The person who says it cannot be done

should not interrupt the person doing it

Therapeutic Fasting

Presenter Disclosure

• Presenters – Jason Fung

• Relationships with commercial interests: – Grants/Research Support: None

– Grants/Speakers Bureau/Honoraria: Consulting Fees: None

– Consulting Fees: None

– Other: None

Two Phases of Type 2 Diabetes

Trajectories of glycaemia, insulin sensitivity, and insulin secretion before diagnosis of type 2 diabetes: an

analysis from the Whitehall II study. Lancet 2009; 373: 2215–2221.

Surgical treatment of obesity and its effect on diabetes: 10-y follow-up

Am J Clin Nutr 1992:55(Suppl.):582S-585S

Insulin Resistance

Surgical treatment of obesity and its effect on diabetes: 10-y follow-up

Am J Clin Nutr 1992:55(Suppl.):582S-585S

Beta Cell Dysfunction

Learned Helplessness

• Fact: For most people, type 2 diabetes is a progressive disease.

• eventually oral medications may not be enough to keep blood glucose levels normal. Using insulin to get blood glucose levels to a healthy level is a good thing, not a bad one.

http://www.diabetes.org/diabetes-basics/myths

What is Insulin Resistance?

The New Paradigm

Eat Food Store Sugar in Liver

Produce Fat in Liver Increase Insulin

No Food

“Fasting”

Burn Stored Sugar in Liver

Burn Fat in Liver Decrease Insulin

Functions of Insulin:

1.Increase glucose entry into cells

2.Turn on De Novo Lipogenesis

The ‘Lock and Key’ paradigm

“Internal Starvation” – Cannot drive DNL

The Central Paradox

Functions of Insulin (Insulin resistant cell):

1. Increase glucose entry into cells - resistant

2. Turn on De Novo Lipogenesis - supersensitive

Liver Cells

Stored Sugar

Glycogen

Stored Fat

De Novo Lipogenesis

High Insulin

Low Insulin

Under conditions of high persistent insulin:

Liver becomes full of sugar and fat

Fatty Liver causes Insulin

Resistance!

Stored Sugar

Stored Fat

High Insulin

Low Insulin

Insulin Resistance is an Overflow

Phenomenon

Insulin Resistance is an Overflow

Phenomenon

Beta cell dysfunction

Burnout?

Surgery cures diabetes

Bariatric Surgery versus Intensive Medical Therapy in Obese Patients with Diabetes

N Engl J Med 2012;366:1567-76 Schauer PR

A: Fasting plasma glucose and weight change 2 years after randomization either to gastric banding or to intensive medical therapy for weight loss and glucose control.

Adjustable gastric banding and conventional therapy for type 2 diabetes JAMA 2008;299:316-232 Taylor R Dia Care 2013;36:1047-1055

Gastric Banding cures Diabetes

Fasting vs. Bariatric Surgery

Rapid Improvement of Diabetes After Gastric Bypass Surgery: Is It the Diet or Surgery?

Diabetes Care. 2013 Mar 25, Lingvay I

http://www.ncbi.nlm.nih.gov/pubmed/23530013

7.3

4

0

1

2

3

4

5

6

7

8

Wei

gh

t L

oss

(k

g)

Diet

Diet +

Surgery 1293

1478

1200

1250

1300

1350

1400

1450

1500

Dail

y G

lyce

mia

Pre

vs

Post

Taylor R Dia Care 2013;36:1047-1055

Copyright © 2011 American Diabetes Association, Inc.

Decrease in Pancreatic Fat

Taylor R Dia Care 2013;36:1047-1055

Copyright © 2011 American Diabetes Association, Inc.

Restoration of Beta Cell Function

Taylor R Dia Care 2013;36:1047-1055

Copyright © 2011 American Diabetes Association, Inc.

Restoration of First Phase Insulin

Response

The Sugar Bowl

The End Game

The Action to Control Cardiovascular Risk in Diabetes Study Group. N Engl J Med 2008;358:2545-2559

ACCORD

Hazard Ratio 1.22

Cumulative Incidences of Events, According to Glucose-Control Strategy

The ADVANCE Collaborative Group. N Engl J Med 2008;358:2560-2572

ADVANCE

0.50 1.00 2.00

Number of events

More

intensive

Less

intensive

Difference in

HbA1c (%)

HR (95% CI)

All-cause mortality 980 884 -0.88 1.04 (0.90,1.20)

CV death 497 441 -0.88 1.10 (0.84,1.42)

Non-CV death 476 432 -0.88 1.02 (0.89,1.18)

Meta-analysis of intensive glucose

control in T2DM: mortality

Favours more intensive Favours less intensive

• Meta-analysis of 27,049 participants and 2370 major vascular events from

– ADVANCE

– UKPDS

– ACCORD

– VADT HR, hazard ratio; CV, cardiovascular

Turnbull FM et al. Diabetologia 2009;52:2288–2298

Recent trials of newer glucose-lowering agents

have been neutral on the primary CV outcome

SAVOR-TIMI 53

EXAMINE

HR: 1.0

(95% CI: 0.89, 1.12)

HR: 0.96

(95% CI: UL ≤1.16)

TECOS

HR: 0.98

(95% CI: 0.88, 1.09)

EMPA-REG

OUTCOME®

ELIXA

HR: 1.02

(95% CI: 0.89, 1.17)

Empagliflozin

DPP-4 inhibitors*

Lixisenatide

CV, cardiovascular; HR, hazard ratio; DPP-4, dipeptidyl peptidase-4

*Saxagliptin, alogliptin, sitagliptin

Adapted from Johansen OE. World J Diabetes 2015;6:1092-96

2013 2014 2015

How To Reverse Type 2 Diabetes

Type 2 diabetes is too much sugar in the body

Treatment

1. Don’t put more in – Low Carbohydrate Diet

2. Burn it off – Intermittent Fasting

Lowering glucose without raising

insulin improves outcomes

Acarbose Treatment and the Risk of Cardiovascular Disease and Hypertension

in Patients with Impaired Glucose Tolerance

JAMA 2003; 290: 486-494

49% RRR

2.5% ARR

Randomized

1,429

patients

3.3 year

follow up

EMPA-REG MACE

31

HR 0.86

(95.02% CI 0.74, 0.99)

p=0.0382*

Cumulative incidence function. MACE, Major Adverse Cardiovascular Event; HR, hazard ratio.

* Two-sided tests for superiority were conducted (statistical significance was

indicated if p≤0.0498)

Myth - Starvation Mode

0

1000

2000

3000

4000

5000

6000

Day

1

Day

2

Day

3

Day

4

Fatty

Acids

Ketones

Norepinep

hrine

Metabolic changes over 4 days of fasting

0

10

20

30

40

50

60

70

80

Day1 Day2 Day3 Day4

Insulin

Glucose

Zaunder C Am J Clin Nutr 2000;71:1511–5.

22 Days Alternate Daily Fasting

Heilbronn et al. Am J Clin Nutr 2005;81:69–73.

Fasting Versus Calorie Restriction

Myth - Burn Muscle

Burn Muscle

70 Days Alternate Daily Fasting

Obesity (2010) 18, 2152-2159

Fasting

versus

Calorie

Restriction

From: Kevin Hall

Myth – It doesn’t work

If I don’t eat, will I lose

weight?

Fasting Advantages

• Flexibility

• Convenience

• Free

• Simplicity

Add To Any Diet

You don't eat meat?

You don't eat wheat?

You have a nut allergy?

You don't have time?

You don't have money?

You are travelling all the time?

You don't cook?

Unlimited Power

Can We Cure Type 2 Diabetes?

No Diabetes – no diabetic

nephropathy, no diabetic foot

ulcers, diabetic retinopathy,

reduced stroke, MI, cancers

No Drugs, No Surgery, No

Cost

12 month intensive dietary

management regime to cure

diabetes

Time to get started…

www.intensivedietarymanagement.com