Jagannath Dixit’s affinity for preventive medicine made him leave a MD (Medicine) seat to do a MD in PSM – Preventive and Social Medicine. He has taught for 30 years at the Government Medical colleges in Maharashtra. He is currently HoD of Community Medicine at BJ Medical College. Dr Dixit, like a lot of us, was worried about his weight. In 2012, a Youtube video by Dr Shrikant Jichkar, suggested a two meals a day diet. Dr. Jichkar, for those who don’t know him, was an MD, an IAS officer and an MLA – all by the age of 26. Apart from the MD, he had 20 other degrees. He went on to be a minister in the Maharashtra government . Dr Jichkar passed away in a road accident in 2001 – at the age of 49.

JD is a student of science – and the initial suggestion of cutting down a meal, seemed quite unscientific. Nevertheless, he tried out the Jichkar recommendation for 3 months – and lost 8 kg and 2 inches of waistline. This seemed interesting enough for JD to research further. After publishing 12 papers, JD is now convinced about the science.

The original hunter-gatherer had a fast-feast diet. I am reminded of the Marathi manoos who will only eat tupashi (with desi ghee) or else will stay upashi (fast). As we civilised – and urbanised – our eating habits changed. With increased food availability and reduced physical work, the planet now has more obese people than malnourished ones. 

What causes obesity? Simple – a mismatch of calories in and calories out. The average Indian, half a century ago, required 3000 calories per day for a lifestyle where physical work played an important role. You had to fetch the water from the well, grind your cereals and pulses manually. Today with technology and fossil fuel energy, the calorie requirement is down to 2000 calories per day. Yet our intake has not gone down in the same proportion as our offtake. One extra apple a day will invite the doctor to stay. 100 calories extra per day will lead to a weight gain of 2 kg in one month.

Our input calories come in different forms – proteins, carbohydrates and fats. Proteins are the body builders. Most muscle and tissue is made of proteins. Although we have come to associate a lot of negativity with fats and oils – we need to keep in mind that our mind is pure cholesterol. Carbohydrates are the energy source – the glucose providers.There has to be a balance between the three forms – and when there is an imbalance, there is a problem. 

Time to deep dive into the currency of nutrition in the body – glucose. This blood sugar needs to be transported to the cell. Once you eat, insulin is secreted. Insulin is produced by the pancreas. First it facilitates entry of glucose into the cells. Then it converts the remaining glucose to glycogen in the liver and muscles. If still glucose is there, it converts it to fatty acids in the liver and stores it in adipose tissue. Insulin has another important role to play – it converts amino acids into proteins.

Every cell has a locked door that lets the glucose in – insulin is the key of that lock. A baseline insulin volume of about 18 to 32 units are produced everyday (1 unit is 0.0347 mg). A similar volume is produced on a need basis – when you consume food. The extra insulin production is not stimulated by the quantity of the food. Even if you were to take a nibble between meals, it is a signal for the pancreas to send out insulin. And it continues pumping insulin for up to 55 minutes after the first nibble. So folks who love snacking end up with more insulin in the blood than is required. 

Man is the only animal who eats when he is not hungry. However, our cells retain their primitive characteristic, of saying no when the hunger is over. So even if insulin is present, the cell keeps its glucose doors locked after it is satiated – this is called developing insulin resistance. The brain misreads the signal from the cells – and treats it as a case of low insulin production. It orders the pancreas to ramp up insulin production – further aggravating the body’s insulin resistance.  

Now you have sugar and an extra 30 units of insulin swimming in your blood. Remember the fast and feast we discussed earlier – the body has designed a mechanism to store energy to take care of our non sabudana fasts. Some of the sugar gets converted to glycogen which is stored in muscles. This store is a local one – as in only that particular muscle will have access to it. The balance excess sugars get converted into fats – which are stored in the liver, and later on around the waist and thighs. An average Indian has 60 days reserve in fat stock!

If the fats pile up in the liver – fatty lever – its filtration efficacy reduces – and ultimately leds to its failure. All this makes hospitals and pharma companies extremely happy. They now have billions of patients – and trillions in revenue. Diabetes is under diagnosed. Of the 12 cr diabetic folks, half of them don’t even realise that they have diabetes. Medicines start in 50% patients on the day of the diagnosis. 30% of the Indian population is pre-diabetic, 10% is diabetic. Half of all amputations are done on diabetic folks – and the same can be said of retinopathy. 

Doctors would like all of us to believe that diabetes is irreversible! GPs and pathologists end up testing patients for blood sugar – whereas it is blood insulin that needs to be checked.  Sugar tests are not conclusive because they provide a snapshot view of the body’s health. A relatively long term health monitor is the hba1c. This provides a 3 month average of sugar – and is a more reliable indicator of sugar control. Hba1c values of less than 6.5 are good – anything above that means diabetes. JD recommends that diabetics should get an Hba1c test done every month.

JD calls diabetes the most overtreated of all diseases – with doctors prescribing metformin instead of lifestyle changes. Preventive medicine does not find a voice in the media because prevention is cheap, and so not profitable for either the doctor or the pharma company. Case in point – PSM conferences are never able to attract sponsorships. There is no lifestyle more important than life! Even lifestyle advice is not up to the mark when a diabetologist asks patients to take small frequent meals. One of the diabetologists in the audience asked JD what happens if patients go into hypoglycaemia (low sugar) when we stop medicines. JD had an interesting answer – a hypo is a good sign. It means that the dose can be reduced.

Baseline secretion is involuntary in nature. Only insulin due to eating episodes can be controlled. So when the likes of JD suggest simple solutions – two meals a day – the media rarely listens. He has patients who have had Hba1c levels of 15 – and have reduced it to 5 – just by switching to two meals a day. Reducing eating frequency is the key! Eat twice when you are really hungry. Finish your meal in a maximum of 55 minutes. In between two meals do not take any food item that causes insulin secretion.

Weight and waist loss, JD says, is just a side effect to the diabetes cure. But JD’s journey started with weight loss. The conventional ways to tackle obesity:

Reducing the food intake – lower the calories. Patients did not find it practical as they would feel less energetic. 

The next experiment is to lower the carbohydrates in a diet – which can be done for a short while – but in the longer term is not sustainable by the patient. 

At the extreme, patients try bariatric surgery – sewing up the stomach. But it’s risky. 30% of surgeries have side effects. There is also some mortality associated with the operation itself. 

And finally we look at Ozempic and the related drug family. Most patients go off Ozempic in 2 years. We do live to eat more than we eat to live, looks like. There are two more factors with Ozempic, JD cautions. Though 60% weight loss happens through fat, 40% happens through muscle. And when you start gaining weight back, it’s all in the fat. And finally – Ozempic is known to create depression – and to some extent suicidal tendencies.

At the start JD would not recommend the two meals a day diet plan to any of his diabetic patients. The good news is that Indian patients rarely listen to their doctors – so some of his diabetic patients tried out the two meals a day plan – and reported drastic drops in sugar levels. So JD made a beginning with pre-diabetics – and then slowly moved on to experiment with diabetics. It worked! 

We are habituated to three meal times – morning, afternoon and evening. JD observes that the only restaurants in America that have crowds at 2030 hrs are the Indian restaurants. The rest of the west finishes dinner by 1830 hrs. In Sanskrit, there is no word for breakfast! Depending on your lifestyle and social calendar, you can choose any of the two mealtimes. Though the two meals can happen at any time of the day, avoiding meals at night is best. But the diet caveat – nothing in between.  

In Jains, there is a term beasana – which again means sitting down to eat – twice a day. If you look at our culture – we find phrases like do wakt ki roti – never teen wakt. There is also another saying – jo ek baar woh yogi, do bar woh bhogi, teen baar rogi. (I have heard that used for trips to the loo too.) In Kannada, this is extended further – 4 baar will soon leave with 4 people – read funeral. 

JD did an experiment where one group of people had 6 meals a day – and the other two meals a day. Blood work indicated a worsening health for the 6 meals group. Then roles were reversed – and soon the earlier healthy group saw its health go down with the increasing eating frequency.

Although major research efforts have focused on how specific components of foodstuffs affect health, relatively little is known about a more fundamental aspect of diet, the frequency and circadian timing of meals, and potential benefits of intermittent periods with no or very low energy intakes.

Although JD presents diabetes as an insulin problem – the glucose sugar correlation still exists. The carbs that come from sugar are the most dangerous. This is in part culture – every celebration is associated with something sweet.  If you were served 75 grams of sugar in unadulterated sugary form you would probably say no. But we don’t hesitate to gulp down the Cokes and Fantas, which contain the same sugar.

The most common eating pattern in modern societies, three meals plus snacks every day, is abnormal from an evolutionary perspective. Findings from studies suggest that intermittent energy restriction periods of as little as 16 hours can improve health indicators and counteract disease processes. In 2016, the Japanese scientist Yoshinori Ohsumi was awarded the Nobel prize in 2016 for the concept of autophagy….If you fast, your normal cells can eat your cancer cells!

So what foods are good for you? Metabolism starts immediately. The best way is to actually measure insulin levels after every type of food is consumed, immediately, after 10 min and after 16 min. JD actually spent Rs. 40 K doing this over 3 months for his own body – and came up with a list of dos and don’ts for food. Here are two thumb rules: Reduce carbohydrates and increase proteins in diet. Reduce sugar/jaggery/sweets/sugar substitutes in diet.

What to eat in a Dixit Diet?

Nuts/fruits/dry fruits/sweet

Bowl of salads

Bowl of sprouts/2 boiled eggs

All other food items

For Prediabetics and diabetics

Salads should not have carrot and beet

Also, no sweets and fruits

What can be taken in between two meals?

Water

Thin homemade buttermilk

Plain green/black tea (no sugar/honey/jaggery/sugar substitute)

Tea with 25% milk

Tender coconut water once in a day

Maximum one tomato in a day

Best is water

For Prediabetics and diabetics

The tender coconut and tomato are contra-indicated

(Caveat: Not to be followed by children below 18 years, pregnant and lactating mothers and patients of type 1 diabetes. Kidney, liver, heart, retina function be checked for end organ damage before adopting lifestyle modifications.)

JD recommends a 250 to 300 calorie burn in cardio exercise. I am a commuting cyclist. A 30-minute ride usually burns around that much. A one hour walk achieves the same results. Or a 45 minutes walk at a brisk pace of 6 kmph. Walk 4.5 Km in 45 minutes everyday. 

It was around 2130 hrs by the time JD’s talk ended. Audience members, yours truly included, were busy drinking sugared beverages and snacking on non vegan paneer as we listened to the doctor speak. True to his words, JD left after the talk without joining us for dinner. As I polished off the second gulab jamun in the dessert – something inside me told me that JD’s experiments may be worth a try. Although I don’t think all of us can be as disciplined as him – having one raw food meal out of 3 looks like a good beginning. To do justice to the gulabjamuns and JD, I started a 36 hour water fast as soon as the dinner ended. The 36 hours are ending as I type this – time for some raw smoothie!

Footnote From Wikipedia: Dixit’s claims have been challenged for lacking scientific validation, and he has been accused of providing potentially harmful advice to those with diabetes. The Indian Medical Association has noted that Dixit is neither a dietician nor a diabetologist. A 2018 article at the JAMA Internal Medicine journal concluded that the hypothesis of carbohydrate -stimulated insulin secretion being the primary cause of common obesity, was difficult to reconcile with available evidence.