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Intermittent Fasting: The Science is Growing

Recent minor kurfuffle on MedPage about Intermittent Fasting. Response today:

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Intermittent Fasting: The Science is Growing
— Important to recognize that, when it comes to diet, one size does not fit all

by Michael Kelley, PhD
January 22, 2018

Earlier this month, a blog post by Suneel Kamath, MD, on intermittent fasting prompted many comments from readers and from diet and nutrition specialists contacted by MedPage Today. Kamath had criticized intermittent fasting as a fad diet with little evidence behind it regarding body weight, compared with traditional caloric restriction. We then heard from nutrition consultant Michael Kelley, PhD, who offered the following additional commentary.

My primary concern upon reading the article was the positioning of the science – the title positioned intermittent fasting as an oddity with scant scientific inquiry into effects on body weight and metabolism. Today, science must often contend with attempts to tell, and at times re-tell, the story of the science. Too often, an accurate portrayal of the science has been lost. I do not think this was Kamath's intent, but at the same time, the body of science was not accurately represented.

A systematic review by Seimon et al. in 2015 considered 12 clinical trials and concluded, "Intermittent fasting thus represents a valid -- albeit apparently not superior -- option to continuous energy restriction for weight loss." The entire review, which considered effects on appetite and metabolism, identified 72 potentially relevant publications, which were refined to 40 publications from 32 clinical studies.

In the more recent American Heart Association statement by St-Onge et al. in 2017, the authors wrote: "There is evidence that both alternate-day fasting and periodic fasting may be effective for weight loss, although there are no data that indicate whether the weight loss can be sustained long term." The 2017 clinical study by Trepanowski et al., reviewed by Kamath, came to a similar conclusion, albeit more conservatively stated.

Although Kamath did not cite further studies, his assessment of intermittent fasting for weight loss does reflect the overall literature. But the number of clinical studies on the topic currently stands at about 17 (depending on inclusion/exclusion criteria) and the body of scientific literature on intermittent fasting overall is several times larger. This is not "little evidence." This is serious and ongoing research performed by scientists who work mightily to gain scarce funding and publish the work. The goal is to provide the information which will ultimately guide our practice. Their efforts deserve an accurate portrayal.
Kamath then turned to an important issue: In practice, why consider intermittent fasting since the body weight effects appear to be no better than traditional caloric restriction?

One possible reason: individuals differ. For example, many in the U.S. have been raised with the concept of breakfast as an essential meal. With aging, some individuals seem to lose the desire for a meal consumed in the morning. An intermittent fasting meal pattern of 8 hours for consuming (e.g., noon to 8 p.m.) and 16 hours for fasting might work very well for some of these individuals -- for weight loss, or simply for weight maintenance and health. The proof would be in the results – it would be an experiment. (Note: There is a sizeable literature on the health effects of breakfast, including associations with body weight. This is beyond the scope of the present comments.)

The different practices of intermittent fasting may initially seem odd if the cultural norm is three or more meals per day. And while fasting may have been practiced and written about for centuries, it is difficult to determine the beginning of intermittent fasting practice beyond blog posts or web sites which appeared in the 1990's. I think this fails to qualify as a "fad," but it is certainly recent.

Those of us in the food and nutrition science world have observed the same frustrating trends Kamath expressed as a physician: Claims of wondrous health benefits resulting from various diets, foods, and ingredients. This growing flow comes direct to consumers via news reports, web sites, blogs, celebrity endorsements and an increasing number of social media channels. The sheer range of resulting questions can be daunting.

For healthcare providers, I think there are some anchors for guidance in a discussion with patients about intermittent fasting.

The MyPlate resources from the U.S. Department of Agriculture are based on the most current U.S. Dietary Guidelines. Although experts debate the evidence base and recommendations in the guidelines, for healthcare professionals in need of authoritative recommendations, it's hard to go wrong with the government guidelines as the basics for a healthy diet. The materials are consumer-friendly, so patients can reasonably be asked to read them.

Patients who want to experiment with their diet can be asked to confirm that the official recommendations be accounted for in the new diet plan. The guidelines recognize explicitly that there is not a single best practice when it comes to diet and that there is room to explore alternatives. The patient can be requested to return in the future to report on progress and issues, as in any situation where dietary change for health is implemented.

If any intermittent fasting-related fasting periods raise concerns regarding existing conditions or medications, the experts queried in the follow-up by MedPage Today have offered an initial source of guidance to augment the provider's expertise.

In the end, healthcare providers should not feel pressed to make an endorsement. If not comfortable with the description of intermittent fasting, or any recent dietary practice, it is reasonable to rely on the current dietary guidelines as the basic recommended practices, and when warranted, refer to a registered dietitian for more detailed guidance. Even with good sources of guidance, dietary change for any patient is an experiment, with a need for observation and follow-up.

Michael Kelley holds a BS, MS, and PhD in Nutrition Science, is a registered dietitian and holds an adjunct faculty appointment in the College of Dentistry at the University of Illinois in Chicago. He is a consultant who works on issues of nutrition science and health with food industry companies and industry associations, and develops continuing education content for health professionals. He is a member of the American Society for Nutrition and contributes to scientific programs and activities of the society. He previously held faculty positions at Emory University and San Diego State University, and as a scientist at Abbott Laboratories and The Wm Wrigley Jr Company (a subsidiary of Mars Inc.).

For more detail on various time restricted eating plans, there is long thread about Dr Jason Fung's use of it to correct high blood sugars in diabetics: http://forum.lowcarber.org/showthread.php?t=472377

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The MyPlate resources from the U.S. Department of Agriculture are based on the most current U.S. Dietary Guidelines. Although experts debate the evidence base and recommendations in the guidelines, for healthcare professionals in need of authoritative recommendations, it's hard to go wrong with the government guidelines as the basics for a healthy diet. The materials are consumer-friendly, so patients can reasonably be asked to read them.

He absolutely lost me there. You can't go wrong, really?

Jean

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"There is evidence that both alternate-day fasting and periodic fasting may be effective for weight loss, although there are no data that indicate whether the weight loss can be sustained long term."

The Biggest Loser gets criticized because there's a lot of relapse among former contestants. I actually think this is unfair--because the bar that needs to be passed to qualify as effective long-term is pretty low. We live in a world where a diet and exercise program can have most participants relapse and still be very effective compared to the average program. I'm not sure "can it be sustained long term" should be a criticism of a weight loss method, that's more along the lines of maintenance. Is the program on the ranch sustainable long term? No. But if the mainstream advice for maintenance, simply don't eat more than you burn was practical, it wouldn't need to be. They shouldn't pretend they've entirely cracked the maintenance problem for any dietary approach.

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Originally Posted by teaser

Good point Teaser. No approach has been shown to be sustainable long term for the vast majority of people. The issue of maintenance is different from the issue of weight loss. I've solved the problem for myself by making no distinction between how I eat to lose weight and how I eat to maintain weight. Perhaps one of the primary problems is the concept of a weight loss diet as something different from maintenance diet. What we need is a deep understanding of how best to eat for general health with weight loss one of the possible benefits.

Jean

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Originally Posted by cotonpal

Excellent point. Making an effective WOE a WOL is the approach that has worked for me. No need to be concerned about maintenance.

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Originally Posted by cotonpal

He absolutely lost me there. You can't go wrong, really?

Jean

Cant get sued? For recommending government approved my plate? :lol: Never mind whether it's healthy or not. Okay, I don't think that's really what he meant. He probably believes my plate is healthy. But at least I don't. :)

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Kamath had criticized intermittent fasting as a fad diet with little evidence behind it regarding body weight, compared with traditional caloric restriction.

Whoa, an idjit with a doctorate, whodathunkit!!!

A fad, huh? We fast intermittently every single day and between every single meal for our entire lives from the moment we're born to the moment we die, and we've done this for as long as our species has emerged on this planet. This makes intermittent fasting the longest standing fad ever. Ever.

Ah but the thing called intermittent fasting is slightly different. It means to extend this fast a little bit longer, like a few hours, maybe every day, maybe every other day, maybe a few days a week, or something like that. Think of it as skipping a meal once in a while, cuz that's all it is really. I just gotta wonder how ancient this practice of skipping a meal once in a while really is. How about some religious practices, huh? That's pretty old methinks, as old as those religions, and some religions are pretty old, like several thousands of years old. What a fad.

But seriously, plausible mechanisms for benefits is easy to figure out. For example, today we ask patients to fast for a day before tests, because it allows normalization of a ton of markers like BG, insulin and other hormones, cholesterol, etc. See this word - normalization. It means things go back to normal, as oppose to things being disrupted by a meal. It means fasting is, ehem, the normal thing to do.

But, we gotta eat, dumbass!!! Yes, we do. We gotta eat something, but this thing must be as close to normal as possible, the least disrupting. But we don't do that, we eat all kinds of crap, disrupt things so far we get sick from it. From there, the benefits of fasting are even more plausible, and in the facts even more, ehem, factual.

Hold on now. We eat all kinds of crap, disrupt things so far we get sick from it? What kind of crap? The processed kind. I mean, if it wasn't processed, nobody in their right mind would eat that crap, cuz it's crap, ya? How do we know it's crap? Before it's processed, in its raw form, it's utterly recognizable as crap - we know for a fact it's inedible.

Nah, all that reasonable plausible stuff, it's woowoo. We need sciance, dagnibit!!! Well here's my promise to you. Science is likely to find that a) intermittent fasting is beneficial, and b) fresh food (you know, the thing that actually feeds us?) is better than processed crap, and c) the benefits of fasting are greater in the context of a diet of processed crap.

I didn't read Kamath's post, need registration and I won't do that.

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I'm quoting this because the writer is a dietician, trained to promote the official guidelines. I'm absolutely certain it would surprise the writer that the relationship is actually reversed. The official guidelines (i.e. consumption) are based on the USDA (i.e. production), with no regards for any and all other pertinent aspects of food, nutrition or health.

The discussion between the two - Kamath and Kelly - is about IF vs CR, when it could be about diet and health in general, i.e. it could include low-carb for example. To me, it looks like an open internal debate between two buddies, cuz there's no actual neutral party involved here. Both advocate the official guidelines from the looks of it. No mention of existing alternative besides CR and IF, i.e. LCHF, keto, etc. It's not obvious, but it smells of CICO. It wouldn't surprise me to hear Kelly (certainly Kamath too, for CR) cite one benefit of IF as "cuz they eat less".

All in all, I'm sorry to say there's nothing fruitful here. It's gonna go nowhere fast. Fake debate. Manufactured problem. Misdirection. I gotta admit I almost got caught in it myself because it talks about IF.

They should examine health markers of patients doing IF other than just weight loss: blood pressure and blood sugar control among many other benefits often seen.

If they want to talk about what is NOT sustainable long term, that would be calorie restriction. I would white-knuckle my way through constant hunger for weeks and lose... a pound.

I would run out of calories at 2 pm and if I could have managed it, I would have fasted until the next morning, but I could not, because I was so hungry.

I happen to be midweek with alternate day fasting (it's easy when I'm feeling well and keeping up with my niacin) and I'm not hungry. I test with some salt and tea with coconut oil if I do feel hungry... and then it goes away.