Dr Jason Fung – A New Paradigm of Insulin Resistance

Dr. Jason Fung looks at how to reverse Type 2 Diabetes using a Low Carb Diet in conjunction with Intermittent Fasting. Here’s the latest release from Low Carb Breckenridge 2017 conference.

Presentation slides are available here to download in PDF format

Dr. Jason Fung completed medical school and internal medicine at the University of Toronto before finishing his nephrology fellowship at the University of California, Los Angeles at the Cedars-Sinai hospital.

He now has a practice in Ontario, Canada where he uses his Intensive Dietary Management program to help all sorts of patients, but especially those suffering from the two big epidemics of modern times: obesity and Type 2 diabetes.

Dr. Fung uses innovative solutions to these problems, realizing that conventional treatments are not that effective in helping people.

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  • Man

    As long as the diet leads to a reduced weight, T2D will be managed or even reversed. As Nigel pointed out, losing weight will clear away excess FFAs which prevents efficient excess glucose clearance from the blood. T2D is a condition of competing “fuels” in circulation. The elevated glucose is not from diet, it is endogenous. i.e. manufactured by the liver because hormone glucagon is triggering the liver to keep on making it. And why would that be so ? Because fat is “clogging” pancreatic beta-cells which should produce insulin that normally shuts down glucagon prod via a paracrine effect on pancreatic alpha-cells.

    Whether you low-carb or low-fat your way out of this with or without IF is up to taste. But to be really efficient, a very low-fat / low cal diet will do wonder in a matter of weeks (cf. Newcastle Diet). I’d rather choose the low-fat route though because a high-carb relatively low cal diet will do wonder for insulin sensitivity. Don’t forget resistance training or you’ll lose precious muscle mass. Low-carb + IF does not look like a good strategy for preserving muscle mass in the long run unless your diet is 50% proteins … who’d do that ??

    • tkent26

      If the goal is to lose weight, LC is easiest and most effective for most people for weight loss, demonstrated in numerous randomized controlled trials. That pancreatic fat was deposited in the context of chronically elevated insulin, and its removal/metabolism was prevented by chronically elevated insulin. LC is also easiest and most effective for most people to lower chronically elevated insulin. YMMV, of course, and some people do well with low fat or calorie restriction (both produce complete lack of satiation for me), some people do well with IF, some with Mediterranean-style, etc. Lots of people maintain muscle mass on LC and/or LF, mostly a matter of exercise + protein.

      Do you think abundant, easily digested dietary glucose is good for T2 diabetics? Will that make the problems stemming from excess endogenous glucose better or worse?

      • “If the goal is to lose weight, LC is easiest and most effective for most people for weight loss, demonstrated in numerous randomized controlled trials.”
        Where protein isn’t matched between groups, yes. Where protein is matched between groups, no.

        If LC is easier than LC, it means that the body lacks metabolic flexibility due to Insulin Resistance.
        ∴ Fix the Insulin Resistance, not the diet! See http://nigeepoo.blogspot.co.uk/2011/02/insulin-resistance-solutions-to.htmln I fixed my IR in 2007 at the age of 52. I can eat whatever produce I like. What’s your excuse for not fixing your IR?

        “Do you think abundant, easily digested dietary glucose is good for T2 diabetics? Will that make the problems stemming from excess endogenous glucose better or worse?”
        As T2DM is a disease of carb AND fat intolerance, do you think abundant, easily digested dietary fat is good for people with T2DM? Will that make the problems stemming from excess endogenous TG’s (fat) better or worse?
        Ref: https://www.ncbi.nlm.nih.gov/pubmed/7621971

  • @nigelkinbrum:disqus, thoughtful comments as usual and you raise some good points that we’ve discussed previously.

    Sorry @river_rance:disqus and @charlesgrashow:disqus, but no ad hominem attacks allowed.

    • charles grashow

      Why is it considered an ad hominem attack to point out that one of the major proponents of a ketogenic diet who co-authored a book on fasting with Dr Fung is morbidly obese??

    • charles grashow

      https://en.wikipedia.org/wiki/Ad_hominem

      ad hominem attacks can be non-fallacious; i.e., if the attack on the character of the person is directly tackling the argument itself. For example, if the truth of the argument relies on the truthfulness of the person making the argument—rather than known facts—then pointing out that the person has previously lied is not a fallacious argument.

    • Gordon

      Since you’ve discussed, and by implication, refuted, Nigel’s points, links would be wonderful. I’d love to see them.

      • Dr Gerber isn’t implying that he’s refuted my points. I’ve previously discussed these points in https://denversdietdoctor.com/dr-david-unwin-glycaemic-index-helping-patients-type-2-diabetes/ Dr Unwin even replied!

        • Gordon

          Thanks. Basically, Unwin said that people aren’t willing to undergo the temporary discomfort of a cure, so he opts for management via LC. OK, I guess it’s the lesser of evils. But that doesn’t address the disturbing comments that Fung has repeatedly made that fly in the face of science, medicine, and common sense.

  • I <3 presentation slides. It's so much faster to read them than watch a video. Also, it's possible to C/P from them. To business!

    1. Type 2 diabetes is too much sugar in the body. Wrong. Type 2 diabetes is too much sugar and fat in the body.
    Treatment: 1.Don’t put more in – Low Carbohydrate Diet. Wrong. 1.Don’t put more in – Low Carbohydrate Low fat Diet.

    Considering that some of the slides are the same as the ones in http://www.fend-lectures.org/index.php?menu=view&id=94 , Dr. Fung appears to have forgotten about ectopic pancreas fat. To deplete ectopic pancreas fat requires a Low Fat (EFAs only) Diet.

    1. Why has Dr. Fung ignored the LF half of the treatment required to cure T2DM? My guess is that it doesn’t fit his LCHF dogma.
    2. Why is Dr Fung an energy balance denialist? My guess is that it doesn’t fit his LCHF dogma.

    Dr. Fung, please respond.

    • River Rance

      For God’s sake he links to Jimmy Moore….and Gary Taubes…wheat belly, fat head and …. wow … !

    • Sanjeev Kumar Sharma

      ‘cos that’s how you do science guvnor[0] – ignore the data points that don’t fit.

      [0] or should that be squire? I always forget your dialect’s quirks.

    • tkent26

      Energy balance is true in physics terms but also useless and unnecessary for the average person just trying to lose body fat. It’s like treating a fever as a “heat balance problem” while ignoring the underlying infection. Complete misunderstanding of proximate vs. ultimate causes.

      • “Energy balance is true in physics terms but also useless and unnecessary for the average person just trying to lose body fat. It’s like treating a fever as a “heat balance problem” while ignoring the underlying infection. Complete misunderstanding of proximate vs. ultimate causes.”
        I completely disagree. Denying that Energy Balance is at the heart of bodyfat loss results in Taubsian nonsense like http://youtu.be/sKIhYQZuLZ8?t=8m13s
        No, you can’t basically exercise as much gluttony as you want, as long as you’re eating fat and protein.

        Jimmy Moore is a perfect example of what happens when you deny Energy Balance. Everything goes to hell in a hand-cart.

        “What you’re describing (LC + LF at the same time) is also called a protein-sparing modified fast. Bodybuilders have known about this forever, it works for rapid fat loss, but most people don’t find it sustainable for more than a couple weeks. After a couple weeks of the protein-sparing modified fast, then what?”
        Who are these “most people”? Watch http://www.fend-lectures.org/index.php?menu=view&id=94 (it uses Flash Player) and you’ll see that you’re wronger than a very wrong thing.

        After T2DM has been permanently reversed after 8 weeks, a diet based on minimally-processed animal & vegetable produce is eaten i.e. a healthy diet.

        Any more questions?

        • Don Reitsma

          Permanent regardless of what you eat after that or have to stay on the healthy diet you are stating forever?

          • “Permanent regardless of what you eat after that or have to stay on the healthy diet you are stating forever?”
            If you want to stay healthy forever (well, for as long as possible), you have to stay on a healthy diet forever (well, for as long as possible).

            Also, exercise is compulsory as per https://blogs.plos.org/obesitypanacea/files/2010/12/Published-Paper.pdf

            It ain’t rocket science! Which reminds me…

            😀

      • Sean Raymond

        Low carbohydrate diets, when controlled for calories & protein, have not been shown to improve weight loss. A similar thing is seen with intermittent fasting diets where we see weight loss being evoked due to reduced consumption either as a result of a narrowed eating window (time restricted feeding) or due to full days with minimal to no calories. In terms of pure weight loss, it does appear to be calories in v calories out that counts. The brain-hormone interactions which regulate intake & energy expenditure is a key player in our understanding of why we may eat more/burn less – dysregulationof this may be the primary cause, as you suggest – with the a positive energy balance being the outcome and with it increased adiposity.

    • Sean Raymond

      Nigel – you say a low fat diet is fundamental to reduction of ectopic fat in the pancreas. Are you isolating this low fat idea to the pancreas only? And are you saying it is independent of a calorie defict but rather is down to macronutrient ratios? My understanding is weight loss results in a reduction of hypertrophic adipocytes – hypertrophic fat cells are what make up ectopic fat – indeed the first reductions in adiposity seems to come from the fat which surrounds the viscera before that seen in the subcutaneous tissues. I have not seen a link with a specific diet and a specific site where this occurs. I would be interested in any links you have to this. I am interested in the potential for intermittent fasting to favour ectopic fat loss, which ties in to the fact visceral fat appears to be the first to go.

      • “Nigel – you say a low fat diet is fundamental to reduction of ectopic fat in the pancreas.”
        Yes. A HF diet results in high postprandial TGs, which are stored after meals in adipocytes. This is why a LCHF caloric deficit diet produced inferior results to Prof. Taylors study. See https://diatribe.org/virta-health-launches-to-reverse-type-2-diabetes-with-low-carb-diets-coaching

        ~50% of subjects had HbA1c <6.5% after 10 weeks.
        100% of subjects had HbA1c <6.5% after 8 weeks on Prof. Taylor's study.

        ~7% body weight loss after 10 weeks.
        ~15% body weight loss after 8 weeks on Prof. Taylor's study.

        Etc etc

        • Sean Raymond

          Many thanks Nigel – I have just seen this reply literally this second, so will read and look at the links in more detail later and respond more fully – I am pushed for time but didn’t want to seem rude so replying now. HOWEVER – off the top of my head – I must say that I do not think high fat diets raise TAG, it seems that high CHO diets do. i have looked at the literature extensively on this – I am no low CHO fanatic trust me, but low CHO does reduce TAG – CHO provides fatty acid substrates for TAG synthesis. Quite why pre-packaged dietary TAG does not do this is something I haven’t got round to looking at but study after study keeps showing me that it is high CHO that raises TAG. I will come back to teh rest of your very much appreciated reply later. Cheers.

          • I’m talking about postprandial TAG, which is definitely elevated on HF diets, even after fat-adaptation. Look at the OFTT results in the first link I posted.

            You’re talking about fasting TAG. CHO only provides substrate for hepatic DNL in caloric surplus.

            See http://nigeepoo.blogspot.co.uk/2014/06/ultra-high-fat-80-diets-good-bad-and.html for lots more information.

            Take all the time you need. There’s a lot of information for you to read. My blog posts are crammed with hyperlinks to relevant evidence, so you may be gone for quite some time. 🙂

          • Sean Raymond

            Good Morning Nigel.

            Yes, a high fat meal will raise post prandial lipid, by the very nature of fat metabolism we will see chylomicrons filled with TAG floating around our blood stream. However, in the fasted state – low CHO definitely reduces blood TAG when compared to high CHO. Fasted states tend to be where clinicians obtain samples from which risk assessments are then made however we live in greedy times and so are in the fed state for much of the day now, so post pranidal states are important for CVD risk. Thank you for reminding me of the importance of the fed state on risk.

            With the links provided, you mention the Taylor study – better known as the Newcastle diet – where a very low calorie diet (600kcals) was used to improve T2DM. You compared it to a ketogenic diet which had CHO under 30g/d. Calorie content does not appear to have been controlled in the ketogenic diet so comparing these diets, from a macronutrient point of view, is irrelevant. The effects of the Taylor diet were down to a massive calorie deficit not fat/CHO ratio whilst the ketogenic diet effects were due to reduction of CHO.

            A low fat diet to remove ectopic fat is not clear cut to me, reduced calorie intake to evoke weight loss or longer fasting periods may promote visceral fat however being in a state of energy balance whilst consuming a diet low in fat doesn’t quite fit. Would like to see a study which tests this idea i.e. a study which used a diet low in fat but met the energy needs of an individual to see if ectopic fat loss occurs.

            Anyway – will look at your blog – another interesting find for me this weekend.

            Many thanks.

        • Don Reitsma

          Seems to me that it is not the only solution since I went on a LCHF diet and had gresst results at 5% carbs, 20% proteint and 75% fat. I was also in a caloroe deficit at 1800 kcal/day with moderate exercise and lost 50 lbs of which was ectopic fat as well.

          I would like to see the study that says it does not work. While you may postulate that there is inly one solution, I can tell you that is not the case. Sounds to me like you have developed a bias against LCHF to somehow justify your choice.

          A low fat diet may be effective but that means replacing calories with protein or carbohydrates or be hungry all the time, which I likely was anyway.

          • A LF diet based on over-refined products will leave you hungry all the time.

            A LF diet based on minimally-refined animal & vegetable produce won’t.

            This is why dietary reductionism to P, F & C percentages is stupid.

            I don’t have a bias. I consider ALL the evidence, unlike you. See http://nigeepoo.blogspot.co.uk/2015/12/low-carbohydrate-diet-green-flags-and.html

            Refute THAT with evidence, if you can.

          • Don Reitsma

            I’m not refuting what you say. Just the effiacy may nit be the same for all.

          • If you have Insulin Resistance (i.e. you are ill), your response to dietary carbohydrates won’t be good (post-meal drowsiness followed by ravenous hunger).

            I recommend reversing IR a.s.a.p. I achieved this in 2007 at the ripe old age of 52, so it’s never too late to try. See http://nigeepoo.blogspot.co.uk/2011/02/insulin-resistance-solutions-to.html for all of the factors that I know of that can cause IR. ALL of them must be addressed.

          • Don Reitsma

            I was on Weight Watchers and regardless of what I ate I was hungry except when eating fat. It cost a lot of points though because points are pretty much calories based.

    • Don Reitsma

      So I went on a Ketogenic diet and didn’t reverse my pre-diabetic condition, lose 50 lbs including ectopic fat, recerse trig/ HDL and LDL count amd particle size? Don’t tell me I didn’t because that is exactly what happened. I am still on a Ketogenic diet and keeping the weight off. I also personally know several people who have done this for more than 5 years.

      I am not saying you have not found another solution that works for you but people in glass houses should not throw stones. You would be better served supporting your own solution rather than attacking one you do not imderstand.

      While Fung may not cover everything in a slide presentation or fully explain himself I suggest you read his books for more information. He has helped thousands of Obese people with T2D to lose weight and reverse / improve T2D.

      • If you’ve permanently reversed your T2D, you’d be able to eat a varied MCMF diet based on minimally-refined animal & vegetable produce. Can you do this without getting wildly-fluctuating BG?

        I’m guessing that the answer’s “NO”, as you haven’t eliminated the ectopic fat deposits in your pancreas, because you didn’t go on a VLED (LCLF) diet as per Prof. Roy Taylor.

        All that Fung has achieved is getting people trapped for life on a restricted diet that merely ameliorates the BG symptoms of T2D. If you still have IR, you have impaired TG clearance from the blood, but you don’t have a TG meter! See https://www.ncbi.nlm.nih.gov/pubmed/7621971

        Postprandial TGs are atherogenic, as per http://nigeepoo.blogspot.co.uk/2014/06/ultra-high-fat-80-diets-good-bad-and.html

        • Don Reitsma

          There is no permanent reversal of T2D. Start eating the SAD again and it will come back. Fasting TG / HDL is also higher on SAD so how cod post prandial be lower or SAD better which is low fat high carb? You seem to think pancreas ectopic fat is the key and while it is likely a problem and conveniently fits your hypothesis it is also other functions of the pancreas andd liver that may have been damaged by decades of poor diet.

          • “There is no permanent reversal of T2D.”
            Yes there is. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168743/ permanently reverses T2D, as a LCLF diet depletes the ectopic fat deposits in the liver & pancreas respectively, UNLIKE FUNG’S LCHF DIET.

            “Start eating the SAD again and it will come back.”
            Are you being disingenuous? Resuming the crap diet that caused T2D in the first place causes T2D AGAIN? Well, DUH! :-/

            After T2D has been permanently reversed using Prof. Taylor’s VLED/LCLF/PSMF, patients have to eat a diet based on animal & vegetable produce to avoid relapse.

            It’s not my hypothesis about ectopic fat deposits. It’s Prof. Taylor’s. Using expensive MRI scanning equipment, Prof. Taylor MEASURED ECTOPIC FAT DEPOSITS. Argue with Prof. Taylor and see how far you get!

          • “There is no permanent reversal of T2D.”
            Yes there is. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3168743/ permanently reverses T2D, as a LCLF diet depletes the ectopic fat deposits in the liver & pancreas respectively, UNLIKE FUNG’S LCHF DIET.

            “Start eating the SAD again and it will come back.”
            Are you being disingenuous? Resuming the crap diet that caused T2D in the first place causes T2D AGAIN? Well, DUH! :-/

            After T2D has been permanently reversed using Prof. Taylor’s VLED/LCLF/PSMF, patients have to eat a diet based on animal & vegetable produce to avoid relapse.

            It’s not my hypothesis about ectopic fat deposits. It’s Prof. Taylor’s. Using expensive MRI scanning equipment, Prof. Taylor MEASURED ECTOPIC FAT DEPOSITS. Argue with Prof. Taylor and see how far you get!

          • Don Reitsma

            Nigel. My point exactly. It is a reprieve but let’s not argue semantics. To me, permanent reversal is synonymous with ‘cure’. Fair enough. We agree that SAD sucks.

            In the study “acute negative energy balance alone” as mentioned suggests it is caloric intake restriction but essentially it is a reduction in in the volume of macronutrients that is processed by the liver and pancreas that really matters since they don’t count calories. Drilling down a bit it is because of significantly reduced glucose and fructose.

            12 weeks seems like a short period of time for the follow up but inderstandable. I would be curious to see what happens after a year or two with the counselling they received. They were obviously be eating more than 600 calories per day after the weight gain of 1 kg or so per month but hopefully kwep estimg healthy.

          • Prof. Taylor’s treatment cures T2D by depleting the ectopic fat deposits in the liver and pancreas (due to the consumption of the SAD/SED) that caused T2D.

            No matter how good a cure is, if the way of eating that caused the disease in the first place is resumed, the disease will return. You’re the one arguing semantics. You cannae change the laws of physics!

            Long-term results depend on the degree of motivation to succeed. The Food Product Industry uses every dirty manipulative trick in the book in order to maximise sales of its crap-in-a-bag/box/bottle.

            Watch the first 2 minutes of http://www.dailymotion.com/video/x2d29tf , if you haven’t already seen it.

    • Don Reitsma

      Energy balance yes, calories in = caloroes out no since they are two different things. There is also energy wasting to consider. wasn’t diabetes called the wasting disease at one time?

      • The Energy Balance Equation takes everything into consideration.

        For the simple version, see http://www.bodyrecomposition.com/fat-loss/the-energy-balance-equation.html/

        For the complicated version, see http://journals.plos.org/ploscompbiol/article?id=10.1371/journal.pcbi.1000045

        If you’re peeing out significant amounts of oxidisable fuels, you’re not to live for much longer :-/

        Energy loss as ketones on a VLCD = ~12kcals/day.

        • Don Reitsma

          The link talks about metabolic efficiency, for one “High-fiber diets tend to have this effect generally, as soluble fiber binds a small amount of protein and fat in the stomach carrying it out without digestion. So if you jack up soluble fiber intake, you end up absorbing less of the calories that went into your mouth; more are lost in your poop.”, so not all calories in food are converted to energy for the body. There are several waste and storage mechanisms that are constantly in play as the body attempts to maintain homeostasis. Unfortunately they are not that efficient at processing food that has been manufactured / modified and easily digestible.

          • It’s digestive efficiency, not metabolic efficiency, as the nutrients haven’t yet been absorbed.

            The amount of energy lost in poop isn’t large. Take fat-blockers (e.g. Alli) or carb-blockers (e.g. Phase 1) and see what happens when digestive efficiency falls. The results ain’t pretty! Ever heard of “Soily Oilies” a.k.a. steatorrhea?

        • Don Reitsma

          Point being hormones are in comtrol of weight / fat loss / gain.

          • Hormones are a surrogate for energy surplus.

            High insulin ≡ High energy surplus.