Fasting

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Table of Contents
Fasting I – A History 1
Fasting II – Fasting Physiology 4
Fasting III – Fasting and Growth Hormone Physiology 7
Fasting IV – Fasting and Lipolysis 10
Fasting V – Fasting Myths 14
Fasting VI – Fasting Regimens 18
Fasting VII – Longer Fasting Regimens 21
Fasting VIII – The Ancient Secret of Weight Loss 24
Fasting IX – Caloric Reduction vs Fasting 26
Fasting X – Women and Fasting 31
Fasting XI – Feasts and Fasts – The Cycle of Life 34
Fasting XII – Practical Fasting Tips 38
Fasting XIII – More Practical Fasting Tips 41
Fasting XIV – The Fasting ‘Advantage’ 45
Fasting XV – Fasting and Muscle Mass 49
Fasting XVI – Fasting Lowers Cholesterol 53
Fasting XVII – Fasting and Hunger 58
Fasting XVIII – Cephalic Phase Response and Hunger 62
Fasting XIX – Circadian Rhythms 65
Fasting XX – Refeeding Syndrome 70
Fasting XXI – Obesity – Solving the Two-Compartment Problem 75
Fasting XXII – The Biggest Loser Diet – Eat Less Move More’s Bigger Brother 80
Fasting XXIII – Fasting and Exercise 84
Fasting XXIV – Fasting and Brain Function 88
Fasting XXV – Fasting and Autophagy 92
Fasting XXVI – Power: Fasting vs Low Carb 95
Fasting XXVII – The Difference Between Calorie Restriction and Fasting 99
Fasting XXVIII – Why You’re Always Hungry 105
Fasting XXIX – Fasting and Ghrelin 108
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Fasting – A History Part I

Fasting is a time tested and ancient tradition. It has been used not only for weight loss, but to
improve concentration, extend life, prevent Alzheimers, prevent insulin resistance and even
reverse the entire aging process. There is much to talk about here so we begin a new subsection
“Fasting”.
There is nothing new, except what has been forgotten – Marie Antoinette
So the forgotten question of weight loss is “When should we eat?” We don’t ignore the question
of frequency anywhere else. Falling from a building 1000 feet off the ground once will likely kill
us. But is this the same as falling from a 1-foot wall 1000 times? Absolutely not. Yet the total
distance fallen is still 1000 feet.
All foods will increase insulin levels to some
degree. Eating the proper foods will prevent
high levels, but won’t do much to lower levels.
Some foods that are better than others, but all
foods still increase insulin. The key to
prevention of resistance is to periodically
sustain very low levels of insulin. If all foods
raise insulin, then the only answer is the
complete voluntary abstinence of food. The
answer we are looking for is, in a word,
fasting.
Fasting
The answer to this vexing problem lies not in
the latest and greatest diet trend, but in the
tried and true. Instead of searching for some exotic, never-before-tried diet miracle, we should
focus on ancient healing traditions of the past. The waaaayyyy past. Fasting is one of the most
ancient healing traditions in human history. This solution has been practiced by virtually every
culture and religion on earth.
Whenever fasting is mentioned, there is always the same eye-rolling response. Starvation? That’s
the answer? No. Fasting is completely different beast. Starvation is the involuntary absence of
food. It is neither deliberate, nor controlled. Starving people have no idea when and where their
next meal will come from. Fasting, on the other hand is the voluntary withholding of food for
spiritual, health, or other reasons. It is the difference between suicide and dying of old age. The
two terms should never be confused with each other. Fasting may be done for any period of time,
from a few hours to months on end. In a sense, fasting is part of everyday life. The term ‘break
fast’ is the meal that breaks the fast – which is done daily.
Fasting is one of the most ancient and widespread healing traditions in the world. Hippocrates of
Cos (c 460 – c370 BC) is widely considered the father of modern medicine. Among the
treatments that he prescribed and championed was the practice of fasting, and the consumption
of apple cider vinegar. Hippocrates wrote, “To eat when you are sick, is to feed your illness”.
 2

The ancient Greek writer and historian Plutarch (cAD46 – c AD 120) also echoed these
sentiments. He wrote, “Instead of using medicine, better fast today”. Ancient Greek thinkers
Plato and his student Aristotle were also staunch supporters of fasting.
The ancient Greeks believed that medical treatment could be observed from nature. Humans, like
most animals, do not eat when they become sick. For this reason, fasting has been called the
‘physician within’. This fasting ‘instinct’ that makes dogs, cats and humans anorexic when sick.
This sensation is certainly familiar to everybody. Consider the last time you were sick with the
flu. Probably the last thing you wanted to do was eat. So, fasting seems to be a universal human
instinct to multiple forms of illnesses. Thus fasting is ingrained into human heritage, and as old
as mankind itself.
The ancient Greeks believed that fasting
improves cognitive abilities. Think about the
last time you ate a huge Thanksgiving meal.
Did you feel more energetic and mentally alert
afterwards? Or, instead did you feel sleepy and
a little dopey? More likely the latter. Blood is
shunted to your digestive system to cope with
the huge influx of food, leaving less blood
going to the brain. Result – food coma.
Other intellectual giants were also great
proponents of fasting. Philip Paracelsus, the
founder of toxicology and one of three fathers
of modern Western medicine (along with Hippocrates and Galen) wrote, “Fasting is the greatest
remedy – the physician within”. Benjamin Franklin (1706-1790), one of America’s founding
fathers and renowned for wide knowledge in many areas once wrote of fasting “The best of all
medicines is resting and fasting”.
Fasting for spiritual purposes is widely practiced, and remains part of virtually every major
religion in the world. Jesus Christ, Buddha and the prophet Muhammed all shared a common
belief in the healing power of fasting. In spiritual terms, it is often called cleansing or
purification, but practically, it amounts to the same thing. The practice of fasting developed
independently among different religions and cultures, not as something that was harmful, but
something that was deeply, intrinsically beneficial to the human body and spirit. In Buddhism,
food is often consumed only in the morning, and followers fast from noon until the next morning
daily. In addition to this, there may be various water-only fasts for days or weeks on end. Greek
Orthodox Christians may follow various fasts over 180-200 days of the year. Dr. Ancel Keys
often considered Crete the poster child of the healthy Mediterranean diet. However, there was a
critically important factor that he completely dismissed. Most of the population of Crete
followed the Greek Orthodox tradition of fasting.
Muslims fast from sunrise to sunset during the holy month of Ramadan. The prophet Muhammad
also encouraged fasting on Mondays and Thursdays of every week. Ramadan is the best studied
of the fasting periods. It differs from many fasting protocols in that fluids are also forbidden. In
addition to fasting, they also undergo a period of mild dehydration. Further, since eating is
permitted before sunrise and after sunset, recent studies (27) indicate that daily caloric intake
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actually rises significantly during this period. Gorging before sunrise and after sunset seems to
negate some of the beneficial effect.
So fasting is truly an idea that has withstood the test of time. Arguable, the three most influential
people to have ever lived agreed that fasting is beneficial. If this was a harmful practice, do you
not think we would have figured this out, oh, say 1000 years ago?
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Fasting Physiology – Part II

There are many misconceptions about fasting. It is useful to review the physiology of what
happens to our body when we eat nothing.
Physiology
Glucose and fat are the body’s main sources of energy.
If glucose is not available, then the body will adjust by
using fat, without any detrimental health effects. This
is simply a natural part of life. Periods of low food
availability have always been a part of human history.
Mechanisms have evolved to adapt to this fact of
Paleolithic life. The transition from the fed state to the
fasted state occurs in several stages.

1. Feeding – During meals, insulin levels are

raised. This allows uptake of glucose into
tissues such as the muscle or brain to be used
directly for energy. Excess glucose is stored as glycogen in the liver.
2. The post-absorptive phase – 6-24 hours after beginning fasting. Insulin levels start to
fall. Breakdown of glycogen releases glucose for energy. Glycogen stores last for roughly
24 hours.
3. Gluconeogenesis – 24 hours to 2 days – The liver manufactures new glucose from amino
acids in a process called “gluconeogenesis”. Literally, this is translated as “making new
glucose”. In non-diabetic persons, glucose levels fall but stay within the normal range.
4. Ketosis – 2-3 days after beginning fasting – The low levels of insulin reached during
fasting stimulate lipolysis, the breakdown of fat for energy. The storage form of fat,
known as triglycerides, is broken into the glycerol backbone and three fatty acid chains.
Glycerol is used for gluconeogenesis. Fatty acids may be used for directly for energy by
many tissues in the body, but not the brain. Ketone bodies, capable of crossing the blood-
brain barrier, are produced from fatty acids for use by the brain. After four days of
fasting, approximately 75% of the energy used by the brain is provided by ketones. The
two major types of ketones produced are beta hydroxybutyrate and acetoacetate, which
can increase over 70 fold during fasting.
5. Protein conservation phase – >5 days – High levels of growth hormone maintain muscle
mass and lean tissues. The energy for maintenance of basal metabolism is almost entirely
met by the use of free fatty acids and ketones. Increased norepinephrine (adrenalin) levels
prevent the decrease in metabolic rate.

The human body has well developed mechanisms for dealing with periods of low food
availability. In essence, what we are describing here is the process of switching from burning
glucose (short term) to burning fat (long term). Fat is simply the body’s stored food energy. In
times of low food availability, stored food is naturally released to fill the void. So no, the body
does not ‘burn muscle’ in an effort to feed itself until all the fat stores are used.
Hormonal Adaptation
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Insulin
Fasting is the most efficient and consistent strategy to decrease insulin levels. This was first
noted decades ago, and widely accepted as true. It is quite simple and obvious. All foods raise
insulin, so the most effective method of reducing insulin is to avoid all foods. Blood glucose
levels remain normal, as the body begins to switch over to burning fat for energy. This effect is
seen with fasting periods as short as 24-36 hours. Longer duration fasts reduce insulin even more
dramatically. More recently, alternate daily fasting has been studied as an acceptable technique
of reducing insulin.
Regular fasting, in addition to lowering insulin levels, has also been shown to improve insulin
sensitivity significantly. This is the missing link in the weight loss puzzle. Most diets reduce
highly insulin-secreting foods, but do not address the insulin resistance issue. Weight is initially
lost, but insulin resistance keeps insulin levels and Body Set Weight high. Fasting is an efficient
method of reducing insulin resistance.
Lowering insulin rids the body of excess salt and water. Insulin causes salt and water retention in
the kidney. Atkins style diets often cause diuresis, the loss of excess water, leading to the
contention that much of the initial weight loss is water. While true, diuresis is beneficial in
reducing bloating, and feeling ‘lighter’. Some may also note a slightly lower blood pressure.
Fasting has also been noted to have an early period of rapid weight loss. For the first five days,
weight loss averages 0.9 kg/ day, far exceeding the caloric restriction and likely due to a diuresis
of salt and water.
Growth Hormone
Growth hormone is known to increase the
availability and utility of fats for fuel. It also
helps to preserve muscle mass and bone density.
Secretion is known to be pulsatile, making
accurate measurement difficult. Growth
hormone secretion decreases steadily with age.
One of the most potent stimuli to growth
hormone secretion is fasting. Over a five-day
fasting period growth hormone secretion more
than doubled. The net physiologic effect is to
maintain muscle and bone tissue mass over the
fasting period.
Electrolytes
Concerns about malnutrition during fasting are
misplaced. Insufficient calories are not a major
worry, since fat stores are quite ample. The main
concern is the development of micronutrient
deficiency. However, even prolonged studies of
fasting have found no evidence of malnutrition.
Potassium levels may decrease slightly, but even two months of continuous fasting does not
decrease levels below 3.0 mEq/L, even without the use of supplements. This duration of fasting
is far longer than generally recommended. Magnesium, calcium and phosphorus levels during
 6

fasting are stable. Presumably, this is due to the large stores of these minerals in the bones.
Ninety nine percent of the calcium and phosphorus in the body is stored in the bones. The use of
a multi-vitamin supplement will provide the recommended daily allowance of micronutrients. A
therapeutic fast of 382 days was maintained with only a multivitamin with no harmful effect on
health. Actually, this man maintained that he had felt terrific during this entire period. The only
concern may be a slight elevation in uric acid that has been described in fasting .
Adrenalin
Adrenalin levels are increased so that we have plenty of energy to go get more food. For
example, 48 hours of fasting produces a 3.6% increase in metabolic rate, not the dreaded
metabolic ‘shut-down’. In response to a 4 day fast, resting energy expenditure increased up to
14%. Rather than slowing the metabolism, instead the body revvs it up. Presumably, this is
done so that we have energy to go out and find more food.
This is really quite interesting. Fasting, but not low calorie diets results in numerous hormonal
adaptations that all appear to be highly beneficial on many levels. In essence, fasting transitions
the body from burning sugar to burning fat. Resting metabolism is NOT decreased but instead
increased. We are, effectively, feeding our bodies through our own fat. We are ‘eating’ our own
fat. This makes total sense. Fat, in essence is stored food. In fact, studies show that the
epinephrine (adrenalin) induced fat burning does not depend upon lowering blood sugar.
Fat is food stored away in the long term, like money in the bank. Short term food is stored as
glycogen, like money in the wallet. The problem we have, is how to access the money in the
bank. As our wallet depletes, we become nervous and go out to fill it again. This prevents us
from getting access to money in the bank.
Fat is stored away in the ‘bank’. As our glycogen ‘wallet’ depletes, we get hungry and want to
eat. That makes us hungry, despite the fact that there is more than enough ‘food’ stored as fat in
the ‘bank’. How do we get to that fat to burn it? Fasting provides an easy way in.
 7

Fasting and Growth Hormone Physiology – Part 3

HGH is a hormone made by the pituitary gland (the master gland). It plays a huge role in the
normal development of children and adolescents as the name implies. However, it also plays a
role in adults. HGH deficiency in adults typically leads to higher levels of body fat, lower lean
body mass and decreased bone mass (osteopenia).
HGH only lasts a few minutes in the bloodstream. It goes to the liver for metabolism, where it is
converted into a number of other growth factors, the most important of which is Insulin Like
Growth Factor 1 (IGF1).
Scientists first harvested HGH from cadavers in the 1950s (eeewww), but only synthesized it in
labs in the early 1980s. Soon afterwards, it became a popular performance enhancing drug.
Normal levels of HGH peak in puberty (as you might expect) and gradually decrease thereafter.
Growth hormone is typically secreted during sleep and is one of the so-called counter-regulatory
hormones. HGH along with cortisol and adrenalin tell the body to increase the availability of
glucose – so it counters the effect of insulin. High doses of HGH, (or cortisol) will produce
higher blood sugars. These hormones are typically secreted in a pulse just before waking (4 am
or so) during the ‘counter-reulatory surge’. Remember that all hormones exhibit pulsatile
secretion to prevent the development of resistance as we covered in a previous post.
Since HGH typically goes down with age, there may be some benefit to giving HGH for its ‘anti-
aging’ effects. Perhaps this decrease in HGH-IGF1 may contribute to the decrease in lean body
mass both in lower muscle mass, but also lowered bone mass. So, what are the effects of giving
HGH in older people? This was studied in 1990 in a New England Journal of Medicine article.
HGH is difficult to measure
since it is pulsatile, so IGF1
can be measured as a
surrogate. Healthy men
with low IGF1 levels were
given HGH for 6 months
and the effects measured.
Group 1 is the HGH group
and Group 2 is the control
group that did not receive
HGH. Over 6 months
weight overall did not
change between the two
groups.
But look at the lean body mass. Compared to the control, the HGH group packed on 3.7 kg
(8.8%) more lean mass. That’s 8 pounds of lean mass! Fat mass decreased an extra 2.4 kg (5.3
pounds)! Thats a decrease of 14.2%. Even the skin thickness improved. That’s anti-aging, baby!
 8

In a 2002 JAMA article, similar results were obtained in women as well. There was a decrease
in fat mass and an increase in lean mass. Sounds pretty great. So, why aren’t we using it for
everybody? Well, there’s a little thing called side effects.
There was an increase in blood sugars. This makes sense, since HGH is a counter-regulatory
hormone. Pre-diabetes also significantly increased. There was an increase in fluid retention as
well as blood pressure, too. Over the long term, there is also a theoretical risk of increased
prostate cancer and heart problems (enlarged heart). So, that’s not very good news.
So artificial injections
of HGH are out. What
if there is an all-
natural method of
increasing growth
hormone? What
about, say, fasting?
In 1982, Kerndt et al
published a study of a
single patient who
decided to undergo a
40 day fast for
religious
purposes. They
measure numerous metabolic indices over that forty days to see what happened. There is a
wealth of data here, but several notable things. Blood pressure slightly decreased. Glucose goes
down. From 96 initially, it drops to 56. Insulin goes way, way down. Starting at 13.5, it quickly
drops to 2.91 and stays down. That is almost an 80% drop!
Glucagon goes from 139 to a peak of 727 or a 423% increase.
But our concern here is HGH. It starts at 0.73 and peaks at 9.86. That is a 1250% increase in
growth hormone. Even with a
relatively short 5 day fast, we are
talking about 300% increase. All
this HGH increases without drugs.
What about the potential side
effects? Increased glucose?
Nope. Increased blood pressure?
Nope. Higher risk of cancer? Nope.
Other studies have shown the same
increase in growth hormone. In
1988, Ho KY et al studied fasting
and HGH. On the control day, you
can see that meals (marked M) very
effectively suppress HGH secretion. This is to be expected. Like cortisol, HGH increases
glucose and thus is suppressed during feeding. Fasting is a great stimulus.
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During fasting, there is the spike in the early morning, but there is regular secretion throughout
the day as well. Hartman et al also showed a 5 fold increase in HGH in response to a 2 day fast.
This HGH is crucial in the maintenance of lean mass – both muscle and bone. One of the major
concerns about fasting is the loss of lean mass. This does not occur. In fact, the opposite
happens – there is likely an increase in lean mass. Think about this for a second.
Let’s imagine that we are living in Paleolithic times. During the summer of plenty, we eat lots of
food and store some of that as fat on our body. Now it is winter, and there is nothing to
eat. What do you suppose our body does. Should we start burning our precious muscle while
preserving our stored food (fat)? Doesn’t that sound pretty idiotic?
It’s as if you store firewood for a wood-burning oven. You pack lots of firewood away in your
storage unit. In fact, you have so much, it is spilling out all over your house and you don’t even
have enough room for all the wood you’ve stored. But when the time comes to start up the oven,
you immediately chop up your sofa and throw that into the oven. Pretty stupid right? Why
would we assume our body is also so stupid?
The logical thing to do is to start burning the stored wood. In the case of the body, we start to
burn the stored food (fat stores) instead of burning precious muscle.
This has enormous implications for athletes. While studies are few, it is possible that the elevated
HGH stimulated by fasting will increase muscle mass as seen in the earlier studies on HGH
administration. This would be an important advantage in elite level athletes, and we are seeing
more and more interest in doing this exact sort of protocol.
The recovery from hard workouts would similarly be improved. The increased adrenalin during
fasting (to be discussed in future) will also allow you to perform a more intense workout. It will
make workouts easier and recovery faster.
It is not by accident that many of the early proponents of training in the fasted state are
bodybuilders. This is a sport that demands, in particular, high intensity training and extremely
low body fat for definition.
So, for all those people who thought that fasting would make you tired, or that you could not
exercise during fasting, well, you’re just wrong. Fasting does not ‘burn’ muscle. There is no
‘starvation’ mode from fasting where you shrivel up into the fetal position on your couch.
Rather, fasting has the potential to unleash the anti-aging properties of HGH without any of the
problems of excessive HGH (prostate cancer, increased blood sugar, increased blood
pressure). For those interested in athletic performance, the benefits are even greater.
So, let’s see. Train harder. Lose Weight. Faster recovery. Decrease insulin and insulin
resistance. Decrease sugars. All of these benefits are achieved without drugs, supplements or
cost. Yes, like all the best things in life, it’s free. So why is everybody so against it?
 10

Fasting and Lipolysis – Part 4

Insulin is the main driver of both obesity and type 2 diabetes. The key to reversing both
conditions is therefore not “How do we reduce calories?”, but instead “How do we reduce
Insulin?” There are almost no drugs that will do this. There is actually two classes of
medications that consistently reduces insulin – one by a lot, one by a little. Not by co-incidence,
they are the only drugs that consistently reduces weight.
But the problem is that they are both expensive and have side effects. Short of drugs, we need an
efficient, effective way to lower insulin if we are to be successful in losing weight. A diet low in
refined carbs and sugar will certainly do the trick for some, but for others it is not enough. The
answer, if you haven’t guessed yet, is fasting.
The classic descriptions of
fasting physiology
were written by Dr. George
Cahill. We reviewed this in
a previous post, but here’s a
pictorial version.
Essentially, fasting is the
gradual shift of burning
glucose to burning fat.
In stage 1, most of the body
is using exogenous
glucose. By stage 2 and 3,
glycogen (stored sugar)
provides much of the
glucose needed. Most
tissues are still using sugar,
but the liver, muscle and fat
cells have started to burn
fat.
By stage 4 and 5, glycogen
stores have run out. Hepatic
and renal (liver and kidney)
gluconeogenesis is now providing all the glucose, but only the brain, red blood cells and the
renal medulla (the inner part of the kidney) uses glucose. Everything else has shifted over to
burning fat. By stage 5, the brain has mostly shifted to burning fat in the form of ketone
bodies. Only a small amount of
glucose is needed for red blood cells.
You can see that the origin of the
blood glucose gradually switches
from exogenous (dietary) to
gluconeogenesis made from
glycerol. Fat is mostly triglyceride,
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which contains one glycerol backbone and three fatty acids of varying lengths.
Most tissues in the body are able to use fatty acids directly as fuel. By stage 5, only the brain and
red blood cells require glucose. So most of the body is now fuelled by fat, not sugar.
You can see the effect of this in the free fatty acid
(FFA) concentrations in the blood in response to
fasting (also called starvation). The FFA levels in
the plasma just skyrocket from almost
undetectable. Ketones (to feed the brain) are
betahydroxybutyrate and Acetoacetate which also
show an increase.
The triglyceride is broken down into the glycerol
backbone and the 3 fatty acids. The fatty acids are
used directly by the body. The glycerol goes to the
liver and is turned into glucose by the process of
gluconeogenesis. Therefore, fat is able to provide
the necessary small amount of glucose for the brain,
red blood cells and renal medulla. You do not need
to break down muscle for this.
So, fasting does not really ‘starve’ the muscles of
fuel. Instead, scarcely available glucose is replaced
with widely available fats as the fuel of
choice. That’s good, because the body is able to
store virtually unlimited amounts of fat, but only a
small amount of glucose. Mother Nature, again, has proven herself far, far smarter than us.
It’s analogous to deciding to switch from hydroelectric power to solar power in the middle of the
Sahara desert. Just smart. If there is no glucose, we will burn fat. That’s really good news
because if there is anything we really, really want to do is BURN FAT. For all the miracle cures
pushed by Dr. Oz that don’t really burn fat, there is one that does – fasting.
We want to burn fat so that we can look like this guy – Brad Pilon (author of authoritative fasting
textbook Eat Stop Eat). That’s actually true, even though this is a blatant and transparent ploy to
put a picture of the shirtless man to increase female readership. But hey! The internet is a dog
eat dog world. Dog, mmmm….
One of the reasons why bodybuilders have a vested interest is that their sport demands extremely
low body fat levels combined with high athletic performance.
The brain is now powered mostly on ketones. This is a normal situation. This is the way our
body is designed. This should not be confused with diabetic ketoacidosis where excessive
ketones are produced in addition to very high glucose levels.
In that situation, there is lots of glucose for the brain to use. However, due to the pathologic lack
of insulin, the body also produces lots of ketones. The ketones are not burned for fuel, but
instead pile up outside, like unused logs.

Brad Pilon - Poster boy of fasting

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As ketone requirements go up, glucose requirements

goes down. In type 1 diabetes, both are very high and
this causes a life-threatening problem.
Here’s a question I get sometimes. Can my overweight
child fast? Seven hells, no. Here’s a graphical
description of why. Children simply may not be able to
produce adequate amounts of ketones. Even if they
could, I sure as hell would not want to take that risk.
In fact, every major religion in the world requires
fasting – but ONLY for adults.
In a more recent study of 4 days of fasting, virtually
identical results were found. Let’s take a closer look
There are many interesting details here. First, you will
notice that fatty acids increase 373%. Blood glucose
drops from 4.9 to 3.5 – lower but still in the normal
range, maintained by hepatic gluconeogenesis. Beta
hydroxybutyrate increases 2527% percent! The brain is powered on ketones and the body is
powered on fat. That’s the mythical fat burning – Burn, Baby, Burn!
Second, you can see that over 4 days of fasting, there is a continuous increase in norepinephrine,
while epinephrine remains relatively stable. The increase in adrenalin increases energy and

prevents the decrease in resting energy expenditure (REE) or metabolism. REE increases more
than 10%. There is no metabolic shut-down. Fasting instead revs the body’s metabolism. VO2
also increases slightly indicating a greater capacity of the body for physical exertion.
So here’s a summary so far of what fasting does for the elite athlete, or even the regular person.
1. Train harder – Increased adrenalin, increased VO2
2. Recover faster and build muscle faster – Increased growth hormone.
3. Burn fat – increased fatty acid oxidation.
4. Insulin goes down. This we will consider in more detail later.
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This is all available to every person in the

entire world, free of charge. Not only do you
NOT have to buy expensive supplements.
You will save money because you don’t need
to buy food. You will save time because you
don’t need to cook or clean up.
If I don’t eat, will I lose weight?
Will you lose weight? Well, DUH. If you
don’t eat, you will definitely lose weight. So
there is no question that this is
an effective treatment of weight loss. There
are virtually no circumstances where it will
not work. Is it unhealthy?
The surprising answer is that fasting is extremely healthy. There are a huge number of incredible
benefits to fasting. Train harder, build muscle, burn fat. Love it! All legal and totally free! This is
only the beginning – we haven’t even touched on the benefits to obesity, diabetes, cancer, and
even the anti-aging effects.
 14

Fasting Myths – Part 5

Many myths are associated with fasting. These myths have been repeated so often that they are
often perceived as infallible truths. Some of the these myths include:

• Fasting puts you in ‘starvation’ mode

• Fasting will overwhelm you with
hunger
• Fasting causes overeating when you
resume feeding
• Fasting will make you lose muscle
• Fasting deprives the body of nutrients
• Fasting causes hypoglycemia
• The brain needs glucose to function
• It’s just ‘crazy’

Long ago disproven, nevertheless these myths still persist. If they were true, none of us would be
alive today. Consider the consequences of burning muscle for energy. During long winters, there
were many days where no food was available. After the first episode, you would be severely
weakened. After several repeated episodes, you would be so weak that you would be unable to
get hunt or gather food. Humans would never have survived as a species. The better question
would be why the human body would store energy as fat if it planned to burn protein instead.
The answer, of course, is that is does not burn muscle as we discussed in the previous post. It
was only a myth.
There is another persistent myth that brain cells require glucose for proper functioning. This is
incorrect. Human brains, unique amongst animals, can use ketones as a major fuel source during
prolonged starvation, allowing the conservation of protein such as skeletal muscle. Again,
consider the consequences if glucose were absolutely necessary for survival. Humans would not
survive as a species. After 24 hours, glucose becomes depleted and we become blubbering idiots
as our brains shut down. Our intellect, our only advantage against wild animals, begins to
disappear. Humans would have soon become extinct. Fat is simply the body’s way of storing
food energy for the long term, and glucose/ glycogen is the short-term solution. When short-term
stores are depleted, the body turns to its long-term stores without problems.
Consider an analogy. A freezer stores food in the long term, and a refrigerator used for short-
term storage. Suppose that three times a day, everyday, we go to the market to buy food. Some
goes into the refrigerator, but the excess goes into the freezer. Soon one freezer is not enough, so
we buy another, then another. Over a period of decades, we have ten freezers, and nowhere else
to put them. Food in the freezer does not get eaten because three times a day, we still buy more
food. There is simply no reason to release the food from the freezer. What would happen if, one
day, we decide not to buy food? Would everything shut down in ‘starvation mode’? Nothing
could be further from the truth. We would first empty the refrigerator. Then the food, so
carefully stored in the freezer would be released.
So, in the body’s case, glucose is used for short-term energy and fat for long-term storage (the
freezer). Fat is not burned when plenty of glucose is available. Over decades of abundant
 15

glucose, fat stores proliferate. What would happen if glucose were suddenly unavailable? Would
everything shut down in ‘starvation mode’? Nothing could be further from the truth. Energy, so
carefully stored as fat, would be released.
Starvation mode, as it is popularly known, is the mysterious
boogieman always raised to scare us away from missing
even a single meal. Over one year, approximately 1000
meals are consumed. Over a span of 60 years, this equals
60,000 meals. To think that skipping 3 meals of the 60,000
will somehow cause irreparable harm is simply absurd.
Breakdown of muscle tissue happens at extremely low
levels of body fat – approximately 4%. This is not
something most people need to worry about. At this point,
there is no further body fat to be mobilized for energy and
lean tissue is consumed. The human body has evolved to
survive episodic periods of starvation. Fat is stored energy
and muscle is functional tissue. Fat is burned first. This is
akin to storing a huge amount of firewood but deciding to burn your sofa instead. It’s stupid.
Why would we assume the human body is so stupid? The body preserves muscle mass until the
body fat becomes so low that it has no choice.
Studies of alternate daily fasting, for example show that the concern over muscle loss is largely
misplaced. Alternate daily fasting over 70 days decreased body weight by 6%, but fat mass
decreased by 11.4%. Lean mass (including muscle and bone) did not change at all. Significant
improvements were seen in LDL cholesterol and triglyceride levels. Growth hormone increases
to maintain muscle mass. Studies of eating a single meal per day found significantly more fat
loss despite the same caloric intake. Importantly, no evidence of muscle loss was found.
The other persistent myth of ‘starvation mode’ is that basal metabolism decreases severely and
our bodies ‘shut down’. This too is highly disadvantageous to survival of the human species. If,
after a single day of fasting, metabolism decreased, then we would have less energy to hunt or
gather food. With less energy, we are less likely to get food. So, another day passes, and we are
even weaker, making us even less likely to get food. This is a vicious cycle that the human
species would not have survived. It’s stupid. Why would we assume the human body is so
stupid? There are, in fact, no species of animals, humans included that are evolved to require
three meals a day, everyday. We have already seen in a previous post that resting energy
expenditure (REE) goes UP, not down during fasting. Metabolism revs up; it does not shut down.
It’s unclear to me where this myth originated. Daily caloric restriction leads to decreased
metabolism so people assumed that this would simply be magnified as food intake dropped to
zero. This is wrong. If you rely on food for energy, then decreasing food will lead to decreased
energy intake, which will be matched by decreased energy expenditure. However, as food intake
goes to zero, the body switches energy inputs from food to stored food (fat). This significantly
increases the availability of ‘food’ and this is matched by an increase in energy expenditure.
 16

So what happened in the Minnesota

Starvation Experiment? These participants
were not fasting. They were eating a reduced
calorie diet. The hormonal adaptations to
fasting were not allowed to happen. In
response to a prolonged period of lowered
food intake, the body makes the adjustment
to lower TEE.
Everything changes when food intake goes
to zero (fasting). The body obviously cannot
take TEE down to zero. Instead, the body
now switches to burning the fat stored on our
bodies. After all, that is precisely, exactly
what it was put there for. Our body fat is
used for food when no food is available. It’s
not put there for looks.
Detailed physiologic measurements show that TEE is maintained or sometimes even increased
over the duration of a fast. Alternate daily fasting over 22 days found no measurable decrease in
TEE. There was no ‘starvation’ mode. There was no decreased metabolism. Fat oxidation
increased 58% while carbohydrate oxidation decreased from 53%. This means that the body has
started to switch over from burning sugar to burning fat with no overall drop in energy. Four
days of fasting actually increase TEE by 12%. Norepinephrine levels (adrenalin) absolutely
skyrocketed 117% to maintain energy. Fatty acids increased over 370% as the body switched to
burning fat. Insulin measurements decreased 17%. Blood glucose levels dropped slightly but
remained in the normal range.
All the incredibly beneficial adaptations to
fasting are not allowed to happen in a low
calorie diet.
In fact, look how quickly the merest touch of
glucose reverses the hormonal changes of
fasting. Only 7.5 grams of glucose (2 teaspoons
of sugar or barely a sip of a soft drink) is
enough to reverse the ketosis. Almost
immediately after consuming glucose, the
ketones beta hydroxybutyrate and acetoacetate
drop to almost nothing, as does fatty acids.
Insulin rises, as does glucose.
What does this mean? The body stops burning
fat. It has now returned to burning the sugar that
you are eating.
Repeated concerns are raised that fasting may provoke overeating. Studies of caloric intake do
show a slight increase at the next meal. After a one day fast, average caloric intake increases
from 2436 to 2914. But over the entire 2-day period, there is still a net deficit of 1958 calories.
 17

The increased calories did not nearly make up for the lack of calories on the fasting day. Personal
experience in our clinic shows that appetite tends to decrease with increased duration of fasting.
Does fasting deprive the body of nutrients? Most people have more than ample quantities of
nutrients. That’s the whole point. To get rid of some of these nutrients – also known as fat.
If you are worried about micronutrients and minerals – you can always take a general multi-
vitamin. A different regimen such as alternate daily fasting (ADF) can also alleviate concerns
about nutrient deficiency.
The science is clear. The myths surrounding fasting were only falsehoods.
 18

Fasting Regimens – Part 6

There are many different fasting regimens. Let’s be very clear to start, though. There is simply
no ‘best’ one. They all work to different degrees for different people. Just as some people prefer
steak to chicken, there is no right or wrong answer. One regimen will work for one person but be
utterly ineffective in the next.
Fasting is defined as the voluntary act of withholding food for a specific period of time. Non-
caloric drinks such as water and tea are permitted. An absolute fast refers to the withholding of
both food and drink. This may be done for religious purposes, such as during Ramadan in the
Muslim tradition, but is not generally recommended for health purposes because of the
accompanying dehydration. In our IDM program, we do not ever use the absolute fast.
Fasting has no standard duration. Fasts can range from twelve hours to three months or more.
You can fast once a week or once a month or once a year. Intermittent fasting involves fasting
for shorter periods of time on a regular basis. Shorter fasts are generally done more frequently.
Longer fasts are typically twenty-four to thirty-six hours, done two to three times per week.
Prolonged fasting may range from one week to one month.
I categorized fasting periods with a break point at 24 hours, although this is somewhat arbitrary.
In my experience in the IDM program, I generally use shorter regimens for those who are mostly
interested in losing weight without much in the way of type 2 diabetes, fatty liver or other
metabolic diseases.
For those who have more significant illnesses, I use longer duration regimens as they tend to
give faster results. After the initial ‘breaking’ in period, we always work with the patients to find
out what they prefer to do. A surprising number of patients prefer longer duration fasts less
frequently.
Short Daily Fasting Regimens
1. 12 hour fasting – There are several
regimens of fasting that use a shorter
period of fasting but done every day. A
12 hour fasting period done every day
used to be ‘normal’. That is, you would
eat 3 meals a day from, say 7 am to 7
pm and refrain from eating anything
from 7 pm to 7 am.
At that point, you would ‘break your
fast’ with a small breakfast. This was
pretty standard in the 1950s and 1960s.
There wasn’t much obesity back then.
However, there were two major changes
that happened since then. First was the change to a higher carbohydrate, lower fat diet. This
tended to increase insulin. Second was the increase in meal frequency, as we detail in a previous
post, which tended to reduce fasting periods.
 19

If you could eat unprocessed foods, avoid excessive added sugars, and did not have significant
insulin resistance to start, this 12 hr daily fasting was probably good enough for most people to
avoid obesity. However, it is not really strong enough to reverse decades of insulin resistance.
2. 16 hour fasting – This regimen involves using a daily 16 hour period of fasting and an 8 hour
‘eating window’. For example, this would mean eating from 11 am – 7 pm, and fasting from 7
pm to 11am. This generally means skipping the morning meal every day. Some people choose to
eat 2 meals during that 8 hour window and others will eat 3.
This regimen was popularized by a bodybuilder by the name of Martin Berkhan who blogged
about it on his website www.leangains.com, and so the method is sometimes called the
LeanGains method. He wrote extensively in the years 2007-2010 but I don’t see much activity on
his blog anymore, which is a real shame, because he had some great ideas and original thought.
There are still some excellent posts there.
He wrote extensively about
training in the fasted state and
eating predominantly in the post-
workout period. These ideas are
supported by the science available
(albeit not a lot). However, they do
make a lot of common sense.
Several years later, an editor at
Men’s Health wrote a book called
The 8 hour diet, which essentially
used the same 8 hour eating
window as the LeanGains method.
In his entire book, he strenuously
avoided any mention of LeanGains
or Berkhans, even though this method transparently ripped-off LeanGains. You can’t really
patent a time period of fasting, but the intellectual dishonestly was appalling, regardless. It is like
writing about E=MC2 and never mentioning Albert Einstein, but instead pretending to have
‘discovered’ it yourself.
3. The ‘Warrior’ diet – This was one of the first diets to popularize intermittent fasting regimens.
Written by Ori Hofmekler in 2002, this diet stressed that timing of meals mattered almost as
much as composition of meals. In other words, ‘when you eat makes what you eat important’.
Actually, I think both are important, but the ‘when’ question is seriously under-appreciated, and
this book was one of the first to really point this out.
Drawing upon inspiration from ancient warrior tribes such as the Spartans and Romans, the core
of the diet consists of eating all meals in the evening during a 4 hour window. The fasting period
of 20 hours consisted of most of the day. There was also an emphasis on natural unprocessed
foods and high intensity training.
 20

The main point of all these fasting

regimens is the same. It allows the
body to lower insulin levels very low
for a specified period of time longer
than usual. This is precisely what
helps to break, or prevent the
development of insulin resistance.
As we’ve mentioned previously, this
is the fundamental biologic principle
of homeostasis.
The body likes to maintain
everything within a relatively narrow
range. Any prolonged stimulus leads
to resistance as the body tries to
resist the change. In this case, prolonged periods of high insulin will lead to insulin resistance,
which will lead back to high insulin levels – in other words, insulin causes insulin resistance.
So, by incorporating daily, or almost daily periods of low insulin, we are able to prevent the
development of insulin resistance and even reverse relatively minor levels of resistance. For
more established resistance, we would need longer fasting periods – 24 hours or greater.
One of the key advantages of fasting, from a therapeutic standpoint is the lack of upper limit.
What this means is that we can continue to apply fasting in an almost unlimited manner with no
upper ceiling. The world record for fasting was 382 days, during which the patient suffered no ill
effects.
Think about medications for a second. If you take metformin – there is a maximum dose. Same
for virtually all meds. Think about low carb or low fat diets – you can only go to zero carbs or
fat. There is a maximum dose. That is why insulin is so popular with doctors. You can keep
increasing the dose with no ceiling. (As an aside, we recently had a lady taking 400 units of
insulin per day in our clinic. Her endocrinologist was happy that her sugars were ‘finally’
controlled. I was appalled.)
Fasting, similarly has no ceiling, which offers much more therapeutic flexibility. In other words,
if I can keep applying fasting until I see the desired effect. The dose can go up indefinitely. If
you don’t eat, will you lose weight? Of course. So there is almost no question of efficacy. It is
only a question of safety and compliance. So for more complicated or serious cases, we can
simply increase the dose. We will consider these longer regimens in the next post.
 21

Longer Fasting Regimens – Part 7

There are several longer duration fasting regimens that are available. I arbitrarily divide it at 24
hours but there is no physiologic reason to do so, other than for classification purposes. There is
no magic dividing line. We covered fasting regimens using periods less than 24 hours in our last
post. This post will cover those schedules that use fasts longer than 24 hours.
24 hour fasts
This period of fasting is essentially going from dinner to dinner, or breakfast to breakfast,
whatever you like. For example, you would eat dinner at 7 pm and then fast until the next day’s
dinner at 7 pm. In this regimen, you do not actually go a full day without eating since you are
still taking one meal on that ‘fasting’ day.
This is very similar to the ‘Warrior’ style of fasting although that allows a 4 hour eating window
so is technically a 20 hour fasting period.
This period of fasting has several important advantages. First, as a longer duration fast, it tends
to be a little more effective. Because you still eat every day, medications that need to be taken
with food can still be taken. For example, metformin, or iron supplements of aspirin should all be
taken with food and can be taken with the one meal on the fasting day.
The other major advantage is that this style is the most easily incorporated into everyday life.
Most people, for example will eat dinner with family every single day. As you still eat dinner
every day, it is possible to routinely fast for 24 hours without anybody knowing any different,
since it really only means skipping breakfast and lunch on that day.
This is particularly easy during a workday. You simply drink your morning cup of joe, but skip
breakfast. You work through lunch and get home in time for dinner, again. This saves both time
and money. There is no cleanup or cooking for breakfast. You save an hour at lunchtime where
you can work, and be home for dinner without anybody
even realizing you had fasted for 24 hrs.
The 5:2 Diet
The 5:2 approach is championed by Dr. Michael Mosley, a
TV producer and physician best known for popularizing
this approach. He appeared on a BBC program called
Horizon entitled “Eat, Fast, and Live Longer”.
While there had been some fringe interest being generated
by pioneers such as Martin Berkhan and Brad Pilon, they
had not really hit the mainstream yet. With the BBC
documentary and the book that soon followed, intense
interest, especially in the UK followed.
The book, entitled “The Fast Diet” became a best seller in
the UK and soon other follow up books were released. The
basic diet was not quite a 24 hour fasting period, as Brad
Pilon described.

Dr. Michael Mosley

 22

Instead, the 5:2 diet consisted of 5 days of normal diet. On the other two days, you could eat a
total of 500 calories. Those 500 calories could be taken all in a single meal. If, for example, this
is taken as dinner, it would be identical to the Eat, Stop, Eat diet. However, you could spread
those 500 calories out into multiple meals instead. These two approaches are quite similar and
the difference physiologically, is likely quite minimal.
Alternate Daily Fasting (ADF)
This is the dietary strategy that has the most research behind it. Much of it was done by Dr.
Krista Varady, an assistant professor of nutrition with the University of Illinois – Chicago. She
wrote a book about her strategy in The Every Other Day Diet, although this was not the
blockbuster success of the 5:2 diet.
Even though it sounds like you only eat every other day, it is not quite. You can eat up to 500
calories on fasting days, just like in the 5:2 diet. However, fasting days are done on alternate
days rather than 2x per week so it is a more intensive regimen. The major advantage of this
regimen is that more research is available on this regimen than any other. We will consider these
studies in more detail in later posts.
36 hour fasts
As you progressively go longer in fasting, there benefits accrue faster, but there is also more risk
of complications. Since I often deal with type 2 diabetics and hard to treat obesity cases, I tend to
gravitate towards longer fasting periods, but you must understand that I always monitor very
closely their blood pressures, and blood work and progress. I cannot stress enough, that if you
do not feel well at any point, you must stop. You can be hungry, but you should not feel sick.
Another major consideration is that medication must be carefully monitored by a physician. The
major problem are diabetic medications because if you take the same dose of medication and do
not eat, you will become hypoglycaemic and that is very dangerous.
Blood sugars going low is not a complication per se, because that is generally the point of
fasting. We want the sugars to go low. However, it does mean that you are overmedicated for
that day. You must work very carefully with a physician to adjust medications and monitor
sugars. Also, there are certain medications that may cause stomach upset on an empty stomach.
NSAIDS, ASA, Iron supplements and metformin are the major drugs here.
In general, diabetic medicates and insulin MUST be reduced on the fasting day to avoid
hypoglycaemia. Exactly how much to reduce it should be overseen by your physician.
I DO NOT RECOMMEND ANYBODY WHO IS TAKING ANY MEDICATION TO TRY
LONGER FASTS WITHOUT CLEARING IT WITH THEIR DOCTOR.
A 36 hour fast means that you fast one entire day. You finish dinner on day 1 at 7pm for
instance, and you would skip all meals on day 2, and not eat again until breakfast at 7 am on day
3. So that is a total of 36 hours of fasting.
42 hour fasts
We often advise our clients to make a routine out of skipping the morning meal and break their
fast around noon hour. This makes it easy to follow a 16:8 fasting period on regular days. After a
 23

few days, most people start to feel quite normal just starting their day with a glass of water and
their usual cup of coffee.
When you combine that with a 36 hour fast, you get a 42 hour fasting period. For example, you
would eat dinner at 6 pm on day 1. You skip all meals on day 2 and eat your regular ‘break fast’
meal at 12:00. This is a total of 42 hours.
For longer duration fasts, we often try NOT to calorie restrict during that eating period. Often, as
people get used to fasting, we hear very often that their appetite starts to seriously go down. Not
up. Down. They should eat to satiation on their eating day.
There’s a very good reason for this decrease in appetite. As you start to break the insulin
resistance cycle, insulin levels start to decrease. Since insulin is the major regulator of the body
set weight (BSW) your body now ‘wants’ to go lower. In response, hunger is suppressed and
total energy expenditure is maintained. So – appetite goes down and TEE stays same or goes up.
Remember that standard Caloric Reduction as Primary (CRaP) strategies produce the opposite.
Appetite goes up and TEE goes down. Which do you think will work in the long run?
 24

The Ancient Secret of Weight Loss – Fasting Part 8

There really is no upper limit to fasting regimens. Once again, I will add a cautionary note. If
you are taking medications or especially if you have diabetes, you need to discuss this with your
physician before starting. The blood sugars often come down with fasting regimens, but if you
are taking medications, it may come down too low. This is a potentially fatal condition called
hypoglycaemia. It often manifests as shaking, sweating and sometimes seizures. Medications
often need to be adjusted including blood sugar and blood pressure medications.
Also, if you feel unwell at any point during the fasting, you must stop. You may feel hungry, but
you should not feel faint, or unwell or nauseated. This is not normal and you should not attempt
to ‘push through’. I am not specifically recommending any fasting regimens, only trying to
document various fasting regimens in widespread use.
The world record for fasting is 382 days. This was a 27
year old man in Scotland who fasted in order to lose
weight. He weight 456 pounds at the start of the fasting
period. During this time, he only took a multi-vitamin,
and something called ‘Paladac’ which was vitamin C
and yeast. Why on earth anybody decided that eating
yeast was that important is really quite beyond me, but
hey, this was 1973, when pet rocks and disco was
popular, too, so there you go.
He was able to drink as much non-caloric fluids as he
wanted. After all, you would only survive less than 3
days without fluids because of significant dehydration. At various periods, he did receive some
potassium and sodium supplements, and he was monitored by a physician throughout the fasting
period to see if there was any deleterious effects on his
health.
Constipation is one of the main problems we see in
fasting. The reason seems simple enough. There is very
little going into the gut, so little comes out the other end.
This is a problem we face routinely in our IDM clinic.
With this world record fast, this patient had bowel
movements roughly every 37-48 days. What’s important
to note is that this is a normal phenomenon and not an
abnormal one. You do not need to have a daily bowel
movement to feel well. Nevertheless, less than once a
month seems kind of extreme.
His weight decreased from 456 to 180 pounds. Even 5
years afterward, he remained at 196 pounds. One of the
most persistent concerns about fasting is the effect on
electrolytes. You can see from the accompanying graph
that blood sugars do go lower, but remain at the lower
limit of normal. There were no episodes of
 25

hypoglycaemia. This is, of course, to be expected, since the body will begin the process of
gluconeogenesis (making of new glucose) in order to supply the brain and certain other parts that
need glucose (renal medulla and red blood cells). Even the brain is mostly using ketones at this
point. As previously shown, muscle is not consumed to provide glucose (gluconeogenesis).
Instead, the glycerol backbone from triglycerides (fat) is recycled into glucose while the three
fatty acid chains are used for fuel by most of the body.
Calcium and phosphorus levels in the blood vary
over the fasting duration but generally remain
within the normal limits and are virtually
unchanged by the end of the fast. The same goes for
plasma urea and creatinine, which are widely used
measures of kidney function. Sodium, potassium,
chloride and bicarbonate were all unchanged and in
the normal range. In this study, uric acid remains
stable although other studies have shown some
increased uric acid.
Serum magnesium levels did decrease in this study. This is consistent with what we see clinically
in our clinic as well. It seems to be especially prevalent in diabetics. It is important to realize that
99% of the body’s magnesium is intracellular and not measured by blood levels. In this study,
researchers took the next step to measure the magnesium content within the cells and the
erythrocyte Mg levels remained firmly in the normal range. Nevertheless, we often supplement
with magnesium to be on the safe side.
The rate of weight loss was 0.72 pounds per day averaged over the entire 382 days. Other studies
of fasting over 200 days had shown similar rates of weight loss (from 0.41 to 0.67 pounds per
day) for periods of 210, 236, 249 and 256 days. This average of 0.565 ((0.41 + 0.72)/2) is
actually quite interesting.
We assume that one pound of fat is 3500 calories. This is a widely quoted figure, but not
especially accurate. If we assume that one eats 2000 calories per day, then we would expect
2000/3500 = 0.57 pounds weight loss per day, which is fairly close to that number actually seen.
So, for a patient with 100 pounds of fat to lose, you might expect that it would take roughly 200
days to lose it all. 200 days! I don’t generally subscribe to calorie theory for the reason the
Caloric Reduction results in reduced Caloric Expenditure. In other words, decreasing Calories In
decreases Calories Out resulting in a plateau of weight loss efforts.
However, in the case of straight-on fasting, the caloric theory holds as promised, resulting in a
weight loss very close to that predicted if Caloric Expenditure stays stable. In other words –
metabolism does not decrease in fasting. A prolonged caloric reduction, on the other hand,
is shown to decrease metabolism.
The Ancient Secret
I’ve sometimes called Intermittent Fasting the ‘Ancient Secret’ of weight loss. Why do I resort to
such hyperbole? Well, because it’s true. It is an ancient technique of weight loss – dating at to
the time of the ancient Greeks over 2. So, if you want to talk about time-tested practices, nothing
beats fasting. Consider that LowCarb diets such as endorsed by William Banting also have a long
 26

history but only dating from the mid 1800’s. Obesity was quite rare in the time of Jesus Christ,
so fasting was used as a method of preserving good health and improving mental clarity.
But why is fasting a
‘secret’? Well, because
the nutritional authorities
have spent the last 30
years convincing us that
we need to eat more to
lose weight. We’ve all
heard these lies.
You must always eat
breakfast within one
minute of getting out of
bed.

You must eat snacks constantly, all day long or else you’ll be consumed by hunger and
stuff your face with Krispy Kreme donuts.
You should eat 6-7 meals a day or else you’ll be consumed by hunger and stuff your face
with Krispy Kreme donuts.
You should eat a bedtime snack or else you’ll be hungry while asleep and then stuff your
face with Krispy Kreme donuts when you wake up.
You must never, ever miss a meal, otherwise you’ll be consumed by hunger and stuff
your face with Krispy Kreme donut.
If you miss a single meal, you’ll develop eating disorders like anorexia.

This last one must be one of the most idiotic myths out there. Fasting is not, like, exactly fun. It’s
a hell of a long way from morbid obesity to anorexia. Furthermore, anorexia is a psychologic
disorder of body image. Fasting does not lead to anorexia any more than washing your hands
leads to obsessive compulsive disorder. But these lies persist.
Nevertheless, because of all the worries, you can rest assured that there are studies that show
that intermittent fasting does not lead to eating disorders.
Sadly, the public at large has bought into these lies. You can
see that from 1977, the vast majority of people ate 3 times a
day. By 2003, most people were eating 5-6 times per day.
This weight loss advice was as useful as a third nostril.
Much of this increase in eating opportunity is likely to have
been funded by Big Food. They want to sell more food. It’s
easier to sell more food if people are eating more
frequently. So, in order to do that, they needed to make sure
that you didn’t ever miss a single meal.
 27

So here’s the bottom line.

Can you fast? Yes – literally millions of people around the world for thousands of years have
done it.
Is it unhealthy? No. In fact, it has enormous health benefits, that we have not even touched upon
yet.
Will you lose weight? Here is the crazy thing. People have been convinced that fasting will make
them gain weight (the bogeyman – starvation mode). OK, Einstein – if you don’t eat anything for
2 weeks, do you think you will lose weight? Of course.
Is it difficult? Not really. Millions of people do it. But it’s not exactly fun, either.
So fasting is effective, simple (one main rule – don’t eat), flexible (lots of different regimens),
practical (saves time and money), and virtually guaranteed to work. So why don’t people support
it? Because nobody makes money off you when you fast. Only when you buy crazy things like
meal replacement shakes. Nobody wants to you to find out the Ancient Secret of Weight Loss.
 28

Caloric Reduction vs Fasting – Part 9

Some would argue that the beneficial effect of fasting is due to the caloric reduction. But why is
there such a striking difference between reducing calories and fasting? Caloric Reduction as
Primary (CRaP) has been tried innumerable times, and failed virtually every single time. Yet
fasting is often effective where simple caloric reduction is not. The short answer is that the
beneficial hormonal changes that happen during fasting are entirely prevented by the constant
intake of food. It is the intermittency of the fasting that makes it so much more effective. This
prevents the development of resistance.
Let’s compare the failed CRaP technique to the intermittent fasting (IF) one. Let’s quickly
review the conventional advice to portion control, or reduce daily caloric intake. We often hear
the advice to simply reduce 500 calories a day and expect to lose 1 pound of fat per week.
Success is as rare as humility in a grizzly bear, but that doesn’t stop well meaning, but idiotic
health professionals from recommending it. After all, who hasn’t tried to portion control strategy
of weight loss. Who has been able to maintain long term weight loss? Does it work? No.
It is always a little surprising to me how fervent the calorie believers are. From a purely practical
standpoint, consider this. We, as medical professionals, have advised people for at least 40 years
to control their calories. We tell them that is all about Calories In, Calories Out. Technically true,
it turns out that the Calories Out, the part we do NOT control is vastly more important than
Calories In. Nevertheless, doctors such as Dr. Katz, continue to advise cutting their calories and
pretend that they will lose weight.
But it has never worked. The failure rate is 98%. Practical
personal experience shows that this is likely to be true. So,
whatever else you may believe, caloric reduction DOES NOT
WORK. This is a proven fact. Proven in the bitter tears of a
million believers. But, no matter how many times I tell a calorie
enthusiast, I get the uncomprehending gaze of an anxious
monkey.
So, what happens with this CRaP strategy? A detailed review
can be found in the Calories series earlier. Essentially, the body
tends to maintain a body set weight (BSW). The body is
initially able to lose some weight. However, as weight goes
down, the body compensates for this weight loss by trying to
regain the lost weight. Hormonal mediators of hunger (ghrelin)
increase. This means that measures of hunger and desire to eat
increase. This happens almost immediately and persists almost Dr. David Katz - Calorie Believer
indefinitely.
Next, the body’s metabolism starts to shut down. In response to a 30% decrease in calories, there
is a roughly 30% decrease in total energy expenditure. We start to feel tired, cold, and we have
little energy for things like exercise.
As the body’s TEE decreases, the weight loss starts to slow down and then plateau. Eventually
the weight starts to go back on, even as we continue to follow the diet. So the metabolic
adaptations to CRaP is an increase in hunger and a decrease in basal metabolism. So, as you diet,
 29

you feel hungry, tired, cold and generally miserable. Does this sound familiar to any dieters?
Probably sounds familiar to every dieter. This is what Dr. Ancel Keys had shown decades ago in
his Minnesota Starvation Experiment.
The worst part is that this strategy is guaranteed to fail. It has been proven by science long ago.
The huge 50,000 woman randomized trial (Women’s Health Initiative) of the low fat low calorie
diet proved to be an utter failure for weight loss. The problem with this strategy is that it does not
address the long term problem of insulin resistance and high insulin levels. Since the insulin sets
the ‘BSW thermostat’ – the body keeps trying to regain the lost weight.
Here’s the bottom line. As you reduce calories, appetite goes up, and TEE goes down. You
reduce Calories In, but Calories Out goes down, too. This is failure guaranteed 100%. It’s as
stupid as cracking the safe of your own bank.
Intermittent Fasting
As we recently detailed in the fasting series, the hormonal changes that happen in IF are
completely different. In contrast to CRaP, during fasting, appetite goes down and TEE goes up.
The body is trying to lose weight and helping you along. The main point is that it addresses the
long term problem of insulin resistance. During caloric reduction alone, you do not get any of
the beneficial hormonal adaptations of fasting.
The hormonal
adaptations are
completely
different, as we
have discussed so
far in this series.
Glucose and insulin
go down and stay
down.
During IF, the intermittent nature of the intervention helps to prevent the insulin resistance
problem. A recent trial – The effects of intermittent or continuous energy restriction on weight
loss and metabolic disease risk markers: a randomized trial in young overweight women –
compares CRaP to IF. In this study, 107 women were randomized to two strategies. The first
was a 25% continuous energy restriction (CER) – similar to the CRaP strategy of portion control.
The second strategy was intermittent energy restriction (IER). Patients were allowed normal
intake on 5 days a week, but only 25% of their usual calories on 2 days of the week – very
similar to the 5:2 diet of Dr. Michael Mosley.
Let’s assume the usual caloric intake was 2000
calories per day. With CER, calories are reduced
to 1500, or 10,500 calories over 1 week. With
IER, weekly calories are 11,000 calories per week.
So this study effectively keeps caloric intake
steady – or even favouring the CER group
slightly. The basic diet was a Mediterranean style
diet with 30% fat.
 30

Over 6 months, what were the results? In terms of weight loss and fat loss, there were no
significant difference although the IER tended to do better (5.7 vs 5.0 kg weight loss, 4.5kg vs
3.2kg fat loss).
But the real important part of the study was the effect on insulin and insulin resistance. After all,
I’ve spent the last 60+ blog posts arguing that insulin and insulin resistance are the key factors in
obesity and weight gain.
What happens to insulin levels? Well, there is a
clear, substantial improvement in insulin levels
favouring the IER group. Even more impressive is
the change in insulin resistance. This is measured
by HOMA, which is a comparison of fasting
glucose to fasting insulin.
In the CER group, there is virtually no change in
their insulin resistance (IR). Because there is no
change in IR, this will continue to lead to higher
insulin levels in a vicious cycle. These higher
insulin levels perpetuate the higher IR.
This is the long term problem of weight loss. This is
exactly the part of the equation that is typically
ignored and leads to the typical weight regain. It is the intermittency of the diet that makes it
effective.
We can look back at human history. Fasting has been used for the last 2000 years as a
tremendously effective method of controlling obesity. Portion control (CRaP) has only been used
extensively for the last 50 years with stunning failure. Yet, pundits such as Dr. Katz and others
continually scream at us through books, TV, and online to reduce calories. Don’t they think
we’ve tried that?
But the one strategy that does help, fasting, is continually belittled as a dangerous practice akin
to blood letting and voodoo. The problem with most diets is that they ignore the biological
principle of homeostasis – that is the ability of the body to adapt to changing environments. The
body has a preferred state. If you move away from it, the body will adapt to it. For example, if
you are in a dark room and suddenly go into the bright sunlight, you will momentarily be
blinded. However, within moments, your body will adapt.
The same applies to weight loss. If you try to keep a constant diet, the body will adapt to it. This
means that successfully dieting requires an intermittent strategy, not a constant one. This is a
crucial difference.
The difference is between restricting some foods all the time (CER) and
restricting all foods some of the time (IER). This is the difference between failure and success.
 31

Women and Fasting – Part 10

Not surprisingly, the use of fasting for weight loss has a long history, since it’s, kind of,
like, obvious. I mean, everybody understands that if you do not eat, you are highly likely to lose
weight. Duh. Which makes it even more surprising how much people fear missing even a single
meal, let alone fast for a prolonged period of time. They think that fasting (not eating) will make
you fat. That’s kind of like saying that splashing water on your head will dry your hair. That’s
modern dietetics for you. Kind of a Bizarro world.
There are still many doctors who argue that eating sugar is not bad for type 2 diabetics. Kind of
makes you wonder how they got into medical school at all. Since it is quite obvious that missing
meals leads to weight gain, the old bogeyman, ‘starvation mode’ is often invoked to instill fear.
Tales of people ‘ruining’ their metabolism abound. Food companies, of course have eagerly
‘educated’ medical professionals about the dangers of missing meals and the safety of eating
sugar. Nobody makes money when you skip meals.
Fasting appeared in the medical
literature over 1 century ago.
Interestingly, they describe
‘professional fasters‘ who would
fast for specific periods of time for
exhibition. One professional faster
went for 30 days and drank a
quantity of his own urine. Talk
about being starved for
entertainment. Kind of like
watching paint dry. This was
depicted in Franz Kafka’s short
story “A Hunger Artist”. Fasting
for entertainment was popular from
1883-1924. My guess is that it
really is not that entertaining.
In the early 1900s, Drs. Folin and Denis described fasting as ‘a safe, harmless and effective
method for reducing weight of those suffering from obesity’. Great. That’s exactly what we
need. Something safe, harmless, and effective. The fact that fasting has been performed (mostly
for religious purposes) for several thousand years only reinforced the long history of safety. It’s
hard to argue that fasting is dangerous if people have been doing for the 5000 years. May as well
argue that using soap is dangerous. Yet, myths about the dangers of fasting are everywhere.
By the early 1950’s, Dr. W. Bloom reignited interest in fasting as a therapeutic measure mostly
using shorter fasting periods. However, many longer periods were also described in the
literature. Dr. Gilliland reviewed fasting in the revival of the 1950’s and1960’s and reported his
experience with 46 patients “whose reducing regime started with a standard absolute fast for 14
days”. Whoa. I love that. When I tell people to fast for more than 24 hours their eyes just about
bug out of their head. These people had a ‘standard’ fast that lasted for 2 weeks! And that was
just the beginning!
 32

Of these, there were 14 males and 32 females. This is important because I constantly get
questions about whether fasting works for females. This is primarily, I think due to a post found
online that’s been viewed close to 100,000 times. What she wrote in 2012 is this – “Intermittent
fasting and women: Should women fast? The few studies that exist point towards no.”
Nothing is further from the truth. There are hundreds of studies spanning over 100 years and
clinical experience spanning 5000 years that point to the fact that women and men respond more
or less equally except in the underweight situation. This is an easy problem. Should anybody
who is seriously underweight, fast? Uh, no. You don’t have to be a genius to figure that out
yourself. If you are severely underweight and fast, you could become infertile, yes.
Consider the past 2000 years of human history. Are Muslim women ‘exempt’ from fasting? Are
Buddhist women ‘exempt’ from fasting. Are Catholic women ‘exempt’ from fasting? So we have
millions of person-years of practical experience with women and fasting. And there are no
problems in 99.9% of cases. In our own clinic, where we’ve treated close to 1000 patients, I have
noticed no significant difference between men and women. If anything, the women tend to do
better. Men, it seems, are sometimes just big babies. I will mention here, too, that the highest
success rates come when husband and wife do it together.
However, pregnant women are, in fact ‘exempt’ from fasting in almost all human religion. As are
children. In both situations, this makes entirely logical sense. These people need adequate
nutrients for growth, and human populations have always acknowledged this.
Let’s be clear here. This point is made that several problems come up with fasting in women.
Well, they come up with men and fasting, too. Sometimes women don’t lose weight the way they
want. Well, that happens with men, too. The problem of amenorrhea arises when body fat is too
low. Yeah, that’s not a problem we treat with fasting. If amenorrhea or any other problems
appear during fasting – stop immediately. The women and fasting issue is just another myth
designed to discourage fasting. Virtually all case series of the past 100 years have included both
men and women.
Anyway, back to the study. The patients
were hospitalized into a metabolic ward
during the first 14 days and only water, tea
and coffee were allowed. After that, they
were discharged and asked to follow a 600-
1000 calorie diet. Funny enough, 2 patients
asked(!) to be readmitted for a second 14
day period of fasting because they wanted
better results. Did it work? Was there ever
any doubt?
Average weight loss was 17.2 pounds in 14
days. This is in excess of the roughly 1/2
pound per day of fat loss seen in more
prolonged fasting. This indicates that some
of the initial early weight loss is water
weight. This is confirmed by the rapid regain of weight upon refeeding. It is important to
understand this in order to avoid the disappointment that often accompanies the weight
 33

gain upon eating again. That quick weight loss and regain is water weight and not a reflection
that the fasting ‘failed’. 44 of 46 patients completed the 2 week fasting period. One developed
nausea and one simply decided against it and dropped out.
That’s a 96% success rate even for a regimen as long as a 2 week fast! This is our clinical
experience as well. People always think they cannot do it without ever having tried it a single
time. Once we start with fasting, patents in our Intensive Dietary Management (IDM) program
quickly realize that it’s actually quite easy.
However, after the fasting period, patients were instructed to go on a low calorie diet. This was
terribly unsuccessful. 50% of patients did not adhere to this diet over the ensuing 2 year follow
up period. Instead of applying successful intermittent techniques, they returned to the
unsuccessful constant energy restriction we discussed at the last post.
The key point here is that the natural rhythm of life is Feast and Fast. There are times that you
should feast (weddings, celebrations), and there are times that you should fast. Intermittent. To
constantly restrict calories for years on end is unnatural and ultimately worse, unsuccessful.
Ketones appeared in the urine
starting on day 2 and persisted
throughout the fasting period. All 3
diabetic patients were all off insulin
by the end of the 2 weeks. One
patient with severe congestive heart
failure was able to walk without
breathlessness by the end. This 2
week fast was not harmful, as we
have been told, but extremely
beneficial.
Was it hard? In fact, Dr. Gilliland
describes a ‘feeling of well being’
and ‘euphoria’. Hungry? Well, no.
“We did not encounter complaints of
hunger after the first day. We did not
meet anorexia.” These experiences
were echoed by other researchers of
the time.
Dr. Drenick, from the VA centre in Los Angeles, also wrote extensively about therapeutic
fasting. His experience was published in 1968. This was a time of renewal of interest in fasting
for weight loss. He published his experience of 6 men and 4 women (yes, again there were
women in the study). Did it work? In a word, yes.
Should women fast? Yes
Should men fast? Yes
 34

Feasts and Fasts – The Cycle of Life – Fasting part 11

Feasts are an important part of life. This is a vitally important fact to acknowledge. That is, every
single important celebration is marked by feasting. Eating is a celebration of life. Any diet that
does not acknowledge this fact is doomed to failure. We eat cake on our birthday. We eat holiday
feasts like Thanksgiving. We celebrate Christmas dinner. We prepare wedding banquets. We go
to a nice restaurant on our anniversary.
We don’t celebrate with birthday salad. We don’t prepare
wedding meal replacement bars. We don’t eat
Thanksgiving ‘green’ shakes. We need to acknowledge a
fact that we’ve known all along. Weight gain is not a
constant phenomenon. It’s an intermittent one. With that
knowledge, you can see that a lasting solution to weight
gain is also intermittent. Weight gain varies throughout
life, and also throughout the year.
Certain periods of life are associated with increased
weight gain. This includes adolescence, where weight
gain is part of normal development. This also includes
pregnancy, another situation where insulin plays a
dominant role. Weight gain during pregnancy is normal.
However, it also increases the risk of obesity later in life
as well – a demonstration of the time dependence of
insulin and obesity. This period of increased insulin effect
(to help the body gain weight) may have lasting effects.
The simplest way to study this question is to compare women who have had children with those
who have not. There are multiple problems with this approach since this is not a randomized
group, and those who have never had children (nulliparous) may differ from those who have had
children. For example, the stress of having children and associated sleep deprivation may have
an effect. However, a randomized study is out of the question, so this is the best data we will get.
10 year follow up data from the first National Health and Nutrition Examination Survey
(NHANES 1971-75) was used in this paper from 1994. Overall, the women’s weight gain in
those with children compared to nulliparous was 1.6 kg after adjustment. With 1, 2, and 3
children the weight gain averaged 1.7kg, 1.7kg, and 2.2 kg respectively, so there shows some
evidence of dose-response.
That doesn’t seem so bad, does it? But the risk of gaining more than 13 kg was increased by 40-
60%! The risk of becoming overweight was increased by 60-110%. So, while the overall effect
seems modest, the health consequences may not be so. There seem to be some who are
predisposed to gain large amounts of weight with childbirth and many who go back to the pre-
birth weights. You probably already know some.
This is far from an isolated finding. In 1994, the Journal of the American Medical Association
published the CARDIA study also showed a 2-3 kg weight gain over 5 years associated with
 35

pregnancy. This happened in both blacks and whites. Waist to hip ratio also increased – an
indicator of visceral fat gain – the more dangerous type.
Menopause is also associated with significant weight gain. Women were measured during their
menopausal years and averaged 2.25 kg weight gain average. Along with this, the blood
pressure, serum cholesterol and fasting insulin tends to increase. In men, weight tends to increase
in the years after marriage. Married men tend to be fatter than unmarried ones. This does not
seem to hold true for women.
The main point is this –
weight gain is not always
steady. Also weight gain is
largely a hormonal, not a
caloric imbalance. The
hormonal changes of
pregnancy and menopause
can certainly precipitate
large weight changes.
Trying to battle a hormonal
problem with calorie-based
weapons is a losing
proposition.
Other life events often
cause or are associated with weight gain. Smoking cessation is a major cause of weight gain. In a
NEJM paper in 1991, it was estimated that weight gains average 2.8 kg in men and 3.8 kg in
women. However, some people have major weight gains of >13 kg – 9.8% in men and 13.4% in
women.
Even with a single year, the majority of weight gain happens in a short period of time. Let’s take
a closer look at where weight gain happens in a paper published in the New England Journal of
Medicine in 2000 called “A prospective study of holiday weight gain“. The holiday period of US
Thanksgiving to New Years covers roughly 6 weeks. Researchers repeatedly measured a sample
of 200 US adults to see whether weight gain happened disproportionately during this time.
Average weight gain over the entire year averages 0.2-0.8 kg per year. This is close to the 1-2
pound per year average that is commonly quoted in the lay press. In this study the average
weight gain over the entire year was 0.62kg.
However, this weight gain is not equally gained throughout the year. In the 6 weeks of the
holiday period, roughly 2/3 of the weight of the entire year was gained (0.37 kg). In the
remaining 46 weeks of the year, only 1/3 of the weight is gained. There is a small attempt to lose
weight in the immediate post-holiday period, but this is clearly not sufficient to offset the holiday
weight gain.
 36

Another interesting finding

was that those subjects who
were already overweight or
obese tended to gain the most
weight during the holiday
period. This is probably not
news to people. The fat get
fatter. Those who have
struggled with weight for the
longest, have the most
trouble.
This is yet another example
of the time-dependency of
obesity. One of the major
shortcomings of the caloric
theory is the overlooking of
this important fact of life.
If weight gain is not uniform
throughout the year, then
weight loss efforts also need
to vary. You need a strategy
of increasing weight loss at
times and maintenance of
weight at others. A constant
diet does not match the cycle of life. Feast and Fast. There are times that you should eat a lot.
There will be other times that you should be eating almost nothing. That is the natural cycle of
life.
If we keep all the feasting, but eliminate all the
fasting, then it is rather predictable what the
result is. Weight gain. In fact, religions have
almost universally acknowledged this fact.
There are many periods where feasting is
prescribed – Christmas for example. There are
other periods of time where fasting is prescribed
– Lent, for example.
The ancient civilizations and religions all knew
this simple rhythm of life. When the harvest
comes in, you feast. But you will fast often in
the upcoming winter. But now, in our modern
day of continuous food availability, religions
have prescribed periods of feasting and fasting.
We have kept the feasts, but fear the fasts. They
have become demonized. And we have paid the
price.
 37

Type 2 diabetes has become an absolute epidemic in all age groups. It seems pretty obvious that
this is a balance problem. If you feast, you must fast. If you keep all the feasting and lose all the
fasting, you get fat. That’s really not so hard to understand, is it?
But what happens when you lose all the feasting? Well, then life becomes a little less special. If
you are the guy at the wedding who won’t drink, who won’t eat the cake, who won’t eat the full
meal, who won’t eat the appetizers – there’s a name for that – the party pooper.
Maybe you can keep it up for 6 months, or 12 months. But forever? Heck, not even the most
extreme religions did that. That’s pretty hard to do. Life is full of ups and downs. Celebrate the
ups because the downs are right around the corner. But you must balance the periods of eating a
lot with periods of eating very little. It’s all a matter of balance
 38

Practical Fasting Tips – Part 12

We’ve dealt extensively with the science of fasting, but sometimes there are many practical
considerations that need exploring, too. Fasting, like anything else in life requires some practice.
In days past, when religious fasting was a communal practice, these sort of practical tips were
passed on from generation to generation. If not, friends would often have useful advice on how
to handle the fasting, because there are definitely some problems that commonly arise. However,
with the decline in the practice of fasting, these sorts of advice are often difficult to find.
What can I take on fasting days?
There are many different rules for fasting. During Ramadan, for example, fasting is practiced
from sunrise to sundown and no food or beverages are taken. Other types of fasting will only
restrict certain types of foods – for example, abstaining from meat for a day. So there are no right
or wrong rules. What I describe is the fasting that we prescribe for health and weight loss, as we
use in our Intensive Dietary Management program.
All calorie-containing foods and beverages are withheld during fasting. Be sure to stay well
hydrated throughout your fast. Water, both still and sparkling, is always a good choice. Aim to
drink two liters of water daily. As a good practice, start every day with eight ounces of cool
water to ensure adequate hydration as the day begins. Add a squeeze of lemon or lime to flavor
the water, if you wish. Alternatively, you can add some slices of orange or cucumber to a pitcher
of water for an infusion of flavor, and then enjoy the water throughout the day. You can dilute
apple-cider vinegar in water and then drink it, which may help with your blood sugars. However,
artificial flavors or sweeteners are prohibited. Kool-Aid, Crystal Light, or Tang should not be
added to the water.
All types of tea are excellent, including green, black,
oolong and herbal. Teas can often be blended
together for variety, and can be enjoyed hot or cold.
You can use spices such as cinnamon or nutmeg to
add flavor to your tea. Adding a small amount of
cream of milk is also acceptable. Sugar, artificial
sweeteners or flavors are not allowed. Green tea is
an especially good choice here. The catechins in
green tea are believed to help suppress appetite.
Coffee, caffeinated or decaffeinated, is also
permitted. A small amount of cream or milk is
acceptable, although these do contain some calories. Spices such as cinnamon may be added, but
not sweeteners, sugar or artificial flavors. On hot days, iced coffee is a great choice. Coffee has
many health benefits, as previously detailed.
Homemade bone broth, made from beef, pork, chicken or fish bones, is a good choice for fasting
days. Vegetable broth is a suitable alternative, although bone broth contains more nutrients.
Adding a good pinch of sea salt to the broth will help you stay hydrated. The other fluids—
coffee, tea, and water—do not contain sodium, so during longer fasting periods, it is possible to
become salt-depleted. Although many fear the added sodium, there is far greater danger in
 39

becoming salt depleted. For shorter fasts such as the twenty-four- and thirty-six-hour variety, it
probably makes little difference. All vegetables, herbs or spices are great additions to broth, but
do not add bouillon cubes, which are full of artificial flavors and monosodium glutamate.
Beware of canned broths: they are poor imitations of the homemade kinds. (See below for a
bone-broth recipe.)
Broth Recipe
Vegetables
Chicken, pork or beef bones
1 tbsp of vinegar
Sea salt, to taste
Pepper, to taste
Ginger, to taste

1. Water to cover
2. Simmer for two to three hours until
ready
3. Strain and de-fat

How do I break my fast?

Be careful to break your fast gently. There is a natural tendency to eat large amounts of food as
soon as the fast is over. Interestingly, most people don’t actually describe overwhelming hunger,
but more of a psychological need to eat. Overeating right after fasting may lead to stomach
discomfort. While not serious, it can be quite uncomfortable. This problem tends to be self-
correcting.
Try breaking your fast with a handful of nuts or a small salad to start. Then wait for 15-30
minutes. This will usually give time for any waves of hunger to pass, and allow you to gradually
adjust. Short duration fasts (24 hours or less) generally require no special breaking of the fast,
but certainly for longer fasts it is a good idea to plan ahead.
I get hungry when I fast. What can I do?
This is probably the number-one concern. People assume they’ll be overwhelmed with hunger
and unable to control themselves. The truth is that hunger does not persist, but instead comes in
waves. If you’re experiencing hunger, it will pass. Staying busy during a fast day is often helpful.
Fasting during a busy day at work keeps your mind off eating.
As the body becomes accustomed to fasting, it starts to burn its stores of fat, and your hunger
will be suppressed. Many people note that as they fast, appetite does not increase but rather starts
to decrease. During longer fasts, many people notice that their hunger completely disappears by
the second or third day.
There are also natural products that can help suppress hunger. Here are my top five natural
appetite suppressants:
 40

1. Water: As mentioned before, start your day

with a full glass of cold water. Staying
hydrated helps prevent hunger. (Drinking a
glass of water prior to a meal may also
reduce hunger.) Sparkling mineral water
may help for noisy stomachs and cramping.
2. Green tea: Full of anti-oxidants and
polyphenols, green tea is a great aid for
dieters. The powerful anti-oxidants may help
stimulate metabolism and weight loss.
3. Cinnamon: Cinnamon has been shown to
slow gastric emptying and may help suppress hunger.(1) It may also help lower blood
sugars and therefore useful in weight loss. Cinnamon may be added to all teas and coffees
for a delicious change.
4. Coffee: While many assume that caffeine suppresses hunger, studies show that this effect
is likely related to anti-oxidants. Both decaffeinated and regular coffee shows greater
hunger suppression than caffeine in water.(2) Given its health benefits (see chapter 21
[REF.]), there is no reason to limit coffee intake. The caffeine in coffee may also raise
your metabolism further boosting fat burning.
5. Chia Seeds: Chia seeds are high in soluble fiber and omega 3 fatty acids. These seeds
absorb water and form a gel when soaked in liquid for thirty minutes, which may aid in
appetite suppression. They can be eaten dry or made into a gel or pudding.

Can I exercise while fasting?

Absolutely. There is no reason to stop your exercise routine. All types of exercise, including
resistance (weights) and cardio, are encouraged. There is a common misperception that eating is
necessary to supply “energy” to the working body. That’s not true. The liver supplies energy via
gluconeogenesis. During longer fasting periods, the muscles are able to use fatty acids directly
for energy.
As your adrenalin levels will be higher, fasting is an ideal time to exercise. The rise in growth
hormone that comes with fasting may also promote muscle growth. These advantages have led
many, especially those within the bodybuilding community, to take a greater interest in
deliberately exercising in the fasted state. Diabetics on medication, however, must take special
precautions because they may experience low blood sugars during exercise and fasting. (See
“What if I have diabetes?” for recommendations, in next post.)
 41

More Practical Fasting Tips – part 13

Will fasting make me tired?
In our experience at the Intensive Dietary Management Clinic, the opposite is true. Many people
find that they have more energy during a fast—probably due to increased adrenalin. Basal
metabolism does not fall during fasting but rises instead. You’ll find you can perform all the
normal activities of daily living. Persistent fatigue is not a normal part of fasting. If you
experience excessive fatigue, you should stop fasting immediately and seek
medical advice.
Will fasting make me confused or forgetful?
No. You should not experience any decrease in memory or concentration.
The ancient Greeks believed that fasting significantly improved cognitive
abilities, helping the great thinkers attain more clarity and mental acuity.
Over the long term, fasting may actually help improve memory. One theory
is that fasting activates a form of cellular cleansing called autophagy that
may help prevent age-associated memory loss.
I get dizzy when I fast. What can I do?
Most likely, you’re becoming dehydrated. Preventing this requires
both salt and water. Be sure to drink plenty of fluids. However, the
low-salt intake on fasting days may cause some dizziness. Extra sea
salt in broth or mineral water often helps alleviate the dizziness.
Another possibility is that your blood pressure is too low—
particularly if you’re taking medications for hypertension. Speak to
your physician about adjusting your medications.
I get headaches when I fast. What can
I do?
As above, try increasing your salt intake. Headaches are quite
common the first few times you try a fast. It is believed that they’re
caused by the transition from a relatively high-salt diet to very low
salt intake on fasting days. Headaches are usually temporary, and as
you become accustomed to fasting, this problem often resolves
itself. In the meantime, take some extra salt in the form of broth or
mineral water.
My stomach is always growling. What can I do?
Try drinking some mineral water.
Since I’ve started fasting, I experience constipation.
What can I do?
Increasing your intake of fiber, fruits and vegetables
during the non-fasting period may help with constipation.
 42

Metamucil can also be taken to increase fiber and stool bulk. If this problem continues, ask your
doctor to consider prescribing a laxative.
I get heartburn. What can I do?
Avoid taking large meals. You may find you have a tendency to overeat once you finish a fast,
but try to just eat normally. Breaking a fast is best done slowly. Avoid lying down immediately
after a meal and try to stay in an upright position for at least one-half hour after meals. Placing
wooden blocks under the head of your bed to raise it may help with night-time symptoms. If
none of these options work for you, consult your physician.
I take medications with food. What can I do during fasting?
There are certain medications that may cause problems on an empty stomach. Aspirin can cause
stomach upset or even ulcers. Iron supplements may cause nausea and vomiting. Metformin,
used for diabetes, may cause nausea or diarrhea. Please discuss whether or not these medications
need to be continued with your physician. Also, you can try taking your medications with a small
serving of leafy greens.
Blood pressure can sometimes become low during a fast. If you take blood-pressure medications,
you may find your blood pressure becomes too low, which can cause light-headedness. Consult
with your physician about adjusting your medications.
I get muscle cramps. What can I do?
Low magnesium levels, particularly common in diabetics, may cause muscle cramps. You may
take an over-the-counter magnesium supplement. You may also soak in Epsom salts, which are
magnesium salts. Add a cup to a warm bath and soak in it for half and hour. The magnesium will
absorb through your skin.
What if I have diabetes?
Special care must be taken if you are diabetic or are taking diabetic medications. (Certain
diabetic medications, such as metformin, are used for other conditions such as polycystic ovarian
syndrome.) Monitor your blood sugars closely and adjust your medications accordingly. Close
medical follow-up by your physician is mandatory. If you cannot be followed closely, do not
fast.
Fasting reduces blood sugars. If you are taking diabetic medications, or especially insulin, your
blood sugars may become extremely low, which can be a life-threatening situation. You must
take some sugar or juice to bring your sugars back to normal, even if it means you must stop
your fast for that day. Close monitoring of your blood sugars is mandatory.
Low blood sugar is expected during fasting, so your dose of diabetic medication or insulin may
need to be reduced. If you have repeated low blood sugars it means that you are over-medicated,
not that the fasting process is not working. In the Intensive Dietary Management Program, we
often reduce medications before starting a fast in anticipation of lower blood sugars. Since the
blood sugar response is unpredictable, close monitoring with a physician is essential.
Monitoring
 43

Close monitoring is essential for all patients, but especially, for diabetics. You should also
monitor your blood pressure regularly, preferably weekly. Be sure to discuss routine blood work,
including electrolyte measurement, with your physician. Should you feel unwell for any reason,
stop your fast immediately and seek medical advice. In addition, diabetics should monitor their
blood sugars a minimum of twice daily and recorded.
In particular, persistent nausea, vomiting, dizziness, fatigue, high or low blood sugars or lethargy
are not normal with intermittent or continuous fasting. Hunger and constipation are normal
symptoms and can be managed.
Top 8 Intermittent Fasting tips
1. Drink water: Start each morning with a full
eight-ounce glass of water.
2. Stay busy: It’ll keep your mind off food. It
often helps to choose a busy day at work for a
fast day.
3. Drink coffee: Coffee is a mild appetite
suppressant. Green tea, black tea, and bone broth
may also help.
4. Ride the waves: Hunger comes in wave; it is
not continuous. When it hits, slowly drink a glass
of water or a hot cup of coffee. Often by the time
you’ve finished, your hunger will have passed.
5. Don’t tell anybody you are fasting: Most
people will try to discourage you, as they do not
understand the benefits. A close-knit support
group is often beneficial, but telling everybody you know is not a good idea.
6. Give yourself one month: It takes time for your body to get used to fasting. The first few
times you fast may be difficult, so be prepared. Don’t be discouraged. It will get easier.
7. Follow a nutritious diet on non-fast days: Intermittent fasting is not an excuse to eat
whatever you like. During non-fasting days, stick to a nutritious diet low in sugars and refined
carbohydrates.
8. Don’t’ binge: After fasting, pretend it never happened. Eat normally, as if you had never
fasted.
The last and most important tip is to fit fasting into your own life! Do not limit yourself socially
because you’re fasting. Arrange your fasting schedule so that it fits in with your lifestyle. There
will be times during which it’s impossible to fast: vacation, holidays, weddings. Do not try to
force fasting into these celebrations. These occasions are times to relax and enjoy. Afterwards,
however, you can simply increase your fasting to compensate. Or just resume your regular
fasting schedule. Adjust your fasting schedule to what makes sense for your lifestyle.

What to expect
 44

The amount of weight lost varies tremendously from person to person. The longer that you have
struggled with obesity, the more difficult you’ll find it to lose weight. Certain medications may
make it hard to lose weight. You must simply persist and be patient.
You’ll probably eventually experience a weight-loss plateau. Changing either your fasting or
dietary regimen, or both, may help. Some patients increase fasting from twenty-four-hour
periods to thirty-six-hour periods, or try a forty-eight-hour fast. Some may try eating only once a
day, every day. Others may try a continuous fast for an entire week. Changing the fasting
protocol is often what’s required to break through a plateau.
Fasting is no different than any other skill in life. Practice and support are essential to performing
it well. Although it has been a part of human culture forever, many people in North America
have never fasted in their lives. Therefore, fasting has been feared and rejected by mainstream
nutritional authorities as difficult and dangerous. The truth, in fact, is radically different.
 45

The Fasting ‘Advantage’ – Part 14

What is the advantage of using a strategy based on intermittent fasting versus simple dietary
changes alone – such as the LowCarb HighFat diets that we prefer? There are several good ones.
Reason #1 – Simplicity
Simplicity.
When I started out my clinic, I tried to
persuade people to adopt the LCHF diet. I
was doing this for people of all ages, of all
nationalities. It is difficult enough for a
well educated English speaking, computer
literate person to adopt a strict LCHF diet.
This is hard given all the conflicting advice
flying around the internet and the airwaves.
We would tell people to go Low Carb and find food diaries full of whole wheat bread and plates
of pasta. Many people honestly did not understand the diet at all. I spent lots of time and grey
hair trying to change their diets, but many people simply did not understand. Furthermore, their
diets had not significantly changed in 40 years, and they were having a lot of trouble changing it.
Since the Low Fat approach had been indoctrinated into them for the last 20 years, it was hard
for people to understand how to eat a diet high in natural fats, rather than the low fat fare they
were used to. Using a completely different approach such as fasting was much easier for people
to understand.
Fasting itself, is so simple that it can be explained in two sentences. Eat nothing including sugars
or sweeteners. Drink water, tea, coffee or bone broth. That’s it. Even with this simple method,
we (Megan, not actually me anymore) spend hours explaining ‘how to’ fast.
The most obvious benefit to simplicity, though is demonstrated by the startlingly simple graph
above. The simpler, the more effective. Amen.
Reason #2 – Cheap
While I may prefer patients to eat organic,
local grass fed beef and avoid the white bread
and processed foods, the truth is that these
foods are often 10 times the cost. Some
people, simply put, cannot afford to eat that
well.
This is due to the distorting effect of
government subsidies on cost of food. Since
grains enjoy substantial government subsidies,
it is far cheaper to make something out of
 46

flour than whole foods. This means that fresh cherries cost $6.99/ pound and an entire loaf of
bread will cost $1.99. Feeding a family on a budget is a lot easier when you buy pasta and white
bread.
But that does not mean they should be doomed to a lifetime of type 2 diabetes and disability.
Fasting is free. Actually, it is not simply free, but it actually saves people money because you do
not need to buy any food.
Reason #3 – Convenience

While I may advise people to always eat a

home cooked, prepared-from-scratch meal,
there are many people who simply do not
have the time or inclination to do so. The
number of meals eaten away from home has
been increasing over the past few decades.
While there are many who try to support the
‘slow food’ movement, it is clear that they are
fighting a losing battle.
Don’t get me wrong, I love cooking as much
as the next guy. But it just takes a lot of time. From the Atlantic "Cheap Eats", March 8 2013
Between work, writing, and taking my kids to
school stuff and hockey, it just doesn’t leave a lot of time.
So asking people to devote themselves to home cooking, as noble as it may be, is not going to be
a winning strategy. Fasting, on the other hand is the opposite. You save time because there is no
time spent buying food, preparing, cooking and cleaning up. It is a way to simplify your life. I
often skip breakfast in the mornings. Man, the time saved! I often skip lunch, too. Man, the time
saved! If time is money….
Reason #4 – Cheat days
While I might advise people to never, ever again eat ice cream, I don’t think that is actually very
practical advice. Sure, you might be able to swear off of it for 6 months, or 1 year, but for life?
And would you really want to? Think about it. Think about the joy that some people get from
savouring an especially delicious dessert at a wedding feast. Do we need to deny ourselves that
little bit of pleasure forever? Let us all enjoy our birthday salad feast! Thanksgiving kale festival!
All you can eat brussel sprouts! Yes, life just got a little less sparkly. Forever is a long time.
Now, I am not saying that you can eat dessert every single day, but fasting gives you the ability
to occasionally enjoy that dessert because if you feast, you can balance the scale by fasting. It is,
after all, the cycle of life. The reason these ‘cheat’ days are important is because it builds
compliance. Simply put, it makes the diet easier to follow and changes it into a lifestyle instead.
We often counsel that the most important aspect of fasting is to fit it into your life.

Reason #5 – Power
 47

I often treat type 2 diabetic patients. Most of

them have had it for 10 years or more. So, of the
obese patients I treat, they are often the worst of
the worst in terms of obesity and insulin
resistance. Sometimes, even a strict LCHF diet
is not strong enough. The fastest and most
efficient way to lower insulin is intermittent
fasting.
In the end, you must ask yourself this question.
If you do not eat anything for 1 week, do you
think you will lose weight? Even a child
understands that you must lose weight. It is
almost inevitable. So its efficacy is
unquestioned.
There are only two remaining questions. First –
is it unhealthy? On the contrary, there are
extraordinary health benefits. Two – can you do it? Well, if you never try it, you will never
know. I think almost everybody can do it.
Reason #6 – Flexibility
Fasting can be done at any time and in any place. Furthermore, if you do not feel well for any
reason, you simply stop. It is entirely reversible within minutes.
Consider bariatric surgery (stomach stapling). These surgeries are done so that people can fast
for prolonged periods of time. And they tend to work, at least in the short term. But these
surgeries have tons of complications, almost all of which are irreversible.
Furthermore, why would we assume that somebody cannot fast for 1 week or 1 month without
ever having tried it?
Reason #7 – Add to any diet
Here is the biggest advantage of all. Fasting can be added to any diet. That is because fasting is
not something you do, but something you do not do. It is subtraction rather than addition.
You don’t eat meat? You can still fast.
You don’t eat wheat? You can still fast.
You have a nut allergy? You can still fast.
You don’t have time? You can still fast.
You don’t have money? You can still fast.
You are travelling all the time? You can still fast.
You don’t cook? You can still fast.
You are 80 years old? You can still fast.
 48

You have problems with chewing or swallowing? You can still fast.
What could possibly be simpler?
 49

Fasting and Muscle Mass – Fasting Part 15

It seems that there are always concerns about loss of muscle mass during fasting. I never get
away from this question. No matter how many times I answer it, somebody always asks,
“Doesn’t fasting burn your muscle?”
Let me say straight up, NO.
Here’s the most important thing to remember. If you are concerned about losing weight and
reversing T2D, then worry about insulin. Fasting and LCHF will help you. If you are worried
about muscle mass, then exercise – especially resistance exercises. OK? Don’t confuse the two
issues. We always confuse the two issues because the calorie enthusiast have intertwined them in
our minds like hamburgers and french fries.
Weight loss and gain is mostly a function of DIET. You can’t exercise your way out of a dietary
problem. Remember the story of Peter Attia? A highly intelligent doctor and elite level distance
swimmer, he found himself on the heavy end of the scale, and it was not muscle. He was
overweight despite exercising 3-4 hours a day. Why? Because muscle is about exercise, and fat
is about diet. You can’t out-run a bad diet.
Muscle gain/ loss is mostly a function of EXERCISE. You can’t eat your way to more muscle.
Supplement companies, of course, try to convince you otherwise. Eat creatine (or protein shakes,
or eye of newt) and you will build muscle. That’s stupid. There’s one good way to build muscle
– exercise. So if you are worried about muscle loss – exercise. It ain’t rocket science. Just don’t
confuse the two issues of diet and exercise. Don’t worry about what your diet (or lack of diet –
fasting) is doing to your
muscle. Exercise builds
muscle. OK? Clear?
So the main question is this
– if you fast for long
enough, doesn’t your body
start to burn muscle in
excess of what it was doing
previously in order to
produce glucose for the
body. Hell, no.
Let’s look carefully at this
graph by Dr. Kevin Hall
from the NIH in the book
“Comparative Physiology
of Fasting, Starvation, and
Food Limitation”. Great
title guys. Amazon probably couldn’t keep enough stock on the shelves.
But anywho, this is a graph of where the energy to power our bodies comes from, from the start
of fasting. At time zero, you can see that there is a mix of energy coming from carbs, fat and
protein. Within the first day or so of fasting, you can see that the body initially starts by burning
 50

carbs (sugar) for energy. However, the body has limited ability to store sugar. So, after the first
day, fat burning starts.
What happens to protein? Well, the amount of protein consumed goes down. There is certainly a
baseline low level of protein turnover, but my point is that we do not start ramping up protein
consumption. We don’t start burning muscle, we start conserving muscle.
Reviews of fasting from the mid 1980s had already noted that “Conservation of energy and
protein by the body has been demonstrated by reduced … urinary nitrogen excretion and
reduced leucine flux (proteolysis). During the first 3 d of fasting, no significant changes in
urinary nitrogen excretion and metabolic rate have been demonstrated”. Leucine is an amino
acid and some studies had shown increased release during fasting and other had not. In other
words, physiologic studies of fasting had already concluded that protein is not ‘burnt’ for
glucose.
It further notes that you can get increase leucine flux with no change in urinary nitrogen
excretion. This happens when amino acids are reincorporated into proteins. Researchers studied
the effect of whole body protein breakdown with 7 days of fasting. Their conclusion was that
“decreased whole body protein breakdown contributes significantly to the decreased nitrogen
excretion observed with fasting in obese subjects”. There is a normal breakdown of muscle
which is balanced by new muscle formation. This breakdown rate slows roughly 25% during
fasting.
The classic studies were done by George Cahill. In a 1983 article on “Starvation” he notes that
glucose requirements fall drastically during fasting as the body feeds on fatty acids and the brain
feeds on ketone bodies significantly reducing the need for gluconeogenesis. Normal protein
breakdown is on the order of 75 grams/day which falls to about 15 – 20 grams/day during
starvation. So, suppose we go crazy and fast for 7 days and lose about 100 grams of protein. We
make up for this protein loss with ease and actually, far, far exceed our needs the next time we
eat.
From Cahill’s study, you can see that the urea nitrogen excretion, which corresponds to protein
breakdown, goes way, way down during fasting/ starvation. This makes sense, since protein is
functional tissue and there is no point to burning useful tissue while fasting when there is plenty
of fat around. So, no, you do not ‘burn’ muscle during fasting.

Where does the glucose comes from? Well, fat is stored as

triglycerides (TG). This consists of 3 fatty acid chains
attached to 1 glycerol molecule. The fatty acids are
released from the TG and most of the body can use these
fatty acids directly for energy.
The glycerol, goes to the liver, where it undergoes the
process of gluconeogenesis and is turned into sugar. So,
Triglyceride the parts of the body that can only use sugar have it. This
is how the body is able to keep a normal blood sugar even
though you are not eating sugar. It has the ability to produce it from stored fat.
 51

Sometimes you will hear a dietician say that the brain ‘needs’ 140 grams of glucose a day to
function. Yes, that may be true, but that does NOT mean that you need to EAT 140 grams of
glucose a day. Your body will take the glucose it needs from your fat stores. If you decide to
EAT the 140 grams instead, your body will simply leave the fat on your ass, hips, and waist. This
is because the body will burn the sugar instead of the fat.

But let’s look at some clinical studies in the real world. In 2010, researchers looked at a group of
subjects who underwent 70 days of alternate daily fasting (ADF). That is, they ate one day and
fasted the next. What happened to their muscle mass?
Their fat free mass started off at 52.0 kg and ended at 51.9 kg. In other words, there was no loss
of lean weight (bone, muscle etc.). There was, however, a significant amount of fat lost. So, no,
you are not ‘burning muscle’, you are ‘burning fat’. This, of course, is only logical. After all,
why would your body store excess energy as fat, if it meant to burn protein as soon as the chips
were down? Protein is functional tissue and has many purposes other than energy storage,
whereas fat is specialized for energy storage. Would it not make sense that you would use fat for
energy instead of protein? Why would we think Mother Nature is some kind of crazy?
That is kind of like storing firewood for heat. But as soon as you need heat, you chop up your
sofa and throw it into the fire. That is completely idiotic and that is not the way our bodies are
designed to work.
How, exactly does the body retain lean tissue? This is likely related to the presence of growth
hormone. In an interesting paper, researchers fasted subjects and then suppressed Growth
Hormone with a drug to see what happened to muscle breakdown. In this paper, they already
acknowledge that “Whole body protein decreases”. In other words, we have known for 50 years
at least, that muscle breakdown decreases substantially during fasting.
By suppressing GH during fasting, there is a 50% increase in muscle break down. This is highly
suggestive that growth hormone plays a large role in maintenance of lean weight during fasting.
The body already has mechanisms in place during fasting to preserve lean mass and to burn fat
for fuel instead of protein.
So let me lay it out as simply as I can. Fat is, at its core essence, stored food for us to ‘eat’ when
there is nothing to eat. We have evolved fat stores to be used in times when there is nothing to
 52

eat. It’s not there for looks, OK? So, when there is nothing to eat (fasting), we ‘eat’ our own fat.
This is natural. This is normal. This is the way we were designed.
And its not just us, but all wild animals are designed the same way. We don’t waste away our
muscle while keeping all our fat stores. That would be idiotic. During fasting, hormonal changes
kick in to give us more energy (increased adrenalin), keep glucose and energy stores high
(burning fatty acids and ketone bodies), and keep our lean muscles and bones (growth hormone).
This is normal and natural and there is nothing here to be feared.
So, I will say it here, yet again.

1. No, fasting does not mean you burn protein for glucose. Your body will run on fat.
2. Yes, your brain needs a certain amount of glucose to function. But no, you do not have to
EAT the glucose to get it there
 53

Fasting Lowers Cholesterol – Fasting 16

How can you lower cholesterol without resorting to medications? High cholesterol is considered
a treatable risk factor for cardiovascular disease such as heart attacks and strokes. There are
many nuances to cholesterol which I do not want to get into, but traditionally, the main division
has been between Low Density Lipoprotein (LDL) or ‘bad’ cholesterol, and High Density
Lipoprotein (HDL) or ‘good’ cholesterol. Many people do not look so closely at total cholesterol
anymore, because there is both good and bad factions and therefore, the total cholesterol gives us
little useful information.
We also measure triglycerides, a type of fat found in the blood. Fat is
stored in fat cells as triglycerides, but also floats around freely in the
body. For example, during fasting, triglycerides get broken down into
free fatty acids and glycerol. Those free fatty acids are used for energy
by most of the body. So triglycerides are a form of stored energy.
Cholesterol is not. This substance is used in cellular repair (in cell
walls) and also used for to make certain hormones.
One might (mistakenly) think that decreasing dietary cholesterol may
reduce blood cholesterol levels. However, 80% of the cholesterol in our
blood is generated by the liver, so reducing dietary cholesterol is quite
Framingham Diet Study unsuccessful. Studies going back to Ancel Key’s original Seven
Country Studies show that how much cholesterol we eat has very little
to do with how much cholesterol is in the blood. Whatever else he got wrong, he got this right –
eating cholesterol does not raise blood cholesterol.
The next thought was
that lowering dietary
fat, especially saturated
fats may help lower
cholesterol. While
untrue, there are still
many who believe it. In
the 1960’s the
Framingham Diet
Study was set up to
specifically look for a
connection between
dietary fat and
cholesterol. Why haven’t you heard of it, before? Well, the findings of this study showed no
correlation between dietary fat and cholesterol whatsoever. Because these results clashed with
the prevailing ‘wisdom’ of the time, they were suppressed and never published in a journal.
Results were tabulated and put away in a dusty corner.
The Tecumseh study divided their subjects into 3 levels of blood cholesterol – low, medium and
high. Then, they looked at how much fat and cholesterol each group ate. It turns out that each
group pretty much ate the same amount of fat, animal fats, saturated fats and cholesterol. So,
 54

what they demonstrated was that dietary intake of fat does not have very much to do with
cholesterol at all.
Low fat and extremely low fat diets can lower the LDL (bad cholesterol) slightly, but they also
tend to lower the HDL (good cholesterol) so it is arguable whether things improve or not.
Actually, we’ve known that for quite some time. For example, here’s a study in 1995, where 50
subjects were fed either a 22% or a 39% fat diet. Baseline cholesterol was 173 mg/dl. After 50
days of a low fat diet, it plummeted to … 173 mg/dl. Oh. High fat diets don’t lower cholesterol
either. After 50 days of high fat diets, cholesterol increased marginally to 177 mg/dl.
Millions of people try a low fat or low cholesterol diet without realizing that these have already
been proven to fail. I hear this all the time. Whenever somebody is told their cholesterol is high,
they say “I don’t understand. I’ve cut out fatty foods”. Well, reducing dietary fat will not change
your cholesterol. So, what to do? Statins, I guess?
“A little starvation can really do more for the average sick man than can the best medicines and
the best doctors” – Mark Twain
Studies show that fasting is a simple dietary strategy that can significantly lower cholesterol
levels.
Now, there are many controversies about lipids that I do not wish to get quagmired in. I’m only
going to discuss the conventional view of it. That is, many of the classic studies, such as the
Framingham study, have pointed out that there is a correlation between high levels of ‘bad’
cholesterol and cardiovascular disease. The higher the LDL, the more bad things happen.
HDL
‘Good’ cholesterol (HDL) shows an inverse relationship. High levels are protective. So the lower
the HDL, the higher the risk of CV disease. This association is actually much more powerful
than that for LDL, so let’s start here. However, it is clear that HDL is not causally related to CV
events. They are only a marker for disease.
Several years ago, Pfizer poured billions of dollars into
researching a drug called torcetrapib (a CETP inhibitor). This
drug had the ability to significantly increase HDL levels. If low
HDL caused heart attacks, then this drug could save lives. Pfizer
was so sure of itself, it spent billions of dollars trying to prove the
drug effective.
The studies were done. And the results were breathtaking.
Breathtakingly bad, that is. The drug increased death rate by 25%.
Yes, it was killing people left and right like Ted Bundy. Several
more drugs of the same class were tested and had the same killing effect. Just one more
illustration of the Correlation is not Causation truth.
What happens to HDL during fasting? You can see from the graph that 70 days of alternate daily
fasting had a minimal impact upon HDL levels. There was some decrease in HDL but it was
minimal.
Triglycerides
 55

The story of triglycerides (TG) is similar. While TGs may be correlated weakly to heart disease,
they do not cause it. There were several drugs that reduce TG to a much greater extent than the
cholesterol medications, the statins. Niacin was one such example. This drug would increase
HDL and lower TG without very much effect on the LDL.
The AIM HIGH study tested whether this would
have any benefit. The results were stunning.
Stunningly bad, that is. While they did not kill
people, they did not help them either. And there
were lots lot side effects. So, TG, like HDL is
only a marker not a causer of disease.
What happens to TG during fasting? There’s a
huge 30% decrease in TG levels (good) during
alternate daily fasting. In fact, triglycerides is
quite sensitive to diet. But it is not reducing
dietary fat or cholesterol that helps. Instead,
reducing carbohydrates seems to be the main
factor that reduces TG levels.
LDL
The LDL story is much more contentious. Certainly, there is a correlation between high LDL
levels and CV disease. However, the more important question is whether this is a causal
relationship. The statin drugs lower LDL cholesterol quite powerfully, and also reduces CV
disease in high risk patients. But these drugs have other effects, often called the pleiotropic
(affecting multiple systems) effects. For example, statins also reduce inflammation, as shown by
the reduction in hsCRP, an inflammatory marker. So, is it the cholesterol lowering or the
pleiotropic effects that are responsible for the benefits?
This is a good question to which I do not have an answer yet. The way to tell would be to lower
LDL using another drug and see if there are similar CV benefits. The drug ezetimibe in
the IMPROVE-IT trial also had some CV benefits, but they were extremely weak. To be fair, the
LDL lowering was also quite modest.
A new class of drugs called the PCSK9
Inhibitors has the power to reduce LDL a lot.
The question, though is whether there will be
any CV benefit. Early indications are quite
positive. But it is far from definitive. So the
possibility exists that LDL may play a causal
role here. This is, after all, why doctors worry
so much about keeping LDL down.
What happens to LDL levels during fasting?
Well, they go down. A lot. Over the 70 days of
alternate daily fasting, there was about a 25%
reduction in LDL (very good). To be sure,
drugs can reduce them about 50% or more, but
this simple dietary measure has almost half the power of one of the most powerful classes of
 56

medications in use today.

In combination with the reduction in body weight, preserved fat-free mass, and decreased waist
circumference, it is clear that fasting produces some very powerful improvements in these
cardiac risk factors. Don’t forget to add in the reduced LDL, reduced Triglycerides and preserved
HDL.
But why does fasting work where regular diets fail? Simply put, during fasting, the body
switches from burning sugar to burning fat for energy. Free fatty acids (FFA) are oxidized for
energy and FFA synthesis is reduced (body is burning fat and not making it). The decrease in
triacylglycerol synthesis results in a decrease in VLDL (Very Low Density Lipoprotein)
secretion from the liver which results in lowered LDL.
The way to low ever LDL is to make your body burn it off. The mistake of the low fat diet is this
– feeding your body sugar instead of fat does not make the body burn fat – it only makes it burn
sugar. The mistake of the Low Carb High Fat diet is this – giving your body lots of fat makes it
burn fat, but it will burn what’s coming into the system (dietary fat). It won’t pull the fat out of
the body.
Here’s the bottom line for those big-picture, spare-me-the-details kind of folks. Fasting has the
following effects:

1. Reduces weight
2. Maintains lean mass
3. Decreases waist size
4. Minimal change in HDL
5. Dramatic reductions in TG
6. Dramatic reductions in LDL

That’s all good. Whether this will all translate into improved cardiac outcomes, I don’t have the
answer for you. My guess is Yes.
However, fasting always boils down to this. There’s all these benefits. There’s very little risk.
What do you have to lose (other than a few pounds)?
 57

For people worried about heart attacks and strokes, the question is not “Why are you fasting?”,
but “Why are you NOT fasting?”
 58

Fasting and Hunger – Fasting 17

Does fasting increase your hunger to unimaginable and uncontrollable dimensions? This is often
how fasting is portrayed, but is it really true? From a purely practical standpoint, it is not. From
my personal experience with hundreds of patients, one of the most consistent, yet surprising
things reported is the reduction, not an augmentation of hunger. They often say things like, “I
thought I would be consumed by hunger, but now I only eat 1/3 of what I used to, because I am
full!” That’s great, because now you are working with your body’s hunger signalling to lose
weight instead of constantly fighting it.
The number 1, most common misperception of fasting is it will leave us overwhelmed with
hunger and therefore prone to severe overeating. Thus you get pronouncements from
‘experts’ like “Don’t even think about fasting, otherwise you will be so hungry that you will stuff
your face full of Krispy Kreme donuts”. Funny enough, these ‘experts’ often have zero
experience with fasting either personally or with clients. So why does it seem so reasonable?
Approximately 4-8 hours after we eat a meal, we start to feel hunger pangs and may become
slightly cranky. Occasionally they are quite strong. So we imagine that fasting for a full 24 hours
creates hunger sensations 5 times stronger – and that will be intolerable. But this is exactly what
does NOT happen. Why?
Hunger is, in fact, a highly suggestible state.
That is, we may not be hungry one second, but
after smelling a steak and hearing the sizzle,
we may become quite ravenous. Hunger is
also a learned phenomenon, as demonstrated
by the classic experiments of Pavlov’s dogs –
known in psychology as Pavlovian, or
classical conditioning.
In the 1890s, Ivan Pavlov was studying
salivation in dogs. Dogs will salivate when
they see food and expect to eat (unconditioned
stimulus – UCS) – that is, this reaction occurs
naturally and without teaching. In his
experiments, lab assistants would go in to feed
the dogs and the dogs soon began to associate
lab coats (conditioned stimulus -CS) with
eating. There is nothing intrinsically
appetizing about a man in a lab coat (yummy!), but the consistent association between the lab
coat and food paired these two in the dog’s mind.
Very soon, the dogs began to salivate at the sight of the lab coats alone (having now been
conditioned) even if food was not available. Ivan Pavlov, genius that he was, noticed this
association and started to work with bells instead and before you know it, he was packing his
bags to Stockholm to get his Nobel Prize and taste some of those oh-so-delicious Swedish
meatballs. By pairing bells and food, the dogs began to anticipate food (salivate) at hearing bells
alone without the food. This was the Conditioned Response
 59

The applicability of this Psychology 101 lesson to hunger is obvious. That is, we can become
hungry for many reasons – some of which are natural (smell and sizzle of steak) and others
which have become conditioned into us. These conditioned responses can be very powerful and
cause great hunger. If we consistently eat breakfast every single morning at 7:00, lunch at 12:00
and dinner at 6:00pm, then the time of day itself becomes a conditioned stimulus for eating. Even
if we ate a huge meal at dinner the night before, and would not otherwise be hungry in the
morning, we may become ‘hungry’ because it is 7:00. The Conditioned Stimulus (time of 7:00)
causes the Conditioned Response (hunger).
Similarly, if we start to pair the act of watching a movie with delicious popcorn and sugary
drinks, then the mere thought of a movie may make us hungry even though we have already
eaten dinner and would normally not be hungry. The movie is the conditioned stimulus. Food
companies, of course, spend billions of dollars trying to increase the number of CS that will
make us hungry. The Conditioned Response is hunger – for popcorn, chips, hot dogs, sodas, etc.
Food at the ballgame! Food with movies! Food with TV! Food in between halves of kids soccer!
Food while listening to a lecture! Food at the concerts! You can eat with a goat. You can eat on a
boat. You can eat in a house. You can eat with a mouse. Conditioned responses, every one.
How to combat this? Well, intermittent fasting offers a unique solution. By randomly skipping
meals and varying the intervals that we eat, we can break our current habit of feeding 3 times a
day, come hell or high water. We no longer have a conditioned response of hunger every 3-5
hours. We would no longer become hungry simply because the time is 12:00. Instead, we would
still get the unconditioned response of hunger, but not the conditioned one. That is, ‘you get
hungry because you are hungry’, rather than ‘you get hungry because it’s noon’.
Similarly, by not eating throughout the entire day, we can break any associations between food
and anything else – TV, movies, car rides, ball game etc. Here’s the solution. Eat only at the
table. No eating at your computer station. No eating in the car. No eating on the couch. No eating
in bed. No eating in the lecture hall. No eating at the ball game. No eating on the toilet. (OK, that
last one is gross, but I’ve seen it!).
Our current Western food environment, of course,
strives to do the opposite. There is a coffee shop
or fast food restaurant on every corner. There are
vending machines in every nook and cranny of
every building in North America. In every
conference, even at the Canadian Obesity
Network, each break time is greeted by fattening
muffins and cookies. Ironic and funny if not so
heartbreaking. (Yes, we are doctors that treat
obesity. Oh look, muffin! I’ll just eat it in the
lecture hall even though I’m not really hungry!)
One key advantage of fasting is the ability to Canadian Obesity Network - from www.weightymatters.ca
break all these conditioned responses. If you are
not accustomed to eating every 4 hours, then you will not start salivating like Pavlov’s dog every
4 hours. If we are conditioned this way, no wonder we find it increasingly difficult to resist all
the Mcdonald’s and Tim Horton’s stores while walking around. We are bombarded daily with
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images of food, references to food, and food stores themselves. The combination of their
convenience and our ingrained Pavlovian response is deadly and fattening.
In breaking habits, you must understand that going cold turkey is not often successful. Instead, it
is far better to replace one habit with another, less harmful habit. For example, suppose you have
a habit to munch while watching TV – chips or popcorn or nuts. Simply quitting will make you
feel that something is ‘missing’. Instead, replace that habit of snacking with a habit of drinking a
cup of herbal or green tea. Yes, you will find this weird at first, but you will feel a lot less like
something is ‘missing’. So, during fasting, you may, instead of completely skipping lunch, drink
a large cup of coffee. Same at breakfast. Or perhaps replace dinner with a bowl of homemade
bone broth. It will be easier in the long run. This is, of course, the same reason that people who
want to quit smoking often chew gum.
Social influence can also play a large role in eating. When we get together with friends, it is
often over a meal, over coffee, or some such dietary event. This is normal, natural and part of
human culture worldwide. Trying to fight it is clearly not a winning strategy. Avoiding social
situations is not healthy either.
So what to do? Simple. Don’t try to fight it. Fit the fasting into your schedule. If you know you
are going to eat a large dinner, then skip breakfast and lunch. One of the easiest ways to fit
fasting into your life is to skip breakfast, since that meal is very uncommonly taken with others
and, during working days is easy to skip without anybody noticing. This will quite easily allow
you to fast for 16 hours (16:8 protocol). Also, unless you go out to lunch every day with the
same crowd, lunch is also quite easy to miss without anybody noticing during the work day. This
allows you to ‘slip in’ a 24 hour fast without any special effort.
So, in essence, there are two major
components to hunger. The
unconditioned biological stimuli –
that is, the part that will normally
stimulate hunger naturally (smells,
sights, and tastes of food) and the
conditioned stimuli (learned –
movie, lecture, ball game). These CS
do not naturally stimulate hunger,
but through consistent association, have become almost as powerful. That is, the movie, the TV,
the sight of McDonalds, the sound of a jingle etc. They have become hopelessly intertwined but
they are by no means irreversibly so. Simply change out the response (drink green tea instead of
eat popcorn). Fasting helps to break all the conditioned stimuli, and thus helps to reduce, not
enhance hunger. Hunger is not so simple as your stomach being ’empty’.
So – here’s the real question – does fasting lead to over-eating? This was answered in a study
published in 2002. 24 healthy subjects underwent a 36 hour fast and then caloric intake was
measured. At baseline, subjects ate 2,436 calories per day. After a 36 hour fast, there was an
increase in caloric intake to 2914 calories. So there was a degree of over-eating – almost 20%.
However, over the 2 day period, there was still a net deficit of 1,958 calories over 2 days. So the
amount ‘over’ eaten did not nearly compensate for the period of time fasting. They conclude the
“a 36 hr fast..did not induce a powerful, unconditioned stimulus to compensate on the subsequent
day.”
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Here’s the ‘spare me the details’ bottom line – NO, fasting does not lead to overeating. No, You
will NOT be overwhelmed with hunger.
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Cephalic Phase Response and Hunger – Fasting 18

The relationship between fasting and hunger is, without doubt, the #1 concern we hear.
Overcoming hunger seems a daunting task, stemming from a misunderstanding of actual hunger.
This is mildly ironic, since my guess is that 95% of us have never, truly been hungry in the sense
of starvation, where we did not know when we would be able to eat again. However, I also
understand that hunger is one of the most basic human drives/instincts known as the 3 F’s (food,
fluids, and procreation).
Much of what we perceive as hunger is actually a learned behaviour, and as such, can be
‘unlearned’. Breaking all the conditioned stimuli of food will help reduce hunger cues. However,
there is also a natural need and desire for food. There are unconditioned stimuli – those signals
for us to eat – smell, touch, taste, sight of food. The hunger response starts well before food is
ingested, and is highly dependent upon hormonal stimuli (gherelin, peptide YY, cholecystokinin,
leptin etc). For example, you might think the smell of food increases hunger. But what if you had
just stuffed yourself at the All You Can Eat Buffet? The smell of french fries is likely to make
you queasy, not hungry.
But, if you are susceptible, then hunger starts
in the mind. This is known as the cephalic
phase response (CPR). ‘Cephalic’ refers to the
brain – so these are measurable physical
responses to the suggestion of food and lasts
for about 10 minutes. The most obvious of
these is the Pavlovian response that we
discussed previously. Salivation increases
immediately upon the expectation, not the
actual delivery of food. Interestingly, the
amount of salivation increases when people are
shown a picture of a lemon compared to other foods, so clearly the CPR is ‘learned’.
Pancreatic fluid and bicarbonate are also secreted into the stomach well before any food is
received. The pancreas also starts to ramp up insulin production and secretion before there is any
change in blood glucose levels. Post-prandial thermogenesis – the body heat produced after
meals – is also increased. These are measurable responses, although much weaker even in
anticipation of food even if no meal is taken afterwards.
The purpose of CPR is to help synchronize the gut response and the incoming food bolus – gut
pre-conditioning. If you deliver food directly into the stomach, there is no preparation and
subsequent blood sugars are much higher as the body has not had a chance to produce insulin.
Of interest, sweetness itself is not sufficient to start the cephalic response. An unflavored
artificial non caloric sweetener by itself did not stimulate insulin secretion. However, when
paired with flavour, it may start the the cephalic phase, even if the gastric phase does not proceed
(because it has no calories or bulk).
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So, why is this relevant?

First, there is controversy whether you can use non-
nutritive sweeteners during fasts (Splenda etc.) Even
though there are no calories, this does not negate the
cephalic phase response. If the flavour and the
sweetener is enough to start the CPR (diet soda, for
example), then this will naturally stimulate hunger and
the desire to eat. You are chumming the shark infested
waters of hunger. If you don’t eat soon, somebody’s
gonna get their head bitten off. So, yes, artificially
sweetened food can make you hungry.
Diet sodas, in my opinion, are generally not helpful to
efforts to fast or lose weight. Recent randomized
controlled studies back up the point that diet drinks may
sabotage weight loss efforts despite the large decrease
in consumed sugars. Of course, common sense would have told you the same thing. If
sweeteners were the answer, we would not have this obesity epidemic, would we? It’s not like
people aren’t eating sweeteners. How many people do you know that have tried sweeteners?
95% of everybody? How many people lost significant weight? 2%? There’s your answer right
there. The proof is in the pudding. In our IDM program, we prohibit the use of all artificial
sweeteners.
However, if the flavouring is weak and CPR is not activated, then use of artificial sweeteners
may be OK. There are certainly those that argue that sweeteners help them lose weight by
increasing compliance. If so, great. My best advice is to try to fast without the use of sweeteners.
If you cannot, then you can try adding a small amount. However, if it makes fasting harder, or
prevents you from seeing results, then stop.
The second practical implication of the CPR is that we must remove ourselves food stimuli.
Trying to cook a meal while fasting is almost unbearably difficult. To see and smell the food
without being able to eat it is hard. This is not simply a matter of weak willpower. Our cephalic
phase responses are fully activated. To stop there is like trying to stop a piranha feeding frenzy.
Or like trying to stop peeing after you started. (This is actually the way you are supposed to do a
urine test). If you can take yourself out away from food stimuli, then keeping to a diet or a fast is
infinitely easier. This, of course is the reason you should not shop for food when hungry, or keep
cookies/ snacks in the pantry.
That is why one of our most important tips for fasting is to stay busy. I often fast during
workdays, because it fits easily into my schedule. I simply work through lunch. By staying busy,
I don’t even remember to be hungry. My cephalic phase response has not been activated. If
somebody were to put food in front of me, I often cannot resist. But if there is only a pile of
paperwork, I just plow right through and forget to be hungry. Then, I get to go home early
because I just saved an hour or so.
Hunger comes in waves
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We often imagine that hunger will build and build until it is unbearable and we need to stuff
ourselves with Krispy Kreme donuts. however, this is not the case at all. Hunger comes in waves.
You just need to ride out the waves.
Remember a time when you skipped lunch. At first, you get hungry. It’s 12:00 noon, but perhaps
you are caught up in a meeting and can’t get away. The hunger builds and builds, but there’s
nothing to be done. Boss is such a jerk! But what happened at 1:00 or 1:30 or so? The hunger
entirely dissipates. The wave has passed. By dinner time, you might remember you missed lunch
and eat.
What’s the best way to pass the wave? I find that drinking a cup of green tea or coffee is enough.
By the time I’ve finished my cup of green tea, the hunger has passed and I’ve gone onto the next
thing to do that day.
Hunger is not predetermined by not eating for a certain period of time. Hunger is a hormonal
signal. It does not come about simply because the stomach is ’empty’. Why is this important?
Because that explains how people can fast for days without being hungry. This is a consistent
finding throughout the scientific literature on fasting as well as in our own IDM program.
For example, Dr. Gilliland, in his description of total fasting found that
A feeling of well-being is certainly engendered in this way and may amount to euphoria. We did
not encounter complaints of hunger after the first day.
Jeez! People weren’t hungry and actually felt ‘euphoric’ during 14 days of fasting. In fact, some
felt so good, they wanted to continue. This was echoed by the experience of Dr. Drenick, of
UCLA. Hunger comes quite strongly during the first 1-2 days of fasting. After that, the hunger
just subsides and then goes away. Some people speculate that the ketones are actively
suppressing appetite.
This explains our response to people who feel they cannot go beyond 24 hours of fasting. We
advise them to try 3-7 full days of fasting. Why would we do that? Well, this rapidly gets their
bodies used to fasting. By getting over the first 1-2 days, hunger starts to disappear and they
become reassured that they are not ‘overwhelmed’ by hunger. Most patients feel that day 2 is the
worst. Once they know this and expect it, they are able to handle it.
So, the bottom line?
Hunger is a state of mind, not a state of stomach.
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Circadian Rhythms – Fasting 19

It is sometimes useful to consider things from an evolutionary standpoint. We can look back at
early humans and make some general recommendations. Granted, there is little or no proof, but
the exercise is still useful and interesting.
There is often great debate about whether we should be eating constantly, or occasionally. Some
recommend to eat as soon as you get up and then every 2.5 hours or so during the day. On the
other hand, Intermittent Fasting proponents would say that it is quite sufficient to eat once a day
or even once every other day. So what’s the truth? First, let me say that there are people who use
both systems and do well. But which system makes more sense?
Let’s consider our cousins – the omnivorous
wild mammals. It is virtually unheard of, in the
natural world, to require feeding 3 times per
day, every day in order to stay healthy. Most
omnivorous large mammals eat considerably
less frequently than that. Obligate herbivores,
because of the low caloric density of their food,
often require constant grazing – think cows and
sheep. Grass, for example has very low caloric
density. Much of the grass is indigestible and
passes through the cow to exit as manure.
Most carnivores, such as lions and wolves will If we were meant to graze, we'd be cows
eat only several times per week or even several
times per month. Sometimes this is because food is scarce, but even in times of plenty,
it’s probably because food is not so easily available. Catching a zebra is much harder than
catching a bag of cheetos. This also likely has something to do with caloric density, since most
of the animal foods are absorbed by our bodies.
We’ve all seen those TV shows with lions and tigers all around a herd of zebra sleeping away in
the hot African sun. Well, those lions were not hungry and therefore did not eat. One meal per
week seems to do just fine for them. If a hippo carcass happens to wash up on shore, sure,they’ll
eat. So, understand that eating several times per day is not a necessity for omnivores and
carnivores. We are not solely driven to eat by nutrient deficiency.
Physical and mental capacity is not impaired by a lion’s week long ‘fast’. If fasting made them
sluggish and stupid, well the lion species would not have survived very long. No, the long
interval between meals does not impair them in any significant manner. They ate a large meal –
storing much of the calories in their bodies and then are using these stored calories to survive.
It’s normal.
Mammals have adaptations that allow them to survive with an intermittent food supply. That is,
the body has a way of storing food energy, so that lion can eat once a week. This goes for
humans as well. The main way to do this is to store glycogen in the liver (stored sugar) and then
to store triglycerides in fat tissue. When you eat, you are putting food energy into your stores.
When you fast, you are pulling food energy out. It’s inconceivable that mammals are designed
with this amazing system for storing food energy and yet it is still necessary to eat every couple
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of hours to stay healthy. That’s like building an amazing pool and spa, and then arbitrarily
deciding that you can’t get wet after all.
Hunter-gatherer societies, as well as wild animals virtually never got the problems of obesity,
diabetes of cardiovascular disease, even during times of plenty. It is estimated that animal foods
provided about 2/3 of their calories. So, for all the modern teeth gnashing about meat and
saturated fats, it seems that our ancestors had little problems eating them. It should also be noted
that many societies ate carbohydrate based diets (eg. Kitavans and Okinawans) and also had no
problems with obesity. It seems to be a modern problem, and I suspect that refined grains and
sugar plays an overwhelming role here.
Things started to change about 10,000 years ago with the agricultural revolution. Early man
started to farm instead of hunt, which led to a greater reliability of food allowing a typical pattern
of eating 2-3 times per day. Even with that, there was little obesity until relatively recently
(1970’s USA).
So, it is certainly possible to eat meat and have little diabesity. It is also possible to eat
carbohydrates and have little diabesity. The problem, (Nutritionism’s Greatest Blunder) is
focusing obsessively on macronutrient content (how much fat, how much carbs). It’s the insulin
response that matters, not the macronutrient breakdown. The toxicity lies in the processing, not
the food. So highly refined and processed grains and sugars, as well as vegetable oils are the
problem, not carbs and fats.
Circadian Rhythms
Circadian rhythms are predictable, 24 hour self-sustained changes in behaviours, hormones,
glandular activity etc. Most hormones of the body, including growth hormone, cortisol and
parathyroid hormone are secreted in a circadian rhythm. These rhythms have evolved to respond
to differences predominantly in ambient light determined by the season and time of day (which
governs food availability). These patterns are seen in virtually all animals from flies to humans,
and it is estimated that 10% of a given organism’s genes show circadian changes.
The master circadian clock is the
suprachiasmatic nucleus (SCN). It is
believed that food was relatively
scarce in Paleolithic times are
predominantly available during
daylight hours. This is mostly
because humans hunt and eat by day
and once the sun went down, well,
you just couldn’t see the food in
front of your face. Other animals are
nocturnal and may very well have
circadian rhythms more suited to
eating at night, but not humans.
So, is there a difference between
eating during the day and eating at night? Well, the studies are few, but perhaps suggestive. One
very interesting study compared the effect of eating a large breakfast versus a large dinner. While
there are many association studies, this is one of the few intervention studies done in humans as
 67

opposed to mice. Most have favoured eating breakfast, or eating earlier in the day, although most
studies have too many confounders to be truly useful.
So what this study did was to randomly assign two groups of overweight women to eating a large
breakfast (BF group) or a large dinner (D group). Both ate 1400 calories/day, and the
macronutrient composition of each diet was matched – only the timing of the largest meal was
changed. While both groups lost weight, the BF group was clearly superior for both weight loss
and waist size (important measure of visceral fat) by almost 2.5 times (-8.7 kg vs -3.6 kg).

So why there such a huge difference in weight gain? Well, this further graph may explain things
a bit. The graph shows the insulin response to meals. The BF group had more insulin in the
morning while the D group had more at night, as expected. However, by totalling the Area Under
the Curve (AUC – graph to the far right) you can see that overall, the dinner group had a much
larger rise in insulin. This is fascinating. The same total calories led to more insulin secretion
simply based on meal timing.
An earlier, smaller 1992 study had shown much the same thing. In response to the same meal
given either early or late in the day, the insulin response was 25-50% greater in the evening.
Weight gain, of course is driven by insulin. So, while the carbohydrates and calories were
identical in both groups, the insulin response was not, translating into more weight for the D
group. This illustrates the very important point that obesity is a hormonal, not a caloric
imbalance. This study has profound implications over meal timing. There is certainly the well
known association of night shift work and obesity. However, this may also have to do with the
increased cortisol response due to disturbed sleep.
Now, this does not necessarily mean that you must eat a large meal as soon as you wake up. But
it means that perhaps eating a large meal in the evening (after the sun goes down) may cause a
much larger rise in insulin than eating that same meal during daylight hours. The problem with
breakfast is generally that we are in a hurry in the morning and tend to eat very highly refined
carbohydrates (toast, cereal, bagels etc) which tend to also stimulate insulin severely. But waiting
until noon to have a large lunch as your main meal seems to be a good solution. This also avoids
the ‘rushing out the door’ or ‘grabbing a muffin’ sort of response to the exhortation to ‘eat
breakfast – it’s the most important meal of the day’.
Folk wisdom, of course, also advises to avoid eating large meals in the evening. The reason
offered usually is something along the lines of “If you eat just before bed, you don’t get a chance
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to burn it off and it will all turn to fat”. Maybe not technically true, but perhaps there is
something here. Eating late at night seems to be especially obesogenic.
There is also a natural circadian
rhythm to hunger. After all, if it was
simply due to food intake, we would
consistently be hungry in the morning
after the long overnight fast. But
personal experience
and studies confirm that
paradoxically, hunger is lowest in the
morning. This is ‘paradoxical’
because the morning time meal
follows the longest period of the day
without food. Breakfast is typically
the smallest, not the largest meal of
the day. This indicates that there is a
circadian rhythm that is independent
of the eat/fast cycle.
Ghrelin, the hunger hormone, shows
a marked circadian rhythm with a
low at 0800. Interestingly, with fasting, ghrelin peaks at day 1-2 and then steadily falls. This
aligns perfectly with what is seen clinically, where hunger is the worst problem on fasting day 1-
2. Many people on longer fasts report that hunger typically disappears after day 2.
Hunger typically falls to its
lowest level at 7:50 am and
peaks at 7:50 pm. This applied
to almost all foods.
Interestingly, vegetables show
no circadian rhythm in desire to
eat. I don’t really know what
this means but I don’t think it’s
because vegetables are not
delicious.
Understand once again, that
these are natural rhythms that
are inherent in our genetic
makeup. If you take away all
external stimuli, these rhythms still persist. What does it mean that hunger is lowest in the
morning? One implication is that hunger is not so simple as ‘the longer you don’t eat, the more
hungry you’ll be’. No, there are many more subtle inputs and hormonal regulation of hunger
plays a key role.
However, the studies are conflicting. NHANES data on evening eating failed to show any
association between late eating and weight gain, as might have been predicted. Nevertheless, the
possibility that eating during daylight hours results in less insulin secretion must be considered.
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So, what’s the practical implication? At 0800 in the morning, our hunger is suppressed actively
by our circadian hormonal rhythm. It seems counter-productive to force oneself to eat. What’s
the point? Eating does not produce weight loss. Forcing ourselves to eat at a time when we are
not hungry is not likely to be a successful strategy.
However, eating late at night also seems to be a poor strategy. Hunger is increased maximally at
approximately 7:50 pm at the same time that insulin will be maximally stimulated by foods. This
means higher insulin levels for the same amount of food intake. This higher insulin level will
naturally drive weight gain. This is the typical pattern of eating in North America, where dinner
is the main meal. This is mostly driven, not by health concerns, but by the hours of the working
and school day. This also leaves shift workers at a particular disadvantage. They tend to eat
larger meals later in the evening, leading to higher insulin.
So the optimal strategy seems to be
eating a large meal in the mid-day –
sometime between 12:00 and 3:00pm
and only a small amount in the evening
hours. Interestingly, this is the typical
traditional Mediterranean eating pattern.
They have traditionally eaten a large
lunch, followed by a siesta and then a
small, almost snack sized ‘dinner’.
While we often think of the
Mediterranean diet as healthy due to the
foods, the timing of the meals may also
play a role.
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Refeeding syndromes – Fasting 20

Complications with refeeding were first described in severely malnourished Americans in
Japanese prisoners of war camps in World War 2. It has also been described upon treatment of
long standing anorexia nervosa, and alcoholic patients. It is important to have an understanding
of these syndromes if you are attempting an extended fast – usually greater than 5-10 days at a
time. Re-feeding refers to the period of time immediately after an extended fast when you are
just starting to eat again. We’ve touched upon this briefly with ‘how to break a fast’. The two
main syndromes are refeeding syndrome and refeeding edema.
In 2003, David Blaine, the magician, emerged from a 44 day water
only fast. Opinions abounded regarding whether or not he was
cheating, although he was in plain sight the entire time. Doctors
recorded every measurement they could think of afterwards during
his hospitalization. He lost 24.5 kg (25% of his body weight) and
his body mass index (BMI) dropped from 29 to 21.6. Blood sugars
and cholesterols were normal. Free fatty acids were high (expected
during fasting).
He developed both refeeding syndrome and edema after this stunt.
His phosphorus levels fell and required intravenous replenishment.
Re-feeding Syndrome
Refeeding syndrome has been defined as the “potentially fatal
shifts in fluids and electrolytes that may occur in malnourished patients”. The key clinical
marker of this is hypophosphatemia – very low phosphorus levels in the blood. However,
lowered potassium, calcium, and magnesium in the blood may also play a role. Calcium,
phosphorus and magnesium are all primarily intra-cellular ions – that is, they are kept inside the
cells and blood levels (which are outside of cells) tend to be quite low compared with
concentrations inside cells.
Adults store 500-800 grams of phosphorus in the body. Approximately 80% of the phosphorus in
our bodies is held within the skeleton and the rest in soft tissues. Almost all of the phosphorus is
inside the cell, rather than outside, in the blood. The blood level of phosphorus is very tightly
controlled and if it goes too high or low, can cause real problems. Average daily intake of
phosphorus is 1g/day, meaning that it often requires many months of undernutrition to produce
these syndromes. Protein rich foods, as well as grains and nuts are good sources of phosphorus.
60-70% of the phosphorus is absorbed, mostly in the small intestine.
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Much of the calcium,

phosphorus and magnesium
in our bodies is stored in the
bones. If the body needs
more or these intracellular
ions, it will take it from the
bone ‘stores’. If there is too
much, these get deposited
into the bone.
During prolonged
malnutrition, blood levels of
phosphorus remain normal
and the deficit is taken from
the bones. This can last for a
very long time, as was
proven with severe
malnutrition imposed on the
Japanese prisoners of war during World War 2.
But there are some problems that can happen once food is given, particularly carbohydrate
containing foods. During the refeeding period, insulin and other hormones are activated. This
causes the movement of the major intracellular ions (phosphorus, potassium, calcium and
magnesium) into the cells. However, due to overall depletion of body stores, this becomes
excessive and too little of these ions are left in the blood. This is what causes the major
symptoms of the refeeding syndrome, some of which are rarely fatal.
Phosphorus is used in all cells for
energy. The basic unit of energy
(ATP) contains 3 phosphorus
molecules so severe depletion of
phosphorus may cause your entire
body to ‘power down’. This
typically happens when the serum
phosphorus level drops below 0.30
mmol/L. The symptoms include
muscle weakness as well as
breathing difficulty as the diaphragm
(the large muscle powering the
lungs) weakens. Outright muscle
breakdown (rhabdomyolysis) has
been described, as well as heart
dysfunction (cardiomyopathy).
Magnesium is a co-factor in most enzyme systems in the body and severe depletion can result in
cramps, confusion, tremor, tetany and occasionally, seizures. Cardiac rhythm abnormalities are
also described – classically the pattern known as Torsades de Point. Most magnesium (about
70%) taken orally is not absorbed but excreted unchanged in the feces.
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Potassium may also be shifted into cells, leaving dangerously low levels in the blood. This, too
can cause heart rhythm disturbances or even outright cardiac arrest.

Insulin stimulates glycogen, fat and protein synthesis which requires many ions like phosphorus,
magnesium, and cofactors like thiamine. The insulin surge puts an enormous demand on
phosphorus stores which have been depleted. In essence, the stores of all these intracellular ions
has been severely depleted and once the signal is given to replenish, too much phosphorus is
taken out of the blood leading to excessively low levels.
So you can see that one of the key pre-requisites for refeeding syndrome is severe, prolonged
malnutrition. How common is it? A study of over 10,000 hospitalized patients only found an
incidence of 0.43%. These are the sickest of sick people, but still was found rarely. This is
actually on overestimate since it also included diabetic ketoacidosis, which is a different
mechanism entirely. The main groups that had this disease? Severe malnourishment and
alcoholics.
Refeeding syndrome is most often described in the situation of parenteral (intravenous) refeeding
in the intensive care unit. These patients are often intubated and cannot eat for weeks. In the
setting of relative malnourishment, extremely calorically dense and nutrient rich fluids are
introduced directly into the vein. A setup for re-feeding syndrome.
The main risk factor for re-feeding syndrome is prolonged malnutrition. When we use fasting as
a therapeutic tool, most people have never missed a single meal in over 25 years! This is hardly
the situation that we deal with currently. However, it is important to understand that patients that
are severely underweight or malnourished should not fast. This is important because re-feeding
syndrome is mostly found in the condition of starvation (uncontrolled, involuntary restriction of
food) or wasting (starvation to the point of severe malnutrition) rather than fasting (controlled,
voluntary restriction of food).
Vitamin deficiencies have also been described, again mostly with prolonged malnutrition. The
most important is thiamine, which is an essential coenzyme in carbohydrate metabolism.
Typically, this has been described in alcoholics with the syndromes of Wernicke’s
encephalopathy (ataxia, confusion, visual disturbances) and Korsakoff’s syndrome (memory loss
and confabulation). Confabulation is a symptom whereby people have a complete lack of short
term memory. They therefore ‘make up’ everything when they are talking because they have no
memory. There is no intent to deceive. Traditionally, it has been taught to treat alcoholics and
other malnourished people with thiamine (intravenous if needed) before treating hypoglycaemia.
Theoretically, the glucose may stimulate acute thiamine uptake and precipitating Wernicke’s.
Re-feeding Edema
Insulin acts on the proximal tubule in the kidney to reabsorb sodium and water. Higher insulin
levels will result in salt and water retention. Low insulin levels will result in loss of salt and
water by the kidney. This has been well described for over 30 years.
During fasting, insulin levels go down quite significantly. This may lead to loss of salt and water.
In some extreme cases there is up to 30 pounds of water weight lost, as George Cahill described
in his article “Starvation“. The body is not able to hold on to salt and water due to low insulin
levels. During re-feeding, especially with carbohydrates, insulin levels start to go back up, and
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the kidney starts to hold onto salt and water extremely tightly. Sodium excretion may fall to less
than 1 mEq/day.
In extreme cases, you may actually see gross edema. This can occur as the legs and feet start to
become very swollen. Occasionally retention of fluid in the lungs leads to congestive failure in
those with heart disease.This has been called”refeeding edema”.
Treatment
Obviously the mainstay of
treatment is prevention. Box 3
identifies those at risk of re-
feeding syndrome. Obviously
the key is to avoid fasting a
malnourished person, but that
should have been pretty
obvious already.
The mainstay of treatment is to
start feeds very slowly.
Generally this means 50% of
the needed food intake with
slow increase in rate if no
problems are found. This is reflected in the traditional advice to break a fast gently. This is more
important the longer the duration of the fasting period. We have often seen people who eat too
much as soon as the fasting period is over. Most complain that the food gives them a stomach-
ache, but this usually passes quite quickly. I’ve never seen or treated re-feeding syndrome
personally, and I hope never to need to.
What happened in the Blaine fast?
There were some differences in the
fasting done by Blaine and the ones
we use in the IDM program. First, it
was a water only fast. Generally, we
only use those in severe cases. We
allow the use of bone broth during
fasts, which is not technically a fast,
but provides phosphorus and other
proteins and electrolytes. This
reduces the chances of developing
the refeeding syndrome.
Second, you can see that Blaine is
suspended in a Plexiglas box for the duration of his fast. He is not able to do any of his usual
activities and does not even stand up for 44 days. This is far more than a fast. His muscles and
bones will actually develop significant atrophy during that period. He was losing far more than
fat. He lost significant lean weight – muscle and bone, but this was NOT due to fasting. It was
due to being cooped up in a box for 44 days.
 74

During fasting, we encourage our patients to do all their usual activities, especially their exercise
program. This helps to maintain their muscles and bones.
 75

Obesity – Solving the Two-Compartment Problem – Fasting 21

One of the major mistakes made by the Calories In/ Calories Out (CICO) hypothesis is the
presumption that energy is stored in the body as a single compartment. They consider that all
foods can be reduced to their caloric equivalent and then stored in a single compartment in the
body (Calories In). The body then uses this energy for basal metabolism and exercise (Calories
Out).
This model looks something like this:
All energy is stored in that one compartment. However, this
model is a complete fabrication. It does not exist. This known
mis-understanding has led to general acceptance of the CICO
theorem. According to this model, by reducing the amount of
calories going in, or increasing the amount going out, you may
reduce the amount of body energy stored as fat.
Of course, this Eat Less, Move More (or Caloric Reduction as
Primary) strategy has a known success rate of about 1% or a
failure rate of roughly 99%. This does not deter any of the
medical or nutritional authorities to question the sagacity of
their advice, though.
To better understand how energy is stored in the body, it is
more accurate to use a two compartment model. Dr. Kieron
Rooney’s diagram demonstrates that the body is able to derive
energy from 3 sources – glucose (carbs), fat or protein. However, protein is not stored as an
energy source and is only used when there is excessive dietary protein after which it is turned to
glucose.
So, this leaves two potential fuel sources – glucose and fat – and these are stored in different
compartments. Glucose is stored in the liver as glycogen – a molecule that is composed of long
chains of sugars. This is easily accessible to the body, but there is a limited amount that is able to
be stored. After that threshold is reached, the body stores fat. Think of glycogen like a
refrigerator. It is very easy to move food in and out of the fridge, but the storage space is limited.
 76

Body fat is much more difficult to access, but you may store unlimited amounts. Dietary fat is
directly added to the body’s fat stores. Excessive carbohydrates are turned into fat by the process
known as De Novo Lipogenesis (DNL). Think of body fat as a freezer that you store in your
basement – you can store lots of food in the freezer but it is more difficult to get at it compared
to the fridge. You can also store more than 1 freezer in the basement if you need more space.
As you eat, the body stores energy. As
you don’t eat (fast), the body must take
stored energy from the body to burn for
fuel. But it does not take equal amount
from both compartments (fat and
glycogen). Glycogen is burned almost
exclusively until it is finished – this can
last 24-48 hours of pure fasting.
This is logical since it is much easier for
the body to get at the glycogen. Think
about it this way. If you buy groceries,
you first store it in the fridge. Once it is
full, then you start to store it in the
freezer. When it comes to taking food
out to eat, you start by eating the food
in the fridge.
Only after almost the glycogen is
already burned for energy does the body
turns to its stores of fat. Similarly, only
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when the food in the fridge is gone do you want to go downstairs to that cold dank basement to
get the food in the freezer. It takes more effort. You do not burn equal amounts of glucose and
fat. For example, if your glycogen ‘fridge’ is full, you will not use any of your fat in the
‘freezer’. If you need 200 calories of energy to go for a walk, you take that exclusively out of the
glycogen with none of the fat being burned.
The two compartments for energy are not burned simultaneously, but sequentially. You need to
empty out the fridge before you can start using the food in the freezer. In essence, the body can
either burn sugar or fat, but not both. This is controlled partially by insulin, and also directly by
the Randle cycle – described in 1963. This is also sometimes called the glucose-fatty acid cycle.
In isolated heart and skeletal muscle cell preparations, Randle and his colleagues were able to
show that cells that were using glucose for energy were inhibited from using fat and vice versa
without any interference from insulin or other hormones. This biochemical mechanism directly
forbids the body from using both fuels at once. You either burn sugar or fat, but not both. You
can see from the diagram that using glucose eventually leads to the production of Malonyl-CoA
which inhibits the use of fat (LCFA – Long Chain Fatty Acid).
So, why can’t you lose
weight using the CICO
method? Because it is
based on the incorrect idea
that all calories are equal.
When you store food
energy (calories), it is
stored as sugar (glycogen)
in the ‘fridge’ and fat in the
‘freezer’. But you must
burn through the sugar first
before you can start
burning fat.
So, now you want to lose
body fat. The first thing
you need to do is clear out
the sugar in your
refrigerator. However, if
you are continually filling up your fridge 3-6 times a day with sugar, then you will never start
burning the fat in the freezer. The CICO method ignores the two compartment problem and
pretends that all calories are stored equally and burned equally (single compartment), even
though this has been known to be false for at least 50 years. This is the equivalent of the standard
calorie restricted diet of eating 3-6 meals a day with a relatively high carbohydrate (50-60%)
content.
You imagine that since you are filing up the fridge with less glucose, it will eventually empty.
However, this does not happen. Why? Because, as you start putting less food in the fridge, your
body senses that and starts to get antsy. So, it starts to make you hungry and want to eat more. If
you don’t fill it up, it will decrease your metabolism so that it is burning less energy.
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What’s the solution? First, you could follow a Low Carb, High Fat (LCHF) diet. By severely
restricting the amount of carbohydrates, we keep our glucose fridge empty. Now any energy that
must be burned must come out of fat freezer. This essentially turns the two compartment
problem into a single compartment problem.
Second, you could try
intermittent fasting (IF).
Fasting essentially burns
through all the stored
sugars in the fridge
quickly. Will you get
hungry? Yes, probably.
But if you push through
that, your body is forced
to burn fat for energy.
The metabolism does not
slow down because of the
compensatory hormonal
changes of fasting. After
several days, hunger is
also suppressed – the
mechanism is unknown, but likely related to the ketone production.
The bottom line is this. You can store energy in the form of sugar or fat. In the fasted state – you
can either burn sugar or fat for energy, but not both. If you are continually supplying your body
with sugar, it will not burn fat.
Fasting provides a very quick way to start burning fat. It provides a solution to the two
compartment problem. The reason why the Calorie pundits never understand why their model
doesn’t work is because they have fundamentally mis-understood the problem as a single
compartment.
Update Jan 28, 2016
I belatedly realized that I forgot to add this section. Actually, it didn’t update, so I thought it was
in here but it actually wasn’t. Sorry.
There is one more critical input into the system. How easy is it to get food energy from the
freezer? If the freezer is locked away in the basement behind steel gates and barred, then it will
be very difficult to get the fat out. What’s the main hormone that controls it? The answer is…
insulin. (Actually, insulin is the answer to most of the questions on this blog)
It’s well known that insulin inhibits lipolysis. That’s a fancy way of saying that insulin stops fat
burning. Well, that’s normal. Insulin goes up when you eat, so it tells the body to start using the
incoming food energy and stop using the fat in the freezer.
So, if your insulin is high from insulin resistance, you may find that your body is not able to get
at the fat in the freezer. So, as you lower the incoming calories (Caloric Reduction as Primary
strategy – Eat Less) your body is unable to get any fat to burn. So it compensates by reducing
caloric expenditure. Hence basal metabolism falls.
 79

If you are 8 years old, your insulin resistance is minimal and fasting insulin is low. That means
it’s really easy to get at the fat in the freezer. It’s like the freezer is right beside the fridge. Easy
Peasy. So, if you simply reduce calories, your body can easily compensate by getting some fat
out of the freezer.
This explains the time dependence of obesity. That is, those that have been obese for a long time
have a much, much harder time losing weight. Because their insulin resistance is high causing
elevated insulin levels all the time.
 80

The Biggest Loser Diet – Fasting 22

The Biggest Loser is a long running American TV reality show that pits obese contestants
against one another in a bid to lose the most weight. The show regularly comes under fire from
physicians and other health professionals for its over the top portrayal and its fat shaming tactics.
A bit of a surprise, then, at how high this diet actually scored in the 2015 USA Today’s rank of
best diets to follow. The Biggest Loser Diet scored #3 under the Best Weight Loss category.
Shocking. Nevertheless, like a horrific train wreck, it is difficult to avoid watching this show at
times and this is why it continues to air new episodes.
First, a bit of
background on the
actual diet and exercise
regimen. Classic Eat
Less, Move More.
Surely something like
this is a good thing,
right? What could go
wrong? All the
‘experts’ recommend
this weight loss
regimen. Well, Kai
Hibbard, the winner of
season three is quoted
as saying, “It was the
biggest mistake of my
life”. Season two’s
Suzanne Mendonca says that the reason there’s no reunion show is that “We’re all fat again”.
Much of this ‘reality’ series is actually fairly scripted, but this is not the first or last reality series
to have that fault.
Luckily, there has been some serious studies done on The Biggest Loser contestants. Dr.
Ravussin and Kevin Hall published some fairly extensive metabolic testing on 16 of these
contestants. There was a dietary intervention combined with an exercise component. The
exercise consisted of 90 minutes per day of vigorous circuit training +/- aerobic training for 6
days a week. This part is often depicted on television, along with some rather questionable fat
shaming/ yelling/ screaming by the personal trainers. The exercise portion sometimes far
exceeded the allotted time. The fact that vomit buckets were regularly used is an indication that
these contestants were pushed quite hard. During their stay on the ranch the minimum time doing
physical activity was 2 hours per day.
The dietary component consisted of a calorie restricted diet which was calculated as being about
70% of their baseline energy requirements. Calorie counts often run to 1200 – 1500 per day but it
depended upon baseline weight. At baseline, the average weight was 149.2 kg (329 pounds) with
a BMI of 49.4. By week 30 (the end of the show’s season), the average weight had dropped to
91.6 kg (202 pounds) – 127 pounds on average! Body fat had dropped from 49% to 28%. Wow.
That’s good. Really really good.
 81

The benefits
went beyond that.
Measurements of blood
glucose, insulin sensitivity
had improved. Much of the
weight lost was fat, not
muscle. This is likely due to
the intensive exercise regimen
undertaken. While there was
some loss of lean mass, it was
not much and the majority of
the rather impressive weight
loss was, indeed fat.
So, essentially the Biggest Loser diet is Caloric Reduction and Increased Exercise. It’s no
wonder the ‘experts’ at US News loves this diet. It is the same Eat Less Move More approach
espoused by nutritional authorities everywhere. The Biggest Loser is simply Eat Less Move
More on mega doses of steroids. It is the same essential diet, just bigger and badder. Eat Less
Move More – looks OK, a little wimpy. Biggest Loser Diet – total badass.
These results are starting to look
pretty damn good. So why did all
those Biggest Loser contestants
gain all their weight back after 6
months? Why do all the Eat Less
Move More patients gain all their
weight back after 6 months? This
is essentially the same question.
The simple answer is that
metabolic adaptations cause that
regain. Specifically, metabolism
slows down in response to Caloric
Reduction. You start to burn less
energy. Your metabolism shuts
down.
Let’s see what happened to the
Biggest Losers. Virtually all of
the contestants slowed down their
Resting Metabolic Rates (RMR).
The energy they use over 24 hours doing no exercise drops significantly. This is energy that is
needed to keep the heart pumping, the lungs breathing, your brain thinking, your kidneys
detoxing etc. – your basic metabolism. It drops. Like a piano out of a 20 storey building.
To give you a sense of the magnitude of the drop, from start to week 30, the RMR dropped
by 789 calories on average. Now that’s not quite accurate, because as your body weight drops,
the RMR is also expected to drop. That is, carrying around all that extra fat still takes some
energy. If you correct for this weight loss related drop in RMR, though, there is still an excess
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of 504 calories drop. That is, their metabolism is burning 500 calories less per day than expected
correcting for their new, lower weight.
But can’t you make up for
this decreased in RMR by
increasing exercise? Well,
no. Despite a massive
increase in the amount of
exercise performed by
contestants, it was simply not
enough to overcome the
drastic slowdown in
metabolism.
Once you stop having Jillian
Michaels screaming in your
ear about how she doesn’t care if you die on the treadmill, the amount of exercise gradually
decreases which further exacerbates the weight regain. From week 6 to week 30, physical
exertion goes down. But resting energy expenditure (your metabolism) continues its slide
downhill. A double whammy.
As you start burning less energy at rest and burn less energy doing exercise, you get the very
familiar weight plateau. The weight loss simply stops because your body has shut down to match
the lowered caloric intake. Once expenditure drops below intake, you start the even more
familiar weight regain. Ba Bam! Weight regain. Goodbye reunion show.
So, here’s the thing. All of this is
completely predictable. Since the Caloric
Reduction as Primary strategy has a
known 99% failure rate, it’s no surprise
that the Biggest Loser diet should also
have a similarly dismal outlook. So are
we doomed to a life of muffin tops?
Hardly. There’s another strategy that
seems to be far more successful.
Intermittent fasting’s bigger, badder
surgical cousin – the gastric bypass.
These are stomach stapling surgeries that
basically force people to fast. The fasting
is not quite intermittent, but rather
continuous for several months, until the stomach re-expands. The difference is that fasting allows
for the numerous hormonal adaptations that keep resting metabolic rates elevated and preserve
lean muscle. We’ve talked (incessantly) about the hormonal adaptations to fasting that seem to
be highly beneficial. Decreased insulin. Increased growth hormone. Increased adrenalin. These
help maintain resting metabolism so that energy expenditure does not decrease.
Hey! We should compare the two strategies directly! Luckily, that study has already been done.
Researchers matched 13 gastric bypass patients with 13 Biggest Loser contestants. They lost a
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similar amount of weight, although the Biggest Loser contestants maintained their lean mass
much better – likely due to intensive exercise. So they should do better, right?
Not at all.
By six months, the Biggest Loser group had significantly dropped their metabolic rate. While the
bypass group did also do so initially, by 12 months the metabolic rate had gone right back up to
normal.
Other studies support the metabolic benefit of
intermittent severe caloric reduction. Looking at
the long term metabolic effect of bariatric surgery,
researchers found that 14 months after surgery, the
total energy expenditure had dropped by 25%.
However, when compared against the expected
decrease due to the weight loss, there was no
decrease in RMR. As I’ve mentioned before – the
difference between daily Caloric Reduction and
intermittent fasting is that the hormonal
adaptations of calorie reduction is to reduce energy
expenditure whereas that of IF is to maintain it.
This makes a huge difference to the long term
outcome of patients. If you reduce your
metabolism by 500 calories per day, that means that you are going to be feeling cold, lethargic,
and tired because your body has started to shut down. Suppose you start by eating 2000 calories
per day. Using Eat Less Move More, you reduce that to 1500 calories per day. Pretty soon, your
body is only burning 1500 calories per day. You feel lousy. So, as you increase your calories
slightly to 1700, you are still eating less than you used to. But now you are gaining weight. Your
body weight goes back up to its original weight as your friends and family silently accuse you of
cheating on your diet.
Notice that we are not breaking any ‘Laws of Thermodynamics’. Calories In Calories Out still
holds. The point, of course, is that Calories Out is the far more important and decisive factor.
However, we focus obsessively on Calories In, which is largely useless. Reducing calories in
only reduces calories out.
So, what can we learn from the disaster known as The Biggest Loser? Or the even bigger disaster
know as Eat Less, Move More (Caloric Reduction as Primary – aka CRaP)?

1. The Biggest Loser diet is the bigger badass brother of Eat Less, Move More.
2. Eat Less Move More – Proven failure. The Biggest Loser – Proven failure on steroids.
3. Bariatric surgery is the bigger badass brother of Intermittent Fasting
4. Bariatric surgery – proven success, but with surgical complications. Intermittent Fasting
– proven success over thousands of years. No surgical complications.

Pretty clear to me which diet I would choose….

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Fasting and Exercise – Fasting 23

Is it possible to exercise while fasting? This is a common question we hear all the time. People
think that food gives them energy and therefore it will be difficult to fast and exercise at the same
time. Some people with physically demanding jobs feel that they could not fast and work
properly. What’s the truth?
Well, let’s think about this logically for a second. When you eat, insulin goes up telling your
body to use some of that food energy immediately. The remainder is stored as sugar (glycogen in
the liver). Once the glycogen stores are full, then the liver manufactures fat (DeNovo
Lipogenesis). Dietary protein is broken down into component amino acids. Some is used to
repair proteins but excess amino acids are turned to glucose. Dietary fat is absorbed directly by
the intestines. It doesn’t undergo any further transformation and is stored as fat.
Insulin’s main action is to inhibit lipolysis. This means that it blocks fat burning. The incoming
flood of glucose from food is sent to the rest of the body to be used as energy.
So what happens during a fast? Well, it’s just
the process in reverse. First, your body burns
the stored sugar, then it burns the stored fat. In
essence, during feeding you burn food energy.
During fasting, you burn energy from your
stored food (sugar and fat).
Note that the amount of energy that is used by
and available to your body stays the same. The
basal metabolic rate stays the same. This is the
basic energy used for vital organs, breathing,
heart function etc. Eating does not increase
basal metabolism except for the small amount used to digest food itself (the thermic effect of
food).
If you exercise while fasting, the
body will start by burning sugar.
Glycogen is a molecule
composed of many sugars all put
together. When it comes time to
use it for energy, the liver simply
starts breaking all the chains to
release the individual sugar
molecules that can now be used
for energy.
As mentioned before, short term storage of food energy (glycogen) is like a refrigerator. The
food energy goes in and out easily, but there is limited storage. Long term storage (fat) is like a
freezer. Food is harder to get to, but you can store much more of it. If you eat 3 times a day, it’s
like you go shopping for food 3 times a day and any leftovers get stored in the fridge. If there is
too much for the fridge, it goes into the freezer.
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Julie Moss 1982 Iron Man Triathlon

So what happens during fasting and exercise?
Well, the body simply pulls energy out of the
‘fridge’. Since you have enough glycogen stored
up to last over 24 hours on a regular day, you
would need to do some serious exercise for a long
time before you could exhaust those stores.
Endurance athletes occasionally do hit this ‘wall‘,
where glycogen stores run out. Perhaps there is no
more indelible image of hitting the wall as the
1982 Ironman Triathlon where American
competitor Julie Moss crawled to the finish line,
unable to even stand. Athletes also term complete
exhaustion of short term energy stores ‘bonking’. I
know some of you may think ‘bonking’ refers to
Julie Moss 1982 Iron Man Triathlon other activities done on all fours, but this is a
nutritional blog!
So, how do you get around that? Glycogen stores are not enough to power you through the entire
IronMan race. However, you know at the same time, that you are still carrying vast amounts of
energy in the form of fat. All that energy is stored away and not accessible during exercise. But
the only reason it cannot be used is because your body is not adapted to burn fat.
By following a very low carbohydrate diet, or ketogenic diet, you can train your body to burn fat.
Similarly, by exercising in the fasted state, you can train your muscles to burn fat. Now, instead
of relying on limited by easily accessible glycogen during competition, you are powered by an
almost unlimited energy drawn directly from your fat stores.
Studies are starting to demonstrate the benefits of such training. For example, this study looked
at muscle fibres both before and after training in the fasted state. This means that you fast for a
certain period of time, usually around 24 hours and then do your endurance or other training. The
combination of low insulin and high adrenalin levels created by the fasted state stimulates
adipose tissue lipolysis (breakdown of fat) and peripheral fat oxidation (burning of fat for
energy). Other studies had already shown that breakdown of intramyocellular lipids (IMCL – fat
inside the muscle) is increased by training in the fasted state. Six weeks of training in the fasted
state also induced a greater increase of fatty acid binding protein and uncoupling-protein-3
content in muscle.
What does this mean in plain English? It means that our bodies have the wonderful ability to
adapt to what’s available. When we fast, we deplete much of the stored sugar (glycogen). Our
muscles then become much more efficient at using fat for energy. This happens because muscle
‘learns’ how to use the fat as energy by increasing the amount of proteins that metabolize that
fat. In other words, our muscles learn to burn fat, not sugar.
Looking at muscle cells before and after exercise in the fasted state, you can see that there are
more muscle bundles, but also that there is a deeper shade of red, indicating more available fat
for energy.
 86

Legendary exercise physiologist and physician Tim Noakes of Cape Town, South Africa has led
the way in understanding the benefits of low carbohydrate diets for elite level athletes. Many
national level teams (such as the Australian cricket team) are now applying these lessons to crush
their competition. Legendary NBA players such as LeBron James, Kobe Bryant and Carmelo
Anthony are turning to low carbohydrate, high fat diets to slim down and prolong their careers.
You can be damn certain that
these elite level athletes would
not be doing this Low Carb
mumbo jumbo and training in
the fasted state malarky if it had
any detrimental effect on their
athletic performance. Quite the
contrary. Hall of Fame NBA
player Steve Nash does not eat
simple carbs at any cost.
Drinking sugary Gatorade? Not
bloody likely to help.
Another study looked at the
effects of a 3.5 day fast on all
different measures of athletic
performance. They measured
strength, anaerobic capacity and
aerobic endurance. All of these
measures did not decrease during the fasting period.
The body simply switches from burning sugar to burning fat. But, for endurance athletes, the
increase in available energy is a significant advantage, since you can store infinitely more energy
in the form of fat rather than sugar. If you are running ultra marathons, being able to utilize your
almost unlimited fat energy instead of highly limited glycogen energy will mean that you won’t
‘bonk’ and might just win you that race.
During the period where you are adjusting to this change, you will likely notice a decrease in
performance. This lasts approximately 2 weeks. As you deplete the body of sugar, your muscles
need time to adapt to using fat for energy. Your energy, your muscle strength and overall
capacity will go down, but they will recover. So, LCHF diets, ketogenic diets and training in the
fasted state may all have benefits in training your muscles to burn fat, but they do require some
time to adapt.
Consider an analogy. Imagine that our
bodies are fuel tankers. We drive these
large tankers around, but only have a
limited amount of gas in the gas tank.
After the gas tank runs out, we are stuck
on the side of the road calling for help.
But wait, you might say. That’s ironic.
You are carrying an entire tank of gas, but
 87

ran out of gas. How is that so? Well, that gas is not accessible.
In the same manner, we carry around huge stores of energy as fat. But our muscles are trained to
run on sugar, and they run out of energy, so we need to continually refuel despite the large tank
of fuel stored as fat.
So, what’s my best advice on physical exertion and fasting? Don’t worry about it. Do everything
you normally do during fasting. If you normally exercise, or even if you don’t, you can still do it
during fasting. Whether you fast for 24 hours or 24 days, you can still exercise. Your muscles
may take up to 2 weeks to become fat adapted, though. During the first 2 weeks of fasting, you
may need to take it a little easy, but you should quickly recover after that.
 88

Fasting and Brain Function – Fasting 24

How does fasting affect brain function? There is very little reliable human data, but some very
interesting animal data, as recently reviewed. There are many potential benefits. While I tend to
focus on weight loss and type 2 diabetes, there are many other benefits, including autophagy (a
cellular cleansing process), lipolysis (fat burning), anti aging effects and anti-seizure effects.

From an evolutionary standpoint, we can look at other mammals for some clues. In many
mammals, the body responds to severe caloric deprivation with a reduction in the size of all
organs with two prominent exceptions – the brain and the male testicles. This suggests that
cognitive function is highly preserved.
This makes quite a lot of sense from an evolutionary standpoint. Suppose you had some trouble
finding food. If your brain started to slow down, well, the mental fog would make it that much
harder to find food. Our brainpower, one of the main advantages we have in the natural world,
would be squandered. No, the brain maintains or even boosts its abilities. In stories of Japanese
prisoners of war in World War II (Unbroken by Laura Hillenbrand), many have described the
amazing clarity of thought that often accompanies starvation.
The preservation of the size of the testicles is also a significant advantage in trying to pass on our
genes to the next generation.
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In all mammals, one of the highly preserved behavioural traits is that mental activity increases
when hungry and decreases with satiation. Of course, we have all experienced this. Sometimes
this is called ‘food coma’. Think about that large Thanksgiving turkey and pumpkin pie. After
that huge meal, are we mentally sharp as a tack? or dull as a concrete block? How about he
opposite? Think about a time that you were really hungry. Were you tired and slothful? I doubt
it. Your senses were probably hyper-alert and you were mentally sharp as a needle. That is to say
that there is likely a large survival advantage to animals that are cognitively sharp, as well as
physically agile during times of food scarcity.
Studies have also proven that mental acuity
does not decrease with fasting. One study
compared cognitive tasks at baseline and after
a 24 hour fast. None of the tasks – including
sustained attention, attentional focus, simple
reaction time or immediate memory were
found to be impaired. Another double-blinded
study of a 2-day ‘almost total’ caloric
deprivation found no detrimental effect even
after repeatedly testing cognitive
performance, activity, sleep and mood.
What we say we are ‘hungry’ for something
(hungry for power, hungry for attention), does it mean we are slothful and dull? No, it means that
we are hyper-vigilant and energetic. So, fasting and hunger clearly activate us towards our goal.
People always worry that fasting will dull their senses, but in fact, it has the opposite, energizing
effect.
These sorts of tests are easy to see in animal studies.
Aging rats were started on intermittent fasting regimens
are markedly improved their scores of motor
coordination and cognitive tests. Learning and memory
scores also improved after IF. Interestingly, there was
increased brain connectivity and new neuron growth
from stem cells. This is believed to be mediated in part
by BDNF (Brain Derived Neurotrophic Factor). In
animal models, both exercise and fasting significantly
increase BDNF expression in several parts of the brain.
BDNF signaling also plays a role in appetite, activity,
glucose metabolism and autonomic control of the
cardiovascular and gastrointestinal systems.
There are also very interesting mouse models of neuro-degenerative diseases. Mice maintained
on IF, compared to normal mice, showed less age related deterioration of neurons and less
symptoms in models of Alzheimers disease, Parksinon’s and Huntington’s disease.
In humans, the benefits to the brain can be found both during fasting and during caloric
restriction (CR). During exercise and CR, there is increased synaptic and electrical activity in the
brain. In a study of 50 normal elderly subjects, memory test improved significantly with a 3
months of CR (30% reduction in calories).
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Neurogenesis is the process where neural stem cells differentiate into neurons that are able to
grow and form synapses with other neurons. Both exercise and CR seem to increase
neurogenesis via pathways including BDNF.
Even more interestingly, the level of fasting insulin
seems to have a direct inverse correlation to memory
as well. That is, the lower you are able to drive down
fasting insulin, the more improvement on memory
score that is seen.
Increased body fat (as measured by BMI) has also
been linked to decline in mental abilities. Using
detailed measurements of blood flow to the brain,
researchers linked a higher BMI to decreased blood
flow to those areas of the brain involved in attention,
reasoning, and higher function.
Intermittent fasting provides one method of decreasing
insulin, while also decreasing caloric intake.
Alzheimer’s disease (AD)
is characterized by the
abnormal accumulation of
proteins. There are 2
main classes – amyloid
plaques and
neurofibrillary tangles
(tau protein). The
symptoms of AD
correlate closely with the
accumulation of these
plaques and tangles. It is
believed that these
abnormal proteins destroy
the synaptic connections
in the memory and
cognition areas of the
brain.
Certain proteins (HSP-70) act to prevent damage and misfolding of the tau and amyloid
proteins. In mouse models, alternate daily fasting increased the levels of HSP-70. Autophagy
removes these tau and amyloid protein when they are damaged beyond repair. This process, too,
is stimulated by fasting.
There is substantial evidence that risk of AD is related to obesity. A recent population based twin
study demonstrated that weight gain in middle age predisposes to AD.
Taken together, this suggests a fascinating possibility in the prevention of Alzheimer’s disease.
Over 5 million American have AD and this number will likely increase rapidly due to the aging
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population. AD creates significant burdens upon families that are forced to care for their afflicted
members.
Certainly fasting may have significant benefits in reducing weight, type 2 diabetes along with its
complications – eye damage, kidney disease, nerve damage, heart attacks, strokes, cancer.
However, the possibility also exists that it may prevent the development of Alzheimer’s disease
as well.
The method of protection may also have to do with autophagy – a cellular self cleansing process
that may help removed damaged proteins from the body and brain. Since AD may result from the
abnormal accumulation of Tau protein or amyloid protein, fasting may provide a unique
opportunity to rid the body of these abnormal proteins. We will cover autophagy next week.
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Fasting and Autophagy – Fasting 25

What is autophagy? The word derives from the Greek auto (self) and phagein (to eat). So the
word literally means to eat oneself. Essentially, this is the body’s mechanism of getting rid of all
the broken down, old cell machinery (organelles, proteins and cell membranes) when there’s no
longer enough energy to sustain it. It is a regulated, orderly process to degrade and recycle
cellular components.
There is a similar, better known process called apoptosis
also known as programmed cell death. Cells, after a certain
number of division, are programmed to die. While this may
sound kind of macabre at first, realize that this process is
essential in maintaining good health. For example, suppose
you own a car. You love this car. You have great memories
in it. You love to ride it.
But after a few years, it starts to look kind of beat up. After
a few more, it’s not looking so great. The car is costing you thousands of dollars every year to
maintain. It’s breaking down all the time. Is it better to keep it around when it’s nothing but a
hunk of junk? Obviously not. So you get rid of it and buy a snazzy new car.
The same thing happens in the body. Cells become old and junky. It is better that they be
programmed to die when their useful life is done. It sounds really cruel, but that’s life. That’s the
process of apoptosis, where cells are pre-destined to die after a certain amount of time. It’s like
leasing a car. After a certain amount of time, you get rid of the car, whether it’s still working or
not. Then you get a new car. You don’t have to worry about it breaking down at the worst
possible time.
The same process also happens at a sub-cellular level. You don’t necessarily need to replace the
entire car. Sometimes, you just need to replace the battery, throw out the old one and get a new
one. This also happens in the cells. Instead of killing off the entire cell (apoptosis), you only
want to replace some cell parts. That is the
process of autophagy, where sub-cellular
organelles are destroyed and new ones are
rebuilt to replace it. Old cell membranes,
organelles and other cellular debris can be
removed. This is done by sending it to the
lysosome which is a specialized organelle
containing enzymes to degrade proteins.
Autophagy was first described in 1962 when
researchers noted an increase in the number of
lysosomes (the part of the cell that destroys
stuff) in rat liver cells after infusing glucagon.
The Nobel prize winning scientist Christian de
Duve coined the term autophagy. Damaged
sub cellular parts and unused proteins become
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marked for destruction and then sent to the lysosomes to finish the job.
One of the key regulators of autophagy is the kinase called mammalian target of rapamycin
(mTOR). When mTOR is activated, it suppresses autophagy, and when dormant, it promotes it.
Nutrient deprivation is the key activator of autophagy. Remember that glucagon is kind of the
opposite hormone to insulin. It’s like the game we played as kids – ‘opposite day’. If insulin goes
up, glucagon goes down. If insulin goes down, glucagon goes up. As we eat insulin goes up
and glucagon goes down. When we don’t eat (fast) insulin goes down and glucagon goes up.
This increase in glucagon stimulates the process of autophagy. In fact, fasting (raises glucagon)
provides the greatest known boost to autophagy.
This is in essence a form of cellular cleansing. The body identifies old and substandard cellular
equipment and marks it for destruction. It is the accumulation of all this junk that may be
responsible for many of the effects of aging.
Fasting is actually far more beneficial than just stimulating autophagy. It does two good things.
By stimulating autophagy, we are clearing out all our old, junky proteins and cellular parts. At
the same time, fasting also stimulates growth hormone, which tells our body to start producing
some new snazzy parts for the body. We are really giving our bodies the complete renovation.
You need to get rid of the old stuff before you can put in new stuff. Think about renovating your
kitchen. If you have old, crappy 1970s style lime green cabinets sitting around, you need to junk
them before putting in some new ones. So the process of destruction (removal) is just as
important as the process of creation. If you simply tried to put in new cabinets without taking out
the old ones, it would be pretty fugly. So fasting may actually reverse the entire aging process by
getting rid of old cellular junk and replacing it with new parts.
Autophagy is a highly regulated process. If it runs amok, out of control, this would be
detrimental, so it must be carefully controlled. In mammalian cells, total depletion of amino
acids is a strong signal for autophagy, but the role of individual amino acids is more variable.
However, the plasma amino acid levels vary only a little. Amino acid signals and growth factor/
insulin signals are thought to converge on the mTOR pathway – sometimes called the master
regulator of nutrient signalling.
So, during autophagy, old junky cell components are broken down into the component amino
acids (the building block of proteins). What happens to these amino acids? In the early stages of
starvation, amino acid levels start to increase. It is thought that these amino acids derived from
autophagy are delivered to the liver for gluconeogenesis. They can also be broken down into
glucose through the tricarboxylic acid (TCA) cycle. The third potential fate of amino acids is to
be incorporated into new proteins.
The consequences of accumulating old junky proteins all over the place can be seen in two main
conditions – Alzheimer’s Disease (AD) and cancer. Alzheimer’s Disease involves the
accumulation of abnormal protein – either amyloid beta or Tau protein which gums up the brain
system. It would make sense that a process like autophagy that has the ability to clear out old
protein could prevent the development of AD.
What turns off autophagy? Eating. Glucose, insulin (or decreased glucagon) and proteins all turn
off this self-cleaning process. And it doesn’t take much. Even a small amount of amino acid
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(leucine) could stop autophagy cold. So this process of autophagy is unique to fasting –
something not found in simple caloric restriction or dieting.
There is a balance here, of course. You get sick from too much autophagy as well as too little.
Which gets us back to the natural cycle of life – feast and fast. Not constant dieting. This allows
for cell growth during eating, and cellular cleansing during fasting – balance. Life is all about
balance.
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Power: Fasting vs Low Carb – Fasting 26

What’s the difference in power between fasting and LowCarb High Fat (LCHF)? Sometimes it
feels like arguing whether Batman or Superman is more powerful (Superman, of course). But
they’re both superheros, and the point of both these dietary superhero regimens is to lower
insulin. This stems from a rational examination about the causes of obesity and type 2 diabetes.
You need to understand the aetiology of obesity (the underlying cause) if you are to have any
hope of treating it.
For decades, we have
laboured under the false
assumption that excessive
calories caused obesity.
However, overfeeding
and underfeeding studies
clearly proved this
hypothesis wrong. If
calories caused obesity,
then overfeeding calories
should cause obesity. It
did, but only in the short
term. Long term, weight
went back to normal.
Underfeeding calories on
the other hand, should
lead to permanent weight
loss. But it did not. The
failure rate of this Caloric Reduction as Primary strategy is an abysmal 99%.
Using a more rational model of obesity as a hormonal disorder (mainly insulin, but also cortisol)
leads to the hypothesis that increasing insulin should lead to lasting weight gain. Decreasing
insulin should lead to weight loss. And guess what? It worked just as advertised. (See
the Hormonal Obesity series for a full description).
So, if we understand that excessive insulin causes weight gain, then the treatment is quite clear
and just really damned obvious. You don’t need to decrease calories, although there is some
overlap. You need to decrease insulin to cause weight loss. Both LCHF diets and fasting
accomplish this goal. Refined carbohydrates are the biggest stimulus to insulin, so reducing carbs
reduces insulin. Protein, especially animal proteins also raise insulin, so keeping protein
moderate and fats high is another way to keep insulin levels down. Fasting, by restricting
everything, also keeps insulin down. A ‘fat fast’ ie. eating nothing except pure fat, may also
accomplish the same thing, but studies are sparse. So ‘bulletproof coffee’ may certainly achieve
the same goal of lowering insulin without lowering calories, but the data are simply no there to
say for certain.
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But which diet is

better? LCHF or
Fasting? A
comparison of
power shows that
fasting wins every
time. In this
study of a
carbohydrate free
diet vs fasting in
type 2 diabetics,
you can see that
carb-free does
extremely well. If
we compare the
glucose response of
Carb Free versus a
Standard Diet, you
can see that blood
sugars come way
down. But fasting
does even better.
If you are trying to
lower blood
glucose, nothing
really beats fasting.
After all, you can’t
go lower than zero. Even then, the carb-free diet does remarkably well – giving you 71% of the
benefits of the fasting, without actual fasting. The standard diet was 55% carbohydrate and 15%
protein, and 30% fat – not far off of what most dieticians and Dietary Guidelines recommend.
You can see how shitty it is for actual blood glucose control.
The carb-free diet is <3% carbs (that is ketogenic or ultra-low carb), 15% protein
(moderate) and 82% fat. LCHF pretty much says it all. The calories delivered were 25 kcal/kg
(1750 calories for a 70 kg man) in 3 meals – this was the same between the standard and carb-
free diets. So the benefits of carb restriction on blood glucose were NOT simply due to calorie
restriction. This is useful knowledge, considering how many ill informed idiots doctors and
dieticians keep saying ‘It’s all about the calories’. Actually, in this study, it had nothing at all to
do with the calories.
Anybody who still believes that ‘It’s all about the calories’ despite 50 years of unrelenting failure
of the Caloric Reduction as Primary (CRaP) model either has not thought about things very hard
or is simply not all that intelligent. Yes. If a strategy such as CRaP fails for 50 years, we should
be changing our strategy. It doesn’t take Albert Einstein to tell us that is the very definition of
insane.
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This graph is pretty sobering. Looking at the Standard Diet (ADA recommended), you can see
how high those peaks of glucose really get. You might rightfully ask yourself, if the good folks
at the ADA knows that their diet sends blood sugars skyrocketing upwards, why on earth would
they recommend it? Are they trying to kill us? Unfortunately, the answer is yes. They are trying
to kill you. Not intentionally, but with their ignorance. All that money showered upon them from
Big Food and Big Pharma have something to do with it, too.
But what is carb-free just isn’t enough? I have lots of patients who limit their carbohydrates but
still have elevated blood sugars. How do you get more power? Sorry, Batman, it’s time to call in
Superman. (Don’t bother about the Wonder Twins – they were always useless. One of them
would turn into a dolphin or something.) In a word, we need Fasting.
The study results are
even more impressive
when you look at
insulin levels. This is
very important
because blood
glucose levels are not
the main driver of
obesity and diabetes.
Insulin is the main
driver. The entire
strategy of weight
loss hinges upon
lowering insulin.
Looking at total area
under the curve, you
can see that carb free
diet can reduce
insulin by roughly
50% but you can go another 50% by fasting. That’s power.
This makes sense, of course. A carb free diet will still contain some protein which will increase
insulin. The only way to get lower would be to eat 100% fat – which is largely an artificial
construct. That is, we don’t generally eat pure olive oil as a meal or pure lard. Bulletproof coffee
is certainly a great ‘hack’ but it’s hardly been tested by thousands of years of human history and
millions of people. Fasting has survived this test of time. It is Anti-Fragile. How? The more we
eat processed and ultra-processed garbage and pretend it is food, the more we need to fast. If you
eat a lot of fast food (foods that are ultra-processed and send insulin skyrocketing) the more you
need to fast (bring those insulin levels back down).
And NOTHING beats fasting for bringing down insulin. It is simply the fastest and most
efficient method of reducing insulin. Luckily, it’s also not as hard as most people believe it to
be.
What about glucagon? Remember that glucagon is sort of the opposite of insulin. One of
insulin’s main physiologic role is to suppress glucagon. Dr Roger Unger did much to explore the
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biological role of glucagon and often considered it the most important. However, in this study, it
had no clinical relevance at all. In dealing with patients, glucagon also plays little or no role.
Let me explain. Insulin causes weight gain – so giving insulin causes weight gain. Does reducing
glucagon cause weight gain? Not really. Does increasing glucagon cause weight loss? Not really.
Sure, glucagon plays a primary role in rat livers, but I don’t really care. I care about humans.
The bottom line of this study is to reinforce what we knew already. Insulin is the primary (but
not the only) driver of obesity. Therefore, for most people, reducing insulin is the best method of
treating obesity. Carb free diets are a powerful method of reducing insulin. But if that doesn’t
work, then intermittent fasting offers an even more powerful strategy.
In type 2 diabetes, you can reduce blood sugars by 50-70% by carb free diets. You can reduce it
another 30% with fasting. So, if we already know how to reduce blood sugars in T2D with
dietary strategies – why do we need medications at all? Here’s the answer, of course. You don’t.
Type 2 Diabetes is an entirely reversible disease.
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The difference between calorie restriction and fasting – Fasting 27

Perhaps one of the most common questions we get is what the difference is between calorie
restriction and fasting. Many calorie enthusiasts say that fasting works, but only because it
restricts calories. In essence, they are saying that only the average matters, not the frequency.
But, of course, the truth is nothing of its kind. So, let’s deal with this thorny problem.
The weather in Death Valley, California should be
perfect with a yearly average temperature is 25
Celsius. Yet, most residents would hardly call the
temperature idyllic. Summers are scorching hot, and
winters are uncomfortably cold.
You can easily drown crossing a river that, on
average, is only 2 feet deep. If most of the river is 1
foot deep and one section is 10 feet deep, then you
will not safely cross. Jumping off a 1 foot wall 1000
times is far different than jumping off a 1000-foot
wall once.
In a week’s weather, there is a huge difference between having 7 grey, drizzling days with 1 inch
of rain each and having 6 sunny, gorgeous days with 1 day of heavy thundershowers.
It’s obvious in all these
examples that overall
averages only tell one part
of the tale, and often,
understanding frequency is
paramount. So why would
we assume that reducing
300 calories per day over 1
week is the same as
reducing 2100 calories
over a single day? The
difference between the two
is the knife-edge between
success and failure.
The portion control
strategy of constant caloric
reduction is the most
common dietary approach
recommended by nutritional authorities for both weight loss and type 2 diabetes. Advocates
suggest that reducing daily caloric consumption by 500 calories will trigger weight loss of
approximately one pound of fat per week.
The American Diabetes Association’s main dietary recommendation suggests to “focus on diet,
physical activity, and behavioral strategies to achieve a 500–750 kcal/day energy deficit.” The
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‘portion control’ advice to reduce calories has been fairly standard since the 1970s. This
reduction is average calories should be spread consistently throughout the day, rather than all at
once. Dieticians often counsel patients to eat four, five or six times a day. There are calorie labels
on restaurant meals, packaged food, and beverages. There are charts for calorie counting, calorie
counting apps, and hundreds of calorie counting books. Even with all this, success is as rare as
humility in a grizzly bear.
After all, who hasn’t tried to portion control strategy of weight loss. Does it work? Just about
never. Data from the United Kingdom indicate that conventional advice succeeds in 1 in 210
obese men and 1 in 124 obese women (4). That is a failure rate of 99.5%, and that number is
even worse for morbid obesity. So, whatever else you may believe, constant caloric reduction
does NOT work. This is an empirically proven fact. Worse, it has also been proven in the bitter
tears of a million believers.
But why doesn’t it work? For the same reason the contestants of The Biggest Loser could not
keep their weight off – metabolic slowdown.
Starvation Mode
The Biggest Loser is a long running American TV reality show that pits obese contestants
against one another in a bid to lose the most weight. The weight loss regimen is a calorie-
restricted diet calculated to be approximately 70% of their energy requirements, typically 1200-
1500 calories per day. This is combined with an intensive exercise regimen typically far in
excess of two hours daily.
This is the classic ‘Eat Less, Move More’ approach endorsed by all the nutritional authorities,
which is why The Biggest Loser diet scores third on the 2015 USA Today’s ranking of best
weight loss diets. And, it does work, in the short term. The average weight loss that season was
127 pounds over 6 months. Does it work long-term? Season two’s contestant Suzanne Mendonca
said it best when she stated that there is never a reunion show because “We’re all fat again”.
Their Resting Metabolic Rates (RMR), the energy needed to keep the heart pumping, the lungs
breathing, your brain thinking, your kidneys detoxing etc., drops like a piano out of a 20 story
building. Over six months, their basal metabolism dropped by an average of 789 calories. Simply
stated, they burning 789 calories less per day every day.
As metabolism drops, weight loss plateaus. Caloric reduction has forced the body has shut down
in order to match the lowered caloric intake. Once expenditure drops below intake, you start the
even more familiar weight regain. Ba Bam! Weight is regained despite dietary compliance with
the caloric restriction and even as your friends and family silently accuse you of cheating on your
diet. Goodbye reunion show. Even after six years, the metabolic rate does not recover .
All of this is completely predictable. This metabolic slowdown has been scientifically proven for
over 50 years. In the 1950s Dr. Ancel Key’s famous Minnesota Starvation Study placed
volunteers on a ‘semi-starvation’ diet of 1500 calories per day. This represented a 30% caloric
reduction from their previous diet. In response, their basal metabolic rate dropped about 30%.
They felt cold, tired, and hungry. When they resumed their typical diet, all their weight came
right back.
Caloric restriction diets only work in the short-term, before basal metabolism falls in response.
This is sometimes called ‘starvation mode’. Daily calorie restriction fails because it unerringly
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put you into metabolic slowdown. It’s a guarantee. Reversing type 2 diabetes relies upon burning
off the body’s excess glucose, so the daily calorie-restricted diet will not work.
The secret to long-term weight loss is to maintain your basal metabolism. What doesn’t put you
into starvation mode? Actual starvation! Or at least the controlled version, intermittent fasting.
Fasting triggers numerous hormonal adaptations that do NOT happen with simple caloric
reduction. Insulin drops precipitously, helping prevent insulin resistance. Noradrenalin rises,
keeping metabolism high. Growth hormone rises, maintaining lean mass.
Over four days of continuous fasting, basal metabolism does not drop. Instead, it increased by
12%. Neither did exercise capacity, as measured by the VO2, decrease, but is instead maintained.
In another study, twenty-two days of alternate daily fasting also does not result in any decrease
in RMR.
Why does this happen? Imagine we are cavemen. It’s winter and food is scarce. If our bodies go
into ‘starvation mode’, then we would become lethargic, with no energy to go out and find food.
Each day the situation gets worse and eventually we die. Nice. The human species would have
become extinct long ago if our bodies slow down each time we didn’t eat for a few hours.
No, instead, during
fasting, the body opens up
its ample supply of stored
food – body fat! Yeah!
Basal metabolism stays
high, and instead we
change fuel sources from
food, to stored food (or
body fat). Now we have
enough energy to go out
and hunt some woolly
mammoth.
During fasting, we first
burn glycogen stored in
the liver. When that is
finished, we use body fat.
Oh, hey, good news – there’s plenty of fat stored here. Burn, baby burn. Since there is plenty of
fuel, there is no reason for basal metabolism to drop. And that’s the difference between long-
term weight loss, and a lifetime of despair. That’s the knife edge between success and failure.
Fasting is effective where simple caloric reduction is not. What is the difference? Obesity is a
hormonal, not a caloric imbalance. Fasting provides beneficial hormonal changes that happen
during fasting are entirely prevented by the constant intake of food. It is the intermittency of the
fasting that makes it so much more effective.
Intermittent Fasting vs Calorie Restriction
The beneficial hormonal adaptations that occur during fasting are completely different from
simple calorie restriction. The reduction of insulin and insulin resistance in intermittent fasting
plays a key role.
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The phenomenon of resistance

depends not only upon
hyperinsulinemia, but also upon
the persistence of those elevated
levels. The intermittent nature of
fasting helps to prevent the
development of insulin resistance.
Keeping insulin levels low for
extended periods of time prevents
the resistance.
Studies have directly compared
daily caloric restriction with
intermittent fasting, while keeping
weekly calorie intake similar. A
30% fat, Mediterranean style diet
with constant daily caloric restriction was compared to the same diet with severe restriction of
calories on two days of the week.
Over six months, weight and body fat loss did not
differ. But there were important hormonal
differences between the two strategies. Insulin
levels, the key driver of insulin resistance and
obesity in the longer term, was initially reduced
on a calorie restriction but soon plateaued.
However, during intermittent fasting, insulin
levels continued to drop significantly. This leads
to improved insulin sensitivity with fasting only,
despite similar total caloric intake. Since type 2
diabetes is a disease of hyperinsulinemia and
insulin resistance, the intermittent fasting strategy
will succeed where caloric restriction will not. It
is the intermittency of the diet that makes it
effective.
Recently, a second trial directly compared zero-
calorie alternate-day fasting and daily caloric
restriction in obese adults. The Caloric Reduction
as Primary (CRaP) strategy was designed to
subtract 400 calories per day from the estimated
energy requirements of participants. The ADF
group ate normally on eating days, but ate zero
calories every other day. The study lasted 24
weeks.
What were the conclusions? First, the most
important conclusion was that this was a safe and
effective therapy that anybody could reasonably
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follow. In terms of weight lost, fasting did better, but only marginally. This is consistent with
most studies, where, in the short term, any decent diet produces weight loss. However, the devil
is in the details. The truncal fat loss, which reflects the more dangerous visceral fat,was almost
twice as good with fasting as opposed to CRaP. In fat mass %, there is almost 6 times (!) the
amount of loss of fat using fasting
The other big concern is that fasting will ‘burn muscle’. Some opponents claim (without any
evidence) that you lost 1/4 pound of muscle for every single day of fasting you do. Considering I
fast at least 2 days a week, and have done so for years, I estimate my muscle percentage should
be just about 0%, and I shouldn’t even have enough muscle to type these words. Funny how that
didn’t happen. But anyway, what happened in that study? The CRaP group lost statistically
significant amounts of lean mass, but not the IF group. Yes, there is LESS lean muscle loss.
Maybe it has to do with all the growth hormone and nor adrenalin being pumped out.
Lean mass % increased by 2.2% with fasting and only 0.5% with CRaP. In other words, fasting
is 4 times better at preserving lean mass. So much of that old ‘fasting burns the muscle’.
What happens to basal metabolism? that’s what determines long term success. If you look at the
change in Resting Metabolic Rate (RMR). Using CRaP, basal metabolism dropped by 76
calories per day. Using fasting, it only dropped 29 calories per day (which is not statistically
significant compared to baseline). In other words, daily caloric reduction causes almost 2 1/2
times as much metabolic slowdown as fasting! So much for that old ‘Fasting puts you into
starvation mode’.
Fasting has
been used
throughout
human history
as a
tremendously
effective
method of
controlling
obesity. By
contrast, the
portion control strategy of daily caloric restriction has only been recommended for the last 50
years with stunning failure. Yet, conventional advice to reduce a few calories every day persists
and fasting is continually belittled as an outdated, dangerous practice akin to blood-letting and
voodoo. The study reports that “Importantly, ADF was not associated with an increased risk for
weight regain”. Holy S***. That’s the Holy Grail, Man! The whole problem is obesity and The
Biggest Loser is WEIGHT REGAIN, not initial weight loss.
Weight regain differed during fasting vs CRaP. The fasting group tended to regain lean mass and
continue to lose fat, while CRaP group gained both fat and lean mass. Part of the issue was that
the fasting group reported that they often continued to fast even after the study was done. Of
course! It is easier than they though, with better results. Only an idiot would stop. One of the
very fascinating things is that ghrelin (the hunger hormone) goes up with CRaP but does NOT
during fasting. We’ve known forever that dieting makes you hungrier. It’s not a matter of
willpower – it’s a hormonal fact of life – the ghrelin goes up and you are hungrier.
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However, fasting does not increase hunger. Fascinating. No wonder it’s easier to keep the
weight off! You’re less hungry.
Calorie restriction diets ignore the biological principle of homeostasis – the body’s ability to
adapt to changing environments. Your eyes adjust whether you are in a dark room or bright
sunlight. Your ears adjust if you are in a loud airport or a quiet house.
The same applies to weight loss. Your body adapts to a constant diet by slowing metabolism.
Successful dieting requires an intermittent strategy, not a constant one.
Restricting some foods all the time (portion control) differs from restricting all foods some of the
time (intermittent fasting). This is the crucial difference between failure and success.
So here’s your choices:

1. Caloric Reduction as Primary: less weight loss (bad), more lean mass loss (bad), less
visceral fat loss (bad), harder to keep weight off (bad), hungrier (bad), higher insulin
(bad), more insulin resistance (bad), perfect track record over 50 years unblemished by
success (bad)
2. Intermittent Fasting: More weight loss, more lean mass gain, more visceral fat loss, less
hunger, been used throughout human history, lower insulin, less insulin resistance.

Almost every medical society, doctor, dietician and mainstream media will tell you to use choice
#1. I prefer to tell people to take choice #2.
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Why you’re always hungry – Fasting 28

How do you reign in hunger? We all think that eating more will prevent hunger, but is this really
true? This is what is behind the advice to eat 6 or 7 times a day. If you can prevent hunger, then
you may be able to make better food choices, or eat less. On the surface, it seems pretty
reasonable. However, on the surface, the calories in calories out paradigm also seem pretty
reasonable, too. Like fool’s gold, appearances can be deceiving, and we must dig deeper to
appreciate the truth, otherwise we are the fools. So, let’s think about this a little more.
The advice to eat all the time to prevent hunger assumes that
eating a little bit will stave off hunger. Is there any evidence this
is true? That would be a big fat no. Somebody made it up, and
it’s been repeated so many times that people assume it’s true.
Mostly, it’s been promoted heavily by the snack food industry to
make sure that people continue to buy their products.
Let’s take some analogous situations. Suppose you need to
urinate. Which is easier?

1. Just hold it until you find the right time/place.

2. Pee just a tiny little amount and then stop yourself voluntarily. Do this repeatedly
throughout the day.

You and I know full well that once that first bit of urine come out, there’s no stopping until it’s
done. How about this situation? Suppose you are thirsty – which is easier?

1. Keep water out of sight and wait to drink until you find the right time/place and can drink
your fill.
2. Drink a thimbleful of water and then voluntarily stop drinking while looking at the full
glass of ice cold water. Do this repeatedly throughout the day.

Again, you and I both know that once you get that first sip,
there’s no stopping until the glass is empty. in both these
cases, it is easier to simply wait. Once you start something,
it is easier to continue until satisfied (empty bladder, thirst
sated, hunger sated). As with everything in life, there is a
certain inertia (the tendency to keep doing what you are
doing) to drinking, eating and urinating. It’s like my son.
You can’t ever get him into the bath. Once he’s in, you
can’t ever get him out of the bath. But this is normal
behaviour. So why do we assume this does not apply to
eating?
Some people would have you believe that eating a small
amount will fill you up so that you can avoid eating so
much. If this was true, what is the point of an appetizer? The hors d’oeuvre is literally served
‘outside the main meal’. For what purpose? So that we will spoil our dinner and cannot eat what
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the host has slaved over all day because we are full? Really? No. The whole point of an appetizer
is that this is a small tasty morsel to make us eat more.
In French, this may also be called an amuse bouche – meaning literally ‘something that amuses
the mouth’. Why? So that we will eat more. It’s not served to fill you up so that you can’t eat
that expensive intricate meal prepared by the chef. Virtually all cultures have this tradition to
whet the appetite, not dull it. So eating a small, less than satiating amount of food, makes us
more hungry, not less. So, eating a tiny bit, enough to make us hungry, and then voluntarily
stopping will take enormous willpower throughout the entire day. Not a good idea.
Now think about a time where you weren’t really all that hungry, but it was breakfast time
anyways. So you start eating because people have always said it’s the most important meal of the
day. To your surprise, as you start eating, you finished an entire meal relatively normally. Before
you started eating, you could have easily skipped the meal and have been full. But once you
started eating, you ate everything. Has this happened to you? It’s happened to me many, many
times, mostly because I’m always aware of this fact.
Eating WHETS the appetite. Got it, McFly? We’ve known this for at least 150 years! Eating all
the time so that you’ll eat less sounds really stupid, because it is really stupid. Don’t fall for it. If
you hear a doctor or dietician giving you this advice, run far, far away, very very quickly. They
will literally kill you with their idiotic advice.
How to stay hungry
So what’s another really great way to increase your hunger and sabotage your weight loss
efforts? Calorie reduced diets, of course. The portion control, or Caloric Reduction as Primary
(CRaP) strategy of weight loss always leaves you hungry. This is a proven fact.
In a well known study on
obesity, researchers took
subjects, had them lose 10% of
their body weight, and then
followed their hormone levels
over the next year. Ghrelin
(more about this next time) is
known as the hunger hormone –
higher levels means you are
more hungry. Peptide YY is a
satiety hormone – higher levels means your are more full.

After a year of maintaining their weight, there was a substantial difference in patients hormone
levels. Ghrelin is much higher (more hungry). Peptide YY is much lower (more hungry). This
translated into a measurable difference in hunger between the groups.
The weight loss group is measurable hungrier because their hormones are driving them to be
hungrier. This is very important, because there is a tendency to play ‘blame the victim’. When
people follow the CRaP advice and then regain their weight because they’re hungry, people think
‘oh, they have no will power’. THAT”S NOT THE CASE AT ALL.
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They are hormonally driven to eat

by hunger, so we should stop the
silent accusations that people can
control it. It’s not their fault. The
problem is not with the people, the
problem is the advice to eat
smaller portions. It is a strategy
guaranteed to fail. After all,
hunger is one of the strongest
basic survival instincts. Yes we
can suppress it for a few days. But
can we do it day after day, week
after week, year after year?
People who have lost weight are
physically, measurable hungrier
than those that have not. You
cannot solve this problem of long
term weight loss until you
understand how to curb hunger. What is the answer?
Well, in case you haven’t figured it out yet, this only being the 28th post on fasting and all, the
answer is fasting. There’s a certain logic here. If you eat all the time, you will get more hungry.
If you eat less, you will get less hungry. How does that work? We’ll see next week….
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Fasting and Ghrelin – Fasting 29

Ghrelin is the so-called hunger hormone. It was purified from rat stomach in 1999 and
subsequently cloned. It binds to growth hormone (GH) secretagogue receptor, which strongly
stimulates GH. So, for all you people who thought that eating makes you gain lean tissue, it is
actually the opposite. Nothing turns off GH like food. Of course, food provides the nutrients
needed to grow, so in fact, you need both feeding and fasting cycles to properly grow. Not all
feeding, and not all fasting. Life lies in the balance of the two. The cycle of life is feast and fast.
Ghrelin, has also been found to increase appetite and weight gain. It also antagonizes the effect
of leptin (in rats at least). Leptin, as you might recall, is the hormone produced by fat cells which
turns off appetite and makes us stop eating. Ghrelin turns on appetite. So, if you want to lose
weight on a long term basis, you need to tune down ghrelin.
So, how to do that? As we discussed last
week, eating all the time sounds like it
will turn off hunger and ghrelin. But
that’s far too simplistic. Surprisingly, the
answer is the opposite – fasting.
Let’s look at this study “Spontaneous 24-
h ghrelin secretion pattern in fasting
subjects“. Patients undertook a 33 hour
fast, and ghrelin was measured every 20
minutes. Here’s what ghrelin levels look
like over time.
There are several things to notice. First,
ghrelin levels are lowest at approximately
9:00 in the morning. This corresponds to
the measures of the circadian rhythm which find consistently that hunger is lowest first thing in
the morning. Recall that this is also generally the longest period of the day where you have not
eaten. This reinforces the fact that hunger is not simply a function of ‘not having eaten in a
while’. At 9:00, you have not eaten for about 14 hours, yet you are the least hungry. Eating,
remember, does not necessarily make you less hungry.
Next, notice that there are 3 distinct peaks corresponding to lunch, dinner and the next day’s
breakfast. BUT IT DOES NOT CONTINUALLY INCREASE. After the initial wave of hunger,
it recedes, even if you don’t eat. Ghrelin shows a “spontaneous decrease after approximately 2 h
without food consumption”. This correlates perfectly to our clinical experience that ‘hunger
comes in waves’. If you simply ignore it, it will disappear. Think of a time that you were too
busy and worked right through lunch. At about 1:00 you were hungry, but if you just drank some
tea, by 3:00 pm, you were no longer hungry. Ride the waves – it passes. Same goes for dinner.
Further it has been shown that ghrelin spontaneously decreases independently of serum insulin or
glucose levels.
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Also, note that ghrelin does have a learned component since all these subjects were used to
eating 3 meals per day. It is not merely by coincidence that these peaks of ghrelin happen. This is
similar to the ‘cephalic phase’ of insulin secretion that we’ve discussed previously.
There was one other big
finding of this study. Look at
the average ghrelin levels over
24 hours. Over the day of
fasting, ghrelin stays stable! In
other words, eating nothing
over 33 hours made you no
more or less hungry than when
you started! Whether you ate or
did not eat, your hunger level
stayed the same.
As we discussed in our last
post – eating more sometime
makes you more hungry, not
less. In the same vein, eating
less can actually make you
physically less hungry. That’s
terrific, because if you are less
hungry, you will eat less, and
are more likely to lose weight.
So what happens over multiple days of fasting? This study looked at the question specifically. 33
subjects had their ghrelin measured over 84 hours of fasting and they divided the results by men
and women, as well as obese and lean. There were no significant differences between the lean
and obese subjects, so I won’t dwell on that further. Once again, there were distinct circadian
variations.
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Over 3 days of fasting, ghrelin gradually DECREASED. This means that patients were far LESS
hungry despite not having eaten for the past 3 days. This jives perfectly with our clinical
experience with patients undergoing extended fasting. They all expect to be ravenously hungry,
but actually find that their hunger completely disappears. They always come in saying ‘I can’t
eat much anymore. I get full so fast. I think my stomach shrank’. That’s PERFECT, because if
you are eating less but getting more full, you are going to be more likely to keep the weight off.
Notice, also the difference between
men and women. There’s only a mild
effect for men. But the women show a
huge decrease in ghrelin. Again, this
addresses one of the major worries
that women are not able to fast.
Actually, women would be expected
to have more benefit from fasting
because their hunger can be expected
to decrease better than men. Notice,
too, how much higher women’s
ghrelin level reaches. I suspect this
correlates to the clinical observation
that many more women are ‘addicted’
to certain foods eg. chocoholics.
Sugar addicts. etc. So many women
have remarked how a longer fast
seemed to completely turn off those
cravings. This is the physiologic
reason why.
A few other notes about the hormonal
changes of fasting. Notice that
cortisol does go up during fasting.
Yes, fasting is a stress to the body and
cortisol acts as general activator as
well as trying to move glucose out of storage and into the blood. So, if too much cortisol is your
problem, then fasting may not be right for you.
Insulin also goes down, which is what we expect. Growth hormone, as we’ve previously noted,
goes up during fasting. I suspect this helps to maintain lean muscle tissue and to rebuild lost
protein when you start to eat again.
However, the main point of this post is to show that over intermittent and extended fasting,
ghrelin, the main hormonal mediator of hunger does not increase to unmanageable levels. Rather
it decreases – which is exactly what we are looking for. We want to eat less, but be more full.
Fasting, unlike caloric restriction diets is the way to do that.