An Open Letter to Dr. Dixit

Dear Dr. Jagannath Dixit,

Let me start by saying this with all due respect to you. I read your credentials and you are a teacher at a reputable medical college. I have great respect and admiration for people who spend their lives teaching and passing the baton of knowledge.

Since the last couple of weeks, I have been reading and hearing a lot about this 2-meal-a-day diet that you are proposing. While it is not wrong to propose something which you believe in, it is also important to understand your belief may not be completely true.

I will start by telling you why you are right and then go on to tell you why you are wrong. Again, I mean no disrespect, I just feel that the people have the right to know the other side of the story.

WHY YOU ARE RIGHT ?

You are right that two meals a day will cause weight loss. It will happen. It will happen in the same way in which if I fast, I will lose weight. Any form of caloric restriction produces weight loss and any form of caloric restriction will help control diabetes mellitus. So I am not surprised that people who follow what you have advised will surely lose weight.

I am happy that you are trying to publish research on what you are trying to propose. (http://www.ijclinicaltrials.com/index.php/ijct/article/download/44/37) This is the right way. It is always better to prove something with evidence rather than to propose theories out of the blue without any evidence to back it up.

WHY YOU ARE WRONG ?

It seems your understanding of the pathophysiology of type 2 diabetes is flawed. An increase in post-meal blood sugar is the earliest defect that occurs in Indian cohorts of diabetic patients. This is the reason why Oral glucose tolerance test (OGTT) is used as a sensitive test for the diagnosis of diabetes mellitus because it recognizes post-prandial hyperglycemia.

Larger meals mean larger insulin release, smaller meals mean smaller degree of release of insulin. Remember insulin release is logarithmic. Hence two large meals would infact cause more insulin release than multiple small meals a day. When combined with defect in insulin secretion, it would mean larger post-prandial glucose levels. What you are proposing is in-fact more detrimental to the human physiology than multiple small meals a day.

Increase in insulin resistance (both peripheral and hepatic insulin resistance) initiates the process leading to type 2 diabetes. To compensate for increased resistance, the beta cells produce more insulin which leads to the development of the typical acanthosis nigricans which you see in these patients. However, there comes a time when the beta cells cannot produce any insulin further and this is when the blood sugars start to rise. This is when you develop frank diabetes mellitus. At the time of diagnosis, a patient with type 2 diabetes has lost almost 50% of his insulin producing capacity. Hence though insulin resistance is the initial issue which initiates the disease process, it is relative insulin deficiency which leads to frank diabetes mellitus. Hence it doesn’t matter how many meals a day you eat, the body of a diabetic would be unable to produce adequate insulin to match the requirement. Larger and less frequent meals would exacerbate the defect compared to smaller and more frequent meals.

So pathophysiologically, your two-meal theory may in-fact be detrimental for a diabetic patient.

Now let us talk about Obesity. The human body is designed to maintain homeostasis. The hunger pathway and metabolism are adapted to the current caloric intake of the body. Hence those who attempt to lose or gain weight find it difficult because the body tends to resist change. Additionally, obese people have higher resting energy expenditure (REE). When they lose weight their REE also reduces hence they regain some of the weight they have lost. This is called as ‘Metabolic handicap’. The only way to beat this handicap is to increase the lean body mass while losing the fat. Hence losing weight is not important, it is important to lose fat while maintaining the muscle mass. Two-meals a day will cause weight loss just like any other caloric restriction mechanism. However, these people will eventually regain the weight.

Most of these people who have two meals a day, will eventually start consuming more calories in these two meals which was equivalent to what was available in three meals. This will make them regain the weight again.

WHAT IS WRONG WITH THE STUDY THAT YOU PUBLISHED?

The study you published is fascinating, however, it contains several flaws.

Sir, being a teacher in Community medicine you would be aware that any published result without a control group has little meaning. The fact that subjects in your study lost weight has no significance because it is not compared with a control group.

If I were to design a study for you, I would do design an open-label prospective study in the following way

a) I would divide the subjects into two groups.
b) The groups would be matched in terms of baseline characteristics
c) I would give the same calories to both the groups. Let us say 1600 Kcal.
d) Group 1 would receive 1600 Kcal divided into three meals while Group 2 would receive the same calories divided into two meals as proposed by you.
e) We would follow-up these patients and compare the weight they have lost.

This is the only way in which you say your theory is correct. An observational study published without a control group means nothing in today’s world of evidence-based medicine.

Finally, your article says and I quote, “Poor and ignorant people are being looted. This simple method of weight loss costs nothing, there is no requirement of a doctor and contrary to many other successful methods of weight loss, can be followed for a lifetime”. Such prejudice does not suit a scientific publication. You make bold statements about people being looted and there is no need for a doctor are unfortunately not true. Obese patients DO NEED a doctor and not only do they need a doctor they also need a good nutritionist or dietician and a physiotherapist or a trainer. Spending money on health is not ‘looting’ poor and ignorant people.

A FINAL WORD.

Dear Sir, again with due respect, I think activism and science should be kept separate. While you are in all rights to design a randomized control trial or any observational study to prove your point, you are NOT within your right to say that everyone apart from you is ‘Looting’ the public and a mere two meals a day would solve all the obesity and metabolic problems in the world.

Thank you.