So about refeeding syndrome. Friend of mine had it. He didn't even fast, just lost weight doing a calorie-restricted diet, which was very successful for him. But one night he was playing with his band and passed out. He was rushed to the hospital via ambulance and admitted to the ICU for IV electrolyte replacement. He nearly died.
Guess how supportive his family and friends are of his dieting now? *Everyone* tries to overfeed him and worries he is too skinny. Last photo I saw, he just looked normal to me, but I advised him to up his protein and work out a bit so he could increase weight without putting on fat and get folks off his back.
Basically, his attempt to lose weight nearly killed him, so he is vaguely suspected of having an eating disorder. And he sure isn't winning converts to his way of eating.
Here's what happened to him... and it's what happens to folks who have starved for a while and sometimes even when fasting. While fasting is significantly different from starvation, in that choice is involved, biochemically it tends to be the same. Your cells don't know *why* your insulin drops, just that it has.
So we have electrolytes in our blood serum, and we have more in our cells. We need certain amounts of electrolytes (NOT just sodium, but also potassium, magnesium, phosphate, bicarbonate, chloride, etc.) in our blood in order for our heart to keep beating. Given that this is pretty much required for life to continue, our bodies have methods of dealing with this. If levels get too high, the cells absorb more from the serum, and later when they get too low, they release them back into the blood.
This works well as long as you have plenty of electrolytes in your cells, it's sort of the "bank" where you deposit extra and then can withdraw later. But if your bank balance is very low, you can get screwed if you want to make a withdrawal.
During fasting, we lose lots of electrolytes and our bank balance can get low. This is why Anna and I nag about electrolytes regularly. Sure sodium loss can cause lots of symptoms of "keto flu" to be avoided, and most electrolyte drinks contain copious amounts of sodium to make people feel better right away.
But there's more to electrolytes than that. Taking sodium can make you feel better now, but it's kind of like buying a homeless guy lunch; you feed him today, but you're not increasing his bank balance. He needs that lunch, but he also needs a job for the long term.
When we nag about wanting you to take sodium, potassium *and* magnesium, we're trying to not only provide electrolytes in your blood today, but build up your bank balance in the cells as well. The advice to break a fast with bone broth is also great advice because bones are a great source of phosphorous. The RBS is actually an excellent source of potassium, as greens tend to be very high in potassium.
Most of us don't know what our bank balance is wrt electrolytes. Typically, when bloodwork is done, it just tests the serum level of electrolytes, which is an extremely fleeting measure, and could very well be different in a half hour! It's like checking your wallet while you're shopping at the mall or a flea market with cash; it can change a lot very rapidly.
To know what is "in the bank", so to speak, we have to do a test of what's inside the cells. Basically, they still take blood, but they separate the red blood cells from the serum, lyse the cells to open them, and then measure what's inside. This is called an rbc test and it's really the only way to know what's really going on... and whether you're at risk for refeeding syndrome.
There is a *reason* you have to eat very nutritionally dense food when you break your fast and it's not just because it's "good" for you, but to replenish nutrients you missed. There's a reason you have to break carefully and slowly, and it's not just because you might have GI distress if you don't, but because you *literally* could die.
It sounds like I'm being over-the-top, but I'm not. People *have* literally died from refeeding syndrome. My friend came pretty close.
This is what happens: when we fast, our insulin levels go low and we get most of our energy from fat; and usually we consider this a good thing as insulin resistance reduces and fat loss occurs. And if our edema resolves, our hypertension decreases, inches of water come off our body, that's all a good thing too.
But we're losing electrolytes with all that water. And because our bodies want the heart to keep beating, the cells release a lot of electrolytes into the blood. It's as if you used up your cash at the mall, but wanted to keep spending, so pulled out a debit card. Now your bank balance is getting low.
So... now when you eat again, your insulin raises, and this tells the cells we're in "growth" mode and the body needs all these electrolytes to synthesize glycogen, proteins etc. and... the cells pull those out of the blood stream. And that can cause refeeding syndrome.
A partial description from https://en.wikipedia.org/wiki/Refeeding_syndrome
"During refeeding, insulin secretion resumes in response to increased blood sugar, resulting in increased glycogen, fat and protein synthesis. Refeeding increases the basal metabolic rate. The process requires phosphates, magnesium and potassium which are already depleted, and the stores rapidly become used up. Formation of phosphorylated carbohydrate compounds in the liver and skeletal muscle depletes intracellular ATP and 2,3-diphosphoglycerate in red blood cells, leading to cellular dysfunction and inadequate oxygen delivery to the body's organs. Intracellular movement of electrolytes occurs along with a fall in the serum electrolytes, including phosphorus and magnesium. Levels of serum glucose may rise, and B1 vitamin thiamine may fall. Abnormal heart rhythms are the most common cause of death from refeeding syndrome, with other significant risks including confusion, coma and convulsions and cardiac failure."
I'm pretty sure most of us would agree Dr. Fung is an expert at fasting, if not *the* expert. And he says in the most extreme cases, obese diabetics that are on over 100 units insulin per day, he has them fast a week, and then come back and do bloodwork and check how they're doing, and if OK, has them go a second week.
The vast majority of doctors wouldn't even *know* to check your "bank balance." I had an excellent endo and a pretty good cardiologist, and as far as I can tell, most of what they know about fasting, they learned from me. My PCP had never even heard of autophagy, he retired and I got a new one who "heard of Dr. Fung from some of her students." These are good doctors I like and trust about a lot of things, but I absolutely would not trust them to supervise a fast like Dr. Fung. They simply don't have enough knowledge about fasting to do so.
Saying you're fasting for longer than a week because your doctor said it was OK isn't useful unless your doctor thoroughly understands the biochemistry of fasting. In the vast majority of cases, I seriously doubt it as it's not taught in medical school, they have to have a specific interest and study it.
There are fasting clinics where experts monitor folks doing longer fasts, often providing infusions, and I expect most of them know how to monitor longer fasts safely as well. But for us mere mortals who don't have thousands of dollars to be properly and safely monitored (checking pockets), in order to do this safely, we need to stick to the one-week rule, be wise about electrolyte intake, break our fasts gently, and refuel with serious nutrition before we do it again.
We got this way, fat, weak and sick, by overdoing the nutrition. Since many of us are excessive people, when we hit upon fasting, our tendency is to overdo it in the opposite direction.
But I'm going to say something controversial here: THE GOAL IS NOT TO LOSE WEIGHT!
Cause ya know, you're going to weigh a HELL of a lot less 6 months after you're dead, but what good is that going to do you?
The goal is to become trim, strong and healthy and STAY that way as long as humanly possible. To succeed in maintenance, we need to have some idea about how to eat for that and build the habits that will sustain us for the long term.
Fasting is not for the long-term. OMAD or TMAD might be, but not extended fasting. We have to eat. And to build trim, strong and healthy bodies, we have to eat *well.*
There's many *reasons* the RBS is brilliant, especially when used with a wide variety of both plant and animal foods as it's extremely nutritionally-dense. Obviously, people have to adapt to whatever their needs and limitations are; it's not a one-size-fits-all type of thing.
But I'm in this for the long haul, not for the next week or month or year.
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