Epidemic of diabesity and COVID-19 Intermittent fasting Therapeutic carbohydrate restriction Exercise A case report

1. Dr Joshua Chadwick Jayaraj, BPT, MD, MPH
Physician and Public Health Consultant

2. Overview
 Epidemic of diabesity and COVID-19
 Intermittent fasting
 Therapeutic carbohydrate restriction
 Exercise
 Comments on oral hypoglycemic agents
(OHAs) and insulin
 Existing evidence

3. Diabetes: a rising epidemic
 Over 30 million have now been
diagnosed with diabetes in India
 The Crude prevalence rate (CPR) in the
urban areas of India is thought to be 9
per cent
 In rural areas, the prevalence is
approximately 3 per cent of the total
population
The increasing burden of diabetes and variations among the states of India: the Global Burden of Disease
Study 1990–2016

4. Covid-19 versus other diseases

6. Intermittent fasting
 Time tested and ancient tradition
 Not only for weight loss
 But to improve concentration, extend
life, prevent Alzheimers
 Prevent insulin resistance and even
reverse the entire aging process

7. Insulin versus fasting
Fasting method.com

8.  There is nothing new, except what has
been forgotten – Marie Antoinette
 To eat when you are sick, is to feed your
illness – Hippocrates
 Fasting is the greatest remedy – the
physician within – Benjamin Franklin
(1706-1790)

9. The answer we are looking for
is, in a word, fasting
 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 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
https://www.bmj.com/content/364/bmj.l42

10.  Effect of breakfast on weight and energy
intake: systematic review and meta-
analysis of randomised controlled trials
 This study suggests that the addition of
breakfast might not be a good strategy for
weight loss, regardless of established
breakfast habit. Caution is needed when
recommending breakfast for weight loss in
adults, as it could have the opposite effect.
https://www.bmj.com/content/364/bmj.l42

11. Fasting versus starving
 This solution has been practiced by
virtually every culture and religion on earth
 Starvation is the involuntary absence of
food. It is neither deliberate, nor controlled
 Fasting, on the other hand is the voluntary
withholding of food for spiritual, health, or
other reasons
 The term ‘break fast’ is the meal that
breaks the fast – which is done daily

12.  There are certainly people who don’t
want you to fast. Such as..
 KFC, McDonald’s
 Swiggy, Zomato..
 So the question comes down to this. To
fast or not to fast. With regards to your
own health, who would you trust?

13. United States Department of
Agriculture’s food pyramid

14. Low Fat Diets and Exercise
for Type 2 Diabetes – T2D
 Type 2 diabetics should eat the very foods
that raise blood glucose the most? Illogical
is the only word that comes to mind – Isn’t?
 The British Diabetes Association, European
Association for the Study of Diabetes
(EASD), Canadian Diabetes Association,
American Heart Association, National
Cholesterol Education Panel recommend
fairly similar diets keeping carbohydrates at
50-60% of total calories and dietary fat at
less than thirty percent.

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

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

17.  In diabetics, the story was the same. The Action for
Health in Diabetes (LookAHEAD) studied the low fat
diet in conjunction with increased exercise. Eating
only 1200-1800 calories per day with less than 30%
from fat, and 175 minutes of moderate intensity
physical activity, this was the recommendation of
every diabetes association in the world. Would it
reduce heart disease as promised?
 Hardly. In 2012, the trial was stopped early due to
futility after 9.6 years of high hopes. There was no
chance of showing cardiovascular benefits. The low-
fat calorie-reduced diet had failed yet again.

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

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

20. Evidence about exercise
 Exercise improves weight loss efforts,
although its effects are much more
modest than most assume
 Nevertheless, physical inactivity is an
independent risk factor for more than 25
chronic diseases, including type 2
diabetes and cardiovascular disease

21. Evidence about exercise
 Low levels of physical activity in obese
subjects are a better predictor of death
than cholesterol levels, smoking status
or blood pressure
 The benefits of exercise extend far
beyond simple weight loss. Exercise
programs improve blood pressure,
cholesterol, blood glucose, insulin
sensitivity, strength and balance.

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

23. Main problem has always non-
compliance
 The spirit is willing but the flesh is weak
 A myriad of issues may deter an
exercise program
 Obesity itself, joint pain, neuropathy,
peripheral vascular disease, back pain,
heart disease may all combine to make
exercise difficult or even unsafe.

24. Standard recommendations
 Exercise seems an ideal way to burn off
the excess ingested calories of glucose
 Standard recommendations are to
exercise 30 minutes per day, five days
per week or 150 minutes per week. At a
modest pace, this may only result in
daily 150-200 kcal of extra energy
expenditure, or 700-1000 kcal per week.

25. Fasting versus exercise
 This pales in comparison to a total
energy intake of 14,000 calories per
week. A single day of fasting creates a
2000-calorie deficit, without doing
anything!

26. Limitations
 First, exercise is known to stimulate
appetite. This tendency to eat more after
exercise reduces expected weight loss
and benefits become self-limiting.
 Secondly, a formal exercise program
tends to decrease non-exercise activity.

27. Main problem: dietary in nature
 Type 2 diabetes is not a disease that is
caused by lack of exercise
 The underlying problem is excessive
dietary glucose and fructose causing
hyperinsulinemia, not lack of exercise
 Exercise can only improve insulin
resistance of the muscles. It does not
improve insulin resistance in the liver at
all.

28. Metabolic syndrome

30. Address the actual cause of the
problem

33. In reality: RBS

34. In reality: HbA1C

37. Thank you
 Happy to answer your questions @
joshua chadwick jayaraj @ Facebook or
mail me @
joshuachadwick89@gmail.com or tweet
me @joshuachadwickj