It's odd how much we obsess about LDL, considering how much has been known that it's a very relatively weak indicator.

I've tweeted out a couple of articles in the New England Journal of Medicine, which is considered sort of the most important medical journal in the world.

They looked at a number of factors, and, you know, there's been a couple sites like this where they look at, you know, what's the most important factor for heart disease, for example?

Smoking is one of the most important, diabetes is very, very close, and LDL cholesterol had almost no effect.

It was very striking.

Hypertension is sort of medium, but it was very striking how little effect lowering your LDL really had, considering how much people obsess about it.

[music] Welcome everyone to our monthly Q&A with Dr.

Jason Fung when he tackles questions submitted by TFM Community members.

Hello to our podcast listeners who will be able to listen to our Q&A a few weeks after our Community members.

All right, so let's get started.

This first question says, "I am a healthy 46-year-old working to improve my sleep.

So I want to take magnesium bisglycinate.

My magnesium supplement actually contains seven forms of magnesium, including malate, taurate, citrate, and others, which is very convenient, but is it better to take just one form in one capsule for absorption?

I've heard that they are fighting for receptor sites if I take several different types at once." In terms of magnesium, I don't know that there's any studies of taking multiple versus one.

There was a study on different types of magnesium and, really, the only thing that stood out was there's one that you should avoid, which is magnesium hydroxide.

Now, that's the cheap stuff.

A lot of places use these blends and then they say, "Oh, there's all these different ones, including magnesium oxide," but they don't tell you what percentage it is.

So I'm always thinking that, oh, they're going to give you like 98% magnesium oxide.

So you know, if they don't tell you what percentage then you don't know.

And that often gets stuck in there.

I know because my son takes magnesium for cramps and stuff.

At Costco there's two; there's magnesium oxide, which is half the price of the magnesium bisglycinate.

And then I remember looking at a pharmacy where there was one that's like a blend, which included magnesium oxide.

So that's the worry if you take a bunch.

If you take a bunch that don't have magnesium oxide, then you're probably fine.

The other thing is that certain magnesiums might do better for you.

There may be some individual differences, as in I might absorb this glycinate better than malate or citrate or one of these other things.

But when you look at large numbers of people, they're all relatively good except for magnesium oxide, which really, really is very, very low.

So I would see how it is.

If the blend has magnesium oxide, then don't take the blend unless you know that they're not giving you a lot.

If the bisglycinate doesn't-- and that seems to be the most popular one these days.

If the bisglycinate doesn't work for you, then you can switch to a blend or use one of these other ones.

I'm glad you said that about experimenting, you know, we're our own science experiment.

I always took magnesium L-threonate for my migraines, and then I discovered that actually, especially if I have a migraine from barometric pressure change, I do better with magnesium malate.

So it's like-- you know, just experiment.

Have fun with it, you know?

Keep track of it.

This next person has two questions about fat fasting.

"Vinegar is not listed as one of the options on TFM's fat fast, but you've mentioned that we can eat it with salads.

Would it be okay to make a healthy dressing with a healthy oil and vinegar during a fat fast?" Yeah, so certainly you can use vinegar.

The reason it's not on there is that a lot of the effect of the vinegar seems to be that it blocks the salivary amylases.

And so the amylases break down carbohydrates.

So when you take vinegar with bread, for example (So say you use olive oil and vinegar for bread, right?

You dip it.

That's very traditional.), the vinegar will block the salivary amylases, which are the enzymes that start the digestion of the carbohydrates.

So because you've slowed down the digestion, the effect on your glucose and the effect on your insulin is much less.

So if you're just not eating any carbohydrates and you take the vinegar-- you can take it anyway, it doesn't hurt you for sure.

But some of the benefits that people talk about with the vinegar apply when you eat it with carbohydrates, so, again, it doesn't hurt you if you want to take it just with the salad dressing, like with some balsamic vinegar and so on.

They have a second question on fat fasting.

They said, "I've seen mention of only eating three or four of the allowed foods on the fat fast.

Is this an alternative manner to step up one's game during the fat fast?

Can I eat more or should I restrict to three or four?" The fat fasting that we recommend is not just fat, but also relatively monotonous too, right?

And the idea is that if you limit it to a certain number of foods, then you're going to take care of the hunger without eating for pleasure sort of thing, right?

So keeping it to a certain number of foods limits this because there's something called sensory-specific satiety, which means that if you eat different foods, you will be more hungry.

Like, if you eat only one thing, and it could be anything-- This is the secret of the-- they used to have this thing called the rice diet, right?

This was from the 20s [sic, 1940s].

It's called the Kempner Rice Diet.

And what he did was he put people on white rice and sugar [sic, rice and fruit - to treat renal failure].

It was monotonous, but it was a lot of carbs and people lost weight on it.

And people said, "Oh, therefore this proves that you can lose weight," and then-- it doesn't prove anything because you're simply using a different thing.

If all you eat every single day for every single meal is white sugar and white rice, you're going to get tired of it so fast, right?

And then when they give you the next meal of white rice and sugar, you're going to be like, "Erm, no thanks.

I don't really want to eat it." So it's really affecting the pleasurable side of eating, the hedonic side of eating, as opposed to the homeostatic side, which is the hunger and, you know, nutrients, and all this sort of thing.

So any monotonous diet, and it doesn't matter what it is.

So it could be any-- you know, whether you limit it to vegetables, or like veganism, or carnivore, or whatever.

When you limit the number of things, you will tend to eat less.

That's just natural human nature because of hedonic hunger.

So the whole point is that, even if you do these sugar diets or white rice diets and stuff, because of the monotony, you can actually do quite well in it.

This is what I always think is funny because the people are like always-- online, there's always people that point out this Kempner Rice Diet.

And I'm always thinking, if you think it's so good, go ahead and do it.

It's a terrible diet to follow.

Like, it's just a horrible, horrible diet because you can't-- like, eating white rice and sugar for every meal, every single day, for like a week, you're just not going to eat very much.

So that part of fat fastiing is cutting down the types of-- the variety of foods so that you are really focused on the hunger as opposed to the eating pleasure of it.

You can do more.

If you do more, then sure, then go ahead.

Right?

Why make it harder on yourself?

But the way it's originally sort of meant to be is a relatively monotonous diet.

So it could be good food.

It could be avocados and bacon, for example.

But it's a relatively monotonous diet.

And it's meant to be a short term thing too.

This person sent in a research study, and I looked at it.

So it's actually a small study, but they were asking about a single infusion of stem-cell-based treatment that could be a permanent solution for insulin issues.

Can you talk to us about the latest information on stem cells, with either the pancreas, the liver, or the kidney?

Yeah, I don't know of any.

Like, I'm not aware that there's any stem cell treatments that are really shown and widely accepted as effective.

I know a lot of people who do stem cell treatments, and mostly they go to places like Costa Rica and India and stuff to do them because it's not sort of licensed in Canada, and I think not in the United States either, because it seems like everybody has to travel abroad to do them.

The scientific literature on these stem cell therapies is relatively small.

I don't know that there's any proof that they actually work.

It doesn't mean it doesn't work.

It just means that, until there's good evidence that it works, then I can't really recommend it.

Is it harmful?

Not that I know of.

I mean, I know a lot of people (just personally) who have said they've gone and done it, and half really thought it was useful and half didn't.

So I wonder if it's more of a placebo effect.

On the other hand, I'm willing to accept that it could be a beneficial thing, but I just don't know.

So I can't really say for sure.

My guess is that the effect is going to be quite small.

Where I've seen the success, and heard of the success from my clients, is with bone.

That's different it seems than these vital organs.

So we'll see.

We'll see what the future holds.

This person says, "Are there any research-based studies that are showing that fasting helps lower cholesterol?" And I know you've done several articles on this.

They're also asking if those studies differentiate between familiar high cholesterol or not.

There are some studies.

So when you look at the cholesterol panel, there's three things that they generally look at which is the LDL (the so-called bad cholesterol), the HDL (which is the so-called good cholesterol), and then the triglycerides.

The triglycerides and the HDL go hand in hand.

So they sort of are like a seesaw, right?

So when the triglycerides go up, the HDL goes down.

When the triglycerides go down, the HDL goes up.

There's really two, you know, major things.

So in terms of LDL, the so-called bad cholesterol, fasting can lower the cholesterol 10 to 25%.

It's not a huge reduction compared to like the statins or something, obviously, because they're very targeted treatments.

But on the other hand it can.

It tends to vary by person, but it's sort of a small to medium effect.

Some people get a larger effect, but it's not a huge drop like you see with some of the medications that have been developed.

The major effect that you see with the fasting is the drop in triglycerides, which causes the rise in the HDL (or good cholesterol).

And in fact, if you look at the those two (sort of triglycerides/HDL versus LDL), the triglycerides/HDL is actually much, much more powerful as an indicator of future coronary events.

And that's been known for like 25 years, which is strange because I learned that in medical school 25 years ago, but nobody talks about that anymore.

That is, if you were to say, which one is more important - to have a good LDL or to have a good HDL?

It's very clear that it's much more important to have a good HDL (or good cholesterol), which is the same as the triglycerides.

And that can be changed with the diet by cutting down the carbohydrates.

Then you lower your triglycerides by about 25 to 50%, and raise-- depending on how much you limit your carbohydrates, of course.

And then you raise your HDL.

And as a marker, it's just much, much more powerful.

It's odd how much we obsess about LDL, considering how much has been known that it's a very-- relatively weak indicator.

I've tweeted out a couple of articles in the New England Journal of Medicine, which is considered sort of the most important medical in the world.

They looked at a number of factors.

And, you know, there's been a couple sites like this where they look at, you know, what's the most important factor for heart disease, for example?

Smoking is one of the most important, diabetes is very, very close, and LDL cholesterol had almost no effect.

It was very striking.

Hypertension is sort of medium, but it was very striking how little effect lowering your LDL really had, considering how much people obsess about it and how much all these sort of longevity gurus and stuff say, "Oh, if you get your cholesterol to zero, you'll live forever." Not according to the research that I've read.

I don't think it plays zero role, but I think it plays a relatively minor role in the whole thing.

As in, I think cholesterol is, like, you know, a tiny, tiny percentage, and diabetes is this huge percentage of risk.

Smoking, I think, of course, is-- you know, everybody agrees you should stop smoking, right?

So that's a no-brainer.

But diabetes was right up there.

Was funny because I heard Dr.

Ben Bikman say

on one podcast, "If your triglycerides:HDL ratio is low," like less than 2, like, you know, really low, he said, "and you have high LDL, you're going to live forever and not get Alzheimer's." I laughed over that.

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[music] This person says that they have been doing a four-day water fast, and, every time they do so, they notice a metallic taste in their mouth.

Is this common?

I think it happens.

I've heard it, although I don't know the mechanism of it.

And there are some things that people notice and I'm not sure why they happen, like I noticed the color of my urine actually changes a little bit.

It's a little odd, and I don't know if it's due to the ketones or whatever it is, but every time I do fasting, I do see that the color is a little bit different.

And that happens every single time so I'm not too worried about it anymore, but I'm still not entirely sure why it looks- like the tone of it is just much different than normal.

So, you know, I'm not sure about the metallic taste in the mouth.

I'm pretty sure I've had that before too, but it's not common for me, but I've heard it as well.

But I don't know the mechanism.

I don't know why that would be.

This person says, "I have various autoimmune conditions (asthma, allergy, eczema, possibly mast cell activation syndrome) and it was suggested that I consider going on LDN (low dose naltrexone), and that this can also help with weight loss.

But I'm wondering what your thoughts are on LDN and, if I decided to start, how would I incorporate it into my fasting schedule?" I can't speak to the specific case, but just in terms of naltrexone, naltrexone is an opiate antagonist, so it's used predominantly for opiate overdose.

So somebody comes in with a heroin overdose or a morphine overdose or whatever, the naltrexone reverses that.

So you can get very, you know, a decreased level of consciousness with opiates.

So if somebody who overdoses on narcotics, for example, and then you give it to them, it reverses it.

It's actually used for weight loss sometimes.

There's been various studies on it and it's been variably successful because I think that some of the overeating behavior is driven by these reward pathways.

And that's why, when you block some of the reward pathways, then people don't eat, that is they're eating because they're getting this sort of pleasurable/addictive sort of feeling, right?

Similar to opiates.

So I think the naltrexone blocks that pathway and therefore reduces that sort of food addiction over eating pathway.

So therefore it's been used for weight loss.

In fact in some studies they've used it in drug trials, where they've combined naltrexone with other things, buproprion and various other things.

These are older weight-loss medications, right?

So that's probably the pathway.

How it helps in autoimmune disease I'm not sure.

However, there's nothing you need to do specifically.

So if it reduces the food cravings, if it reduces the food addictions, then you just do the fasting just as usual.

There wouldn't be any need to change if you are on that medication.

Great.

Now this one I had to look up and it is a thing.

It says, "What is the difference between dawn phenomenon and feet-to-floor syndrome?" I'd never heard of that before, the feet-to-floor.

"From what I can find, they both cause a rise in morning blood sugar, one due to circadian rhythm and the other due to stress response from getting the day started.

Is there a different eating and fasting protocol that would be best for one over the other?".

I had never heard of this before.

What is the feet-to-floor phenomenon?

The feet-to-floor phenomenon is when you spike your blood sugar just because you're starting the day.

So from what I've seen, timing is very important.

It can happen immediately upon setting your feet on the floor, getting out of bed, and becoming active.

So some think that it's because of the physical stress response to movement and activity, such as standing and walking, that it triggers your sympathetic nervous system response and releases stress hormones as well as glucose.

That makes sense.

Yeah.

So it's basically along the same pathway, right?

So the circadian rhythm is that you get a normal spike in cortisol growth hormone and so on (these counterregulatory hormones) at around 5 a.m..

And that's because your body's like, "Okay, we need to get you ready for the day." And the counterregulatory hormones go up, which tell your body basically to try and release some glucose so that you're sort of fueled up for the day.

I imagine the feet-to-floor is the same thing.

So as soon as you touch the floor, I guess, then you trigger the same sort of reaction, and it'll be the same - sympathetic nervous system, cortisol, that kind of thing.

So it's sort of along that same pathway.

I don't think that there's anything specifically you need to do for it.

I mean, if it's exaggerated, then, you know, you may have to see about what else can be done for it, but it seems to be just a normal phenomenon.

If your blood glucose goes up without eating, then really you're just releasing your body's own stores of sugar.

You can push it back in, but it doesn't do you any good in the long term.

One of the things they said that you could do is do gentle stretching in the bed before you get up.

Avoid jumping up and out of bed and going, you know, full at it.

Also trying meditation first thing in the morning to calm yourself.

Both of them do better if you get a regular sleep pattern and do stress management techniques, which I know you're always, always recommending.

Yeah.

I mean, it makes sense because it's-- again, you're trying to push yourself more towards the parasympathetic system, right?

Meditation and stretching and all that sort of stuff.

Versus a sympathetic tone, which is generally when your body is like, "Oh, we need to get moving," right, which is the sympathetic nervous system.

This person has a question in the Q&A box they wanted to know about whether kidney disease is the cause of interstitial cystitis and how to treat it.

Have you ever heard of that?

Interstitial cystitis is different.

It's not a kidney disease, it's a bladder disease.

So cystitis refers to the bladder.

And it's this condition where you get white cells in the urine and inflammation, but it's not entirely clear what's causing it.

So you can get bladder infections (and that's cystitis from bacteria usually, right?), but what interstitial cystitis is not clear.

So I'm not a urologist, so I don't know too much about it, but, from my general medical training, it was one of these things that happens over and over.

People get this interstitial cystitis.

People go in with a cystoscope, they see this inflammation, but it's not entirely clear what's causing it.

It doesn't affect the kidneys so much, though.

This person says, "I recently learned that I have high uric acid and Megan Ramos suggested taking three tablespoons of lime juice a day.

However, I forgot to mention to her that I also have the APOE 4-4 gene, so I'm fasting for neural autophagy and it's very important to me.

How does the lime juice affect the neural autophagy and how do I navigate fasting with these two needs?" For the autophagy, you generally want to be in that longer 30-hour window, 24 to 36-hour window for fasting.

The problem is that most stuff goes down during fasting, but uric acid can sometimes go up, and it's thought to be the reabsorption of some of the stuff from the urine which causes it to go up.

So lime juice, you know, is one of these sort of natural things that's supposed to help get rid of the acid and so on so that you don't reabsorb it so much, so maybe the uric acid doesn't go up as much.

It's possible that it works.

There's no harm in it, but it really doesn't affect the fast in in any way, right?

There's very, very few calories in it.

There's no real carbohydrates in it.

It's just a lot of citric acid.

But the acidity may be beneficial so that, you know, reabsorb so much of the uric acid perhaps and keep that down.

So yeah, I think the lime juice could work.

And then for the neuro part, just try and get in that 26, 30-hour sort of window for the autophagy.

I think that's probably as good as it goes.

If you're really worried, then I actually mostly advise people to do a mix of the longer and the shorter fasting, because you don't always know where your benefits come in from.

So there are a lot of studies on five-day fasst.

You know, we do the five-day modified fasts now in the Community, which I think is very, very beneficial.

But there's actually more evidence with that strategy in terms of all kinds of diseases like cancer.

I mean, of course, diabetes and metabolic disease, but in terms of aging, in terms of cancers, in terms of inflammatory diseases.

So that's why if you don't know where-- because, you know, the data is relatively new in fasting-- then it's probably beneficial to (in addition to the sort of daily fasts, you know, 24, 30 hours) every so often (as we're doing now in the Community) do the longer, five-day modified fast to make sure that we're getting any benefits of the longer fast as opposed to the shorter fast.

And the longer ones don't have to be zero calories.

They don't have to be zero.

They can be like, you know, 500 calories.

You're still going to get a lot of the benefits.

So, because-- if you're worried about the Alzheimer's, the APOE 4-4, and stuff, then you probably want to do a mix so that you're getting-- to be sure that you're getting any benefits of both types.

Yes, and by the way, our five-day reset was a big hit in the Community, if you want to join us for that.

So this person says, "Are there any dangers to keeping your blood sugars in a consistently low range (50s, 60s and 70s) if you are having no symptoms of hypoglycemia?" There's no harm in it.

I mean, certainly 50s and 60s is-- if you're not eating a lot of carbohydrates, that can be just normal, right?

Some people are just very low, but there's no harm in keeping it down unless you're on medications.

If you're on medications, then you shouldn't really be keeping it that low, because then the worry is that you can actually push it too low and you can get hypoglycemic.

But no, there's no harm in doing it.

Is there any benefit?

I don't know that there is, but there's almost no studies pushing people that low for long periods of time.

All right.

This person says, "There are a lot of big groups on the internet now breaking fasts with watermelon and fruit juices.

How do you feel about breaking fast with these things?" Just doing the fast is good.

I mean, watermelon and fruit probably wouldn't be my sort of go-to options.

If you do it and you like it and it makes it enjoyable, sure.

Everything's a trade off, right, but carb-heavy foods is not really what I would go for.

If you think about what's happening during fasting, you're really trying to lower your insulin levels and your insulin goes down.

Your body's going to release energy.

It's going to either burn your fat or burn your sugar.

If you eat relatively low carb afterwards, then you're going to continue in that sort of fat-burning mode or ketosis.

If you immediately break it, spike up your insulin with a lot of sugary, simple carbohydrates sort of thing, well, you're going to stop any benefit dead in its tracks because then you're going to flip up your insulin to a higher level, which is going to put you into sort of a fat-storing mode, right?

Because as soon as insulin goes up, your body's like, "Hey, calories are coming in.

We need to store some of this for later." If you like it, though, and it makes everything good, then there's a tradeoff there.

So I'm not-- you know, I'm never really against anything if it works for you, right?

Because there's people who will swear that it's great.

And if that's what gets you through and keeps youdoing the fasting, then, hey, maybe that's what you need to do, but it wouldn't be my choice of what to eat afterwards.

I would tend to stick more with low carb and so on.

You have a great article on glycemic index versus glycemic load, so I know it has a high glycemic index but a very short glycemic load.

Now, if that leads to your advantage or not, I don't know because I think if I spiked my blood sugar like that, I would want more.

[laughs] So I don't know.

Yeah.

Certainly it's-- yeah.

I mean watermelon does that for me too because, you know, it's so-- you know I really love watermelon, so when I eat it I tend to keep eating it, right?

And luckily it's only in season for a very short time.

So you know, most of the year I don't eat watermelon because it's not very good, but you know...

I put it at the end of my meal like you suggest - carb order.

[laughter] Dr.

Fung has a very good video on carb order.

Well, thank you very much, Dr.

Fung, and I will see you next month.

Okay.

Thanks, guys.

[music]