On 20th Nov 2018, The Times of India published an article titled- ‘Two-meals-a-day’ professor to drive diabetes fight. The article quoted Dr. Jagannath Dixit who stated that,
“If one follows the two meal (a day) practice, I am sure there will not only be weight loss, but it will also help in controlling diabetes. Reversal of diabetes is also possible.”
Dr. Dixit is the appointed brand ambassador for tackling obesity and diabetes by the medical education department of Govt. of Maharashtra. BJP leader Girish Mahajan, who heads the medical education department, stated that ‘the reason to appoint Dr. Dixit as the brand ambassador was that his ‘diet plan’ to tackle obesity and diabetes is yielding results.’
Dr. Dixit has popularized this notion of ‘two meals a day’ by several videos on Youtube, with the most popular video with 1.6M views, as well as viral content on social media, spread largely through WhatsApp groups.
Dr. Dixit claims that having only 2 meals a day, each lasting less than 55 mins, leads to significant weight loss of around 8kg in 3 months. As per Dr. Dixit, reducing the frequency of food intake, regardless of the quantity or the quality of the food, can have an impact on the insulin level.
In his Marathi video below, he has also claimed that this method can potentially reverse the pre-diabetic conditions.
In this article, we will discuss:
- The link between obesity and diabetes
- The recommendations for weight loss in diabetic patients
- Dr. Dixit’s theory related to ‘two meals a day’
- Whether these claims are based on existing research by Dr. Dixit
- Conclusion and hazards of the misinformation
What is the link between Obesity & Diabetes?
Diabetes and obesity have emerged as the biggest health challenges in India. Calorie intake (though eating) in excess of consumption (exercise), which is then converted into excessive fat that can lead to obesity.
Obesity, a surplus of energy in cells, in turn leads to insulin resistance, a condition where glucose uptake is impaired. This impairment in glucose uptake leads to higher glucose in blood terms as diabetes.
Insulin resistance is the primary cause of type 2 diabetes and it occurs well before type 2 diabetes starts in humans. In addition to food intake, exercise and other lifestyle factors, genetics play a huge role in determining the risk of obesity and diabetes.
While, over 90% of diabetic patients fall in this category called Type 2 Diabetes Mellitus, there are several other variants of Diabetes such as type 1 with different pathophysiological mechanisms.
The standard recommendations for weight loss in diabetic patients are:
- Calorie restriction,
- Small frequent meals,
- Regular exercises, and
- Anti-hyperglycaemic drugs may be prescribed by specialist diabetes physicians, to maintain a basal blood glucose.
Large rapid changes in blood glucose in diabetic patients can be hazardous and patients must maintain optimal glucose in the meal by controlling the frequency, quality and quantity of their diet.
These recommendations are based on published data from randomised controlled trials (RCTs) and meta-analyses, i.e. a collective evaluation of several RCTs to increase sample size (patient numbers).
Is the ‘two meals a day’ theory effective in managing insulin? We examine Dr. Dixit’s claims:
Claim 1: Food intake should be no more than 55 mins long to avoid the second bout of insulin
Dr. Dixit’s argument is that if one continues to eat for more than 55 minutes, a second bout of insulin (in equal amount) would be released.
In addition to a low amount of continuous insulin release, insulin is released in two phases in healthy humans in larger quantities. Phase I, soon after starting the meal and, phase II, about 45 to 60 mins after the consumption of a meal. Any meal would trigger the two phases of insulin release, in proportion to the quality of the meal.
However, in type 2 diabetes patients, the first phase of insulin release is impaired which produces the inability to process glucose after meals leading to postprandial hyperglycaemia.
Since, the insulin release varies with food intake, it is false to claim that limiting food intake time to 55 mins can stop the phase II insulin release.
Claim 2: Quantity and quality of food is irrelevant to insulin release
Dr. Dixit’s claim that ‘a fixed amount of insulin is released in response to every meal irrespective of quantity and quality of meal’. In his english video, he also elaborated that even eating sweets is permissible even for diabetic patients if they follow the two meal a day diet plan.
On the contrary, numerous publications with well-designed studies suggested that the insulin response is proportional to the amount of food and correlated with carbohydrate content of the food. That is, larger quantities of food releases larger doses of insulin.
Food insulin index (FII), the amount of insulin released in response to a meal as against the reference food (bread), for various meal compositions has been studied and published in American Journal of Clinical Nutrition. The study showed that, when insulin level was measured in healthy people, who consumed 13 different meals with the same energy content, it strongly correlated with the insulin demand predicted by FII of the component foods.
This means that, quantity and quality both, has a huge impact on the amount of insulin released, which negates the second and most dangerous claim.
Claim 3: Two meals, anytime during the day, can reduce weight and possibly control diabetes
Dr. Dixit suggested in his popular video, that having two meals anytime during the day, even as late as at 9 pm in the evening, can help with obesity and diabetes. We examined two contradictory studies to understand and fact-check Dr. Dixit’s statements.
A study, published in 2014 in Diabetologia, with 27 type-2 diabetic patients in each group, tested this effect that compared 2 large meals which were consumed earlier in the day (e.g. lunch and breakfast) vs. 6 small meals throughout the day, and concluded that there was a significant difference in body weight and fasting plasma glucose among others.
However, according to a study published in the journal ‘Diabetes Care’, two meals can lead to a significantly higher insulin response as compared to multiple meals. In 12 diabetic patients, two large meals produced greater increase in glucose and insulin release than 6 small meals, provided that the caloric consumption in two large meals were the same as six small meals.
This means, that while Dr. Dixit may not be entirely wrong in suggesting the two meal a day plan. However, suggesting that the timing of the two meals are irrelevant for obesity and diabetes is factually incorrect.
Also, there is far greater evidence, in reliable journals, that suggests that, if the total components of the meals are of the same calorific value, i.e. iso-caloric diets, smaller-regular meals are far better for obesity and diabetes than larger-infrequent meals.
We fact-checked if Dr. Dixit has published any research to support his claims?
We conducted a scientific literature review on claims made by Mr. Girish Mahajan, the BJP leader, and Dr. Dixit using Google, Google scholar and PUBMED. On all portals we could not find any research in the area of obesity or diabetes with their names.
However, from Dr. Dixit’s speeches, we found two articles published in a non-indexed journal called International Journal of Clinical Trials.
Study 1: This study has little scientific value as the parameters such as weight and waist size were not accurately measured by a researcher using calibrated equipment and instead were taken over the phone from the patient (self-reported).
Study 2: This was a preventive study in pre-diabetic patients with a sample size of 48. The results showed that HbA1C, (a parameter to measure overall glycemic load) decreased by 0.8% after 3 months of treatment. In this study, in addition to two meals a day in pre-diabetic patients, the subjects were advised to go for a 45-minute brisk walk, 5 days a week.
However, another meta-analysis study of 20 randomised control trials have shown that HbA1C (maximum 0.78%) can be reduced by regular exercise alone.
- We could not find any published research to substantiate his claim with regards to limiting the meal time to 55 minutes and as a result, the subsequent avoidance of the 2nd phase insulin release.
- The claims of Dr. Dixit that amount of insulin released in response to meals has no relation with the quality and quantity of meals is factually incorrect, and is in stark contrast to the physiological facts established via numerous published studies.
- While according to one study, two meals earlier in the day had an impact on body weight and plasma glucose, the benefits were not extended to other time periods such as late evening meals as suggested by Dr. Dixit. The larger body of established evidence suggest it is beneficial to consume smaller meals of low calories throughout the day as opposed to two large meals, leaving the subject open for further research in a larger cohort of patients.
In particular, Dr. Dixit made a dangerous claim in the initial part of the video that diabetes patients can consume sweets as long as they stick to the two-meal diet, but later suggested that it is preferable to have more proteins instead.
Dr. Dixit is associated with a social media campaign related to diabetes and obesity. The majority of case studies and experiments conducted by him are based on self-testing or self-reported measures and cannot be taken as scientific evidence.
Hence, Dr. Dixit’s viral claim is not only misinformed but is potentially harmful for the pre-diabetic and type-2 diabetes patients for following reasons.
- The patients with type 2 diabetes who are on glucose lowering drugs are at a very high risk of hypo-glycaemia, which can cause light-headedness and shivering, if they do not take frequent meals as advised by the doctor.
- Consuming limitless food in one go would lead to consumption of excessive calories, especially if the patients opt for high caloric food and would in turn lead to weight gain.
For more information on guidelines for Diabetes, please visit the WHO website: https://www.who.int/diabetes/publications/en/
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