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The diabetes code with Megan Ramos

Today we meet Megan Ramos and discuss Dr Jason Fung’s book, the Diabetes Code. She co-founded the intensive dietary management clinic with Dr Fung and she's also a co-host with him on the Obesity Code Podcast. They talk about keto, obesity, diabetes, and fasting. It’s really fascinating things they're doing with their patients. I know you're gonna enjoy this. I heard her speak at Keto Fest last year. She's an active speaker and author.

Allan (3:45): Megan, welcome to 40+ Fitness.

Megan Ramos (3:47): Hi, thanks for having me today.

Allan (3:49): I'm really excited to have you here. It's funny, my Internet went down over the weekend and I haven't quite gotten it up, so I'm just putting this through my phone. So I'm hopeful that we can get everything in. This book we're talking about today is The Diabetes Code by Dr. Fung, and you work with Dr. Fung in his clinic so you see this stuff every day. I was driving down the road the other day and I saw this business, and it was a renal care facility where they basically do the dialysis. And I was thinking, how can that be a standalone business? But in some of the stats that were in the book, it's really amazing how many people are affected by diabetes and then go on to have kidney issues.

Megan Ramos (4:38): Almost all of them. I've worked with Jason for 20 years and we co-founded this clinic, the Dietary Management Clinic. It's within our nephrology practice. And over 80% of our patients that come in for intensive dietary management have a diabetic-related kidney disease. It might not be full blown, but they have the early onset of diabetic-related kidney disease. The number every year of people that come into the clinic with diabetic-kidney disease is incredible. When I first started doing research there 20 years ago, diabetic-kidney disease was not as common. The other causes of kidney disease were much more prevalent, but nowadays over 80% of these kidney patients have kidney disease because of their diabetes. This is the most disheartening thing to both Jason and I, was that as diabetes got worse, the kidneys totally failed. And there is nothing as people in the field of nephrology or as kidney specialists we could do for these people.

As the diabetes became more out of control, the kidneys declined and declined and declined, and we couldn't help these people. We were essentially watching them die, or watching their kidneys fail and just telling them they need to prep emotionally for dialysis, and helping guide them through dialysis education and emotional support and connecting them with other people on dialysis. Because that was all we could do for these people. We couldn't help them out. Probably until about five years ago, we had nothing that we could do to help these people. As long as the diabetes got worse, they were going to end up with complete kidney failure.

Allan (6:33): I guess that's what's shocking, because I looked it up – there are about 6,500 of these dialysis centers around the world, and growing. It's a growing industry. But this is mostly a preventable disease. I guess the doctors had always thought this is just a progressive thing that happens. But the subtitle of the book is Prevent and Reverse. So, if someone does have prediabetes or diabetes, there are some things that they can do to deal with those. And that's what you guys are getting into as part of what this book is about. We'll talk about in a minute, but I want to take a couple of little divergences, because there were things in this book that I found fascinating, and they're not topics that people talk about a lot. One of those was the TOFIs, which I know basically means that they look thin, they look healthy, but they have diabetes effectively, or they're close to having diabetes because of their visceral fat. Can you talk about TOFIs in particular, because I think a lot of people think, “If I lose weight or I'm thin, then I'm healthy.”? And that's not entirely true.

Megan Ramos (7:45): No, we spend a tremendous amount of time trying to explain body composition to our patients. Actually, I had a patient in clinic the other week. She was 98 pounds, but her liver was so fat and her pancreas was so fat. She was diabetic. As a result, even though she was 98 pounds, her body fat percentage was way over 40%. So she's clinically morbidly obese, even though she weighs 98 pounds and she's about five foot three. She looks very slender, she's a size zero, maybe a size two on a bloated day. But we spend a lot of time talking about body composition. A lot of the people who follow the standard North American diet have more fat than lean mass. They don't have a whole lot of muscle mass. We’re a very sedentary society here in North America, so we're not as active, we don't have as much lean mass, and our dietary choices too, especially in women, have led to destruction of our bone mass density. And now we're seeing osteoporosis more and more often in men too. So bad food choices, things like phosphoric acid being extremely abundant in a lot of the processed foods that we're eating, are really taking a toll on our bone mass density. So this woman is very petite, but she's just a little sack of fat. It's fine if you’re a certain weight, but the majority of your body is strong bone and good muscle mass that’s going protect your joints and your body and your organs in general as you age. So we try to talk to our patients about how the scale doesn't really matter. Of course you don't want to weigh 500 pounds, you don't want to weigh 600 pounds. But myself, I've been 90 pounds and I've been morbidly obese, and I've been 120 pounds and extremely healthy. So it's really about body composition.

Diabetes originates in the liver, and certain kinds of foods that we eat can make us more prone to developing a fatty liver, and that kickstarts diabetes. We have a lot of these patients come into the clinic, they're very slender and they have an extreme fatty liver and as a result they have diabetes. And they go on to tell me about how they've never really eaten that badly and they don't understand how they had a fatty liver, because they don't drink alcohol very often or not at all. And I say, “You're diabetic because you drink too much soda. You're diabetic because you drink too much fruit juice.” The fructose and the excessive sugar diet cause this fatty liver disease. As a result, you might not have a beer gut with your belly hanging over the edge of your pants, but your liver is much larger than it needs to be, and your liver has a beer gut in itself. So we have to eliminate the organ fat.

There are a lot of people out there that are digitally obese and that are in much healthier shape than the skinny people who have a lot of this organ fat. When you have so much organ fat, that fat's going to prevent your organ from functioning well. We see fatty liver, fatty pancreas, fatty spleen. When you have a fatty liver and it gets so fatty, you start to develop liver cirrhosis, hardening of the liver. Then the liver can't do its job at detoxifying the body, then you have fatty pancreas. We see this all the time now because we have these type 2 diabetics and we see that their liver is so fatty that they can no longer produce adequate insulin to be able to regulate their blood glucose levels. So they end up with very high blood glucose levels and they end up on insulin as a result.

Allan (11:45): Yeah. There was another thing. Like I said, I love these little tangents. Sometimes I get into a book because I think that's where I really learn some things that help me be better at talking with people. And one of them is the Randle cycle. The Randle cycle makes sense to me in a lot of ways because so many people will say, “I want to lose fat”, and then they're eating a low fat diet. But based on what the Randle cycle says a cell can only use sugar or it can use fat, but it really can't use both simultaneously. I think that's a really important fact to put out there, because if someone wants to burn body fat and they're eating a predominantly sugar-laden or carbohydrate-laden diet, they're making it that much harder for themselves, aren't they?

Megan Ramos (12:38): Absolutely. You can't be a sugar burner and a fat burner simultaneously. The hormones that are produced when you eat excessive carbohydrates block fat loss. So you can't be eating a diet that's producing hormones that are blocking fat loss, and actually expect to lose body fat. That's just not how it works.

Allan (13:03): I think a lot of people think, “If I eat less calories total…” There are more calories in fat than there are in carbs. When they want to do the calories in, calories out, it seems to make more sense from a math perspective. But our bodies don't actually work that way.

Megan Ramos (13:21): That's correct.

Allan (13:23): There’s a drug I know that a lot of people will get on when they're prediabetic or diabetic, because they go in, and the symptom and how we know someone is diabetic is effectively blood glucose. They get up to a certain level of blood glucose and they’re said they're prediabetic. And then if they get up to another level, at that point they're called diabetic. A drug that's very commonly prescribed is called metformin. Could you talk about metformin, when it is appropriate to have metformin and when it's not?

Megan Ramos (13:58): Usually we’re not necessarily opposed to metformin in our clinic. It's a relatively benign medication and it does have some benefits that other medications don't have. The risk factor for taking metformin is much lower than a lot of the other medications on the market. But usually at our clinic, if someone is being proactive with their lifestyle and their diet, we usually don't put them on anything. We wouldn't start them on metformin until the sugars went over 10 or 180, or their hemoglobin A1c was over 9. If someone's being proactive with their diet and their lifestyle, so they've gone low carb, they increase the fats in their diet, they're not snacking, they're following a restricted eating protocol – we usually leave them off of metformin.

And we don't actually find it helps a lot with weight loss. A lot of our patients come into the clinic with lower hemoglobin A1c of 6.4, 7.1, and their doctors have told them that metformin will help them lose weight. I've never in 20 years have seen metformin help a patient actually lose weight, and the research out there on that is not very compelling. It's not really great quality research studies to go by. So when someone's blood sugar levels are excessively high… For us there's a certain range that we like to cap our patients under when they're being proactive with their lifestyle, because we do see their blood sugar levels drop really quickly. Cut out the carbs, stop snacking, stop eating late at night, skip breakfast. We see people's blood sugar levels drop by anywhere from 25% to 50% within two weeks, so we really don't engage in metformin until someone's blood sugar level’s over 180 or until their hemoglobin A1c is over 9 in our clinic.

Allan (16:01): Okay. And that's because at those levels now, this is dangerous to the brain and its function, because it needs the blood sugars in a fairly tight range and you're well outside that range at this point. So, a drastic measure like a medication actually does make some sense. And when they make the lifestyle changes, I'm guessing they start to come off the metformin as well.

Megan Ramos (16:23): Very much so. Usually most people who are just on metformin when they start can be off of it within a couple of months of being very proactive and consistent with their dietary changes. When the blood is so concentrated with sugar… Sugar is very pointy, it's spiky, it's like a little ball of spikes. And as it goes through your circulatory system, it has the potential to really scrape and scratch the sides of your blood vessels. When you lose integrity in your blood vessels, you prevent them from being able to expand and contract when they needed to, to allow more blood flow at certain times. So they can no longer expand, and this is where you run into a lot of difficulties. It's okay to have some spiky little balls of sugar go around in your circulatory system, but when you have so much and the blood is so concentrated with it, you can guarantee that your blood vessels are being scratched to heck. At that point when they can no longer expand the way they need to, then you're going to run into a lot of problems and have blockages and put yourself at high risk for stroke.

Allan (17:40): Yeah. Everybody loves simple rules. You can say something like calories in, calories out, step on the scale. It's a very easy number for us to use, and I think people love those simple things. But what I found is a lot of the times simple doesn't actually answer the whole thing. One of the cool things is you've taken the time to write basically three rules, and then there’s a fourth add-on to it, that are fairly simple. They're simple on the outside, but when you actually start drilling into them, it’s very important. In fact, for many of us it’s a huge life change to do some of these things. But I liked the idea that they're simple enough for you to know what the rule is, and then you can start applying it. The first rule that you have in here, and this is for reversing type 2 diabetes, is to avoid fructose.

Megan Ramos (18:39): Absolutely. So fructose doesn't go into your bloodstream. When you check your blood glucose levels, you're checking your blood glucose levels. You're not checking your blood fructose levels. So when you break out your glucometer, you're not measuring fructose. Fructose gets directly imported to your liver. If you give your liver a little bit of fructose, your liver can handle it, and it will process it and utilize it for energy. But when you dump a massive amount of fructose in your liver, it gets overwhelmed by it. And how it copes with that onslaught of fructose is to pump it out as fat and convert it to fat instantaneously. And when it gets so overwhelmed, that fat gets stuck in the liver, because the liver can't process it as effectively as it needs to. So that is the number one cause for fatty liver disease, is excessive fructose.

I was diagnosed at the age of 12 with fatty liver disease and I can tell you that was from excessive apple juice consumption during the first 12 years of my life on this planet. And I was a skinny kid. I was underweight until I was 26, and then I went from skinny fat to just plain out fat at 26. But it's just fructose; it really doesn't reflect in your bloodstream. This is why when you look at the glucose index, you'll see something like a popular mainstream chocolate bar is considered to be moderate, and that's because the sugar that we use is half fructose and have glucose. So if you look at the glucose index, you'll see something like a popular chocolate bar being considered moderately okay. Where something like a slice of bread is one of the top things, being the food most likely to raise your blood glucose levels. The sugar in bread is all glucose, but that in fruits and things like chocolate bars – those are all half fructose and half glucose, so you're only actually seeing half of the sugar that you're consuming with those items when you're checking your blood glucose levels. So fructose goes straight to your liver, it overwhelms your liver, it becomes fat instantaneously, and if it becomes so overwhelmed with fructose, you start to develop fat in the liver as well.

Allan (21:06): We're getting most of this fructose now from soft drinks, and it's a food additive now because it’s very cheap to get from corn, so they have the high fructose corn syrup that they use to sweeten just about everything that's processed. That's where we're getting a lot of this, and from the fruit juices, as you mentioned. This isn't to cry against fruit; there's a lot of nutritional benefits to having some fruit in your diet, but you shouldn't drink those calories as a form of juice, because then you're not getting the fiber and the other things you would be getting from that fruit. Rule number two is to reduce refined carbohydrates and enjoy natural fats. And I like that term, “natural fats” a lot, because I think that's been the struggle. We say “good fats” and “bad fats”, people want to try to define those in different ways. But I like the term “natural fats” because at that point it's very clear what it is. This is from a plant or an animal product and it's something that's naturally occurring. It's not something that you have to squeeze or process to make this thing happen. It’s just there. Can you talk a little bit about how eliminating refined carbohydrates and focusing on natural fats is going to help us?

Megan Ramos (22:25): Absolutely. When you consume carbohydrates, your body has to produce insulin to help you utilize the energy from those carbohydrates. Carbohydrates are large bunches of sugar molecules, primarily glucose. When we can consume a carbohydrate from our mouth, and then continuing down into our small intestine the carbohydrate is broken down into its individual sugar molecules, or glucose molecules, and they're released into the blood. In order for those glucose molecules to get into our cells, they need to be guided there by insulin. You need to have insulin latch onto the glucose and take it to the cell because the insulin molecule knows which cells need the glucose, and the insulin molecules have the key to enable the glucose to get into the cell, so the cell can gobble it up and utilize it for energy.

Our bodies only need so much energy, Allan. We don't need to be eating and constantly refilling our fuel tank, and this is what we do in society. We eat multiple times throughout the day, we're eating refined carbs, we're trying to bombard and completely overwhelm ourselves with energy, and our cells don't utilize this energy. So we have all this insulin and all this glucose hanging around, and then the insulin essentially packages the excess glucose that your cell doesn't need and stores it as body fat to be utilized later. So insulin is a fat-trapping hormone in a sense. Its purpose is to trap this excess sugar and store it for us to utilize later when our cells need it. We’re constantly feeding our bodies nowadays, so we're constantly storing excess sugar energy with insulin’s help, rather than going back and burning what's already been stored and saved to be utilized later on.

When you consume dietary fat though, you get very little insulin secretion. So a fat molecule is a bunch of fatty acids attached to a glycerol backbone. When you consume fat and you're digesting fat, your body doesn't actually need to produce any insulin or any fat-trapping hormones to help your body break down the fatty acids to be able to utilize those for fuel in the body. You do require a little bit of insulin to metabolize that backbone of the fatty acid molecule, but you don't need a whole lot of insulin to be able to get rid of that glycerol backbone. So it's negligible. When you consume fat, you produce zero fat-trapping hormones. There are other fat-trapping hormones – estrogen and cortisol. You don't produce those when you consume fat.

Another thing about fat is that it's absolutely the most satiating macronutrient that we have. When you consume fat, it sends a powerful and rapid response to your brain that you're being fed all this energy. You can actually get satiated off of eating fat before your belly starts to expand. Whereas when you eat carbohydrates, the message that's being sent from the stomach to the brain is very slow. When you eat carbohydrates, you have to wait until your belly is fully expanded, and once that expansion has occurred, that's when your brain starts to receive faster messages saying that you're full. So you get quite bloated and you end up overeating when you eat carbohydrates, because you have to wait for that belly expansion to occur before your brain gets the message that you need to stop eating. You don't need that for fat, so people actually end up eating only what they need when they're eating primarily natural fats. So you don't end up bloated, you finish eating and you're quite satiated before you have to undo that belt notch and undo the button on your pants. That's one of the other great things about eating fat. We tend to just eat the fat that our bodies actually need at the time for energy. We tend not to overeat it because of that rapid messaging that occurs when we consume fat, to our brain, telling us to turn off our hunger.

Allan (27:02): I think another thing when you are eating high fat, low carb, is that you're not as hungry as often, whereas with carbohydrates and sugar, if you have a high carbohydrate breakfast, they now have a term called “second breakfast” that's become very popular. The fast food restaurants are latching onto that by serving breakfast foods later in the day, because they're high carb and it gets people eating another breakfast fairly soon after they ate the one they just ate. It’s insane, but it is what it is. I can't blame McDonald's for wanting to make that money if people are going to take them up on it. The third rule of these three rules and the plus, is actually my favorite, and it's because it's a very simple thing that I think if people wrap their heads around, they're like, “Yeah, that actually does make a lot of sense.” And it is, just eat real food.

Megan Ramos (28:00): Absolutely. A lot of our patients live on government assistance. They're in bad shape. They're given $700 a month to live off of. I can't imagine that, because of the cost of living in Toronto. That’s what I pay to rent two parking spaces a month downtown Toronto. So the fact that they have to pay for all of their expenses with that, it’s astounding to me that they can live off of that. So sometimes buying all these fancier food items that are labeled “ketogenic friendly” or have different stamps of approval on them from for low carb, aren't possible. But eating real food is the most important thing. If you can only afford to eat legumes and lentils because they're more economical, at least they're real food. So really trying to utilize this real food to keep away from the refined carbohydrates, preventing your blood from having this rush of glucose and this insulin surge and really damaging the connection between insulin and your cells in the body.

Allan (29:14): It's one of the strangest things, when I really started getting into food and understanding the foods that I should be eating versus not eating – I go to the farmer's market and I buy a stake. And it's a one-pound steak, which is normally what I would have eaten. That would be my dinner, a one-pound steak. But I get this grass-fed beef and I find that I only need about a quarter of it and then I’m full, because my body's getting the nutrition it needs, it's getting high quality fat, natural fat. So I feel satiated with actually less food, because it's a higher quality product. I know it can seem expensive when you start pricing out what these are, but there are two things that are going to happen here if you can do this, and do this more often than not.

One is, you're going to find that you get satiated by whole food, real food, much faster because you're getting the nutrition your body needs, and then two, if we're out there buying this stuff, the supermarkets are going to start trying to carry it more and more. And you're seeing that now – you can go into the Walmart supermarkets here and you can find higher quality meats, grass-fed meats and local meats in some cases, because they're trying to cater to what the demand is. So just adding one or two of these high quality meals and trying to stay away from the processed stuff I think is going to mean a world of difference.

Megan Ramos (30:46): I agree. The more of us that do it are going to put a lot of pressure on these big corporate organizations to be able to charge this at an affordable price. In Canada, we're a little bit slow on this. Costco every now and then is a bit better, but I've noticed a huge improvement in the States. My husband's American and every year we go down to Florida for a few weeks at some point to visit with his family. It's amazing how in some of the supermarkets down there like Publix, they actually have pretty affordable grass-fed beef and hormone-free, antibiotic-free free range chicken. It's cool to me now that you can see that even at regular chain supermarkets within the United States. It's really neat.

Allan (31:34): Yeah, and that's what I'm saying, I think they're getting on board and realizing there's a demand for this. As we create that demand, we're going to drive these stores to start carrying that type of food. Invariably they compete with the other stores. There's, like you said, Publix here, there's Winn-Dixie and there's the Walmart market. They're all within two miles of each other, so they've got to push for your business and that's going to drive the price down. So again, just eat real food. These three rules will work for the vast majority of us that have walked into your doctor and the doctor's like, “Your A1c, you're prediabetic”, and you're like, “Okay, what do I do?” These three rules are going to work for quite a few of us. But you get patients because of it being a kidney issue – they're typically a good bit further down the line of this, so some of the strategies, some of the things that you have to do go above and beyond these three rules. That's where we get to talking about fasting, both intermittent and in some cases extended fasting. Can you talk a little bit about fasting as a protocol? How someone should go about this and what they should look for, as far as how to do it and the benefits they're going to get from fasting?

Megan Ramos (32:51): In terms of how to do it, it's always very important to have physician supervision or have a nurse practitioner watching over you while you do this, because like I said earlier, we see really rapid reductions in blood glucose levels. We also see very rapid improvement with blood pressure too, even in our kidney patients. Kidneys control blood pressure, so usually when there's so much kidney damage, we can't do anything about blood pressure. But we even see huge improvements with our patients as they start to lose weight, as their blood sugar levels start to come down, with their blood pressure, and so patients will feel very dizzy and unwell. So always have physician supervision, have someone monitoring your meds, go to your doctor if you don't feel well, stop fasting if you don't feel well. You can always start again once your medications have been adjusted. But the best thing to do is just to start off slowly.

So if I have a patient who comes into the clinic who's quite nervous about fasting but has done some research and does understand that there are benefits to fasting, such as weight loss and blood sugar reduction, blood pressure reduction, less medications across the board, improved lipid panels. They want to do it, but they're frightened to do it or they're just someone who's always eaten. When I was diagnosed with diabetes, I probably ate every two hours that I was awake for about 27 years. So the idea of not eating for an entire day… It was just habitual, constantly eating. I ate 30 cups of popcorn every night for probably a good 25 years to satiate myself after dinner time. And it's just habit. You go to make it whether or not you actually feel like you need it. So there are habits that need to be adjusted too, and those definitely take a lot of time.

The first step that we have a patient do is we encourage them to eat real meals. Eat a proper sized breakfast, eat until you feel satiated. Eat a proper sized lunch; again, eat until you feel satiated. We really encourage our patients to start fasting between meals. Sometimes going from breakfast to lunch and lunch to dinner, and then from dinner to breakfast the next morning – that's a huge change for them. Women in particular are terrified of feeling full, because we have chronically followed these low calorie diets that are very low fat and very high carb and if we ever ate to satiation, that meant that we overate and that we didn't lose weight, and that we rather gained weight. A lot of women in particular have been conditioned to think that when they feel satiated, that's counterproductive.

I was one of those women. It took me years and actually seeing that in other patients to realize that was a big part of my own struggle too, was that if you ate a proper meal and you ate until you're satiated, that you had failed because you were going to gain weight. And in the past on a high carb, low fat diet, that's absolutely true. That’s not the case on a low carb, high fat diet. It's quite different in how your body produces these hormones when you consume these macronutrients. When you eat back to satiation, you don't overeat, you don't produce fat-stimulating or fat-trapping hormones – you're in the clear, you're perfectly safe. You’re just going to give your body the adequate amount of fuel that it needs. That's really difficult for women.

So first thing we do is try to teach our patients how to eat proper meals and eat until they're full, and just cut out all snacking. Sometimes that's still really hard for them, so we'll first work on cutting out evening snacking. And that's the biggest vice for everyone we work with, is that evening snacking, sitting around the television with your family or going on the computer and surfing the Internet and having your bag of snacks or your bowl of snacks with you. So the first thing to do is to cut out snacking. Then the next thing that we recommend is that people try cutting out one meal and going down to two meals a day. We usually encourage people to cut out breakfast first, because diabetics will know that no matter what they do, their morning blood sugar levels are always the highest, unless they take a lot of long-acting insulin at night time or a medication such as Diamicron or Glyburide in the evening time, which stimulates a lot of insulin to be produced and secreted by the pancreas throughout the night.

But otherwise, if we're not taking these medications in the evening, our blood sugar levels are high regardless of what we eat in the evening before. So we encourage our patients initially to try cutting out breakfast. At breakfast time our blood sugar levels are high, as a result our insulin levels are high and this is because your liver tries to dump out extra sugar and tries to get you to burn it in the morning time. It's a survival mechanism. You've got excess sugar in you, your body needs to burn it. It will dump it out in the morning time, because historically we never ate in the morning time. In cavemen days they didn't have cavemen cupboards or cavemen refrigerators.

Allan (38:16): Or microwaves.

Megan Ramos (38:18): Exactly. We've evolved to have this process where our body self-fuels in the morning time anyways. When your liver dumps out the sugar in the morning, your pancreas automatically secretes insulin first thing to help your body metabolize and utilizes glucose to fuel you. So your glucose is already higher, insulin is already high, so burn it out, use that fuel. If my car has a completely full tank of gas in the morning, I’m not going to go to the gas station and try to squeeze in more fuel. My gas tank doesn't need any more fuel; it's completely full. It's better that I drive to work in the morning time and do my errands, and then later on in the day when my fuel tank is no longer full to add some fuel to it.

So that's what we encourage patients to do next, once they've sort of mastered the eliminating snacking and eating proper meals, is just to cut out one meal and then see how they're feeling, see how their bodies respond. Usually by this point we can gauge whether or not they're going to be a quick case or a more challenging case. It's hard to predict because there are some people with very stubborn insulin resistance who were only diagnosed with diabetes a few months ago, and there are some people who are actually quite quick to respond to therapeutic fasting, even though they were diagnosed with diabetes before I was even born. So we gauge this. We use the 16/8 diet, which is where you just eat lunch and dinner, we gauge how well a patient will respond. From there we would either recommend an intermittent fasting regimen or a prolonged period of fasting. Of course that depends on the patients, how they're feeling about fasting – if they've decided to develop a good relationship with it, if they're willing to try to do a little bit more.

If someone looks like they're going to respond quite well to fasting and they're going to be able to come off their medications quite quickly and see a good reduction in weight loss in a short period of time, we would have them do an intermittent fasting regimen anywhere from three 24-hour fasts a week to three 42-hour fasts a week. So, the therapeutic intermittent fasting regimens we recommend are 24 hours, 36 hours or 42 hours. And the frequency at which we like our patients to do them is three times a week. We've experimented; three times a week gives us the best overall results. Sometimes twice a week is just not enough to give us consistent results or give the patients enough results that really motivates them to continue fasting. But three times a week seems to compensate for any blemishes they might have in their diets on the weekends or when they eat out on Friday nights. So we have stuck to this three-time-a-week rule for the last five years and we've had a lot of success with it. So we start someone out with 24 hours with the goal of working them up to doing a 42-hour fast three times a week if they're suitable to do so. We'll keep them there until they start to hit normal blood sugar ranges, normal fasting insulin levels and normal A1c. Then we start to bring them down into more of a maintenance range.

If someone looks like they're going to be more of a stubborn case in terms of losing body fat or reducing their blood glucose levels, we’ll try to work on more prolonged periods of fasting with them. This could be anywhere from doing two 48-hour fasts a week or a 72-hour fast a week to sometimes doing five to seven days. We usually cap patients at 14 days within our clinic. The odd time we have a patient that will surpass 14 days. Usually at that point we're checking their bloodwork once or twice a week, we're seeing them in clinic twice a week. So we get to know them pretty well in a short period of time. We just had one gentleman, I saw him last Thursday and he was on day 26 of a fast. And his A1c had come down from 13 to about 11, and his blood sugar levels in millimoles per liter were 14 when he started and he had finally broken the double digit barrier. So after 26 days of fasting his sugars dropped to 9. That's just a little bit below 180, I believe. So sugars were still that high and he was actually taking a little bit of insulin still. I joke with him and I say he's the sweetest man I've ever worked with, because his body is just full of sugar. And he's quite slender; it's all in his organs. It's all visceral fat.

Allan (43:15): I think there's a couple of key things here. One, this is not a protocol that you just up and do yourself. You work with your physician, because if you're on certain medications, those medications will very likely have to be adjusted at some point in there and you don't want to be in a situation where you've done something and your physician's not available to know that you're doing that, to guide you through that process. So, it is important to involve your physician. Then the other question I had was, as you're putting them into these fasting protocols, is this just them drinking water, are they taking any kind of electrolytes? I know some folks have used bone broth while they're on a fast. What is the protocol you're using most with your clients?

Megan Ramos (44:01): For people who are just looking to lose weight and for those who are trying to combat metabolic syndrome, diabetes and obesity – we do permit them to utilize bone broth – not unlimited quantities of it. If they're doing a 24-hour fast or even less, like 16 or 18 hours of fasting, we usually ask them to try to do the fast with just water, if they can. Usually bone broth we would recommend to someone who's doing 36 hours of fasting or longer, and no more than about one or two cups a day at most. We definitely recommend bone broth once a day for our patients who are doing longer than three days of fasting. That's sort of a guideline. Sometimes our patients choose to ignore us, but we make them sign a form saying they're ignoring us. The purpose for that is to prevent refeeding syndrome and to make sure that they are getting in phosphorus and magnesium and calcium when they're fasting.

But for shorter fasts, it's not much of a concern. Most of us nowadays, especially us who are obese and who are combating diabetes – we're not malnourished. We have too much excess body fat, we’re too nourished – that's why we’re struggling. For most of our patients with metabolic syndrome, we do recommend a bit of bone broth. We do let our patients have about three to six cups of coffee a day if they don't experience a glucose spike from drinking coffee. Some of our patients do, even with decaffeinated coffee, it's very bizarre. But I'd say most of our patients can consume coffee. About 10%-20% of them have quite a large glucose spike, so we'll take them off of coffee. They're allowed to drink herbal tea and water – flat water, mineral water or carbonated water. So that's what we use for metabolic syndrome.

We do treat patients with various neurological conditions and some cancer patients, and for them we focus on shorter bursts of water-only fasts. We don't do longer fasts with these patients, because we're trying to induce autophagy in these patients to help kill cancer cells and repair their mitochondrial function. We need to have some nutrient deprivation in order to induce that. We don't know if too much autophagy, too much of the cellular regeneration is a bad thing, so we do these shorter bursts of water-only fasts. And another reason why we keep them short is to, again, prevent refeeding syndrome in cancer patients. A lot of these cancer patients have already lost a substantial amount of weight and they're not as hungry, and there's lots of nausea associated with chemotherapy treatments as well. We try to keep them short, so there's lots of refeeding in between each round of fasting, just to prevent any issues when they are fasting.

Allan (47:06): Okay. Again, the book is called The Diabetes Code. I learned so much, and I do every time I read one of Dr. Fung’s and your books. It's fascinating, the tidbits here. But I think if people do follow those three basic rules… And whether you have diabetes or not, they're still really important rules for you to function by, so that you keep from getting diabetes with our current food supply. Eating real food, avoiding the processed stuff and cutting out fructose, particularly in your drinks, like apple juice, like you said, and sodas. If someone wanted to learn more about you, learn more about the book, where would you like for me to send them?

Megan Ramos (47:50): People can check us out and learn more about Dr. Fung and myself and all the work that we're doing up here in Toronto on our website. Our website is IDMProgram.com. There's information about our podcast, our books (The Diabetes CodeThe Obesity Code, and The Complete Guide to Fasting, where you can get more information, what we're doing, clinic-recommended resources, as well as our program and how our program works, up on our website. And there's links to following both Dr. Fung and myself and the rest of our team on various social media platforms, like Facebook and Instagram and Twitter, up on IDMProgram.com as well.

Allan (48:29): Okay, cool. This is episode 321, so you can go to 40PlusFitnessPodcast.com/321, and I'll be sure to have a link there. Megan, thank you so much for being a part of 40+ Fitness.

Megan Ramos (48:42): Thanks for having me on, Allan. It's great to talk diabetes code with you.

Allan (48:46): Absolutely, thank you.


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