Jagannath Dixit\u2019s affinity for preventive medicine made him leave a MD (Medicine) seat to do a MD in PSM \u2013 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\u2019t 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.<\/p>\n\n\n\n
JD is a student of science \u2013 and the initial suggestion of cutting down a meal, seemed quite unscientific. Nevertheless, he tried out the Jichkar recommendation for 3 months \u2013 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.<\/p>\n\n\n\n
The original hunter-gatherer had a fast-feast diet. I am reminded of the Marathi manoos <\/em>who will only eat tupashi <\/em>(with desi ghee) or else will stay upashi <\/em>(fast). As we civilised \u2013 and urbanised \u2013 our eating habits changed. With increased food availability and reduced physical work, the planet now has more obese people than malnourished ones. <\/p>\n\n\n\n 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.<\/p>\n\n\n\n Our input calories come in different forms \u2013 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 \u2013 we need to keep in mind that our mind is pure cholesterol. Carbohydrates are the energy source \u2013 the glucose providers.There has to be a balance between the three forms \u2013 and when there is an imbalance, there is a problem. <\/p>\n\n\n\n Time to deep dive into the currency of nutrition in the body \u2013 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.<\/p>\n\n\n\n Every cell has a locked door that lets the glucose in \u2013 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 \u2013 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. <\/p>\n\n\n\n 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 \u2013 this is called developing insulin resistance. The brain misreads the signal from the cells \u2013 and treats it as a case of low insulin production. It orders the pancreas to ramp up insulin production \u2013 further aggravating the body\u2019s insulin resistance. <\/p>\n\n\n\n Now you have sugar and an extra 30 units of insulin swimming in your blood. Remember the fast and feast we discussed earlier \u2013 the body has designed a mechanism to store energy to take care of our non sabudana <\/em>fasts. Some of the sugar gets converted to glycogen which is stored in muscles. This store is a local one \u2013 as in only that particular muscle will have access to it. The balance excess sugars get converted into fats \u2013 which are stored in the liver, and later on around the waist and thighs. An average Indian has 60 days reserve in fat stock!<\/p>\n\n\n\n If the fats pile up in the liver \u2013 fatty lever \u2013 its filtration efficacy reduces \u2013 and ultimately leds to its failure. All this makes hospitals and pharma companies extremely happy. They now have billions of patients \u2013 and trillions in revenue. Diabetes is under diagnosed. Of the 12 cr diabetic folks, half of them don\u2019t 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 \u2013 and the same can be said of retinopathy. <\/p>\n\n\n\n Doctors would like all of us to believe that diabetes is irreversible! GPs and pathologists end up testing patients for blood sugar \u2013 whereas it is blood insulin that needs to be checked. Sugar tests are not conclusive because they provide a snapshot view of the body\u2019s health. A relatively long term health monitor is the hba1c. This provides a 3 month average of sugar \u2013 and is a more reliable indicator of sugar control. Hba1c values of less than 6.5 are good \u2013 anything above that means diabetes. JD recommends that diabetics should get an Hba1c test done every month.<\/p>\n\n\n\n JD calls diabetes the most overtreated of all diseases \u2013 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 \u2013 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 \u2013 a hypo is a good sign. It means that the dose can be reduced.<\/p>\n\n\n\n Baseline secretion is involuntary in nature. Only insulin due to eating episodes can be controlled. So when the likes of JD suggest simple solutions \u2013 two meals a day \u2013 the media rarely listens. He has patients who have had Hba1c levels of 15 \u2013 and have reduced it to 5 \u2013 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.<\/p>\n\n\n\n Weight and waist loss, JD says, is just a side effect to the diabetes cure. But JD\u2019s journey started with weight loss. The conventional ways to tackle obesity:<\/p>\n\n\n\n Reducing the food intake \u2013 lower the calories. Patients did not find it practical as they would feel less energetic. <\/p>\n\n\n\n The next experiment is to lower the carbohydrates in a diet \u2013 which can be done for a short while \u2013 but in the longer term is not sustainable by the patient. <\/p>\n\n\n\n At the extreme, patients try bariatric surgery \u2013 sewing up the stomach. But it\u2019s risky. 30% of surgeries have side effects. There is also some mortality associated with the operation itself. <\/p>\n\n\n\n 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\u2019s all in the fat. And finally \u2013 Ozempic is known to create depression \u2013 and to some extent suicidal tendencies.<\/p>\n\n\n\n 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 \u2013 so some of his diabetic patients tried out the two meals a day plan \u2013 and reported drastic drops in sugar levels. So JD made a beginning with pre-diabetics \u2013 and then slowly moved on to experiment with diabetics. It worked! <\/p>\n\n\n\n We are habituated to three meal times \u2013 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 \u2013 nothing in between. <\/p>\n\n\n\n In Jains, there is a term beasana \u2013 which again means sitting down to eat \u2013 twice a day. If you look at our culture \u2013 we find phrases like do wakt ki roti <\/em>\u2013 never teen wakt<\/em>. There is also another saying \u2013 jo ek baar woh yogi, do bar woh bhogi, teen baar rogi.<\/em> (I have heard that used for trips to the loo too.) In Kannada, this is extended further \u2013 4 baar <\/em>will soon leave with 4 people \u2013 read funeral. <\/p>\n\n\n\n JD did an experiment where one group of people had 6 meals a day \u2013 and the other two meals a day. Blood work indicated a worsening health for the 6 meals group. Then roles were reversed \u2013 and soon the earlier healthy group saw its health go down with the increasing eating frequency.<\/p>\n\n\n\n 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.<\/p>\n\n\n\n Although JD presents diabetes as an insulin problem \u2013 the glucose sugar correlation still exists. The carbs that come from sugar are the most dangerous. This is in part culture \u2013 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\u2019t hesitate to gulp down the Cokes and Fantas, which contain the same sugar.<\/p>\n\n\n\n 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!<\/p>\n\n\n\n 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 \u2013 and came up with a list of dos and don\u2019ts for food. Here are two thumb rules: Reduce carbohydrates and increase proteins in diet. Reduce sugar\/jaggery\/sweets\/sugar substitutes in diet.<\/p>\n\n\n\n What to eat in a Dixit Diet?<\/p>\n\n\n\n Nuts\/fruits\/dry fruits\/sweet<\/p>\n\n\n\n Bowl of salads<\/p>\n\n\n\n Bowl of sprouts\/2 boiled eggs<\/p>\n\n\n\n All other food items<\/p>\n\n\n\n For Prediabetics and diabetics<\/em><\/p>\n\n\n\n Salads should not have carrot and beet<\/p>\n\n\n\n Also, no sweets and fruits<\/p>\n\n\n\n What can be taken in between two meals?<\/p>\n\n\n\n Water<\/p>\n\n\n\n Thin homemade buttermilk<\/p>\n\n\n\n Plain green\/black tea (no sugar\/honey\/jaggery\/sugar substitute)<\/p>\n\n\n\n Tea with 25% milk<\/p>\n\n\n\n Tender coconut water once in a day<\/p>\n\n\n\n Maximum one tomato in a day<\/p>\n\n\n\n Best is water<\/p>\n\n\n\n For Prediabetics and diabetics<\/em><\/p>\n\n\n\n The tender coconut and tomato are contra-indicated<\/p>\n\n\n\n (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.)<\/p>\n\n\n\n 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. <\/p>\n\n\n\n It was around 2130 hrs by the time JD\u2019s 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\u2019s experiments may be worth a try. Although I don\u2019t 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!<\/p>\n\n\n\n