cakes and eat those. They're tasty. William Li has a good book that explains the benefits of certain foods.

When a person eats is just as important as what a person eats. This is Satchin Panda's work on circadian biology. Stop eating as close to 5 pm as possible and inflammation will be reduced. Work to improve sleep because not being rested leads to insulin problems. This is what Panda's research is showing. His book is worth reading, too.

If you want to get into the nitty-gritty, check out Rhonda Patrick's videos on her YouTube account, FoundMyFitness, where she's interviewed Valter Longo twice and Satchin twice. She is pretty darned expert in the area of micronutrients herself (a PhD). Your cousin will eventually want to pay more attention to that but she'll probably learn more as she goes along.

Good luck to your cousin!

 

Edited June 7, 2019 by BeachGal

[Carol in Cal.]

There isn’t really a good way to lose a ton of long term weight.  There are a lot of bad ways and less bad ways, but for someone who is morbidly obese, there isn’t actually a good way.  I think that someday there will be, and it will probably have to do with lepton control through microbieme changes but in the meantime, unless she is putting herself into dangerous bloodsugar levels by taking the drug and not eating, I don’t think it matters all that much what approach she uses.  She is working extremely hard at this, clearly, and it’s no wonder that it’s all she talks about—it’s very hard work.  I don’t think I could do it.

Edited June 7, 2019 by Carol in Cal.

[Hoggirl]

1 hour ago, Carol in Cal. said:

There isn’t really a good way to lose a ton of long term weight.  There are a lot of bad ways and less bad ways, but for someone who is morbidly obese, there isn’t actually a good way.  I think that someday there will be, and it will probably have to do with lepton control through microbieme changes but in the meantime, unless she is putting herself into dangerous bloodsugar levels by taking the drug and not eating, I don’t think it matters all that much what approach she uses.  She is working extremely hard at this, clearly, and it’s no wonder that it’s all she talks about—it’s very hard work.  I don’t think I could do it.

 

I guess this is what worries me the most - the still taking the Metformin in conjunction with the fasting without talking to her doctor about it. 

I do hope she gets positive feedback from him on her weight loss and that her “numbers” (whatever those consist of) have improved when she returns next week.  I am hoping he will at least ask her how she is losing so she can explain her method to him. 

[Laura Corin]

2 hours ago, EKS said:

The problem is that there are two conflicting messages about the best way to lose weight--carbs are bad and fat is bad.  But you need to choose one or the other, otherwise, all you're eating is protein.

It's a shame people are so polarised. You can eat lean protein and tons of non-starchy veg with moderate amounts of plant oils. It's healthy and it works.

[Pen]

 

2 hours ago, Hoggirl said:

Obviously I encourage her and tell her I am proud of her. 

 

That sounds like an excellent approach!!!

 

[BeachGal]

She should be okay with the Metformin. To be on the safe side, she could check her blood glucose herself if she isn't already and be aware of signs of hypoglycemia. 🙂

[Pen]

Vitamin D and Calcium are also supposed to have K2

 

Is there a reason she’s avoiding Keto  direction ?

[Pen]

 

4 hours ago, Hoggirl said:

 Sometimes oatmeal for breakfast, I think.  

 

 

I thought Fung was mostly against cereal.  ???

[Katy]

Your primary concern- Metformin and fasting together - isn't a concern.  Metformin isn't insulin.  It doesn't lower blood sugar.  It makes you less insulin resistant.  It's fine.  Many underweight people have it prescribed off label because it's thought to extend lifespan because it makes the body behave as if you are drastically limiting calories.  Doing so is the only thing proven to increase lifespan in mammalian studies. That is absolutely safe.  If she was on insulin and fasting that would be a different story but with this drug you can relax.

MANY morbidly obese people, especially those from a young age have a sensitivity to both carbs and to saturated fat.  For most people (probably 95% of the population), either low fat OR low carb works best for them.  For some people (oftentimes those with native american ancestry), they have a genetic condition where they have less insulin receptors on certain classes of muscle cells. If that's the case for your cousin, when she eats saturated fat that fat blocks insulin receptors and skyrockets her blood sugar.  One number I read is that at the extreme end of this scale a person might have only two insulin receptors per smooth muscle cell.  Whereas the average number is 18 receptors per smooth muscle cell.  For the average person blocking a few insulin receptors with saturated fat makes no difference in blood glucose whatsoever.  For the person with less receptors than average a high fat diet is terrible.

I'm almost certain your cousin's doctor told her to eat a certain number of grams of protein if she was asked to limit calories to 300 per meal.  Why?  Because if you go below that number and you're not fasting you can damage vital organs because your body can do things like grab protein from your heart.  Eating enough protein when rapidly losing weight is why people who have a bariatric surgery are encouraged to eat mostly protein, a little bit of veggies, and scant amounts of everything else.

 

Dr Fung personally likes lower carb but he's fine with eating a low fat vegan diet combined with intermittent fasting.  It works with any diet.  His books are bestsellers.  You can probably grab The Obesity Code or his fasting book at any library.  Or you can search for him on YouTube and you'll probably be reassured in less than an hour of watching his videos.

 

ETA: I have a nursing background, I have Native American Ancestry on the line that I got diabetes from, I am personally sensitive to both carbs and saturated fat, I follow Dr Fung (with limited compliance recently), and as a foster parent I've cared for a morbidly obese infant who had to have a university nutritionist figure out a custom recipe for infant formula because at the calorie level this baby needed to eat to simply maintain weight rather than lose the protein level was dangerously low.  Also if you search for the way you eat after having a gastric bypass I'm betting you'll find most people eat remarkably similar to how your cousin is eating now.

Edited June 7, 2019 by Katy

[Reefgazer]

I understand your concerns, but I look at it this way:  She is trying and if this helps her to lose, the benefits will outweigh (har-de-har-har) the dangers.  As long as she is aware of low-blood sugar signs and is getting minimal nutrition, she should be OK for the short term.  It sounds like she has pre-diabetes or early diabetes, so she still has *some* control over her sugar levels.  I am not a doctor, so I wouldn't take what I say too seriously, but that's just my non-medical opinion and she should talk to her doc; if it's working, he may be fine with what she is doing.

[Hoggirl]

@Katy - thank you!!  This helps tremendously!!  I kept reading about not starting a fasting protocol if one is on “diabetes” medication.  Your clarifying that this specifically means insulin is extremely reassuring to me.  That was what was worrying me most (in addition to the nutrients).  It sounds like she will be fine as long as she gets enough Calcium.  I will ask her if she takes a supplement the next time we chat.  I certainly do! 

I have no idea if she has Native American ancestry - she is adopted.  AFAIK, she has no medical information about her birth parents at all.  


 

[Carol in Cal.]

1 hour ago, HeighHo said:

She needs the Vitamin D also..most people need to supplement.   The K2 is usually via diet (dark poultry, high quality butter and eggs, among others)  -- K2 a precursor to another substance that improves insulin sensitivity as well as vital to bone.

This is an ideal time of the year to get sunshine outside.  She should really concentrate on that—get some sun every day, not get burned but get exposure.  This is when to store up D for the winter, and it will make everything else work better.  It’s remarkable the difference when you do this.

[Sunshine State Sue]

22 hours ago, Katy said:

 For most people (probably 95% of the population), either low fat OR low carb works best for them. 

I find this interesting.  The body is so amazing.  I know one woman who was thisclose to diabetes who was able to lose weight and keep it off by going and staying low carb.  She eats mainly lean protein and veges.  She eats very little processed food.  She eats almost no fruit.  Now she's developed Parkinson's. 

I personally think all carbs are not created equal.  Sugar is definitely bad.  White rice, white flour, bad.  But, beans, sweet potatoes, blueberries?  Can't convince me.

I don't claim to be an expert.  I've only been overweight 2x in my life and nowhere near obese.  The 2nd time, I learned about eating a whole food plant based diet from Eat to Live by Fuhrmann.  He also has a fasting book.  He says that if you want to lose weight, you are going to have to eat fewer calories long-term.  The goal is to make those fewer calories be as nutritious as possible.  That makes sense to me.  So, I can completely understand your concern about her nutrition.  I would encourage her to eat as nutritiously as possible.  Dr Neal Barnard has a scientifically proven program to reverse diabetes using a whole food, plant based (vegan) diet.  I probably have met a few people who have used it.  I don't know how easy it is to maintain in this day and age, though.

IMO, your cousin is blessed to have you in her support group. 

[Katy]

I know I've posted this on multiple threads, but chances are the best diet for her is highly individual. 

 

[Liz CA]

On 6/7/2019 at 3:23 PM, Pen said:

Vitamin D and Calcium are also supposed to have K2

 

Is there a reason she’s avoiding Keto  direction ?

 

I'd throw some mag in there too to balance out with calcium.

[Ottakee]

Has she tried weight watchers?  My friend lost over 100 pounds on it with just following the WW plan and very moderate walking.

 

For exercise can she get into a local pool to walk in the pool or do a light water aerobics class?  The pool takes a lot of stress of joints and some therapy pools are quite a bit warmer than other pools so might feel really good on her back.

Edited June 10, 2019 by Ottakee

[Pawz4me]

A NYT article this morning  --

Nutrition for One? Scientists Stalk the Dream of a Personalized Diet

It corroborates the video that @Katy posted above -- it's looking more and more likely that what foods are "good" or "bad" vary from one individual to the next. This is interesting, so I'm also going to post it on the other current weight/health thread.

From the article:

The full data set will take Dr. Spector and his extended team of colleagues — some 40 scientists around the world — years to analyze, even with the help of machine learning. And they have already begun follow-up studies to tease out the complex relationships among factors.

But it was already possible to glean individual insights, he said. After eating potato chips, one subject repeatedly experienced a triglyceride peak six times higher than that of an identical twin. That degree of awareness could help steer the chip-sensitive twin toward a lower-fat snack, Dr. Spector said.

“We are omnivores and we do need a diverse diet,” he said. “But if you can just swap some foods around so that you have exactly the same calories and enjoyment but a lower peak either in glucose or in lipids, then you’re going to put on less weight and be healthier long term.”

Jennie Brand-Miller, a professor of human nutrition at the University of Sydney in Australia, who was not involved with Predict, said that individualized nutrition advice, rather than standard dietary guidelines based on population-wide averages, could significantly improve public health.

“I think the one-size-fits-all nutrition guideline is antiquated,” Dr. Brand-Miller said. She noted that one in three people have a poor metabolic response to sugar; identifying those individuals, and then teaching them how to avoid spikes in blood glucose, could reduce their odds of later developing diabetes by as much as 40 percent.

[Hoggirl]

Coming back to report on my cousin. 

She was incorrect about her starting weight from her last MD visit.  She thought it had been 303, but it was only 293.  She had lost 30 lbs since her last doctor visit 3 mos ago. 

All of her “numbers” were significantly improved.  He was very pleased with her progress and told her to keep it up.  He was aware of Dr. Fang (sp?).  He did, however, reduce her amount of Metformin on the 2 days she does a 24 hour fast.  

I hope she can keep it up.  She is back to walking 1 mile, two or three times per week.  I think her goal weight is 153 which is what she got down to before. 

ETA:  She does take a daily multivitamin but not any additional calcium.  I suggested she ask about that on her next visit.  My daily vitamin only has about 30% of the recommended amount of calcium. 

Edited June 21, 2019 by Hoggirl