Archives for August 2018

August 16, 2018 By spao 2 Comments

TOFI – Thin on the outside, Fat on the inside

When I was first diagnosed with diabetes in 2003, my doctors were puzzled. While most of their patients were obese, I was a so-called “normal weight” (BMI < 25) patient. How did I get diabetes at my BMI and and at my age (36 at the time…)?

Today, much of the mystery is solved. I am a “TOFI” (think on the outside, fat on the inside) Asian-American.

The term TOFI was popularized in an article published in The Guardian describing how apparently “thin” people have hidden fat around the organs, which can lead to diabetes.

Tofis probably need to worry more about their health than others, because the fat deposits they carry are hidden in the white fat that lies around their vital organs, streaked through their underused muscles, and wrapped around the heart. It is this fat that sends out the chemical signals which eventually lead to insulin resistance, diabetes and heart conditions, rather than the fat lying in dimples underneath the skin.

While The Guardian article did cite genetics playing an “enormous role,” the data at the time was more anecdotal, with no specific mention of Asian-Americans.

The data came in 2012!

The CDC’s National Health and Nutrition Examination Survey (NHANES) data taken from 1998-2012 revealed that I was actually part of a larger group of TOFI Asian-Americans living with diabetes. In 2015, the NIH issued a press release titled “More than half of Asian Americans with diabetes are undiagnosed.” In it, they wrote:

One difference between Asian Americans and the other groups studied, however, is that Asian Americans often develop type 2 diabetes at a lower body mass index (BMI). The NHANES data showed the average BMI for all Asian Americans surveyed was under 25.

Today, the CDC has a page “Diabetes and Asian Americans” devoted to this issue.

But people of Asian descent have less muscle and more fat than other groups and often develop diabetes at a younger age and lower weight. That extra body fat tends to be in the belly (visceral fat). This isn’t the “inch you can pinch,” the fat stored just under the skin. Visceral fat is out of sight, wrapped around organs deep in the body. You can’t tell how much visceral fat someone has by looking at them.

So, looks can be deceiving when it comes to Asian-Americans and diabetes!

Affiliated with Harvard Medical School, the Joslin Diabetes Center has gone so far as to create a new BMI chart specific to Asians.

Asian-BMI-Chart-Joslin-AADI — Chart from the Joslin Diabetes Center – Asian American Diabetes Initiative

Note that while being Asian-American and TOFI is linked to diabetes, there is some broader work suggesting a distinct “Asian phenotype” be applied in medicine as a whole!

Factoring in Asian phenotypes is essential for the medical research community and the development of improved clinical practice guidelines across a continuum of disciplines that will ultimately translate to better human health round the world.

So, while the medical research community still has a ways to go, it is clear that we TOFI Asian-Americans need to take matters of Type 2 diabetes into our own hands!

August 14, 2018 By spao Leave a Comment

Two videos to watch for diabetes care

For anyone interested in fasting and treatment of diabetes, I recommend two videos out of the UK.

Eat, Fast, and Live Longer

Eat, Fast, and Live Longer is well known for educating people about the 5:2 diet, where subjects can pick 2 days per week to consume just 600 calories (500 for a woman), and eat whatever they want the rest of the week. It also covered several other strategies, which got less attention, including calorie restriction, alternate day fasting, and prolonged fasting — all of which I will cover in separate blogs. For the section in this video on extended fasting, check out from 18:22 to 36:15, where Dr. Michael Mosley of BBC does a 3½ day fast, drinking only soup packets at night! He gets great metabolic results!

Eat, Fast and Live Longer

The Truth About Carbs

The other relevant BBC video I really liked was The Truth About Carbs. It is well known for popularizing the UK’s famous Low Carb Program, which is an online program that provides health tracking, education, and motivation to battle prediabetes and diabetes. The video does a good job discussing the different types of carbohydrates and how they are processed differently by the body. You can expect 100 calories of green, leafy vegetables to be processed very differently from 100 calories of soda!

Even for non-diabetics, there’s a really interesting section of the video describing why exercisers should spit, not swallow sports drinks to get an energy boost without the calories! Check out from 18:53 to 25:59, where Dr. Xand van Tulleken repeats the experiment during two different exercise sessions.

The truth about carbs

My take

Overall, I am a fan of these videos. The BBC isn’t funded by advertisements, so they can openly report on research that does not involve pharmaceuticals or medical devices.

At a personal level, I have tried 5:2, and I do think 5:2 works for weight loss. Still, there are two reasons I prefer prolonged fasting for diabetes management (and reversal!)

I found myself obsessing about food for the 2 days when I limited myself to 600 calories. Mentally giving myself the opportunity to eat 600 calories seemed to just open the floodgates to want to eat more. I prefer following fewer rules and having fewer opportunities to break them.
Some researchers contend that 5:2 does not provide the metabolic benefits of prolonged fasting for diabetes and that even the weight loss from 5:2 is more akin to calorie restriction.

I believe that the UK’s Low Carb Program also works, and the practices remain an important complementary step to fasting and keeping insulin levels low when eating. The reason I didn’t sign up for the digital program is that the content is very similar to that found in the classic work at the time I was diagnosed with diabetes — Dr. Bernstein’s Diabetes Solution (originally published in 1997).

To me, a big part of coping with diabetes and managing it is to be educated about what’s out there. I’ve referred these two videos to many others because they very compactly present the research with both a journalistic and entertaining twist.

August 7, 2018 By spao Leave a Comment

Yes to fasting. No to drugs, USDA, and dieting.

Hello world!

This blog is about my journey to reverse Type II diabetes through fasting (or, more positively time-restricted feeding.).

Warning: much of this blog will contradict what doctors say.

Yes to fasting.

Cutting to the chase, I’ll aim to document my own personal experiences with fasting, as well as relevant work from other researchers in the field.

I’ve personally done 5-day fasts, and fasting has temporarily lowered my blood sugar levels. I will be experimenting later this month with more extended fasting (a 28 day program). More on this later in other articles!

No to drugs, USDA, and dieting

Most people don’t really understand Type II diabetes. I personally was surprised to learn I had diabetes through a routine life insurance medical exam in 2003. At the time, I was 36 years old, 5’10”, and 153 pounds (BMI=22). In the prior two years, I had completed four marathons and a one-day Seattle-to-Portland (“STP”) 200 mile bicycle ride. I am proof that diabetes can afflict those who are young, normal weight, and active.

Today, over 29 million Americans live with diabetes, and 86 million Americans have prediabetes. More than 20% of health care spending in the US is for people with diabetes. The lack of success at a national level in treating diabetes and the enormous profit incentives make me question what the doctors or the drug companies say.

Some key lessons over time:

Drugs stop working. The drugs my doctors would prescribe would “work” initially, but became less effective over time. The typical drug progression is described in a Healthline article:

Yet these drugs aren’t perfect — and they don’t always work in the long term. Even if you’ve been taking your medicine just as your doctor prescribed, you might not feel as well as you should.

Diabetes drugs can and often do stop working.

Doctors and the USDA are slow to change. The American Diabetes Association dietary guidelines touted by both doctors and nutritionists when I was initially diagnosed with diabetes were based on the USDA food pyramid and contained some very harmful advice which actually caused by blood sugar levels to rise! See the archived page “Using the Diabetes Food Pyramid” from 2003 (fortunately now removed from the live site!) where they advised diabetics at the time to:

Eat more starches! It is healthiest for everyone to eat more whole grains, beans, and starchy vegetables such as peas, corn, potatoes and winter squash. Starches are good for you because they have very little fat, saturated fat, or cholesterol.

Weight means a lot, but not everything. While 85% of diabetics are overweight, know this means that 15% are not. Weight doesn’t always correlate with diabetes and heart disease. On one end of the spectrum, there is some data to suggest that certain types of fat in obese people may have some health benefit. This phenomenon has been termed the “obesity paradox.”On the other end of the spectrum, thin people can get diabetes. In my case, as an Asian-American, I’ve come to learn that I’m not alone in being normal weight with diabetes. A 2016 LA Times article describes this phenomenon well.

What Sinha noticed a decade ago is now supported by a growing body of scientific research: Asians, in part for genetic reasons, are disproportionately likely to develop diabetes. They get the disease at younger ages and lower weights than others, experts say.

I am writing from the perspective of a very active patient, not a doctor or researcher. I encourage everyone to form their own opinions, some of which may conflict with the current “standard of care” in today’s Western Medicine or the sales pitches of today’s drug companies. I do believe the truth will come out over time, but it may not happen before many of today’s diabetics do irreversible damage to their organs.

The punchline here is that I am saying “Yes” to fasting, and I will write about my experiences. Please share this blog with friends and loved ones who are also managing through diabetes and are looking for answers.