Intermittent fasting – questions & answers

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Here you can find common questions about intermittent fasting with answers from our top expert, Dr. Jason Fung.

Choose a topic below or scroll down for every question and answer.

  1. Who can use intermittent fasting (IF)?
  2. Different variants of IF
  3. Things to consider during fasting
  4. Blood sugar and other tests during fasting
  5. Dietary advice between fasting periods
  6. Weight loss problems and IF
  7. Type 2 diabetes and IF
  8. Positive effects of IF beyond weight loss and type 2 diabetes
  9. Potential negative effects of IF and LCHF
  10. IF and ketosis
  11. Recommendations on blood tests


Who can use intermittent fasting?

 

Is fasting an option for children who need to lose weight?

Fasting is not an option for children. My advice is to severely restrict added sugars and snacking. Reducing down to 2 meals per day is also possible, but not longer duration fasting.

My daughter who is 31 and a healthy weight exercises (rowing) four times a week. She wants to know if she can fast or is this not recommended for people who exercise?

Not only is it safe, but training in the fasted state has several theoretical benefits that many elite level athletes are using. So, yes, it is highly recommended.

Can women fast during pregnancy and after birth during breast feeding?

I don’t advise fasting during pregnancy or breast feeding. There is a concern of nutrient deficiency which I think far outweighs any potential benefit.

How should intermittent fasting be used in conjunction with resistance training to maximize muscle growth and fat burning?

Should there be any differences between intermittent fasting on training days and non-training days? And during the fasting periods – or days – is it advisable to take supplements such as BCAA’s to prevent muscle loss?

There are many different schedules. Most people fast for 24 hrs and then do their training – this is called ‘training in the fasted state’. Since growth hormone is high, you theoretically will recover and build muscle faster in this state.

There is minimal muscle loss during short term fasting, so BCAA is not needed, but often used by bodybuilders. It’s efficacy is unknown, with mostly anecdotal evidence. Many athletes follow a schedule of 24 hr fast, then exercise, then breaking the fast with a high protein meal.

How appropriate is intermittent fasting for teenagers?

Not appropriate. Certainly occasional short fasts, (less than 24 hours) are fine but not longer ones. Even most religions do not make children fast because their bodies require more nutrients to grow.

Is fasting still a good idea if you are trying to conceive? Should Intermittent fasting be used instead, or none at all?

You can certainly try although we don’t have good data one way or the other. Fasting should not be used during pregnancy however.


Intermittent fasting – different variants

 

Are there significant differences in benefits from 24-hour fasting vs. multi-day fasting vs. 16:8 fasting?

The main difference, as you may suspect, is that shorter fasting periods are easier to do, but are likely less effective for weight loss and they can be done more frequently. So a 16:8 fast is often done daily, whereas a 24 hr fasting period is done much less often. For more severe insulin resistance, I tend to prescribe longer fasting periods, whereas for maintenance I tend to prescribe shorter ones. The right duration and frequency depend on your health status and your health goals.

The fasting protocol that fits my life style best is a fasting all day with a 4 to 5 hour eating window in the evening. I feel that I could do this daily during the work week. Is this recommended? How many days a week of IF is healthy?

Periods of fasting less than 24 hours (20 hours fasting, 4 hr eating) or ‘Warrior’ style fasting can be done daily. The term ‘healthy’ always depends upon what your goals are. If you are simply trying to lose weight, then fasting can be done as needed for that. There are no known negative health consequences to eating only during 4 hours of the day, although in truth it hasn’t been studied much.

I have done 18hr, 24hr and 3 days without any real difficulties and have switched it up during the week, depending how I feel and whether I have social plans. Is it a good idea to change the fasting routine regularly, or would I be better off sticking to a 24hr regime for consistency?

I am not aware of any good data on this, but personally, I believe that it is much better to switch things up so that the body does not have a chance to adapt. However, sometimes this inconsistency leads to people not fasting at all, which is also bad.

So it all depends upon your ‘style’. If a regular routine works better for you for compliance reasons, then do so. However, physiologically, my personal opinion is that changing things up will likely work better.

My hubby is very overweight, he weighs 164kg and is 179 cm tall, his fasting glucose is normal between 4.8 and 5.6 mmol/L his insulin is very high, when he was first tested it was 32.2 uU/mL… I know that keeping his insulin low will be the key to his weight loss, but what would be better? A daily 16:8 IF or a 24 hour fast 2 times a week? What would you recommend?

Both are acceptable fasting regimens. It only depends upon which one you prefer and which one gives you the best results. We use both regimens. My own feeling is that the 24 hr fast 2-3 times per week is stronger than the 16:8 regimen, but you must decide which is best for you.

I would like to ask about people who work night shifts? Can you just suggest what pattern of daily fasting might be good ? I think maybe from 14:00-22:00 eating window ( 2-3 meals and than fast during the night ) of course it doesn’t have to fit everyone.

I am also interested about feeding window, isn’t it the same when I eat from 10:00-18:00 as if I eat from 13:00 – to 21:00? when I go to bed 22:00-23:00 ? I mean isn’t it better to eat sooner the day so the energy will be used better or is it just another myth that evening eating leads to weight gain?

People working night shifts often have problems with sleep deprivation and disturbed circadian rhythms. This may result in elevated cortisol that makes it difficult to lose weight. This pathway is separate from the insulin pathway that is typical in most people.

The time of day you eat likely matters to some degree. I think it is important to try eating at different times of the day and see which works best for you, both from your lifestyle perspective and weight loss.

When people use longer fasting regimes, what is the trigger to cease fasting? I have been on an LCHF diet for over six months and have been intermittent fasting (with some food) with very slow results. I finally bit the bullet last weekend and started a fast that has lasted 4 days, each evening telling myself I can eat scrambled eggs for breakfast. I wake up not hungry, so the fast continues (broth, water, coffee with cream and coconut oil). I have lost about 12kgs since last October and have about 20 – 25kgs to go. I’m feeling good (though taking the chicken off the bones after soup making this morning was very tempting) and wonder how long to continue. Until I’ve lost 10kgs? 20kgs? It is a daily decision for me to continue the fast, so I don’t want to ‘commit’ to “until I’ve lost 10kgs more” but to have an idea of what it is possible to pursue would be really interesting. I know you’ve had patients who’ve gone on for quite a while!

There is no set limit. It depends upon how you are feeling and your goals. We have had people go as long as a month, but this is under direct medical supervision. We have many people doing 10 day to 2 week fasts as well, but again, under strict medical supervision. There are many people who do a 1 week fast themselves or as part of a ‘cleanse’.

However, I cannot provide personalized advice and you would need to make your own decision with your physician.

I’m very afraid of fasting because every time I tried, I get the common cold. How should I begin the fasting process? Should I start with a shorter fast and then progressing with more and more hours?

Personally, I don’t think there is any link. You can certainly try skipping breakfast 2-3 times per week and working upwards from there. Some people prefer to work themselves in slowly, and others to jump in with both feet. Kind of like a swimming pool. Some wade in, others cannonball right in. Your choice.

As a Muslim person I am required to do fasting for 30 days from Thursday, 18th June and I have done so far for three days, fasting between 18 to 20 hours a day. Any tips to maximise the benefits of the fasting for this period. In fact even after Ramadan, fasting period, it is recommended adult still fast 2 days a week, Monday and Thursday. This is almost reiteration of what you said in your interview with Andreas.

Some people tend to overeat and indulge in foods before sunrise and after sundown. I would recommend to not eat before sunrise and eat as normally as possible after sundown. Some studies of Ramadan have shown weight gain during this period, likely for that reason.

I would like to fast for a small amount of weight loss (10 lbs or so) and overall health. I have tried the 24-hour fast twice on different weeks and I was so hungry for dinner I overstuffed myself both times and then proceeded to eat more than usual the next day. Is this overstuffing desire normal? Or is this something that will normalize over time, and if so, how long will it take? Or is my body telling me the 24-hour fast isn’t for me?

You should try to eat as normal a dinner as possible. You will eat slightly more than usual, but as you get used to the fasting, it should get better. This is quite common. Many people will find that the overeating will cause some stomach upset.

 

Intermittent fasting – things to consider during fasting

 

Can you drink bone broth while you are fasting?

Yes – I highly recommend bone broth. It contains numerous minerals and vitamins and is quite ‘filling’ in terms of reducing hunger pangs. The other benefit is that you can add a good amount of sea salt to it. The other fluids taken during a fast – water, tea, coffee – don’t have sodium and you can become dehydrated. Mild dehydration, for example, may lead to cramps and headaches during longer fasting.

So, yes, bone broth is highly recommended (recipe). Also very ‘Paleo’ in the sense that this is a very traditional food with a long tradition.

While fasting is it okay to drink coffee with milk? I can’t do black coffee. I have a little milk with my coffee.

Technically, the milk does not fall within the guidelines of a true fast, but the small amount of milk/ cream added to coffee can improve compliance for some people. So in our program, we allow milk/ cream in coffee, but no sweeteners or sugar.

I am sorry for this stupid question but how much is little amount of cream ?:-)))) I want to hear it from you because otherwise I am starting thinking that 250 ml are ok, which I don’t think so:-) I am on my day 3 of fasting and today I had whipped heavy cream ( 33% percent ) 2x 40g in my coffee. Is this too much?

Yeah, I was more thinking along the lines of 1-2 teaspoons, not the whole carton. Because cream still contains milk protein, it will stimulate insulin which defeats the point of fasting. Pure fat, such as coconut oil, will be less.

Do you suggest the use of any liquids other than water during a 16 to 18 hour fast? Is regular black coffee or tea with caffeine ok or does caffeine raise blood sugar?

Tea (all kinds), coffee, and bone broth are all acceptable. I allow a small amount of cream or coconut oil in coffee for compliance sake, although technically, it would not be allowed. I don’t worry about the caffeine content.

What is your opinion on the use of Xylitol for sweetening coffee and tea in the fasting state? Would insulin levels still rise?

There is little information on the sugar alcohols including xylitol. So I don’t really know if they are acceptable or not. However, when in doubt, my position is that these are not traditional, real foods, so best avoided.

I already fasted a few times. My longest run was 14 days some time ago. I’m now fasting again, day 3 right now, feeling terrific by the way. I’m doing all my traveling on the bicycle, so I have some problems with cramps in my legs. Magnesium and 1 tablespoon salt in water really helps but salty water is getting ugly on my tongue… so I found this cup-soup: 0.6g fat, 1g carbs, 0.2g protein, 2.7g salt per portion… am I too paranoid because of the 1g carbs? One in the morning & one in the evening is okay?

If you feel better taking the soup, then, yes, I wouldn’t be too concerned about the small amount of carbs.

What do you recommend for constipation, bloating, heavy stomach? I found adding fibre makes the bloating worse.

Fiber is often our first approach, but if that fails, we often use laxatives such as milk of magnesia or senna tea. Constipation is common and often bothersome. Stool softeners often help with the problem.

When an intermittent fast is complete (say after 16 to 20 hours) , does one then consume that day’s entire allocated macros for dinner? As an example, after a 20 hour intermittent fast would a person then consume a dinner of 1200 calories in the “standard” LCHF ratios of ~5% carbs, ~20% protein, and ~75% fats? Or should the gross number of dinner calories be ratcheted down? I’ve tried the 1200 calorie “break fast” method, and it’s very difficult! But an alternate “break fast” dinner of, say 600 calories at the LCHF macro ratio of 5/20/75 means that one is getting only about 25g protein daily, which becomes questionable if one is doing 20/4 fasting every day.

I don’t recommend counting calories. After the fast, I would try to eat as normally as possible. That would be your usual dinner but perhaps a slightly larger portion of it.

Remember that protein intake on a fasting day will be much lower than normal. On your eating day, you can simply make up for it by taking higher dose.

Is drinking two tablespoons of apple cider vinegar (in water) during the fast acceptable, or should I move that to a meal?

Dr. Jason Fung: Yes, both are acceptable.

How about high blood pressure patients, how do you substitute salt for them during fast? Is salted bone broth still good option? Should they be careful about the amount?

In uncomplicated hypertension, I generally don’t advise a low salt diet – just a regular salt diet. With bone broth, the amount of sodium is still going to be far less than what is taken on a regular eating day, so I would not worry.


Blood sugar and other tests during fasting

 

When I fast on just chicken broth my blood glucose drops to 65 and then on the 5th day to 55 mg/dl.
Have you observed a drop like this in your fasting patients?

We often see this drop during fasting.

Should i worry if my blood sugar while fasting goes up to in the 140’s [Around 8]?

This is quite common, and due to the breakdown of glycogen or the production of new glucose in response to some of the hormonal changes of fasting. It is neither good nor bad.

Think of it this way. Your body is simply moving sugar from its stores (glycogen and fat) and pushing it into the blood. Here your body has a chance to burn it off.

I purchased a glucose and ketone meter last week. Measured my glucose on Friday after fasting for about 21 hours and the reading was 3.6 mmol with the ketones at 1.9 mmol. It worried me a bit that the glucose was this low, should I be worried? On Saturday I went for a 6 km trail run at a high tempo and my glucose reading afterward were 2,4 mmol. I would like to stay in ketosis, but my fluctuating glucose readings are making me nervous. I do not experience any of the low glucose symptoms, but I tend to become paranoid when the numbers don’t look right!

Listen to your body. If you feel unwell, then stop. Otherwise, if you are worried, reduce the fasting duration.


Dietary advice between fasting periods

Dear Dr. Fung, I have been following your blog and protocols since last July with much success, and have the Insulin Index paper from Marty Kendall. I look forward to your every post.

What do you suggest about using Whey Protein Powders and what is their impact on insulin? Mark Sisson (who sells it) wrote whey can lower insulin yet often heard is that as a concentrated Dairy, whey protein raises insulin.

I advise against using whey powder for the main reason that it is a highly processed chemical, not a real food. Whey can stimulate insulin, but also is very satiating, so the effect on weight is likely closer to neutral.

Is it necessary to take a multi vitamin on the HFLC or Ketogenic diet?

If you eat a diet predominantly of whole, unprocessed, real foods, then no, it is not necessary.

Seems the rage today is taking care of the gut flora from both probiotics and prebiotics. Are there foods you recommend that help the gut flora. Some diets like “Perfect Health Diet” recommend “safe starches” such as potatoes and rice to feed the good bacteria in the gut. Do you personally eat rice or potatoes? Can we get sick from not getting adequate amounts of these “safe starches” and can you comment on proper care of the gut?

I know that I will ruffle some feathers, but I am quite skeptical about the gut micro biome theory with regards to obesity. So, there are no foods I recommend for that reason alone.

With regards to rice and potatoes – these are not necessary in any diet. Personally, I eat both, simply because I enjoy them occasionally. However, I am not trying to lose weight. If I were, yes I would restrict rice and potatoes.

It is not carbs per se that cause obesity, but insulin. While starches raise insulin, there are ways to bring it back down. You can add protective factors such as fibre and vinegar. You can also alter meal timing (intermittent fasting) and adding natural fats.

[Editorial note: While fiber, fat and even vinegar can slow down the absorption of some carbohydrates and delay or blunt the resulting glucose rise, this does not mean it completely prevents the glucose and insulin spikes. Furthermore, even though it may delay the spike in blood sugar, it can extend the overall time blood sugar remains elevated. Therefore, we do not recommend this technique as a “safe” way of eating more carbs. If you are absolutely craving that potato and are going to have it one way or the other, then by all means take these steps to make it somewhat “safer”. But to get the benefits of a low-carb diet you are still better off not having it to begin with.]

I use high fat Mayonnaise as extra fat to my meals. It has zero crabs and protein, and has 11g of Saturated Fat. However, it says in that serving there are 70mg of Sodium. Does this cause any problem?

Except in certain medical circumstances, sodium restriction is not necessary. This was recently shown by Dr. Salim Youssef in the New England Journal of Medicine.

There is an ongoing debate about the need for sodium restriction, but for otherwise healthy people, I do not worry about restricting sodium.

Two questions about alcohol and Ketosis/Fasting…
1) I already heard Alcohol “stops” Ketosis. Does it mean that if you drink your body burns the alcohol to get rid of it and then (after the alcohol is gone) immediately continues ketosis?

2) I once made the dumb decision to drink a bottle of red wine during a longer fast on day 6 or 7 (or something like that). I really felt horrible that night but in the morning… no problem anymore. Can drinking alcohol during a longer fast be dangerous? And: does the body ONLY burn alcohol while being drunk? (I remember feeling cold and extremely hungry that night…)

I generally advise patients to stop alcohol during the period that they are trying to lose weight/ reverse diabetes for the simple reason that the body can burn the alcohol for fuel, and we are trying to get the body to burn stored sugar. I’ve also heard it ‘stops ketosis’ for a similar reason.

What do you think about opinions on fibre in the diet being dangerous and able to “tear holes in the bowel wall”? Is too much fiber bad? Also what’s your thoughts on the diets effect on pH acidity/alkalinity of our body?

I don’t think fibre is inherently toxic. Actually, I think that it may help protect against insulin spikes. I don’t think fibre is bad for the gut. I also don’t agree with the acid/alkaline theory.

I am confused by some position on carbs vs net carbs and that fiber should count… what is the bottom line on net or not net carbs?

I am of the opinion that the main issue is high insulin levels. Therefore, fibre, which tends to reduce insulin, should not be counted and think that the net carbs (carbs minus fibre) concept makes good sense.

What if any limitations are there for an individual to follow the LCHF lifestyle if they have had their gallbladder removed.

None that I am aware of.

I keep on experimenting different combinations of fasting and LCHF diet. I have easy to overeat especially after fasting. Is it dangerous to break the fast with a large meal immediately. I am so hungry when I start eating so it easily becomes too much food in the stomach. Get hurt and diarrhea. Can it be unhealthy to the stomach in the long term to go between en empty and a full stomach ?

I don’t believe it dangerous, but it sure is uncomfortable. That is generally why it is easier to plan a small ‘break fast’ meal. A handful of nuts, a small salad and then give yourself at least half and hour to digest.


Weight loss problems and intermittent fasting

Intermittent fasting and type 2 diabetes

I am a type 2 diabetic off all meds and have been on a LCHF diet for 8 months. When I try fasting for multiple days my blood sugars scores are in the low 60’s and have been taught that this range is to low and need to have some food. Is this normal when fasting and short term affect. Is it normal for sugar levels to be low during fasting? Also ketone levels average per day is 2.5.

If you are taking blood sugar medications, then you must be very careful to avoid low sugars (hypoglycemia) and work with your doctor. Otherwise, your body should be able to manufacture new glucose during fasting, although in rare cases, some people still develop hypoglycemia.

Sugars should normally be low during fasting and ketones increased. This is the normal situation as ketones are produced as energy for the brain.

Does the presence of ketones in the urine indicate improved (lower) insulin in someone with T2 diabetes when the ketones are the result of ketogenic diet?

Ketones are produced by the body when insulin levels are low for the brain to use as fuel. Some people measure it to make sure that their diet is sufficiently low in carbohydrates

What exactly does eGFR of 80ml/min mean in a type 2 Diabetic and what can the patient do to prevent further kidney disease?

An eGFR of 80 is pretty close to normal. The only way to prevent diabetic kidney disease is to get rid of the diabetes. Anything else is just rearranging chairs on the Titanic

What is best fasting regime to help diabetic who had high HbA1c above 10 ?

There is no ‘best’ fasting regimen. More intensive regimens produce faster results, but are not ‘better’. Some prefer to go slow and others fast. Some will find shorter duration fasts better and others find longer is better. Please see Diet Doctor’s detailed fasting guide for more information.

I’m on Metformin. I absolutely can’t take this med without food as it will cause me serious gastro issues. The last fast that I did, I simply discontinued the med for the 4 days and then resumed when I started eating solids again. Is that a wise thing to do, or am I potentially causing a problem?

I can only say that we often hold metformin during fasting in our IDM clinic due to GI upset. This is OK as long as blood sugars remain in a good range. I cannot comment on whether you should take them yourself.

I’m a 48 Y0 female, obese, T2, 2000 mg Metformin/day, no insulin or any other meds, in good health otherwise. I have noted that I am unable to produce any appreciable blood ketones UNLESS I fast completely (water, broth, clear tea only) for a minimum of 3 days. Even the 90% fat “Aktin’s fat fast” will not produce blood ketones (I don’t bother with urine dip sticks). I am presuming that this is due to the IR.

1. Is it common for a very IR individual to have to go to this extreme measure to begin producing ketones?
2. If extended fasts (4-ish days) are performed between 2 and 4 times per month, and a LCHF diet is followed when not fasting… in your experience, how long might it take to resolve or at least dramatically improve this level of IR?

1. Ketones are produced by the body to feed the brain instead of using glucose. If you have enough glucose coming out of storage, there is no reason for your body to make ketones. So, yes, that is normal, and likely due to your IR.

2. There is no normal and depends upon the individual. Some people reverse their IR within weeks and others take more than a year.

I have had type 2 diabetes for 17 years, I am now 67. In my studies concerning reversing diabetes, I have come across a couple of statements saying in effect that for those of us who have had diabetes for a long period of time it is more difficult to reverse diabetes? Is this accurate information?

That is certainly our experience. If you are recently diagnosed with T2D, it generally reverses quickly. If you have had it for 17 years, it may take more than a few months at least.

In your opinion when to say type 2 dietetes is “reversed”, at what blood glucose numbers?

I consider diabetes to be reversed when you are taking no medication and able to maintain an A1C of less than 6.4%.


Positive effects of IF beyond weight loss and type 2 diabetes

 

Lots of people get relief from indigestion when they start a LCHF diet. Why is that? I need to convince my nephew that LCHF is his best approach and at 23 years old, nutrition isn’t really his thing so I can’t convince him to read your blog! He gets terrible heartburn and I’m sure it is due to his high carb, high soda diet! (He’s also overweight!)

My guess is that there are two main effects. One, the focus on real food rather than highly processed ones is very important to maintain normal function of the GI system. Two, losing weight often improves symptoms of reflux.

Dr. Fung – I am 70 and overweight, but have lost 30 lbs on the LCHF diet over about 6 months. Initially, my BP also dropped and my doctor took me off my BP meds because of the lightheadedness I experienced with the BP drop. But, now my BP is up again, even with the addition of ramipril, and my weight loss has stalled. I am still at a BMI of about 30. Do you think the 16:8 IF might help both theses issues?

The link between BP and diet is not quite as tight as with blood sugars. I think trying a 16:8 IF sure couldn’t hurt.

LCHF diet did not budge my weight and only modestly reduced my Type II Diabetes until I started the Intermittent fasting. I saw my first numbers ever in the 80’s and 90’s. Now my Thyroid has gone bonkers. I’ve had hypothyroidism for maybe 20 years and take synthetic hormones to balance it. The dosage has remained constant over this time. I’ve suddenly become hyperthyroid with my TSH dropping to zero. The doctor reduced the medication to almost nothing. However, my fasting blood glucose has risen back into the 130 – 140 range. I eat no sugar and only low glycemic vegetables and a lot of fat and oil. My liver must be dumping all the glucose into my blood. Have you had any experience with this scenario and do you have any suggestions?

There is not much literature about fasting and change in thyroid dosing, so I can’t help you there, but I have heard several anecdotal cases of the same thing happening where thyroid function suddenly improves. With the high blood sugars, the only thing to do is to continue with your plan. It certainly seems that you are now mobilizing some of that stored sugar.

I am just wondering if it is the same treatment with diabetes 1 and type 2? Low carb high fat?

Yes. Both types of diabetes would improve on LCHF compared to a standard 50% carbohydrate diet. The reasons are entirely different in the two types, though.


Potential negative effects of intermittent fasting and LCHF

Is it normal that during fast I am quite cold? like hands and feet … especially feet at night thanks. Hope Its not the sign my REE [Resting Energy Expenditure] is going down.

No, it is not normal to be cold – it means your REE is going down. Try to eat sufficiently on eating days or consider fasting less often. If it continues, you should consult your physician.

I have started intermittent fasting by skipping breakfast. Today i saw this on medXp: In study, skipping meals is linked to abdominal weight gain

I am sure the study was not done with low carb diets so there is that. What do you think?

This was an animal study and I would ignore it. Most studies ‘proving’ that you must eat all the time prove nothing of the kind. Eating all the time to lose weight? I don’t think so.

My health care practitioner is completely on board with LCHF – in fact, advocates it for all patients. I have had limited success in using LCHF in fat loss. Although gaining muscle, my weight loss is minimal after 4 months of solid, no-cheating LCHF plan (mild to moderate ketosis).
I am currently trialling 16:8. My HCP is completely AGAINST fasting, as he claims that there is definitely protein status loss. He didn’t mention starvation mode or anything like that, just a major concern that the level of protein in the body is always affected by IF
What is your take on this? Does protein get used in the same way that fat stores do? If so, can you compensate by eating more protein in the 8 hour window?

There is minimal protein loss is a 16:8 regimen or even after a couple of days of fasting.

Why would your body store energy as fat if it starts burning protein (muscle) for energy? As long as you have adequate stored body fat, the answer is that it does not.

I have been LCHF/IF for a while…I eat approx. 1200 cal with less than 5% carbs…every third day. Comfortable for me…but can one end up with too many ketones…and what might their effect be?

Unless you have type 1 diabetes, the ketones are normal and are produced by the body for the brain to use instead of glucose.

Does fasting cause loss of lean muscle due to gluconeogensis? Some weight loss studies give patients some protein to prevent lean muscle breakdown. Does this make sense?

No, it does not make sense to me.

In the first 24 hours after eating, you will use amino acids (from dietary protein) as substrate for gluconeogenesis. Afterward, glycerol from the breakdown of triglycerides provides the substrate. Protein (muscle etc.) is conserved during fasting.

Ask yourself this. Do you believe that Mother Nature designed us to store excess energy as fat, but as soon as we need it, we start burning protein instead of fat? No, protein is conserved and fat is burned for fuel during fasting.

I am not looking for medical advice, just your thoughts on a general situation, what do you think would happen in general, in a hypothetic situation like this. You have somebody who are severly overweight, have been diagnosed with diabetes type-2 and have been on insulin for several years. The next day you remove all their medications and let them fast for 3 days. Off all the medications would such a person experience dangerously low sugars? I know that in un-diabetic people, bloodsugar never goes too low when they fast, even with weeks of fasting. I thought it only was dangerous for diabetics in general to fast if they used drugs, that ramped up their insulin production and they failed to meet this with adequate carbohydrate intake, during a fast.

Yes, in the diabetic situation it is possible to get both high and low blood sugars. This should always be undertaken with physician supervision. As you point out, in people without diabetes, this hypoglycemia does not happen, but in people with diabetes, with their high baseline insulin levels, it is a strong possibility.

We have seen this before, where people with diabetes who were taking a very high dose of insulin were able to get off their medications, but became hypoglycemic off all medications. It typically passes in a few weeks time, but in the meantime, clients can become symptomatic.

I just saw that it is possible for a T2-diabetic to get too low blodsugar when fasting even when not taking medicine, which worries me as I live by myself.
I´m 60 and have T2 since 17 years (insulin since 15 years as I had bad side effect from Metformin). Before I started moderate LCHF 2 years ago I had 100 i.u. insulin/day.
After a year and half on moderate LCHF I took 29 units/day. And after having seen your videos I got inspired to quit insulin a month ago, so I had to eat more strict LCHF, eat 2 times a day and I have done a few 24 hour fasting, and the last month I only took 1-3 units a few times a week (I try to keep it under 10mmol).
Bloodsugar during this month has been 7-10mmol/l with hardly no insuline.
I have now been fasting for one day on only water and feel good and I wonder if there is a risk to get to low bloodsugar during sleep.
Is there really a risk of to low bloodsugar when I have taken it so slow and let my body get used to less carbohydrates?
Wouldn´t people with pre-diabetes get to low sugar too then?
So how do a t2 diabetic fast then?
Is there a minimum blood sugar level before bed or should I consume something?

The body will start producing glucose when it gets too low to prevent hypoglycaemia, except if you are taking medications. We do occasionally see hypoglycaemia on people taking no meds, but this is usually when people have just recently stopped insulin and presumably, the mechanism for gluconeogenesis is ‘rusty’. This usually improves within a few weeks although can last longer.

I recently had someone suggest to me that fasting may affect gut bacteria (it seems that everything these days is about the gut bugs…) Have you heard of this?

Everything you eat or do not eat will affect your gut bacteria. Whether it is important is a different question. I tend to think that it is of minor importance, but evidence is so far scarce.

I try to combine 24 hours of fasting with longer periods. 3 days fasts every 2 weeks or 7 day fasts every third week or so. It is very flexible. I feel good during fasts as well. I manage to work, go every day by bicycle and even do my exercise 2-3 times/weak at the gym ( not very regularly). Have no medications or problems with my health either.
Do you have any contra-indications on how often I should fast? Have read about fasts on your blog and even listened to your wonderful lectures on you tube and understands that it is individual and free up the experiment as long as you feel good. Yet, I am a little afraid (even though I am a registered nurse) because I combine short fasts periods (24 hours fasting) with the longer fasting periods quit often. Can it be too much of a good thing and dangerous for my health in a longer turm of time to do my fasts?

If you are feeling well, there is no contraindication, except in children, pregnancy, and breastfeeding. Also, if you have diabetes, medications may need to be adjusted.

What you say makes so much sense. I struggle, however, with serious nausea when I try to fast. Is there anything I can do to relieve or prevent nausea?

The most common reason is other medications especially iron and aspirin. Check those. Otherwise, you can try to build up to the longer fasting periods.

I understand that fasting may push up the blood level of norepinephrine. My husband has atrial fibrilllation. Will fasting make him more prone to arrhythmia?

It is certainly possible. If it happens, then he should stop.

I am very interested about your opinion in book It Starts With Food, from Dallas and Melissa Hartwig, Their program Whole 30 is very well known, concretely I am interested about your opinion in two things,
About fasting and about frequency of eating, they recommend to eat 3 times a day, and they suggest to eat as soon as you wake up, even if you are not hungry, which I don’t agree based on information from your blog, … they say that if you are not hungry in the morning its bad and it means your hormones are not in order…

They say that leptin is connected with our consumption and if we start to eat too late that whole process is disrupted then, and leptin and cortisol does bad values then, …..

Also about fasting they are saying that prolonged periods without food (more than 8 hours) are too stresfull and bad for your cortisol control. and that it can raise stress levels.

They say that cortisol then protects the body fat, and etc. My question is do you have some studies about cortisol and fasting? Do you measure cortisol in your clients? I suggest that If I measure blood glucose and it goes low during fasting like to 3,8 molar then I don’t have problems right? its normal not to be hungry in the morning isn’t it?… and I don’t have to stuffed myself with food my body obviously don’t want at that time.

If you are not hungry in the morning, then I think you should not eat. This is called ‘listening to your body’. It doesn’t mean your hormones are messed up, it means your body is telling you that you don’t need to eat. So you should not.

Leptin is not likely affected by skipping breakfast. It is not necessary to eat constantly. Neither does missing a meal increase cortisol. I fail to see how forcing yourself to eat when you are not hungry is going to help you lose weight.

There are actually very few studies on cortisol and fasting and they are mostly contradictory. I do not measure cortisol in our clinic patients. If your problems are cortisol (stress) related, then changing your diet is not going to be very effective. Instead, you need stress relief (meditation, yoga, massage, pain management etc.) I try to stick to diet related issues.

Cortisol is normally raised in the morning as part of the circadian rhythm. This is normal and found in everybody. This helps release some of the stored sugar in the morning to give your body some energy for the upcoming day.

Therefore, you do not ‘need’ to eat because your body has already given you energy. You have plenty of sugar available for whatever you need to do in the morning without eating. Since you are ‘tanked up’, you do not feel hunger. Most of morning hunger is trained through decades of eating as soon as we get up.

Are there any possible connections between kidney stones and ketosis? Do you feel this way of eating can affect blood/urine PH or anything else that would increase the chances of stones? And are their preventive measures that can be taken, while still following the plan?

There is no connection, unless you do not stay hydrated. It is important to consume enough water as well as salt/ electrolytes during fasting. This will help prevent kidney stones.


Intermittent fasting and ketosis

I’ve recently read that ketogenic diets can lead to renal tubular acidosis. How concerned should I be? Whats your opinion on this?

I would not be concerned. As a nephrologist, I am referred all cases of RTA and I have perhaps seen only 3 or 4 cases in the last 15 years – all of which were not related to diet. RTA would be amongst the very lowest of my concerns with a ketogenic diet.


Recommendations on blood tests

What blood tests do you recommend if I suspect Insulin Resistance/Metabolic Syndrome?

The tests I focus on are the fasting glucose and the hemoglobin A1C. I also test ALT to look for fatty liver and Triglycerides (indicates a diet very high in carbs).

Are you able to provide general information about symtoms that are commonly associated with excess cortisol? How would one find out whether cortisol was a relevant factor?

Cortisol excess can be difficult to diagnose for certain, but most people will know if they are under excessive stress (psychological, physical, chronic pain etc).