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Endocrinologist William Hsu discusses his article, “Reimagining diabetes care with nutrition, not prescriptions.” William argues for a paradigm shift in treating Type 2 diabetes, moving away from a primary reliance on medications for symptom management towards a focus on achieving disease remission and regression through comprehensive, nutrition-based lifestyle interventions. He critiques the traditional model that often consigns patients to a lifelong battle with chronic illness and a heavy medication burden, emphasizing the need to address the root causes of the disease, such as insulin resistance and impaired pancreatic beta-cell function, while aiming for optimal body composition and tackling premature aging. William highlights programmatic approaches like the Fasting Mimicking Diet (FMD), used under medical and dietetic supervision, as a promising strategy that not only improves glucose levels and promotes fat-focused weight loss while preserving muscle mass but also fosters deeper cellular renewal and offers a sustainable, long-term plan. He advocates for a “triple bottom line” in diabetes care: achieving remission or regression, addressing underlying mechanisms, and enhancing longevity and quality of life, positioning nutrition-led programs as the new gold standard.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome William Hsu. He’s an endocrinologist. Today’s KevinMD article is “Reimagining diabetes care with nutrition, not prescriptions.” William, welcome to the show.

William Hsu: Thank you, Kevin. Fantastic to be on your show.

Kevin Pho: So tell us a little bit about your story and then tell us about the article that you wrote on KevinMD.

William Hsu: I’ve been in research, in clinical care for over 25 years. And throughout the journey, I’ve always been asking the question: how can we push the envelope? How can we improve diabetes care? So having been a faculty at Harvard Medical School and researching and also taking care of patients at Joslin Diabetes Center in Boston, I’ve been exposed to a lot of new thinking around diabetes.

But something still stuck with me. It continued to strike me: the fact that we continue to rely on medications as the only way for these age and chronic related conditions continues to bug me, and that’s what gave me the incentive to start this article.

Kevin Pho: So tell us about the article itself, “Reimagining diabetes care with nutrition, not prescriptions.” What’s it about for those who didn’t get a chance to read it yet?

William Hsu: It’s really about rethinking what it should be because we are all influenced by our past, our history, our training, our environment. And so as a physician trained in Western medicine, and who teaches Western medicine and practices Western medicine, the question’s always: Sure, we believe in nutrition, and every doctor will tell you they believe in nutrition. But after 30 seconds, let’s talk about what medication you should be on. That’s always the paradigm. I taught it to the medical students, I taught it to my residents, to my fellows.

And when you ask why that is, it’s clearly not because we don’t believe in nutrition. Every study shows nutrition works, but the problem is: everyday commitment to a lifestyle change, to a dietary pattern, is great in studies, but in real life, it’s too hard to do. And therefore we need new solutions. And that’s why in the article, I invited the readers to imagine what the new paradigm should look like.

Kevin Pho: So I’m a primary care internal medicine physician, and everything that you said is right. We always pay lip service to nutrition. We send people to dietitians. So, you’re obviously at the Joslin; you’re an endocrinologist. Tell me, what are some of the barriers that you see that contrast real life from what you see in studies? What are patients telling you?

William Hsu: This is the typical experience. A patient comes to me, they see me, maybe because they like me or maybe not. They would always say, “Sure, doctor, I will do this.” You motivate them. They say, “Yes, I’ll go back to the gym. I’ll eat better. I’ll lose weight.” That motivation, I think, begins to drop the day after. And a week later, they already forgot their promise to you. A month later, the results are not impressive. And so this is when study efficacy versus real-world effectiveness—these things really don’t jell together because in real life, many other things occupy our attention. The will is there, but the ability to execute it is not.

So think about every piece of nutrition advice we ever heard from our dietitian, from our specialist—like myself, an endocrinologist—is that you have to eat better, right? You have to eat less; you have to choose the right food. And now with the new concept, you also have to eat at the right timing. So that’s the new dimension. But if we could really imagine that everybody can now all of a sudden become a saint when they were, quote-unquote, “sinner,” if you will. I certainly don’t mean to sound derogatory, but if you could not have followed the right diet for the last 20 or 30 years, how can you imagine our patients to all of a sudden be empowered to do the same thing, be a saint every single day? This is why most of us just say, “Well, I’m going to go to medications.”

And this is also why now when you look at somebody living with type two diabetes, on average they’re taking six medicines. Diabetes medicine (two or three), blood pressure medicine, aspirin, cholesterol medicine—now we become a pharmacy. And because we also do not address the root cause of these problems, we are just treating the numbers: we’re treating the cholesterol number, we’re treating the blood pressure numbers, we’re treating the glucose numbers. I’m not saying that those are not important. They will save lives, but it also results in a couple of things.

Number one: chronic illness becomes truly chronic illness; instead of a death sentence, now it becomes a life sentence. Now you are committed. You’re married to a pharmacy for the rest of your lives. Number two: when you keep addressing the symptoms and you don’t really address the root cause, then there will, there will be a cure. There will never be a remission. That will always be chronic diseases. And those are the things I really want to invite us to reimagine.

Kevin Pho: So, just give us a scope. Let’s say, how successful are you at getting people to fundamentally change a diet? Just give us a ballpark percentage. Are we talking about one in 10, 10 percent, half? Just how successful are you in terms of getting long-term lifestyle diet changes in these patients that you see?

William Hsu: I think one number tells us: every year we continue to see about a million new cases of diabetes in the U.S. Every year we’re seeing more. Every year now, we’re talking about over a 70 percent overweight or obese rate in the U.S. It’s not slowing down, so we’re not doing well at all. We’re talking about probably, I don’t know, 3 percent, 5 percent. And these numbers are continuing to grow, telling us that we as a society cannot implement all the things in the brain.

I’ll tell you, Kevin, you and I are both physicians, and whenever I walk into a medical office now, what do we see? We see heavy physicians. We see people. Our office staff are also struggling with weight. Why is it? Is it because of the lack of knowledge? Of course not. It’s the environment. It’s too difficult to go into all the socioeconomic and the macro industry that has made us continue to be heavy. But the reality is we’re losing the battle.

Kevin Pho: So you talk about reimagining the paradigm when it comes to that connection between diet and diabetes. So tell us what you’re talking about.

William Hsu: I think we have to work backwards. In other words, what is the end goal for these diabetes, for these metabolic diseases such as obesity and diabetes? It cannot simply be a better number. It has to be because if you start with better numbers, then all you want to do is give me the tools that can get the numbers down. A couple of years ago, about four years ago, the American Diabetes Association, the Endocrine Society, and then UK Diabetes and EASD—these European groups—got together and redefined a term called type two diabetes remission.

Now that’s a term that’s borrowed from the cancer world. You think about oncology: you don’t talk about cure; you talk about remission. So the experts around the world got together and said, “We really need to reimagine a new end goal that is not just MOG GLO one A1C lower than a certain number”—that’s a glucose metric—”but rather a state where your A1C number falls below the diabetic range for at least for three months without any use of medications.”

Now that’s step number one, because without the new goal, you can never begin to go there. Without a new end goal, you cannot work backwards. So the step one in reimagined diabetes care is calling all clinicians, calling all patients to say, “Hey, it’s a lifestyle-driven disease. We can now at least set the goal to get diabetes under remission.” Not a cure, because we don’t understand all the pathophysiology of what led to type two diabetes, but at least we can get the numbers down without relying on medications.

The big battle here is obviously we as clinicians, and we all as patients and communities, trust our medications as the go-to. Doctors, as we said, pay lip service for 30 seconds on nutrition, and then, “Let me give you GLP-1s. Let me give you other types of drugs.” We’ve been trained to do that. But this reimagining has to start with a new vision of what we can achieve.

Kevin Pho: OK. So what’s the next step? How do we achieve that goal?

William Hsu: Number two is that we need to then address the root cause of what we’re talking about. What are the root causes? Well, it’s because of central obesity; it’s because of incessant eating patterns, insulin resistance. And we have to begin not just to give a prescription and say, “You could do whatever you want, but just take this medicine,” but begin to address them.

Clearly, now we’re running into a contradiction. We just said that you cannot do it every single day, change your lifestyle. But still, that becomes the crux of what we need to do. This is where innovation needs to come in. We talk about lifestyle medicine as the fundamental things, for example: better sleep, more exercise, eat better, better community, reduce your stress, and avoid harmful substances. These are pillars of lifestyle medicine. We understand them.

But money and investment and research have to now begin to think about how do we bypass some of these burdens of carrying out lifestyle changes. We’re in the 21st century. Some of that money going to drugs should be put into innovations in lifestyle medicine. Are there shortcuts? How do we really change behavior from an easier perspective, rather than just say by brute force, by sheer willpower, you have to do this.

Kevin Pho: So what are some examples of perhaps some of these innovations that you’re talking about when it comes to non-pharmacologic interventions?

William Hsu: About six years ago, I stumbled across a number of research projects and publications focusing on, for example, the idea of fasting. Fasting, but not in the traditional sense of willpower. Let’s bear it through five days of water-only fast. But the idea of a fasting-mimicking diet. Now, as the name suggests, it mimics a diet but actually gives nutrition.

It’s after 25 years of research by a research scientist by the name of Valter Longo at the University of Southern California: $36 million of NIH funding to figure out what actually happens on the cellular level. When you eat, it turns out that cells have these ears and eyes that sense nutrients coming through. And there are certain pathways you activate by each of the nutrients. But each of these nutrient sensors also has a threshold. Much like the thermostat, if you don’t hit a certain kind of temperature, it doesn’t trigger your air conditioner.

And the idea of how do you give nutrition right below the threshold of these nutrient-sensing pathways so you can actually hack the system, if you will, provide nutrients while providing the effects of fasting. This is what I mean by innovation in lifestyle medicine, where we know the lifestyle changes. Lifestyle interventions such as fasting for a long time could be helpful, but they also come with a lot of burdens and a lot of safety issues. So the fasting-mimicking diet is one, but many other innovations that shortcut these challenges to a commitment to a lifestyle change for life but still drive tremendous results.

Kevin Pho: So what exactly is that? What is a fasting-mimicking diet?

William Hsu: It’s a five-day structured meal plan that basically is designed to fly under the radar like a stealth plane, if you will, that won’t be detected by the radars of your cells. Now there are more than 47 clinical trials that have demonstrated or are in the process of demonstrating effectiveness. And I’ll give you one example: a paper that was published in JCEM about four years ago, looking at five days of this fasting-mimicking diet meal. It’s nutrition.

Just five days alone, while people went back to eating normally for the remaining 25 days, and repeated this for six months—a total of five times, so 30 days of intervention—compared to a control arm that just continued with their normal diet, still. For example, the A1C drop was 1.4. That’s respectable. Twenty-two pounds of weight loss without sacrificing muscle. That’s unique. That’s different than a drug. A 59 percent reduction in insulin resistance that treats the root cause of diabetes. And the most differentiated feature is that 67 percent—we’re talking about two-thirds of people in the study—were able to reduce their medications in diabetes.

So think about that. Do you have five days you could give per month? I bet you can. When I was in research and in clinical practice, you ask people, “Can you do a good diet every day for 30 days?” Everybody says yes, but the reality is very few people could do it. But if you ask them, “Can you do it for five days?” Almost everybody says yes. For my health, to reduce my medications, to improve my outcomes, I could do five days. That’s what I call innovation in medicine.

Kevin Pho: So for those five days per month, what does that look like for the patient? What can the patient expect? Any effects because of these low-calorie intakes? So what exactly would a patient feel during those five days?

William Hsu: It is the stress onto the body because it’s the stress that forces the cell to say, “My goodness, there’s no food coming in, so I need to rejuvenate. I need to do something.” And in fact, what happens is the cells begin to digest parts of the cellular organelles: older mitochondria, misfolded protein. This process is so critical it actually won the Nobel Prize in 2016, called cellular autophagy. Professor Ohsumi won the Nobel Prize for describing that process. So we’re creating this artificial environment but still sneaking nutrients in there while causing the autophagy to happen.

So, obviously, if it’s the first time doing this, this is not the time you want to go run a marathon. This is the time to really allow the body to go through that intense stress, if you will—very guarded, well-designed stress to cause the cells to say, “Oh my goodness, I better chew up some things to keep me going.” But after the fast is over, it’s the refeeding time. This is when the cells then grow those old parts that it chewed up and return them, regrow them completely, thereby completing the cycles of cellular recycling or rejuvenation.

So, slow down, take it easy during the first time. These symptoms of hunger do get better with each cycle. I’ll give you another very potent lifestyle medicine intervention: exercise, for example, is able to benefit multiple organ systems in the body. How? Because it works on the entire system; it’s a lifestyle medicine, much like fasting, it works on the entire body system.

The first time you go to the gym, what happens? The next day you’re going to have soreness. And you’re going to say, “Oh my goodness, my muscle is torn apart.” It’s good for you because when you give it rest and give it nutrition, your muscle becomes stronger. You have more endurance, you have more strength, you have more flexibility. With this fasting-mimicking diet, the same thing happens the first time you experience it; it’s like a shock to the body. But each time when you do go through this, your body’s now able to use keto, use fat as a source of fuel. You become metabolically more flexible over time. So those feelings of discomfort do decrease and disappear over multiple cycles of the fasting-mimicking diet.

Kevin Pho: And how many monthly cycles would a patient have to go through, or how long does it take before they notice an appreciable subjective and objective difference?

William Hsu: So, there was a study published in Nature Communications, by the way, that last year was the number two most downloaded scientific article from that journal, that showed merely three cycles of the FMD—we call it the fasting-mimicking diet—lowers biological age by two and a half years. Wow. This was a study that was done by Yale, UCLA, and the University of Southern California. So it’s a very potent intervention on the cellular level that results in a reduction in biological age. So for health and for longevity and wellness, all you need is actually three cycles, according to the study.

Now, if you have a disease state such as diabetes and metabolic syndrome, and you’re going for health care reversal, I would always recommend that you talk to your doctor, be under the supervision of a doctor. Why? Because we know it will change the root cause of these conditions, where your medications, your requirement will decrease. And for safety, go through your doctor. We do have a program that pairs the doctor and dietitian together with the product. But obviously, you could also do this under the supervision of your own doctor.

Kevin Pho: And from a cost standpoint, what kind of cost impact is it going to have on a patient?

William Hsu: So, to me, it is almost cost-neutral. Why? For the five days that you are on this per month, you don’t buy groceries, you don’t go shop, you don’t go out to eat. I don’t know, Kevin, where you stay, how much per day your grocery is, but the product alone, if you will, is south of $200. And so we’re talking about $40 per day. OK. And which is almost cost-neutral. So $20 for those five days of the fasting-mimicking diet per month. That’s right. To me, it’s a swap. I live in Boston. It’s a swap. It’s cost-neutral, and it reduces your biological age. It reduces your visceral fat.

On the health care side, because now we are putting a lifestyle medicine board-certified physician, we are arranging a registered dietitian to support you every other week, twice a month for the course of that diabetes remission and regression, it’s south of $300, including also labs and lab monitoring, an app, but also the product, the suite of nutrition products, including the fasting-mimicking diet, south of $300.

Kevin Pho: And in general, how long do patients have to stay on this diet? You mentioned earlier, yes, you have to speak to the physician, but on average, how long do they stay on this diet?

William Hsu: We were informed by the clinical trials that we published in Metabolic Health. We generally recommend a six-month cycle, a six-month program for diabetes remission and regression. We’re talking about probably a 12-month journey to change the composition of the body, to rejuvenate and reprogram the cells, and so that you get to a stage where you rely less on medications over the course of 12 months.

Kevin Pho: We’re talking to William Hsu. He’s an endocrinologist. Today’s KevinMD article is “Reimagining diabetes care with nutrition, not prescriptions.” William, let’s end with some take-home messages you want to leave with the KevinMD audience.

William Hsu: I think for a long time we believe that change in our lifestyle is fundamental to our health, and I still believe that. But now we live in the 21st century. There are now new innovations such as the fasting-mimicking diet that can help hack, circumvent, and still get the benefits of these long-term lifestyle changes with much easier interventions. This is where medicine should head, and I invite you to look into it.

Kevin Pho: William, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

William Hsu: Thank you, Kevin.