- Bariatric Surgery
- Very Low Calorie Diet
- Low Carbohydrate Diet
Bariatric Surgery works for many people, with 30% or more able to achieve long-term remission. It also has the obvious downsides of surgical risk and expense. But it should be presented as an option, and some people will find it right for them.
A Very Low Calorie Diet, depending on the study, ranges from 300 to 1,800 calories per day. While these work really well in the short term, there is an issue with weight gain after the period of calorie restriction ends. It’s difficult to maintain the weight loss: the faster you lose weight, the faster you tend to regain it, and progress on diabetes can be lost too.
Low Carbohydrate Diets – Dr. Hallberg points to 22 randomized controlled trials (RCTs), 10 meta-analyses and 10 non-randomized trials, including six studies of two years or longer, including the Virta Health/Indiana University Health study she leads.
I think it’s worth watching the video below in its entirety for context, but if you want to skip ahead, she starts describing her results at about the 16:00 mark:
These results are phenomenal: Half of patients maintaining diabetes reversal at two years.
As she says, can you imagine if a drug had that kind of sustained effectiveness?
Here’s how the methods compare in blood sugar control:
In HbA1c, low carbohydrate is better than sleeve or very low calorie at two years, and equal to bypass.
And here’s how they compare from a weight loss perspective:
As Dr. Hallberg pointed out, the patients in her study (the purple line) started at a higher weight, and the average time with diabetes before the study was 8 years. Shifting the purple line’s starting point down 10 kg would make it pretty similar to either of the surgical options.
I greatly admire Dr. Hallberg and her collaborators, and I think the work Virta Health is doing is outstanding. Their results are great, and I think their intensive coaching intervention is valuable for people adopting this new way of eating.
I would add a fourth approach that I think will be the most effective, however: a combination of a low carbohydrate diet with intermittent fasting.
It conceptually combines the effects of the purple and orange lines in the graphs above.
Dr. Jason Fung calls fasting “medical bariatrics.” It has the benefits of bariatric surgery without the surgical expense and risk. It’s a lot easier to undo, too: You simply resume eating.
In fact, you have unlimited flexibility in adjusting the dosage of fasting. You can start with a 12-hour eating window each day, or you can fast for 16 or 18 hours and only eat from noon to 6 p.m. or noon to 8 p.m.
You can even consider alternate-day fasting, as in the #July4Challenge.
Low carbohydrate eating makes those fasting periods much less difficult, because fat and protein are more satiating than carbohydrates.
It’s kind of magical how these two strategies work together.
One final observation: At about the 23-minute mark of the video, Dr. Hallberg makes a really important point about the misplaced emphasis on randomized controlled trials in gauging efficacy.
RCTs are important when you have a drug intervention, because you’re typically testing a drug vs. a placebo, and the only thing you’re asking of the patients in the study is to just be sure they take whichever pill is assigned.
Diet is different. Motivation matters.
So does belief. If you’re randomly assigned to a diet for purposes of a study, even if you’re really motivated to change, you may not have really bought into the rationale behind the diet.
More on belief in a bit.
Dr. Hallberg in the U.S. and Dr. David Unwin in the U.K. have each demonstrated that a significant portion of patients under their care (as many as half) are able to reverse type 2 diabetes, going off diabetes medications, through a truly low-carb diet.
They’re not alone. Dr. Eric Westman at Duke, Dr. Tro and Dr. Brian Lenzkes, Dr. Ken Berry and scores or even hundreds of others are doing the same, although perhaps not quite at the same scale or with rigorous comparative studies.
They’re just helping patients who are motivated to get healthy and lose weight, and who are willing to try a low-carb approach.
For type 2 diabetes reversal (and prevention) and for weight loss, low-carb works.
I believe low carb + periodic fasting works even better.
I can’t “prove” it by the RCT standard, and the people I’ve mentioned above may not all agree with the combination.
They each have their own emphases: Dr. Fung’s is mainly on fasting, while I think some of the others who promote low-carb think it’s most important to eat healthy fat and moderate protein meals to satiety. They say the key is avoiding hunger, which makes compliance easier.
My experience has been that combining both perspectives has led to the best result for Lisa and me.
Now back to what I said about belief.
There’s plenty of evidence that if you will adopt a low-carb eating pattern you can eat until you’re full, rarely feel hungry, improve your metabolic health and lose weight.
But as long as you toy with the idea instead of taking the plunge, you’ll never really know. As one of the great Christian theologians put it in a different context:
“Understanding is the reward of faith. Therefore, seek not to understand that you may believe, but believe that you may understand.”St. Augustine of Hippo
Give low carb with periodic fasting a try.
Embrace the journey. Take the plunge.
If it doesn’t work for you, you can always have bariatric surgery later.
In the next few days I’ll have a post describing a new free community we’re setting up to support people in making these changes and swimming against the societal dietary currents. I look forward to telling you about it.
If you’re ready to get started yourself, use my #BodyBabySteps.
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