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Myth exploded
CASE REPORT
Therapeutic use of intermittent fasting for people with type 2 diabetes as an
alternative to insulin
1. Suleiman Furmli1,
2. Rami Elmasry2,3,
3. Megan Ramos4,
4. Jason Fung4,5
1. 1 Family Medicine, University of Toronto Faculty of Medicine, Toronto,
Ontario, Canada
2. 2 Saint James School of Medicine, Arnos Vale, Saint Vincent and the
Grenadines
3. 3 Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
4. 4 Corporate Medical Centre, Scarborough, Ontario, Canada
5. 5 Department of Medicine, Scarborough Hospital, Scarborough, Ontario, Canada
1. Correspondence to Dr Suleiman Furmli, furmli55@gmail.com
SUMMARY
This case series documents three patients referred to the Intensive Dietary
Management clinic in Toronto, Canada, for insulin-dependent type 2 diabetes. It
demonstrates the effectiveness of therapeutic fasting to reverse their insulin
resistance, resulting in cessation of insulin therapy while maintaining control
of their blood sugars. In addition, these patients were also able to lose
significant amounts of body weight, reduce their waist circumference and also
reduce their glycated haemoglobin level.
* diet
* obesity (nutrition)
* metabolic disorders
* diabetes
* endocrine system
This is an open access article distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others
to distribute, remix, adapt, build upon this work non-commercially, and license
their derivative works on different terms, provided the original work is
properly cited and the use is non-commercial. See:
http://creativecommons.org/licenses/by-nc/4.0/
https://doi.org/10.1136/bcr-2017-221854
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* diet
* obesity (nutrition)
* metabolic disorders
* diabetes
* endocrine system
BACKGROUND
Type 2 diabetes (T2D) is a chronic disease closely linked to the epidemic of
obesity that requires long-term medical attention to limit the development of
its wide range of microvascular, macrovascular and neuropathic complications.
Many of these complications arise from the combination of resistance to insulin
action, inadequate insulin secretion, and excessive or inappropriate glucagon
secretion. Approximately 10% of the population of the USA and Canada have a
diagnosis of T2D, and the morbidity and mortality rates associated with it are
fairly high. The economic burden of T2D in the USA is $245 billion.1 2
These three cases exemplify that therapeutic fasting may reduce insulin
requirements in T2D. Given the rising cost of insulin, patients may potentially
save significant money. Further, the reduced need for syringes and blood glucose
monitoring may reduce patient discomfort.
Although lifestyle modifications are universally acknowledged to be the
first-line treatment of T2D, adequate glycaemic control is difficult to achieve
in majority of obese patients. Bariatric surgery is an effective treatment
option for obese patients with T2D, but is invasive, costly and not without its
risks. Long-term effects have not been definitively established, and failure of
the surgical intervention may occur due to non-compliance with diet and
lifestyle factors. In addition, many patients require surgical reversal.3 4
Medications help manage the symptoms of diabetes, but they cannot prevent the
progression of the disease.5
Therapeutic fasting has the potential to fill this gap in diabetes care by
providing similar intensive caloric restriction and hormonal benefits as
bariatric surgery without the invasive surgery. Therapeutic fasting is defined
as the controlled and voluntary abstinence from all calorie-containing food and
drinks from a specified period of time.6 This differs from starvation, which is
neither deliberate nor controlled. During fasting periods, patients are allowed
to drink unlimited amounts of very low-calorie fluids such as water, coffee, tea
and bone broth. A general multivitamin supplement is encouraged to provide
adequate micronutrients. Precise fasting schedules vary depending primarily on
the patient’s preference, ranging from 16 hours to several days. On eating days,
patients are encouraged to eat a diet low in sugar and refined carbohydrates,
which decreases blood glucose and insulin secretion. The full manual of the
dietary regimen used in this study has been published and is quoted in the
references.7
As such, patients with T2D can reverse their diseases without the worry of side
effects and financial burden of many pharmaceuticals, as well as the unknown
long-term risks and uncertainty of surgery, all by means of therapeutic fasting.
CASE PRESENTATION
Our case series involved three patients. Chart reviews of each patient were
completed in November 2016, which included printed notes from the referring
physicians, blood work and Intensive Dietary Management (IDM) clinic notes from
each visit. On the initial consultation, all patients had been receiving various
pharmacological therapies for their T2D, including at least 70 units of insulin
daily. Patients were then seen monthly thereafter. Patient characteristics are
summarised in table 1.
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Table 1
Patient characteristics
Patient 1 is a 40-year-old man diagnosed with T2D for 20 years. Other
significant medical history includes hypertension and hypercholesterolaemia. His
diabetic pharmacotherapy at the time of admission was insulin glargine 58 units
at bedtime, insulin aspart 22 units twice daily, canagliflozin 300 mg once daily
and metformin 1 g twice daily.
Patient 2 is a 52-year-old man diagnosed with T2D for 25 years. Other
significant medical history includes chronic kidney disease, renal cell
carcinoma (treated with previous nephrectomy), hypertension and
hypercholesterolaemia. His diabetic pharmacotherapy at the time of admission
consisted of insulin lispro mix units −38/32 25 IU twice daily.
Patient 3 is a 67-year-old man diagnosed with T2D for 10 years. Other
significant medical history includes hypertension and hypercholesterolaemia. His
diabetic pharmacotherapy at the time of admission consisted of metformin 1 g
twice daily and insulin lispro mix 25–30 units in the morning and 20 units at
night.
TREATMENT
All patients were seen in the IDM clinic after the initial educational seminar
and dietary and insulin adjustments were made. Patients were followed in the
clinic biweekly in the first few weeks until the insulin was discontinued.
The primary intervention used in this case series was dietary education and
medically supervised therapeutic fasting. All patients were given detailed
instructions on monitoring blood glucose, and insulin dosage was reduced prior
to starting their fasting regimen in anticipation of the reduced dietary intake.
Patients were closely monitored medically and instructed to stop fasting
immediately if unwell for any reason.
All three patients participated in a 6-hour long nutritional training seminar
which outlined many topics including the pathophysiology of diabetes, insulin
resistance, education on macronutrients, and the principles of dietary
management of diabetes including therapeutic fasting as well as safety.
After completing the educational training, the patients were instructed to
follow a scheduled 24-hour fasts three times per week over a period of several
months. Over the time period they were evaluated for glycaemic control and other
diabetes-related health measures.
All patients followed similar dietary regimen. Patients 1 and 3 followed
alternating-day 24-hour fasts, and patient 2 followed the triweekly 24-hour
fasts schedule. On fasting days, the patients only consumed dinner, whereas on
non-fasting days the patients consumed lunch and dinner. Low-carbohydrate meals
were recommended when eating meals. Patients were examined on average twice a
month and labs were recorded.
At each visit, patients’ daily blood sugar diaries were reviewed and further
dietary and medication adjustments made if needed. Blood sugars were measured by
patients at least four times daily during the insulin-weaning period. Target
daily blood sugars were <10 during the initial insulin-weaning phase and
<7 thereafter.
In addition, patients’ weight, waist circumference and blood pressures were
measured and recorded at each visit.
OUTCOME AND FOLLOW-UP
There were five outcome measures in this case series:
1. Time to discontinuation of insulin.
2. Fasting blood glucose.
3. Serum A1C level (%, mmol/mol).
4. Patient weight (kg).
5. Patient waist circumference (cm).
The most noteworthy outcome from this case series is the complete
discontinuation of insulin in all three patients. The changes in diabetic
medications in all three patients are summarised in table 2. Both patients 2 and
3 discontinued all diabetic medications entirely. Patient 3 discontinued three
out of four medications post fasting regimen. All three were able to discontinue
their insulin. The minimum number of days to discontinuation of insulin was 5
and the maximum was 18. There was a general reduction of haemoglobin A1C (HbA1C)
levels for all patients during the course of the fast. No symptomatic episodes
of hypoglycaemia were reported in any of the patients.
View this table:
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Table 2
Changes in glycaemic and other health parameters from baseline to end of
follow-up
Patient 1, depicted in figure 1, fasted 3×/week and reported that he tolerated
fasting without difficulty and felt ‘excellent’ on his fasting days. Blood
glucose ranged from 5 to 10. Further, he had a 12% weight loss and 13% waist
circumference reduction (table 2). Patient 2, who followed the same fasting
regimen, significantly reduced his HbA1C overall, with some fluctuations as
summarised in figure 2. Patient 2 also subjectively reported feeling ‘terrific’,
and his daily blood sugars ranged from 5 to 6. Further, he had 18% weight loss
and 22% waist circumference reduction (table 2).
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Figure 1
Change in glycosylated haemoglobin while on fast for patient 1. HbA1C,
haemoglobin A1C.
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Figure 2
Change in glycosylated haemoglobin while on fast for patient 2. HbA1C,
haemoglobin A1C.
Patient 3 maintained a low HbA1C along the course of fasting scheduling as he
eliminated his insulin and 75% of his oral hypoglycaemic medications (figure 3).
He subjectively reported the fasting was ‘easy’ and does not have the
carbohydrate cravings he once had before he started the diet, and he also
experienced higher energy levels. Further, he had 10% weight loss and waist
circumference reductions (table 2).
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Figure 3
Change in glycosylated haemoglobin while on fast for patient 3. HbA1C,
haemoglobin A1C.
Despite its complete novelty of fasting for all three patients, it was well
tolerated. No patient stopped fasting at any point out of choice. In general,
our feedback from the patients in this programme was very positive, and a number
of patients commented on enjoying being actively involved in the process of
managing their diabetes.
DISCUSSION
The goals in caring for patients with T2D are to reduce symptoms and to prevent
or slow the development of complications. The main interventions for treating
T2D have been lifestyle modification, pharmacological and in some cases
surgical. The use of a therapeutic fasting regimen for treatment of T2D is
virtually unheard of. This present case series showed that 24-hour fasting
regimens can significantly reverse or eliminate the need for diabetic
medication.
A case review by Unwin and Tobin8 documented that they were able to
‘deprescribe’ a 52-year-old man who was living with T2D for 14 years. He was
suffering from gastrointestinal side effects from his metformin medication.
Following a low-carbohydrate diet, the patient steadily lost a total of 16 kg
over 7 months and successfully stopped all prescribed drugs, thereby achieving
his goal of being medication-free.8
Caloric restriction and weight loss are important factors for remission of T2D,
as recently demonstrated in an open-label Diabetes Remission Clinical Trial
(DiRECT). The DiRECT study showed diabetes remission and maintenance through
caloric restriction (~840 calories/day) and weight loss in a
non-insulin-dependent diabetic population.9 To date, however, very few studies
or cases have been documented or published with respect to therapeutic fasting
as a cure for T2D, reversing it completely and eliminating the use of insulin.
We were unable to locate a single case study published in the last 30 years.
In our study all three patients eliminated the need for insulin by initiating a
therapeutic fasting regimen. All three patients succeeded within a month and one
in as little as 5 days. Further, all patients improved in multiple other
clinically significant health outcome measures, such as HbA1C, body mass index
and waist circumference.
This reduction in risk factors will likely reduce the risk for further
complications. A study by Wing et al 10 found that modest weight losses of
5%–10% have been associated with significant improvements in cardiovascular
disease risk factors (ie, decreased HbA1C levels, reduced blood pressure,
increase in HDL cholesterol, decreased plasma triglycerides) in patients with
T2D. Risk factor reduction was even greater with losses of 10%–15% of body
weight. In our present study, all three patients experienced weight loss of 10%
or more.
Educating patients on the benefits of fasting in the management of T2D may aid
in the remission of the disease and curtail the use of pharmacological
interventions. A systematic review suggested that patients with T2D who have a
baseline HbA1C of greater than 8% may achieve better glycaemic control when
given individual education rather than usual care.11 Additionally, patients
should be educated about and encouraged to follow an appropriate treatment plan
tailored to them. Adherence to a fasting diet should continue to be stressed
throughout treatment, because these lifestyle measures and modifications can
have a large impact on the degree of diabetic control that patients can achieve,
as seen with this case series. This is further emphasised by a study by Morrison
et al,12 who found that more frequent visits with a primary care provider led to
markedly rapid reductions in serum glucose, HbA1C and low-density lipoprotein
cholesterol levels. In our study patients followed up with the treating
physician on average every 2 weeks.
LEARNING POINTS
* Medically supervised, therapeutic fasting regimens can help reverse type 2
diabetes (T2D) and minimise the use of pharmacological and possibly surgical
interventions in patients with T2D.
* Therapeutic fasting is an underutilised dietary intervention that can provide
superior blood glucose reduction compared with standard pharmacological
agents.
* Fasting is a practical dietary strategy.
* With proper education and support, we found compliance to be good.
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SUPPLEMENTARY MATERIALS
* BCR-2017-221854-PRESS-RELEASE
bcr-2017-221854-press-release
* bcr-2017-221854-press-release.docx
FOOTNOTES
* Contributors SF compiled all patient results and medical records for the
purpose of analysing the data; completed 50% of the background literature
review to help support the manuscript; assisted in writing approximately 50%
of the manuscript. RE assisted in 50% of the background literature search and
writing up 50% of the manuscript; created the graphs and figures for the
manuscript. MR took all of the patients' measurements and medical histories
for each appointment, and ensured that the data were correct and kept
up-to-date, safe and confidential; arranged follow-up appointments for the
patients and assisted with coaching and motivational interviewing at each
visit; organised and retrieved all medical information to complete this
study; ensured proper verbal and written patient consent for all three study
subjects. JF provided clinical oversight for the management of each patient
at each visit, including pharmacological management and deprescribing when
needed; provided methodological support including design, analysis and
interpretation of the results; proof-read the manuscript entirely at least
three times.
* Funding The authors have not declared a specific grant for this research from
any funding agency in the public, commercial or not-for-profit sectors.
* Competing interests None declared.
* Patient consent Obtained.
* Provenance and peer review Not commissioned; externally peer reviewed.
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