Low Fat Diets and Exercise for Type2 Diabetes – T2D 41

The Low Fat Era

Several years back, the monumental task of recommending an optimal diet for type 2 diabetics was assigned to Dr. Richard Kahn, then the chief medical and scientific officer of the American Diabetes Association (ADA). Like any good scientist, he began by reviewing the available published data.

When you look at the literature, whoa is it weak. It is so weak”, he said. But that was not an answer that the ADA could give. People demanded dietary advice. So, without any evidence to guide him one way or the other, Dr. Kahn went with the generic advice to eat a low fat, high carbohydrate diet. This was the same general diet advice given to public at large.

The United States Department of Agriculture’s food pyramid would guide food choices. The foods that formed the base of the pyramid, the ones to be eaten preferentially were grains and other refined carbohydrates. These are the exact foods that caused the greatest increase in blood glucose. This was also the precise diet that failed to halt obesity and type 2 diabetes epidemics in generations of Americans.

Let’s juxtapose these two incontrovertible facts together.

  1. Type 2 diabetes is characterized by high blood glucose.
  2. Refined carbohydrates raise blood glucose the most.

Type 2 diabetics should eat the very foods that raise blood glucose the most? Illogical is the only word that comes to mind. This happened, not just in the United States, but around the world. The British Diabetes Association, European Association for the Study of Diabetes (EASD), Canadian Diabetes Association, American Heart Association, National Cholesterol Education Panel recommend fairly similar diets keeping carbohydrates at 50-60% of total calories and dietary fat at less than thirty percent.

The 2008 American Diabetes Association position statement on nutrition advised that “Dietary strategies including reduced calories and reduced intake of dietary fat, can reduce the risk for developing diabetes and are therefore recommended”. The logic is hard to follow. Dietary fat does not raise blood glucose. Reducing fat to emphasize carbohydrates, known to raise blood glucose could protect against diabetes? How they believed that would work is unknown.

It further advised, against all common sense that “intake of sucrose and sucrose-containing foods by people with diabetes does not need to be restricted”. Eating sugar was OK for type 2 diabetics? This could not realistically be expected to lower blood glucose, and the proof came soon enough.

The 2012 Treatment Options for Type 2 Diabetes in Adolescents and Youths (TODAY) randomized study reduced caloric intake to a miniscule 1200-1500 calories per day of a low-fat diet. Despite this massive effort, blood glucose was not improved. This classic ‘Eat Less, Move More’ strategy failed yet again, continuing its perfect record, unblemished by success. That this diet would not work should have been fairly obvious from the beginning.

A comprehensive review in 2013 concluded that several different types of diets did in fact provide better glycemic control. Specifically, four were found beneficial – the low carbohydrate, low glycemic-index, Mediterranean and high protein diet. All four diets are bound by a single commonality – a reduction in dietary carbohydrates, and specifically, not a reduction in dietary fat, saturated or otherwise.

Low-fat diets were falsely believed to reduce cardiovascular disease. A recent review by Dr. Zoë Harcombe found no evidence to support this contention . Indeed, five separate prospective trials since the 1960s have failed to find any relationship between dietary fat and cardiovascular disease, including the Puerto Rico Heart Health Program and the Western Electric Study. The Nurse’s Health Study, once adjusted for trans-fats, found no relationship between dietary fat or dietary cholesterol and heart disease. Despite forty years of studies trying vainly to link dietary fat, dietary cholesterol and heart disease, still not a single shred of evidence could be found.

The final nail in the coffin was the 2006 Women’s Health Initiative, the largest randomized dietary study ever undertaken, which proved this notion false. Almost 50,000 women followed this low-fat, calorie-reduced diet for over 8 years. Daily caloric intake was reduced by over 350. Yet the rates of heart disease, stroke did not improve whatsoever. Neither did this calorie-reduced diet provide any weight loss. Despite good compliance, the weight difference at the end of the study was less than ¼ pounds despite years of caloric restriction. There were absolutely no tangible benefits to long-term compliance to a low-fat diet.

In diabetics, the story was the same. The Action for Health in Diabetes (LookAHEAD) studied the low fat diet in conjunction with increased exercise. Eating only 1200-1800 calories per day with less than 30% from fat, and 175 minutes of moderate intensity physical activity, this was the recommendation of every diabetes association in the world. Would it reduce heart disease as promised?

Hardly. In 2012, the trial was stopped early due to futility after 9.6 years of high hopes. There was no chance of showing cardiovascular benefits. The low-fat calorie-reduced diet had failed yet again.

Exercise

Lifestyle interventions, typically a combination of diet and exercise, are universally acknowledged as the mainstay of type 2 diabetes treatments. These two stalwarts are often portrayed as equally beneficial and why not?

Exercise improves weight loss efforts, although its effects are much more modest than most assume. Nevertheless, physical inactivity is an independent risk factor for more than 25 chronic diseases, including type 2 diabetes and cardiovascular disease. Low levels of physical activity in obese subjects are a better predictor of death than cholesterol levels, smoking status or blood pressure. The benefits of exercise extend far beyond simple weight loss. Exercise programs improve blood pressure, cholesterol, blood glucose, insulin sensitivity, strength and balance.

Exercise enhances insulin sensitivity, without involving medications and their potential side effects. Exercise has the added benefit of being low-cost. Trained athletes have consistently lower insulin levels, and these benefits can be maintained for life as demonstrated by studies on Masters’ level athletes. Exercise programs have proven themselves in obese type 2 diabetics as well.

Yet results of both aerobic and resistance exercise studies in type 2 diabetes are varied. Some show benefit for A1C, but others do not. Meta-analysis shows significant reduction in A1C, but not in body mass, suggesting that exercise does not need to reduce body weight to have benefits.

Despite all the benefits of exercise, it may surprise you to learn that I think that this is not useful information. Why not? Because everybody already knows this. The benefits of exercise have been extolled relentlessly for the last forty years. I have yet to meet a single person who had not already understood that exercise might help type 2 diabetes and heart disease. If people already know its importance, then what is the point of telling them again?

The main problem has always non-compliance. The spirit is willing but the flesh is weak. This is only more of the game of ‘Blame the Victim’. A myriad of issues may deter an exercise program. Obesity itself, joint pain, neuropathy, peripheral vascular disease, back pain, heart disease may all combine to make exercise difficult or even unsafe. Overall, I suspect the biggest issue is lack of results. The benefits are greatly overhyped and exercise doesn’t work nearly as well as advertised. Weight loss is often minimal. This lack of results, despite great effort is demoralizing.

Conceptually, exercise seems an ideal way to burn off the excess ingested calories of glucose. Standard recommendations are to exercise 30 minutes per day, five days per week or 150 minutes per week. At a modest pace, this may only result in daily 150-200 kcal of extra energy expenditure, or 700-1000 kcal per week. This pales in comparison to a total energy intake of 14,000 calories per week. A single day of fasting creates a 2000-calorie deficit, without doing anything!

There are other well-known limitations to exercise. In studies, all exercise programs produce substantially fewer benefits than expected. There are two main mechanisms. First, exercise is known to stimulate appetite. This tendency to eat more after exercise reduces expected weight loss and benefits become self-limiting. Secondly, a formal exercise program tends to decrease non-exercise activity. For example, if you have been doing hard physical labor all day, you are unlikely to come home and run ten kilometers for fun. On the other had, if you’ve been sitting in front of the computer all day, that ten kilometer run might start sounding pretty good. Compensation is a well-described phenomenon in exercise studies.

In the end, here’s the main problem. Type 2 diabetes is not a disease that is caused by lack of exercise. The underlying problem is excessive dietary glucose and fructose causing hyperinsulinemia, not lack of exercise. Exercise can only improve insulin resistance of the muscles. It does not improve insulin resistance in the liver at all. Reversing type 2 diabetes depends upon treating the root cause of the disease, which is dietary in nature.

Imagine that you turn on your bathroom faucet full blast. The sink starts to fill quickly, as the drain is small. Widening the drain slightly is not the solution, because it does not address the underlying problem. The obvious solution is to turn off the faucet.

In type 2 diabetes, a diet full of processed grains and sugar is filling our bodies quickly with glucose and fructose. Widening the ‘drain’ by exercise is minimally effective. The obvious solution is to turn off the faucet. If the underlying cause of the disease is not lack of exercise, increasing it will not address the actual cause of the problem and is only a Band-Aid solution at best.

 

 

2018-01-10T11:10:12+00:0034 Comments

About the Author:

Dr. Fung is a Toronto based kidney specialist, having graduated from the University of Toronto and finishing his medical specialty at the University of California, Los Angeles in 2001. He is the author of the bestsellers ‘The Obesity Code’ and ‘The Complete Guide to Fasting’. He has pioneered the use of therapeutic fasting for weight loss and type 2 diabetes reversal in his IDM clinic.

34
Leave a Reply

avatar
17 Comment threads
17 Thread replies
14 Followers
 
Most reacted comment
Hottest comment thread
20 Comment authors
gerald.holmanEnergia reikiMichelesaiba maisBarrett Recent comment authors
  Subscribe  
newest oldest most voted
Notify of
John N
Guest
John N

The current page on diabetes diet at the mayoclinic has some advice: ”When you eat excess calories and fat, your body responds by creating an undesirable rise in blood glucose.” So they state flat out that FAT is the main culprit that makes blood glucose go up. More:• ”A diabetes diet is a healthy-eating plan that’s naturally rich in nutrients and low in fat and calories.” Fat again. Fruit and whole grains otoh are not only permissible but among the best a diabetic can eat: ”Focus on the healthiest carbohydrates, such as fruits, vegetables, whole grains, legumes (beans, peas and… Read more »

Moni
Guest
Moni

Most of the “official” medical websites refuse to look seriously at the abundance and quality of scientific evidence. I was reading an endocrinology website yesterday… same thing. I guess it took ages for people to understand the world was not flat. Unfortunately, the health of millions around the world is at stake.

John N
Guest
John N

We’ve all seen bad nutritional advice many times, but claiming that fat is what makes blood glucose rise is beyond the standard level of badness. It’s downright insane, and you don’t even need science to know it, anyone with cheap equipment can test it for themselves. I’ve tested my blood glucose thousands of times, and I’m not even diabetic.

Lian
Guest
Lian

So what is the solution then? Fasting?

Jim
Guest
Jim

Fasting plus low carbohydrate way of eating. I do keto, but different strokes for different folks.

sten bjorsell
Guest
sten bjorsell

Exercise is great to build muscles and body mass as it makes us hungry! Drinks with fructose makes as fat after a while as fructose reduces insulin sensitivity, so that the sugar in a sugary drink can make us obese!. Tim Noakes is the best example I know of a healthy athlete that after 50 in spite of daily runs gradually found himself gaining weight and had become pre-diabetic! He reversed it and wrote a few books about it, one called The Lore of Nutrition!
Fat is the real friend!

Hap
Guest
Hap

The idea of “exercise” has ultimately proved to be a joke in the mainstream way of thinking about it. Mechanical stress produces under appropriate conditions a whole organism physiological adaptation….. Anyone who tells you that external mechanical stress only affects muscle and not fat or liver metabolism….needs to read and rethink the question. “move more” is not a prescription and is a meaningless concept. Other meaningless formulations include the exhortation to “increase activity etc”. Dr fung lists his two incontrovertible facts in the blog post. Well, it’s also fairly well established that increased lean body mass substantially decreases all cause… Read more »

Moni
Guest
Moni

How do we know if we have insulin resistance in the liver?

JohnM
Guest
JohnM

My three factor answer is: being overweight with a high fasting glucose level and a high triglyceride level. Pages 164-165 in the Obesity Code is a good place to start to understand why.

Moni
Guest
Moni

Thank you for your reply, John. I am not overweight, have completely normal BS levels (fasting glucose lower than 85 usually as part of my efforts to combat insulin resistance) and my TGs are normal as well. I am fighting insulin resistance after having had single reading of 103 (fasting BS) last July. I am neither predibetic or diabetic. That single reading scared me enough to research, start LCHF and read everything I can about insulin resistance. But insulin resistance could have been present for a long, long time and it can’t be reversed overnight. I guess it takes quite… Read more »

Hap
Guest
Hap

You could just have dawn phenomenon…..or an outlier reading.

Need more data points including tg to hdl ratio.

Hap
Guest
Hap

Moni I did not read your post carefully enough. You have one FBS reading of 103?!…otherwise 85? Not overweight, not HTN? TG normal? OK…..now you are concerned, I get it.. I wouldn’t be all that concerned but if you want to reduce carbs or eliminate sugars…..sure go ahead. While you are at it….consider eliminating seed oils high in Omega 6. But even then it could be for you, just symbolic. If you were really uptight you might go for a Kraft test and see what your GTT and Insulin response after sugar meal……and figure out which of the five “patterns”… Read more »

Hap
Guest
Hap

Moni Here is your “go to” article on IR and how to measure from the “discoverer” of the Metabolic Syndrome.(2017) http://www.sciencedirect.com/science/article/pii/S0168822717309142?via%3Dihub You will find a discussion, although partly in the weeds for many people, of all of this including the definition of Metsyn (and the somewhat arbitrary ranges specified) on Breaknutrition podcast. http://www.breaknutrition.com Steady state plasma glucose is pretty much the gold standard but very difficult or impossible to use for populations studies. OGTT and frankly the Kraft test is about as good. The MacAuley Index is pretty close to OGTT and SSPG. The MI includes FBS, TG and corrected… Read more »

Hap
Guest
Hap

Throw in hypertension or pre hypertension….
Overweight is probably not a good part of definition….a little to ambiguous.
Traditionally, BMI is used or waist circumference. BMI problematic but better indicator in sedentary younger to middle age. Waist circumference might be preferred.

Low HDL

Sedentary.

All of this stuff….with caveats.

Jaysankar Talukdar
Guest
Jaysankar Talukdar

Fasting ,Resting and Yoga (meditation ,breathing and asana ) are the three main ways to combat with Type2 Diabetes. After I started following Mr. Fung, I have been following 1-2 days fasting and it helped a lot to reduce my weight. Here, FYI i am not a diabetic nor obese. I just love to be fit. Thank you Dr. Fung for the insight

Jim
Guest
Jim

Good for you. I am the same. But diabetes appears frequently in both mothers and fathers ancestors and families. Fasting, yoga, weight lifting, cardio, and keto way of eating for me. I am 70. So far so good. Good luck to you.

Jim
Guest
Jim

Great post Dr Fung. Wonderful what you do for everyone in the world. Thanks so much.

Ed C
Guest
Ed C

For the sake of enlightenment, an alternative method and discussion is the Kempner Rice Diet (true low fat diet, <10% cal. from fat, or less than ~200 calories/day), which was successfully used to treat diabetes. The standard so called "low fat diets" aren't even low fat diets when they're typically at 30% cal. from fat. We know about Keto, we know about fasting, we know about true low fat diets. The next few years will be about incorporating it all into macronutrient cycling – LCHF for X days cycled with LFHC for X days while incorporating fasting, or, for the… Read more »

Moni
Guest
Moni

The sugar and rice diet? I understand that mixing nutrients appears to be the issue for some unknown biochemical reason to me. Sugar does not nourish anybody in any way, though… That diet sounds like nutritional suicide nowadays. LOL.

Ed C
Guest
Ed C

Low fat high carb. No oils. Light protein. Think of clear soups and bread. Noodle soups. Pho. Shoyu Ramen. Pasta and marinara, no cheese. Korean beef bone soups with radish and rice and kimchi side dishes. Of course throw in all the veggies that you want into these. Roasted potato, sweet potato, yam. Rice and beef stew. Rice and polish cabbage stew. Corn tortillas and beans and rice with soup. Tomato and corn soups. Etc etc.. Let different cultures be a guide. It’s up to your imagination, but let it run to the bright side, not your devious side. All… Read more »

Katrina M Iannuzzi
Guest
Katrina M Iannuzzi

Excellent

Johnny
Guest
Johnny

Funny, the so called low-carb diet revered to in the nytimes article was only low carb in the first months…

Ed C
Guest
Ed C

When you separate carbs/fats, the foods themselves are self regulating.

When you combine carbs/fats, the regulation is defeated and bubbles up to the society and family customs/norms to regulate.

And when that is destroyed then it bubbles up to the govt.

Reitha McCabe
Guest
Reitha McCabe

Dr. I am on day 7 of my first ever extended fast. I am type 2 diabetic. I was only taking in water until Day 4 I was not feeling well, confused, agitated, blood sugar 75. So I added bone broth to my eating, also tea and coffee with 1 teas cream. That helped clear my head. Blood sugars in the 80s. But now my mouth feels continually dry and I’m always thirsty. Should I be concerned? My goal is spiritual and I want to reset my insulin resistance. I’ve come off all diabetes and high blood pressure meds. Still… Read more »

Hap
Guest
Hap

Dear Reitha
It would seem you might benefit from holding off on extended fasts and limiting to a couple days or less……and seeking extended fasts only starting with medical supervision by a practitioner with experience in extended fasts. Synthroid powerful stuff and you could be jeopardizing your health by fasting without supervision.

Dina Ralt
Guest

Do not underestimate the contribution of exercises to our health… it’s not just the more calories we spend, it’s a turn on energy “switch” like in car shifts… the illustration in the link demonstrates the idea – when showering, it’s much faster to get rid of soap when more water are running… Thus it’s easier to repair maladies when the body “knows” energy is abundant, and this is what exercising signals.
http://nettingno.blogspot.co.il/2008/03/two-urges-to-eat.html

Srinath
Guest
Srinath

Not only does 24 hrs of fasting create 2000+ calorie deficit, it also creates a monster sized insulin deficit allowing the gates of fat to be open to be burnt. That insulin deficit is what is the key factor in being able to burn fat.

dgtrites
Guest
dgtrites

THE MANTRA OF A LOW CARB DIET TO MANAGE DIABETES IS TOO SIMPLISTIC AND NEEDS TO FADE AWAY FOR THE GOOD OF OUR HEALTH. On January 1 of this year, overnight, I switched from a low carb-high fat diet to a low fat-high carb diet. I began following a plant based diet that avoids using any processed carbs or oils. It turns out to be about 10-15% fat by calories, which is much lower than the conventional low fat diets studied in the literature which are around 30%, WHICH REALLY ARN’T LOW FAT STUDIES. These studies are flawed in this… Read more »

Ed C
Guest
Ed C

Yes. Good one there.

Just remember to cycle in some LCHF days. Living long term without much fats will pull you in a bad direction as well. We need both. Just not at the same time.

Barrett
Guest
Barrett

Sorry to be the naysayer, because in general i am a huge Dr. Fung fan, but nobody in mainstream nutrition or medicine has advised anyone to eat lots of refined carbohydrates in at least two decades. To conflate whole grains – grains in their whole form and full of fibre – with refined carbohydrates is to blur the issue and mislead people. You might have a view on all carbohydrates, whether refined or unrefined, and that view may be valid or true to your own experience, but implying that anybody is advising people to eat lots of refined carbohydrates or… Read more »

Michele
Guest
Michele

Sorry, but a lot of healthcare providers (especially nutritionists) are still dishing out the old low-fat, food pyramid, “eat less, move more” dietary advice (the advice that in my opinion drove two of my diabetic grandparents to early graves). A lot of doctors are getting hip to eating low-carb as a valid healthy diet, but some are still stuck to the old dogma, even today. They might have changed “refined” to “whole-grain”, and they might say it’s okay to eat an avocado or two, but the advice is pretty much the same.

saiba mais
Guest

Meu sogro tem esse problema e foi bom ter mais conhecimento sobre o assunto,gostei demais, foram tantas dúvidas que tirei neste poste, parabéns trabalho excelente.

Energia reiki
Guest

Very nice article!! Congratulations.

gerald.holman
Member
gerald.holman

Fasting apple cider vinegar