What You Eat First During Meals Can Lower Glucose by 40% - Dr Jason Fung

What you eat is quite possibly the most important strategy for optimizing your metabolic health and reducing your risk of diseases like Type 2 diabetes. However, the order in which you eat your food also matters, such that you can consume the same foods — same calories, same total carbs, same nutrients — and have drastically different metabolic effects depending on what you eat first.

In the video above, Dr. Jason Fung, a nephrologist (kidney specialist) and author of several books, including “The Diabetes Code: Prevent and Reverse Type 2 Diabetes Naturally,” explains how you can get a more beneficial response, including reducing insulin and glucose, by front-loading protein and fats in your meal and leaving the carbs for later.

Dr Jason Fung's Story

Dr Jason Fung, in his book entitled “The Complete Guide to Fasting”, articulated the following: 

I grew up in Toronto, Canada, and studied biochemistry at the University of Toronto, where I also completed medical school and my residency in internal medicine. After my residency, I chose to study nephrology (kidney disease) at the University of California, Los Angeles, mostly at Cedars-Sinai Medical Center and West Los Angeles VA Medical Centers (then known as the VA Wadsworth). Each field of internal medicine draws its own personalities, and nephrology has the reputation of being a “thinker’s specialty.” Kidney disease involves intricate fluid and electrolyte problems, and I enjoy these puzzles. In 2001 I returned to Toronto to start my career as a nephrologist. 

Type 2 diabetes is far and away the leading cause of kidney disease, and I treat many hundreds of patients with this disease. Most type 2 diabetics also suffer from obesity. By the early 2010s my interest in puzzles, combined with my professional focus on obesity and type 2 diabetes, had led me to focus on diet and nutrition. 

How did I go from preaching conventional medicine to prescribing intensive dietary strategies, including fasting? Despite what you might think, nutrition is not a topic covered extensively in medical school. Most schools, including the University of Toronto, spend a bare minimum of time teaching nutrition. There were perhaps a handful of lectures on nutrition in my first year of medical school and virtually no teaching on nutrition throughout the rest of medical school, internship, residency and fellowship. Out of the nine years spent in formal medical education, I would estimate I had four hours of lectures on nutrition.

As a result, I had no more than a passing interest in nutrition until the mid-2000s. At the time, the Atkins diet, promoting low-carb eating, was in full swing. It was everywhere. Some family members of mine tried it and were ecstatic with the results. However, like most conventionally trained physicians, I believed their arteries would eventually pay the price. I, along with thousands of other physicians, had been taught and certainly believed that low-carbohydrate diets were simply a fad and the low-fat diet would prove to be the best. 

Then studies on the low-carb diet started to appear in the most prestigious medical journal in the world, the New England Journal of Medicine. Randomized controlled trials compared the Atkins diet to the standard low-fat diet that most health-care providers recommended. These studies all came to the same startling conclusion: the low-carb diet was significantly better for weight loss than the low-fat diet. Even more stunning was that all the important risk factors for cardiovascular disease—including cholesterol, blood sugar level, and blood pressure—were also much improved on the low-carb diet. This was a puzzle, a real conundrum. And that was where my journey began. 

The new studies proved that the low-carb approach was a viable one. But this didn’t make any sense to me because I was still steeped in the conventional “calories in, calories out” (CICO) approach—the idea that the only way to lose weight is to consume fewer calories than you expend. Diets based on the Atkins methodology, for example, did not necessarily restrict caloric intake, yet people were still losing weight. Something didn’t add up. One possibility was that the new studies were wrong. However, that was unlikely, given that multiple studies all showed the same result. Furthermore, they confirmed the clinical experience of thousands of patients, who were all reporting weight loss on the Atkins diet. Logically, accepting that the studies were correct meant the CICO approach had to be wrong. Much as I tried to deny it, there was no saving the CICO hypothesis. It was dead wrong. And if the CICO hypothesis was wrong, then what was right? What caused weight gain? What was the etiology—the underlying cause—of obesity? 

Doctors spend almost no time thinking about this question. Why? Because we think we already know the answer. We think that excessive caloric intake causes obesity. And if eating too many calories is the problem, then the solution is eating fewer calories and burning more through an increase in activity. This is the “eat less, move more” approach. But there’s an obvious problem. “Eat less, move more” has been done to death over the past fifty years, and it doesn’t work. For all practical purposes, it doesn’t really matter why it doesn’t work; the bottom line is that we’ve all done it, and it doesn’t work.

The underlying cause of obesity turns out to be a hormonal, rather than a caloric, imbalance. Insulin is a fat-storage hormone. When we eat, insulin increases, signaling our body to store some of this food energy as fat for later use. It’s a natural and essential process that has helped humans survive famine for thousands of years, but excessively and persistently high insulin levels result inexorably in obesity. Understanding this leads naturally to a solution: if excessive insulin is causing obesity, then clearly the answer lies in reducing insulin. Both the ketogenic diet (a low-carb, moderate-protein, high-fat diet) and intermittent fasting are excellent methods of reducing high insulin levels. 

However, in my work with type 2 diabetics, I realized that there was an inconsistency between the treatment of obesity and the treatment of type 2 diabetes, two problems that are closely linked. Reducing insulin may be effective in reducing obesity, but doctors like me were prescribing insulin as a cure-all treatment for diabetes, both types 1 and 2. Insulin certainly lowers blood sugars. But just as surely, it causes weight gain. I finally realized that the answer was really quite simple. We were treating the wrong thing. Type 1 diabetes is an entirely different problem than type 2. In type 1 diabetes, the body’s own immune system destroys the insulin-producing cells in the pancreas. The resulting low insulin level leads to high blood sugar. Therefore, since insulin levels are low to begin with, it makes sense to treat the problem with supplemental insulin. And sure enough, it works. In type 2 diabetes, however, insulin levels are not low but high. Blood sugar is elevated not because the body can’t make insulin but because it’s become resistant to insulin—it doesn’t let insulin do its job. By prescribing more insulin to treat type 2 diabetes, we were not treating the underlying cause of high blood sugar: insulin resistance. That’s why, over time, patients saw their type 2 diabetes get worse and required higher and higher doses of medications.

But what caused the high insulin resistance in the first place? This was the real question. After all, we didn’t stand a chance of treating the underlying disease if we didn’t know what caused it. As it turns out, insulin causes insulin resistance. The body responds to excessively high levels of any substance by developing resistance to it. If you drink excessive alcohol, the body will develop resistance, up to a point—we often call this “tolerance.” If you take narcotics such as heroin, your body will develop resistance. If you use prescription sleep medications such as benzodiazepines, your body will develop resistance. The same holds true for insulin. Excessive insulin causes obesity, and excessive insulin causes insulin resistance, which is the disease known as type 2 diabetes. 

With that understanding, the problem with how doctors treat type 2 diabetes became clear: we were prescribing insulin to treat it, when excessive insulin was the problem in the first place. Instinctively, most patients knew what we were doing was wrong. They would say to me, “Doctor, you have always told me that weight loss is critical in the treatment of type 2 diabetes, yet you have prescribed me insulin, which has made me gain so much weight. How is that good for me?” I never had a good answer for this. Now I knew why. They were absolutely right; it wasn’t good for them. As patients took insulin, they gained weight, and when they did, their type 2 diabetes got worse, demanding more insulin. And the cycle repeated: they took more insulin, they gained more weight, and as they gained more weight, they needed more insulin. It was a classic vicious cycle.

We doctors had been treating type 2 diabetes exactly wrong. With the proper treatment, it is a curable disease. Type 2 diabetes, like obesity, is a disease of too much insulin. The treatment is to lower insulin, not raise it. We were making things worse. We were fighting the fire with gasoline. I needed to help my obesity and type 2 diabetes patients lower their insulin levels, but what was the best approach? Certainly, there are no medications that do this. There are surgical options that help, such as bariatric surgery (commonly called “stomach stapling”), but they are highly invasive and have many irreversible side effects. The only feasible treatment left was dietary: reducing insulin levels by changing eating habits. 

In 2012, I established the Intensive Dietary Management Program, which has a unique focus on diet as a treatment for the twin problems of obesity and type 2 diabetes. At first, I prescribed low and very low carbohydrate diets. Since refined carbohydrates highly stimulate insulin, reducing these carbohydrates should be an effective method of lowering insulin. I gave my patients lengthy sessions of dietary advice. I reviewed their food diaries. I begged. I pleaded. I cajoled. But the diets just didn’t work. The advice seemed hard to follow; my patients had busy lives and changing their dietary habits was difficult, especially since much of it ran contrary to the standard advice to eat low-fat and low calorie. But I couldn’t just give up on them. Their health, and indeed their very lives, depended upon reducing their insulin levels. If they had trouble avoiding certain foods, then why not make it as simple as possible? They could simply eat nothing at all. The solution was, in a word, fasting.

Eat Carbs Last for Better Health

It’s previously been found that consuming whey protein prior to a meal reduces post-meal glucose levels.2 Building on this, a pilot study by researchers with Weill Cornell Medical College in New York City revealed that food order also has a significant impact on postprandial (or post-meal) glucose and insulin levels.3

The study included 11 overweight or obese adults with Type 2 diabetes, who fasted for 12 hours overnight and then consumed the same meal on two separate days, one week apart. All that differed was the order of the meal.

On the first day, the subjects ate carbohydrates, consisting of ciabatta bread and orange juice, first. Fifteen minutes later, they consumed the protein component (skinless grilled chicken breast) and vegetables (a salad with Italian vinaigrette dressing and steamed broccoli with butter).

A week later, the food order was reversed, with the vegetables and protein eaten first, followed by the carbohydrates last. Better outcomes were achieved when the carbs were consumed last. Specifically, postmeal glucose levels decreased by 28.6%, 36.7% and 16.8% after 30, 60 and 120 minutes, respectively when vegetables and protein comprised the first part of the meal. Postprandial insulin levels were also significantly lower in this scenario.

The beneficial effects of food order on glucose levels were so powerful that the researchers deemed them “comparable to that observed with pharmacological agents that preferentially target postprandial glucose.”4 “Moreover, the reduced insulin excursions observed in this experimental setting suggest that this meal pattern may improve insulin sensitivity,” they suggested, adding:

“In contrast to conventional nutritional counseling in diabetes, which is largely restrictive and focuses on “how much” and “what not to eat,” this pilot study suggests that improvement in glycemia may be achieved by optimal timing of carbohydrate ingestion during a meal.”

Food Order Matters in Prediabetes

Worldwide, 463 million adults have Type 2 diabetes, a number that’s expected to increase to 700 million by 2045 and doesn’t account for the many others who have prediabetes, which increases the risk of developing Type 2 diabetes, heart disease and stroke.5 Approximately 1 in 3 U.S. adults, or 96 million, have prediabetes, more than 80% of whom don’t know they have it.6

Changing food order “presents a novel, simple behavioral strategy to reduce glycemic excursions in prediabetes,” according to a study published in the journal Diabetes, Obesity & Metabolism.7 The study involved 15 participants with prediabetes who consumed the same meal on three days in random order:

• Carbohydrate first, followed 10 minutes later by protein and vegetables (CF)
• Protein and vegetables first, followed 10 minutes later by carbohydrate (PVF)
• Vegetables first followed by protein and carbohydrate (VF)

Total glucose was decreased by 38% following the PVF meal compared with CF, while incremental glucose peaks were attenuated by more than 40% in the PVF and VF meals, compared with CF.

“The CF meal pattern demonstrated marked glycemic variability whereas glucose levels were stable in the PVF and VF meal conditions,” the researchers noted,8 explaining that simply by altering food order to consume carbohydrates last it could help to mitigate the metabolic effects of carbohydrates.9

Consuming Carbs Last Benefits Type 1 Diabetes

Even among children with Type 1 diabetes, consuming carbohydrates at the end of the meal was beneficial. Twenty patients with Type 1 diabetes aged 7 to 17 years were included in the study.10 They consumed two meals in random order. For the first meal, the protein and fat components were consumed first, followed 15 minutes later by the carbohydrates.

In the other meal, protein, fat and carbohydrates were consumed together, the way they would be in a typical meal. Mean glucose levels were 1 mmol/L lower when carbs were consumed last compared to the typical meal. Fung explained:11

“This might mean a lot of things, including you need less insulin, which might lead to less weight gain overall because we know that those high glucose levels, those high insulin levels, are going to drive weight gain.

This actually has massive implications for the way we need to structure our meals. If eating the exact same number of calories, eating the exact same food, but simply switching the order means that we can face 40% less glucose, that means we may be able to prevent the onset of Type 2 diabetes.

We might be able to take less medications. We may be able to lose weight, because again that lower level of insulin is going to cause less weight gain. And what it means is that you really have to frontload your meals so that you’re taking your protein, and your fat and your vegetables right upfront and leaving the carbohydrates to the end.”

For best results, he says, wait about 10 minutes after consuming the protein and fats before you eat the carbs, similar to the way you might eat an appetizer before your next course.

The Timing of Your Meals Also Matters

As science is increasingly showing, what you eat is not the only factor in how food affects your health. Along with food order, the timing of your meals is another important factor. Fung is a big proponent of fasting, or what I like to refer to as time-restricted eating (TRE).

The answer for Type 2 diabetes, he believes, is to stop feeding your body sugar and burn off the sugar already in your cells, and the most effective way to do this is TRE. In our past interview below, he explained that metabolic treatments such as TRE are the only way to resolve diabetes: 

 

“It really gets to the point that you cannot follow this old paradigm [of drug treatment] because you're going to fail ... Remember, the glucose goes into the cell, and insulin resistance is when the glucose doesn't go out of the cell. So, for years we’ve used this paradigm of lock and key.

That is, the cell is sort of gated off. Outside the cell there's blood, and when insulin comes around it turns the key, opens the gate and glucose goes in. So, if insulin is there, why is the glucose not going in? ... You can measure the insulin and the insulin level is high. You can look at the insulin receptor, the gate is completely normal.

So, [conventional medicine] said something like, 'Well, maybe there's something gumming up the mechanism. It's stuck in the lock so it doesn't open properly, therefore the glucose can't get into the cell.' There's a huge problem with this sort of paradigm, because if that is happening, the cell has no glucose and should be starving.

You should be losing lots of weight; you’d have a very thin liver. All your fat should just melt away, because if you think about untreated Type 1 diabetes, where you don't have enough insulin, that's exactly what happens. The cell literally starves and everything just wastes away ... But that's not what's happening here.

In Type 2 diabetes you see that people are generally obese, they have large abdomens ... What's happening instead is that it's actually an overflow syndrome. The cell can't accept any more glucose because it's jam packed full of glucose already. That's the reason you have insulin resistance. Insulin is trying to move glucose into the cell but the cell is full ... So, it's really an overflow mechanism ...

That's also why your liver is full — it's a big fatty liver. The liver is busy trying to get rid of all this glucose by turning it into fat ... Now, if Type 2 diabetes and insulin resistance are the same sort of thing, it's really about too much sugar. That's the bottom line.

And if you understand that the whole problem is too much sugar, then the solution is not to use more insulin to jam more glucose into an already full cell. The key is to get rid of it all. So, what you want to do is: 1) Don't put more sugar into your system, because you have too much sugar in already, and 2) Burn it off.”

Limit Your Eating Window to Six to Eight Hours Per Day

While fasting may sound intimidating, TRE is manageable as it involves limiting your eating window to six to eight hours per day instead of the more than 12 hours that most people do. TRE promotes insulin sensitivity and improves blood sugar management by increasing insulin-mediated glucose uptake rates,12 which is important for resolving Type 2 diabetes.

In another study, when 15 men at risk of Type 2 diabetes restricted their eating to even a nine-hour window, they lowered their mean fasting glucose, regardless of when the “eating window” commenced.13 A 2022 review also highlighted many of the benefits of TRE for the prevention of Type 2 diabetes, reveling that it:14

• Produces mild weight loss of 1% to 4%
• Reduces fasting insulin
• Improves insulin sensitivity in people with prediabetes or obesity
• Improves glucose tolerance
• Reduces oxidative stress

So simply by restricting your eating window to six to eight hours per day, and consuming carbs at the end of your meal, you may be able to improve your metabolic health significantly. This isn’t to say that food quality doesn’t matter, particularly when it comes to ultraprocessed foods.

Linoleic acid (LA) in seed oils — commonly known as vegetable oils — plays a major role in producing chronic diseases like diabetes.15 Linoleic acid is found in virtually every processed food, including restaurant foods, sauces and salad dressings, and even “healthy” foods like chicken and pork. So in addition to embracing TRE and optimizing food order, reducing LA is essential for diabetes prevention and management.

The Case Against Intermittent Fasting

However it should be noted that intermittent fasting is not recommended for:

• People younger than the age of 18, as it can prevent growth. 
• Pregnant and breastfeeding women are also not recommended to fast intermittently. 
• Older people are notorious for getting frail very quickly if they skip even one meal. They don’t eat very often, but they need their meal. If you don’t give it to them, they can very quickly decline. 
• Extended fasting is also not a healthy long term strategy as it increases your stress hormones and worsens mitochondrial function.
• People with diabetes and kidney disease are also recommended to check with their primary care physicians before considering intermittent fasting.
• Those taking hypoglycemic or antihypertensive medication are particularly at risk, as they may end up overdosing. If you're on medication, you need to work with your doctor to ensure safety, as some medications need to be taken with food and/or can become toxic when your body chemistry normalizes. 

Sources and References:

• 1 YouTube, Jason Fung, Why Food Order Matters May 22, 2022
• 2, 3, 4 Diabetes Care. 2015 Jul; 38(7): e98–e99
• 5 Molecules. 2019 Dec; 24(24): 4501
• 6 U.S. CDC, Prediabetes
• 7 Diabetes Obes Metab. 2019 Feb; 21(2): 377–381
• 8 Diabetes Obes Metab. 2019 Feb; 21(2): 377–381. Abstract
• 9 Diabetes Obes Metab. 2019 Feb; 21(2): 377–381. Conclusions
• 10 Pediatr Diabetes. 2018 Jun;19(4):809-815. doi: 10.1111/pedi.12640. Epub 2018 Mar 12
• 11 YouTube, Jason Fung, Why Food Order Matters May 22, 2022, 7:15
• 12 Science November 16, 2018; 362(6416): 770-775
• 13 Obesity April 19, 2019; 27(5)
• 14 J Physiol. 2022 Mar;600(5):1253-1264. doi: 10.1113/JP281101. Epub 2021 Sep 8
• 15 YouTube, Omega-6 Apocalypse 2, Chris Knobbe August 25, 2021
How to Reverse Type 2 Diabetes Naturally

Original Article: https://articles.mercola.com/sites/articles/archive/2022/07/04/food-order.aspx

This article is part of the intermittent fasting series.

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