Time Restricted

Experiences with Time-Restricted Eating and Managing Chronic Disease

Diabetes

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Digestive Rest Day

Today was our “digestive rest day.”  The concept is to choose one main food staple to eat throughout the day to prepare the body for fasting.

Choices were:

  • fruit
  • potatoes
  • rice
  • oatmeal

For me, Dr. Lischke recommended oatmeal because it works best for diabetics.  My wife chose potatoes.

My breakfast was oatmeal with a cinnamon-apple sauce over it.  Lunch and dinner consisted of a savory oatmeal with tomato sauce, zucchini, and squash medley.  I was concerned about all the carbs and what that would do for my blood sugar, but I also have now learned that blood sugar seems to be way less about inputs and outputs and much more about hormones…  We’ll see how this looks tomorrow morning for comparison!

Every day, we have to see our nurse between 7am-9:30am.  I get my blood pressure, blood sugar, and weight measured.  I am also logging sleep, how I feel, and other symptoms in a diary.

Today’s baseline:

  • Blood pressure: 152 / 87
  • Blood sugar: 142
  • Weight: 73.5 kg (161.7 lbs)

I know my blood pressure and blood sugar are high.  This is why I’m here!  The nurse said she always sees these two measurements go down as the days go by.  Let’s see how it goes!

 

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Diabetes and non-alcoholic fatty liver disease

In my last post, I discussed the “fat on the inside” of people with diabetes.  One of the most insidious places for this fat to live is in the liver!  Science is now showing the relationship between liver fat and diabetes, and the potential cure for both — fasting!

Diabetes and non-alcoholic fatty liver disease (NAFLD) are closely linked, with studies showing that NAFLD is present in up to 70% of patients with Type II diabetes.

While the association between diabetes and fatty liver disease is well known, the relationship between the two has been unclear in Western Medicine.  Which comes first – diabetes or NAFLD? A study of a Korean population published in 2011 sought to investigate this question and found that the presence of fat in the liver was a good predictor of Type II diabetes risk:

Nonetheless, fatty liver detectable by ultrasound identified individuals with worse metabolic profile and greater risk for T2DM [Type 2 diabetes mellitus], regardless of baseline fasting insulin concentration. Therefore, our findings suggest that fatty liver, although associated with insulin resistance, is also an independent predictor of T2DM.

A newer analysis of Chinese patients published in 2017 demonstrated a bidirectional relationship between fatty liver disease and diabetes.

In conclusion, the present prospective cohort study provides evidence that the association between NAFLD and T2DM is bidirectional. Future studies are needed to investigate the potential mechanisms.

The irony is that despite the growing evidence of a causal relationship between diabetes and NAFLD, the current treatments don’t really address fat accumulation in the liver!  Diabetes drugs use different mechanisms, such as getting your liver to produce less glucose, getting your pancreas to create more insulin, or even getting you to pee out sugar from your blood excreted through your kidneys.  However, they don’t address what appears to be a root cause.

To that end, a recent study out of Germany has identified a specific protein responsible for controlling the absorption of fatty acids in the liver and associated blood sugar levels!

Subsequent simulation tests showed that GADD45β is responsible for controlling the absorption of fatty acids in the liver. Mice who lacked the corresponding gene were more likely to develop fatty liver disease. However when the protein was restored, the fat content of the liver normalized and also sugar metabolism improved. The scientists were able to confirm the result also in humans: a low GADD45β level was accompanied by increased fat accumulation in the liver and an elevated blood sugar level.

How do you restore the protein levels to normal?  By stressing the liver cells through FASTING!

“The stress on the liver cells caused by fasting consequently appears to stimulate GADD45β production, which then adjusts the metabolism to the low food intake,” Herzig summarizes.

While the follow-on to this research is to find other ways to stimulate the protein production through drugs, the easier mechanism I see now is through fasting!

This is why I am taking my journey!

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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!

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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.