The Dr. Hyman Show - The Power of a Ketogenic Diet to Reverse Disease with Dr. Sarah Hallberg

Episode Date: September 5, 2018

Dr. Sarah Hallberg is a diabetes expert, who is here to change the way we treat diabetes. Her number one weapon for reversing type 2 diabetes: a ketogenic diet. Dr. Hallberg is a Medical Director at Virta Health and a Fellow of the Aspen Institute’s Health Innovator Fellowship and a member of the Aspen Global Leadership Network. She is also the Medical Director and founder of the Medically Supervised Weight Loss Program at Indiana University Health Arnett and an adjunct Professor of Clinical Medicine at the Indiana University School of Medicine. Dr. Hallberg is serving as Chair of the Board of Directors and Chair of the Scientific Advisory Council for The Nutrition Coalition. Dr. Hallberg is a diplomate of the American Board of Internal Medicine, American Board of Obesity Medicine, and The American Board of Clinical Lipidology and is a Registered Exercise Physiologist by the ACSM. She is also a Fellow of the Obesity Medicine Association and The National Lipid Association. In this episode, Dr. Hallberg shares the benefits of a high fat, or ketogenic, diet. You may have heard that a ketogenic diet can be beneficial for your health—that it promotes weight loss, longevity, and enhanced cognitive function—and wondered if the hype is true. Tune into this week’s episode to find out.

So welcome Sarah Halberg. You are an extraordinary physician who's embarked on something that is pretty much heresy. Oh yes, that's right. Well, thank you first of all for having me today. I appreciate it. And your heresy is that we have believed forever that type 2 diabetes is a chronic progressive incurable disease that has to be managed and what that means is more and more medications over time and then insulin and then hopefully you know prevent complications but often it still is a terrible fatal disease and you you have suggested and not only suggested but seemingly proven that type 2 diabetes is a terrible fatal disease. And you have suggested, and not only suggested, but seemingly proven that type 2 diabetes is a reversible disease, which is complete heresy in the medical world.

Right, that's right. But I think it's becoming less heresy as we move on and the data become even more robust. So, you know, first I'll go back to that original idea of it being a chronic and progressive disease and just how terrible it is that that has been pushed out, not only on Americans, but the globe for a very long time. You know, you get this disease and there's nothing you can do about it.

No going back. There's no going back. And, you know, that paralyzes people. It takes away their hope and it takes away their control. And so, you know, as we move forward to looking how we can touch and reach more people, the idea of just allowing people the knowledge that this is something you can reverse. You can back out of type 2 diabetes. It empowers people.

It motivates them. And we just need to at least agree and embark on that very first step. Number one, reversal is possible. There are several ways to do it. You need to choose the one that's best for you. But most importantly, the idea of reversal is a discussion that needs to be had with every patient who struggles with type two diabetes and their healthcare provider. And that's a radical idea. So Sarah, how did you come to this? You're a physician. You practice family medicine, internal medicine? Internal medicine, correct.

And what was the aha for you? Because you got the same training as the rest of us. I did. I did. And actually, you know what? I was a Dean Ornish's number one fan in medical school. Right? I was, you know, never touched red meat.

I was close to a vegetarian. You know, was doing quote unquote everything right, you know, exercising every day. And because my background is actually as an exercise physiologist, I have a master's degree in that. And I'm actually registered clinical exercise physiologist by the ACSM. So the preventative, the preventative, um, uh, prevention is in my background. Um, and was something I was always interested in. And I wound up doing, uh, primary care as an internal medicine physician. Um, again, preaching what everyone taught me, right. Which is low fat is the way to go. And I was frustrated. To lose weight and to prevent heart disease. Yeah. Just,

just for everything. It was the way to do it. It was just, to prevent heart disease. Yeah, just for everything. It was the way to do it. It was just, there was, it was universal, right? You have any problem, low fat diet, right? Exercise more. And it was depressing, right? It was depressing to be in primary care. I have so many memories of coming home and my poor husband having to listen to me, as I told him, I am part of the problem. I am doing nothing to back us out of this state of our country. I just, all I do is prescribe medications. And quite frankly, it was, it was demoralizing to me professionally.

Yeah, we're basically pharmaceutical. I was a drug dealer. Drug dealer. I was a legal drug dealer. That is exactly what I did. And so I was really fortunate that because of my background in exercise physiology and preventative medicine, when IU wanted to open an obesity program, they came to me and asked me to do it. And I jumped at it. I was like, oh yes, heck yes. So I spent a year, an entire year, literally with my nose in the literature, because what I was really being asked to do was solve the unsolvable problem,

right? Obesity. We all know it can't be solved. And so spent a year reviewing the literature and was shocked, was really shocked when I did that to find there's no evidence for the low-fat diet. Hold the phone. What is going on? So the party line and the science just didn't match up. Didn't match up. And so I really realized that the best data existed for a low-carb approach, and that's how we opened the clinic. Because we built it from scratch and it opened as a low carb-

This is in Indiana. This is in Indiana, right? Lafayette, Indiana. And we opened it from scratch as a low carb clinic. And so that was a big change and a pivot from the standard of care. But we really quickly had another pivot because it was overnight that we

realized, wait a minute, people are losing weight, but the bigger issue is that they don't have diabetes anymore. And this was happening instantaneously. Like within a week, people come off of hundreds of units of insulin. It was crazy. Yeah. And back to the books I went, okay, who's doing this? Where is this happening? Where is this in the guidelines? And, you know, a big fat nothing. Yeah. You know, you get the cricket in the back of the room, right? Like this was not happening with some, you, as you know, notable exceptions. Um, and so I got angry. I was really angry because, you know, seeing people whose lives have been transformed with your advice. I mean, it's not me who did it. My patients deserve all the credit and did the work. But it was on advice that we were giving them is incredibly motivating. Right. And I tell you, it's what gets me up every day and i wanted to see this change there was no reason that this should only be able uh to be given to the patients who are coming to my clinic this is something that

everyone needed so when you say low carb what do you mean so i started out with under 50 grams a day generally speaking um and since then for patients with type 2 diabetes have lowered to at least an initial starting of under 30 total grams a day we don't use net carbs we use total carbs um so if you add a lot of uh psyllium to your wonder bread it doesn't work no that's right that's right because because i would say that the number one important thing about what we do is that it's a whole foods based diet. So. Does that mean no vegetables? No, I would consider vegetables. Because those are carbs, right?

Well, exactly. But you can do a lot of non-starchy vegetables and still stick under 30 grams. So you could have three cups of broccoli? Absolutely. Absolutely, absolutely. But you want to make sure you butter the heck out of them, right? Or put olive oil on them or something. See, I think it's actually a high carb diet by volume, right? And I suppose that's a way to look at it, right? Maybe that would be less intimidating. Right, you're eating a high carb diet. A high carb by volume, I like that. I always say it's basically by calories, it's high in fat. By volume, it's high in carbs. I like that.

I'm going to use that. Please do. Can I? Please do, because it is an act. I mean, I might be actually, carbs are probably among the most important foods we eat, which are plant foods and specific plant foods that are non-starchy vegetables. Yes. Yes. I mean, we definitely, I mean, we encourage five servings of non-starchy vegetables a day and people say, well, wait a minute, you know, you can't do that. But as I just said, yes, you can, right. You can do that and

still stick, um, with your carb limit. Uh, it's not that difficult actually so because of the major results that we were seeing with diabetes i pivoted into research and this is in atkins which is high protein no absolutely and the problem with protein is it turns to sugar if you eat more than you need for your protein correct yeah correct so this is a low carb high fat fat, moderate protein, whole foods intervention. And so. Sounds yummy. It is. That's right.

You know, and it's funny because people say, oh, I just couldn't do that. I can't give up my bread. And my first response to that always is the same. It's spoken like someone who's never given up bread. Because wait until you taste bacon cooked uh brussels sprouts or some of the things i saw someone made a macadamia keto bread the other day and i thought it was really good i mean you can do so much with a whole foods low carb high fat uh meal plan i mean the diversity uh can be immense and which is great and important because then it can reach across other cultures as well

right so it can work with our kind of standard american fare but we can also modify things for different cultural backgrounds as well that can still stick with the same premise low carb high fat moderate protein so is that keto or are we talking about some variation of that? No, it winds up being a ketogenic diet, meaning that the way that we do our macronutrients are very specifically and intentionally to get people into nutritional ketosis. That means you have to measure their blood level with a finger stick and it has to be over 0.5, 0.3. Well, yes, we're not 100% sure.

Like we are still trying to work out what is the best level because we had initially always been going for 0.5 millimole of beta hydroxybutyrate. And I still think overall that's our general goal. But, you know, what we kind of see is that it looks like some other people can do just fine and still reverse their type 2 diabetes, lose weight, feel good, maybe even a little less than that. And I think that there's going to be so much more in the next few years that we learn about beta-hydroxybutyrate. I mean, we've already, just in the last few years, increased our knowledge of this remarkable hormone, really, in our body. And I think that we're going to learn more what other potential benefits outside of just type 2 diabetes reversal from having elevated ketones. And so, in a sense, what you're kind of saying is that type 2 diabetes is a disease of carbohydrate intolerance.

It absolutely is a disease of carbohydrate intolerance, yes. And that affects a lot of people. What about people who are overweight who don't have diabetes? Are they also insulin resistant? Oftentimes, not 100%, right? And again, it goes back to treating everyone individually. But I think just recently, there have been a couple of studies that have come out that said, you know, we had this idea for a very long time that you could be fit and fat, right?

Yeah, what about that? That was like a big, you know... Sounds like, you know, my mom said, if it sounds too good to be true, it probably is. Right, right. Is that true? Is that true for this? Yeah, I think that the longer termterm studies are panning that out, that maybe they're in a honeymoon period, right,

where they're still metabolically healthy, but that eventually it catches up with them. And what we get into is issues with metabolic health, then prediabetes and into type 2 diabetes. So we need to be dealing with this, and we need to be dealing with this and we need to be dealing with this as early as possible. So early as possible in each individual case, you know, the quicker we let people know you have a diagnosis of prediabetes, this is what you need to do to reverse out of that

condition, easier it's going to be for them. Do they need to be keto too or they could get rid of it with more milder changes? Yeah, I think early on people don do they need to be keto too or they could get rid of it with more milder changes yeah i think early on people don't necessarily have to be in nutritional ketosis and that's again one of those things i think with ketone bodies that we're going to be working out in a few years who need to do that who can benefit even if they're not producing um higher levels of beta hydroxybutyrate you you know, it's just a little bit above normal, okay, for some. I mean, I think the answer is likely yes, but we don't know the exact on that yet.

So it's sort of what Benjamin Franklin said, you know, an ounce of prevention is worth a pound of cure. So by the time you have type 2 diabetes, you need the pound of cure. Right. That's right. That's right. And can we avoid that, right? By catching people earlier. I mean, can these people, once you sort of reverse the type 2 diabetes and they get healthy and they're more metabolically resilient, can they

start to eat more carbohydrates? So the term I like to use for that is metabolic flexibility, right? And so when someone starts, we don't really know if they're going to regain some metabolic flexibility but i will tell you that many people do and meaning that even say they reverse their type 2 diabetes with under 30 total grams of carbs a day they regain some metabolic flexibility and they can go up from there now that doesn't mean they're going to go back to 200 carbs a day because this is a reversal this is not a cure you go back to the way you were eating it's going to come right back um but it doesn't mean necessarily that you couldn't increase it to some degree and it's not only how much we increase it but what we increase it with so someone has managed to reverse their type 2 diabetes

less than 30 grams a day they want to add some so they add 30 grams of sugar you know bad idea right what are those 30 grams what do we want to be aiming for sweet potato maybe i mean or or berries you know that would be another one more nuts nuts in their diet, things like that. So we have to be cautious how much we add back in and we have to be cautious of what the composition is that we add back in. But what we find is that many people can regain some metabolic flexibility and the people who can't generally, who don't regain that metabolic flexibility, that's because they really don't have the beta cell function. Beta cells are the cells of our pancreas that produce insulin. And the longer you've had type 2 diabetes, the more likely you are to have beta cell burnout, really. And that creates a condition called insulinopenia.

And you can't recover that? And well, you know, I believe that many of our patients start out with significant insulinopenia and some of them regain some of it and some of them don't. And this brings up a whole nother research question that's really important, which is, you know, how quickly do we have to get to people? What are the characteristics of people who will regain more function than others? And we don't have the answers to that yet, you know, but depending on how much insulin your body is still able to make is going to be a big determinant in what your eventual metabolic flexibility is going to be.

Yeah, it's pretty profound what you said earlier, which is that you have people in a week getting off 100 units of insulin. I mean, that sounds insane, right? And if you tell physicians who have never seen this for themselves, they're likely to not believe you. Yeah. But it's so profound. And it's not just like this.

We see it routinely in clinic and in my practice. I've seen it. It's amazing. It's amazing. And it's amazing and it's not something that's just this oh once in a thousand patients this is a regular occurrence you take carbohydrates away which truly are what is driving right the root cause of this problem and it literally can resolve itself in a matter of days to weeks. So I want to dig into this story a little bit more because you became part of a company

called Virta Health. Correct. And this company was started by a guy named Sammy, who was an elite athlete, used to row his boat from LA to Hawaii and went to the doctor and found out he had prediabetes. And he's like, what the heck? And he was having all those sports goos and gels and sugar basically and then he read a book by Steve Finney and Jeff Bullock the art of low carbohydrate living which I've read which was profound and he's like wait a minute this is wrong what I've been taught is

wrong and and started this company which I think is revolutionary in a number of ways one it actually provides a structured way for type 2 diabetes to be reversed using a ketogenic diet. It also is done virtually, meaning it kind of subverts the healthcare system. It disintermediates the healthcare system so that you're not really having to go to the doctor. In fact, if you went to the doctor and you did see the doctor every month, you probably wouldn't succeed. And the secret sauce seems to me to be the ongoing level of coaching support and the monitoring keeps patients accountable, connected,

and actually being able to succeed. And your level of adherence in this study that you did was 83%, meaning 83% of the people who were type 2 diabetics who did the study had their beta-hydroxybutyrate levels stay above 0.5 for the period of the study, which means they were actually doing it. It wasn't just like they were saying they were doing it. And you had a 60% of the types of diabetes reversed, 94% got lowered or off their insulin and 100% got off oral hypoglycemics. And the average weight loss was 12% body weight, which is a lot for a study.

That's like 30 pounds. A lot of weight. So that's not a typical weight loss study. There's like 5% everybody starts jumping up and down and getting excited, but 12% is massive. So I'd love you to tell us about that study and about Berta and also to sort of answer the question about why only 60%? If people were doing it right, why wasn't it 100%?

Great question. Well, first of all, yes, Sami's story is quite remarkable. And I love his story because you know when you start something that's going to be taking up a lot of your time that you're going to have your life wrapped up in for a while you need to be approaching it with passion and because of his story is you know he brings that passion like if this can happen to me this elite athlete who does everything right you know you look at the old advice of eat less and exercise more. I mean, Sami's point was, I cannot do that. That is

physically impossible. I am eating less and exercising more. And this is happening to me. You know, how is this presenting itself to all these other people? I mean, if this is unfair and ridiculous for me, I'm not alone. And so, you know, I just have to put a shout out for, you know, that where he sits with passion into this subject. And so then, yes, I agree. So with Virta, what we really have are two things that are the key. Number one is that we have the nutrition science right. So in addition to Sami, the other founders of the company were Dr. Jeff Bullock and Dr. Steve Finney, who have done decades of research into low-carb nutrition.

And they were doing keto before it was popular. Now every major diet book is out there as keto. Right, right, right. But they're really like the leaders in this field as far as the research goes. And so they were, again, helping make sure that the nutrition science that we're utilizing in the Virta treatment is the best that's out there. But you can tell people about the science and still not have them succeed, right?

And so Virta has a second big important aspect to it, which is the technology and the remote care piece. So you get the nutrition science right, you get the remote care technology piece right, and that remote care technology allows, as you already said, to really support a person. And it doesn't mean just from one angle, because when you're talking about a lifestyle change, so someone who's eaten bread their whole life, right, and is embarking on a really important lifestyle change for their health, you can't just give them support from one direction, right? You really have to surround a person with support because making a lifestyle change, let's face it, Mark, right? I mean, you know this, it's hard. And so not only do our patients have access to the app in the Virta treatment, they can put in their biomarkers directly into an app where they track things like their weight.

They step up onto a Virta scale every day. It automatically populates into their personal portal on the app. They track their blood pressure, they track their blood glucose, and their beta-hydroxybutyrate levels. Now, on the receiving end of that data is, of course, the person, the patient who can track and follow those things over time. But key is that the other people on the receiving end are that patient's individual health coach and physician. And so the health coach-patient interaction is happening all the time. Multiple times a day. Multiple times a day, correct.

And so a patient can be at a restaurant for the very first time, not sure what to order, and text their health coach right away. Send a picture of the menu. Send a picture of the menu. It can be done directly through the app, and the health coach can walk them through it right then and there. And the other thing is the... Skip the pasta and the ice cream. That's right. That's right. But you know, honestly, the first time you go into a restaurant, you're trying to do things right with a new lifestyle. That can be intimidating. Sure. Right.

But you also know and you have developed this relationship with a health coach right on the other end of the phone that you can feel confident is going to give you the support and information needed to make the right choice. And the other person at the receiving end of all that data is going to be the physician. And the reason that that is key is that we want people to make sustainable lifestyle changes safely. And we take patients who have longstanding type 2 diabetes all the time, who are on multiple medications, including insulin. And if you remove carbohydrates and don't adjust the insulin, they'll be in a coma. That's right. I mean, they can really get themselves into trouble quickly. So safety is our number one priority. What do you do? You take them off the oral hypoglycemics and the insulin and just run them a little high? So we make adjustments before they begin. So depending on what their medications are,

we definitely decrease or eliminate even before they make dietary changes. But then we're really on them for the first days to weeks, depending on what their blood sugars look like. So yes, I would say that patients don't run under 100 in the first days to weeks if they're on a lot of medications, because we want to make sure that they're adjusted down gradually and safely um but again as we already talked about 100 units in a week you can be off those medications really quickly and then that becomes less of an issue but someone who knows what they're doing in the de-prescribing world needs to be involved and that's like a whole new lingo right right? Because physicians, I mean, we all were taught how to prescribe medications in medical school, right?

Not how to un-prescribe them. But we were taught how to un-prescribe them. And so I would say that de-prescribing is actually an art and a science as well. And so, you know, the patient then has their biomarkers, they have the support of their health coach, they have the safety, and they can feel that, of knowing their physician is watching them and assuring that their blood sugars are going to be coming down appropriately. And as part of this, they never see the doctor or the health coach. It's all done virtually. Correct. Well, they may see them, but it would be on a virtual platform, right? So, and then in addition to that, patients are also given access to a huge resource center. So, you know, they can have recipes there for what

to bring to a 4th of July cookout, right? Or, you know, if they have 10 minutes, they could watch a bit on cholesterol and what it means. So we want to educate our patients. I mean, that's really critical. You don't want to tell someone what to do. You want to educate our patients i mean that's really critical you don't want to tell someone what to do you want to explain to them why what we're saying makes sense so that resource center is key to patient education and of course patient convenience when it comes to things like recipes and this is massively scalable because it's digital absolutely yeah which i bet you is the plan that's's right. I think, you know, I think that's the concern is how do you scale up because we've got so many diabetics and so much need and

how do you build it and how do you get reimbursement? It seems like, you know, you're going to start to have insurance companies and corporations pounding on your door. Correct. What's fascinating to me is that I think you have had some of that happen since you published a study. There has been interest from industry, from insurers, but there's been crickets from the medical community. It's just the most bizarre thing. I thought the study would come out. It's front page of the New York Times, Cover Time magazine, greatest breakthrough in science in 100 years, reversing diabetes, 60% of patients, getting them off insulin. But like there was one dinky newspaper in Detroit that picked it up under much duress. Right. So, you know, I mean, it goes to say that it's hard

to push back against the status quo because you're right. I mean, this is a landmark study, right? I mean, reversing a disease that we thought was not reversible in not just anecdotes here and there, right? But in a substantial, large clinical trial. And it just goes to show you that pushing back against the status quo is going to take some doing. I mean, and- So what does the American Diabetic Association guidelines tell us to do? So yeah, the American Diabetes Guideline Associations tell us again to eat a low-fat diet, which is completely counterproductive for someone with diabetes.

If you look through the guidelines, and I'll tell you I've just done a really deep dive into the American Diabetes Association guidelines, and what you find is, again, in these evidence, quote, air quote, evidence-based guidelines, that they're really lack of evidence-based guidelines. And they actually, when it comes to fat, for example, they quote the recommendations of the Institute of Medicine, which is 10 to 35 percent of your daily intake should be in fat in the institute of medicine if you go and look at where that came from all over the place is this is for healthy populations so here you have the advocacy group for patients with this terrible disease of type 2 diabetes that advocacy association is mixing up healthy people with metabolically ill patients. And I'm not so sure that's the right advice for healthy people either. Well, that's a whole other story. I totally agree with you on that.

But certainly, again, it's counterproductive for someone with type 2 diabetes. And it is going to guarantee them that they are going to have the status quo aggressive disease occur to them, right? Could it be that a lot of their funding is from the food industry? I think a lot of their funding is from the food industry and from the drug industry, right? And I mean, pharmaceutical companies have no interest in reversing type 2 diabetes. It would go against their business model. I remember being at a diabetes conference, a nutrition conference,

and I saw this giant poster and banner that said, cure for diabetes. And then I walked over and there was a bariatric surgery sort of promotion. And I was like, oh, okay. I would say what you're doing is sort of like and I was like oh okay yeah I would say you know this what you're doing is sort of like a gastric bypass without the pain of surgery vomiting and malnutrition right right without the long-term consequences of it right and and that's huge um and bariatric

surgery you know I'll say I'm not a huge fan of it for the majority of people every once in a while you get someone who chooses that route and that's their choice and that's fine. It is something that will reverse type 2 diabetes in many cases, but again- Within weeks, by the way. Within weeks, right. While they're still morbidly obese. So it's not the fat, it's the food.

Correct, correct. And so, but the majority of patients, especially when you hear about the long-term problems with bariatric surgery, you know, don't want to jump into that route. They'd rather attack it through whole foods. And so, again, that's what the Virta treatment offers. So, you know, it's reversing type 2 diabetes without the side effects of medications or surgery. And, again, it's been really efficacious. I mean, and so our clinical trial results are really important.

And I think that as we get into our two-year and beyond results, my guess is with the one-year results to kind of start us off, that we will be seeing more attention to some of the later results. Because the longer you go out, the more this is not a fluke, right? This is a large number of people who have been able to reverse their type 2 diabetes. People criticize the study and say it's not randomized, meaning people self-select into the study, they're motivated, they want to do it, whereas the average person may not. Well i i would i agree that is the criticism that it's getting but i'm going to push back on that and in many ways and i have

forcefully um because you cannot tell someone to um start a lifestyle that they're not interested in doing um self-selection when it comes to nutrition and trying to study long-term, self-selection is critical to this. I mean, this is, oh, you're going to take someone who is a vegan and tell them that they all of a sudden have to eat meat or someone who's a carnivore and tell them they have to be vegan and this is what they have to do for the long-term. I mean, people don't want to do that.

They want to have control of what the lifestyle choice choices that they make for their own personal reasons. And so that makes randomization of a long-term clinical trial. I mean, you could do a short one that way. You could randomize and have someone do something for three months. But to randomize them and not allow them to select their dietary intervention over the long term is not going to be successful you know people dismiss it as discrediting the study but that's kind of ridiculous because what you're doing is showing that people actually did the change that it actually created reversal right and you're testing a biological idea as opposed to, will people do what they don't want to do? That's a behavioral idea. So you're testing the biology. The behavior is another issue. How do

you bring people along who may not want to change? What are the drivers of social behavior? How do we rethink the drivers by building different models of peer support? Or, you know, you're more likely to be overweight if your friends overweight than if your parents overweight right so the data there is there on how our social networks drive our behavior and if all your friends are you know eating you know pasta and bread and chips and beer and watching TV then you're likely to be overweight if all your friends are going to yoga and drinking green juices and walking around with a yoga mat, you'd probably be healthier, right? Right. So, and I think that's key to the Virta treatment, right? That is key. It's one of

the things that we recognize and have built support for, right? Because you're absolutely right. You know, telling someone to do something and then having them go out into the real world, right, into their personal, you know, communities, their friends, their neighbors, their workplace, which is a big problem for people, you know, family gatherings, I mean, and their travel plans. You have to take all of these things into consideration. You have to have built a model to help support people, not just in one circumstances. Okay, well when you have the time to cook a home meal, you do okay, but forget everything else. No, you have to be able to reach them where they're at on every aspect of their life.

And so going back again to the kind of support that the Virta treatment gives them, once again we allow them to be tracking their biomarkers, give them a health coach, they have their own physician, they have the resource center, and they have an online peer support group. And that's fantastic because sometimes it really helps to be hearing from people who are going through the same thing you are. And so again, this can help them to touch all aspects of their life. You know, when someone who's doing fantastic has a life crisis come up, for example, we can't just leave them alone then, right? That's the time when they're struggling and they need the support even more. And so because of the way that we surround people with different

ways to give them support that can even be more fine-tuned when someone is having a crisis. That is just key to the sustainability and the long-term success, because this is not a diet, and that's really important. Like I always say, diet is a four-letter word. We don't do diets. We do lifestyle, and that that is critical and a lifestyle means that it doesn't matter what phase of your life you're in or what you happen to be doing that week that we can work this into the life you're living and not try to change that. Alright so let's go into the biology a bit. Well how does this work and you know how do you all of a sudden eat like 70% of your diet is fat and lose

weight and reverse your diabetes because it seems so counterintuitive right because that's supposed to make you fat and right supposed to be bad for your heart and yet you're seeing all the cardiovascular risk markers and the weight just kind of fall off right so you know it comes back to some really basic nutrition and insulin physiology. Basic biochemistry you all had in first year medical school, right? That's right. It turns out that does come in handy sometimes. The joke in medical school is, you know, you get through biochemistry and then you forget it all on purpose.

And you never look at it again. You cram the night before and then that's it. It's the most irrelevant class in your medical school training. Turns out it's the most relevant. It is. It is. And so, and I'll tell you that, you know, when you take a group of physicians, for example, get more into the specific biochemistry here in a minute, but when you take a group of physicians who have been like I was, you know, pushing a low fat diet, even for type two diabetes, and you just sit them down for 10 or 15 minutes and walk them through that basic physiology, I mean, physicians get it.

They're like, just hadn't had the time or the impetus to think about it yet. And when you explain it to them, you get this aha moment, like, well, that makes sense. Why are we doing it the other way again? And that's the response that we get. But so let's go back to that basic physiology. I mean, how does this eating fat make sense, right? When we've been told for decades to do the opposite. And it really comes down to understanding macronutrients and our body's response to them. I like to say everybody is

different. Personalization is key, but there are some human things that are the same. And our response to macronutrients are one of them. So we have three food macronutrients. That's proteins, carbohydrates, and fats. And when we consume them, we have very different physiologic reactions. When you consume carbohydrates, we have very different physiologic reactions. When you consume carbohydrates, your insulin levels go up and your blood glucose goes up. Not necessarily broccoli, but you mean starch and sugar. Well, yes, but even some with broccoli. I mean, it does go up with broccoli, clearly less.

You know what I mean? If you're taking 5 grams of broccoli or 50 grams of broccoli and 50 grams of sugar, you're going to have very different blood sugar and insulin excursions. But even in the broccoli, it goes up. It's just not going to throw you out of whack. But carbohydrates cause our blood sugar and insulin to go up. Proteins, you know, not so much. But the important fact here is that fats don't cause a reaction. They don't cause blood sugar or insulin to go up. So again, if we go back to the root problem with type 2 diabetes, you don't all of a sudden wake up with type 2 diabetes.

There's actually a path to get there. And the first thing that occurs is insulin resistance. So our cells become resistant to insulin. And in order to make up for that, our body starts producing more insulin and more insulin and more insulin so that we can still dispose of the carbohydrates that we're eating. And that works for a while to keep blood sugar normal. The problem is a couple here on this elevated insulin response. And that is insulin is our fat storage hormone. So people usually have insulin resistance and then start having problems with their weight because they are walking around with these really high levels of insulin all the time.

And they get insulin resistance because they eat a lot of refined carbohydrates and sugar. Correct. Correct. So they've got this high level of insulin, insulin resistance. The next phase is that their body can't quite keep up anymore, putting out these really high levels of insulin. And we start to see blood sugars creep up. That's pre-diabetes. And then of course that just progresses into type two diabetes and if we go back again and remember okay carbohydrates cause insulin and blood sugar to go up the root beginning problem with type 2 diabetes if we therefore switch our macronutrients to the one that doesn't cause a blood sugar or insulin response fact yeah hold on a second we're gonna take care of not a band-aid on the problem right

we're gonna take care of the root cause of the problem yeah and a lot of the drugs for diabetes actually increase insulin even more it's like flogging a dead horse it absolutely is i mean if you think about that and those drugs are on the label says they cause heart attacks because we know that insulin makes your blood thicker and causes inflammation and all the things says they cause heart attacks because we know that insulin makes your blood thicker and causes inflammation and all the things that we know cause heart attacks. Right. I mean, insulin is, is a huge problem. And in the whole, if we back up from just prescribing more insulin for type two diabetes, I mean, and this is what I encourage all physicians to think about, wait a minute, you know, what you've've done if you prescribe insulin for a patient with type 2 diabetes

is you've sped up their vicious cycle. Yeah, in fact, we know as doctors that when you start people on insulin, their cholesterol goes up, their triglycerides go up, their HDL goes down, their weight goes up, their blood pressure goes up, they gain weight. I mean, it's all the things going in the wrong direction except your blood sugar.

Right, and the blood sugar will go down with exogenous insulin temporarily for a little while. But then, wait a minute, it's not working for long because of all those things, right, that you just said, because everything else is just getting worse now and worse and worse and worse. And we just need more and more and more insulin. And of course, then that brings in things like, you know, patients who are on exogenous insulin are much higher risk for surgeries, as you already said, for cardiovascular disease.

I mean, so the problems begin to mount and mount and mount and mount. And unfortunately, what they really result in is they result in a decreased quality of life and length of life for patients. Cardiovascular disease is the number one killer for someone with type 2 diabetes. And what we've done with our standard of care treatment is just speed up the process to get there. And we can't do that any longer. We can't do that any longer. It's not fair to our patients. We want to be able to give people control of their life back. Let them make the decisions in the lifestyle that they

choose to reverse out of this disease. And that's not only going to improve the health of our country, but let's face it, and here's an important one, right? We all want to say that we're doing this for the better and that, you know, we're doing this strictly because of people's health. And I think those providers in the mix are doing it for that reason. But the interest is now becoming more financial as well. I mean, what is it? One in three Medicare dollars is for type 2 diabetes? One in three Medicare dollars. And probably if you add in pre-diabetes, it's probably two in three Medicare dollars.

Yeah. And I think the numbers in 2012 were $255 billion a year in this disease, and the new numbers are over 400 billion. What are they going to be next year? I mean, it's breaking us, right? I mean, there's no way around it. It's financially breaking us. So it's decreasing our quality of life, right? And it's breaking us financially. We can't do the standard of care anymore because it has failed miserably. Hmm. So you call it a public health emergency. Why isn't everybody just jumping up and down trying to fix it?

The million-dollar question. Yes. I mean, people should be, right? And I think that we're seeing more and more that starting to happen. So when I entered this field, you know, the idea that I was telling my patients to eat a lot of fat was as you began to say here's you know heresy and people looked at me weird cross-eyed all those kinds of things but now i think that we have much more acceptance of this because people are understanding the basic physiology of it the um peer-reviewed literature on this is becoming, you can't

ignore it anymore. It's robust. It's robust. And then everybody knows somebody who's done this and improved their health, right? And so that's really important as well. And so I think that we're seeing this grow. I think the momentum is behind really allowing patients to take control of their health and reverse out of this disease. And I just think step one, I really wish would be a complete consensus that reversal is a thing. It's possible. I think that we could get agreement from all aspects of experts in nutrition and chronic disease management on that and we just need to push that into the public arena so that people can be aware not only the people who are suffering from type 2 diabetes but the health care providers

who are taking care of them so are there risks to a ketogenic diet so you know the people who shouldn't follow a ketogenic diet are patients with something called hyperkylomicronemia and this is like one in you know, the people who shouldn't follow a ketogenic diet are patients with something called hyperchylomicronemia. And this is like one in, you know, over 10,000 people. Okay. This is rare disease. Those people should probably not do a ketogenic diet. I don't know anyone else who shouldn't.

What about if they have a missing their gallbladder? Because people often complain, oh, I can't digest fat. No, we have plenty of our patients don't have their gallbladder right so we have patients who have had organ transplants who do well on a ketogenic diet i mean anyone who has metabolic issues can thrive on a ketogenic diet if it is done right and that's that's another thing with our what does that mean exactly that's another thing with our... What does that mean? Exactly. With our Virta treatment, we ensure that it is done right. So it has the right macro and micronutrient content. And we avoid things, you know, one of the things people talk about all the time is, oh, I can't do it.

I get that keto flu. I don't feel well. Well, you know, if that happens to you, you're not getting enough salt. And so we need to teach people... Or muscle cramps, you're not getting enough salt. And so we need to teach people. Or muscle cramps, you're not getting enough magnesium. Exactly. We need magnesium. And so these are things that, again, it takes an expert to help and coach people. What about the whole fiber issue and the microbiome changes that happen with the ketogenic diet?

There's been question about whether that's safe or not. Well, you know, I think that the microbiome is a huge factor. And I think the thing is that we get diversity of our vegetables in a ketogenic diet and patients are consuming things like nuts. So the idea that this has to be a, you know, very low fiber diet is actually not the case. I mean, we are encouraging fiber in our patients all the time. How do you do that? Through the vegetables, right? Through nuts and vegetables and seeds. So you get like 50 grams of fiber through that? So maybe not 50 grams, but you can certainly get a lot and a lot of diversity. And the other really interesting thing that I'd

like to see studied is, you know, the reason that we talk about fiber and gut health is that the fiber breakdown produces short chain fatty acids in the gut right they feed the gut lining lots of positives come out of that but one of those short chain fatty acids that's produced with fiber is butyrate. Now, wait a minute. Our patients have elevated beta hydroxybutyrate. So one of the other questions that we need more research on is, wait a minute, is that alone good? Not to say we're not encouraging fiber because we do. I mean, that's part of a well-formulated ketogenic diet is definitely fiber from those non-starchy vegetables, nuts, and seeds. But we also may be getting additional colon health from

the beta-hydroxybutyrate as well. That you produce as a result of the ketogenic diet. Of nutritional ketosis, correct. That gets in your gut. Yeah. Incredible. So how do you see all this playing out i mean you you see we're just going to be struggling for the next decade trying to convince everybody that we should do this or you think it's going to shift no i think it's shifting i think that for a long time for years now those of us in this like are there major medical centers where they're using ketogenic diets for treating type of diabetes more and more and more i, take a look at my institution, right? Indiana University Health. When I first started, I was kind of alone in this. And now we're seeing providers use a ketogenic diet in their individual patients too. And, you know, people will say, well, the

cardiologist must not like you. And I'll say, well, excuse me, actually the cardiologists are my best referral source. And so, you know, we're seeing this more and more. They're not worried about the saturated fat or the... No, because, you know, that's not what we see. So again, that's one of these status quo ideas is that, you know, you put someone on, sure you can reverse their type two diabetes and, you know, you're going to kill them with a heart attack. And we have published a paper on that as well. And that's not what we see. We see cardiovascular risk factors across the board improve or don't change. Like blood pressure, cholesterol, things like that. Blood pressure goes down, blood pressure medication use goes down, inflammation decreases, and LDLP or ApoB, those really important cholesterol numbers, don't change. So we've got all these improvements with that LDLP and ApoB not increasing,

as people would think. Now, there's a slight increase, 10% in LDLC in our patients. But again, especially in people who have metabolic illness, the ApoB or LDLP is a much better indicator of cardiovascular risk. Yeah, a lot of the type 2 diabetics have actually normal LDL, but the particles are terrible. The particles are terrible, right, because they're small and dense, and therefore it takes more of them to carry the cholesterol. And so as we change the morphology of the LDL particles, again, what happens is it leads to unchanged

LDL-P and ApoB while improving all these other cardiovascular risk factors. So I think, again, going back to when we began in this field, we constantly talked to each other about, okay, it'll happen. It will happen. I think we're going to get there. I think we're going to get there i think we're going to get there and all of a sudden the discussions with uh providers in this field have changed to we're there it's happening the change is now and i i think you're going to really see that come to fruition my feeling is that the next set of guidelines, both the DGAs and the American Diabetes Association guidelines, are going to have to acknowledge and move forward on recommending a low-carbohydrate diet for patients with metabolic problems.

I think we're going to see change. I think that there is, again, let me just for a moment focus on the American Diabetes Association guidelines, for example, right? So, you know, they actually promote three eating patterns. And those three eating patterns are DASH diet, plant-based diet, and the Mediterranean diet. And they have reviewed low-carbohydrate diets, but fall short of recommending it as an eating pattern for the disease. Now, interestingly, if you go in to take a look at what evidence is supporting the eating patterns, let's just focus on the DASH diet for a minute, because this is the worst example. The dietary approach to stop hypertension, which is sort of low fat, more plant-based, low lean meat. And in type 2 diabetes, there is a single study of 31 people, all of the same ethnic background,

with a high dropout rate being used by the American Diabetes Association to recommend a DASH diet. One. A single study, 31 people. Now, you compare that to what the evidence is for a low carbohydrate diet i mean there's no comparison there are now you know dozens of studies here and so we have to pause for a moment and say really this makes no sense what's the resistance is it is it ideological is it political is economic it's the resistance? Is it ideological? Is it political? Is it economic? It's status quo. Yeah.

And there's a lot of intellectual bias. I mean, this is what we've been recommending for our patients with type 2 diabetes for years. Why would we change? And the answer to why we would change is things keep getting worse because our recommendations make no sense. But it's not only financial bias, but it's more important. I mean, absolutely more important. It's intellectual bias. This is what people have been saying for a long time.

And to make someone pause and say, wait a minute, look at the evidence here. There's no evidence for what you're recommending. And there's a lot of evidence for a low-carbohydrate approach in type 2 diabetes. We're at that point where we are calling them on it. I'm anxious to see what happens with the guidelines. I am too. Even the U.S. Dietary Guidelines. Because, you know, obesity.

I mean, there's one in two Americans has prediabetes or type 2 diabetes. And they're 70% overweight. And many of those probably also have insulin resistance. And it's just that we have a narrow criteria for diagnosing that, but maybe we should include earlier in the spectrum. I'm totally with you on that, right? The earlier that we get to people, the better off they will be. Let me just make one note on that one,

is one of the important populations that we must focus on early is in pregnancy. Because when a mother has gestational diabetes, that really risks the future health of her children. And unfortunately, her children's children. It was interesting, we're at this Food for Thought conference and the science and politics of nutrition. One of the speakers got up and said, low carb diets may be okay,

but not for pregnant women. And I thought that was interesting because gestational diabetes is the biggest issue. Right. And it's like, where could you possibly come to that conclusion with the evidence that we have? Because gestational diabetes is dangerous.

The way to avoid it is a low-carbohydrate diet that's best for the mother, that's best for the mother, that's best for the baby, and that's best for the generations to come. Yeah, for sure. So what's next in terms of the studies you're doing? Where are you headed? What's going on with the next step in your evolution of curing diabetes for the hundreds of millions of people who have it around the world? Right. Well, right now we're really still working on our main clinical trial. So we've just wrapped up two years of data collection. So the next step is going to be writing up and publishing the two-year paper.

And that's going to be really important because, you know, when we released our 70 days, the results looked great, right? But it was only 70 days. And so, of course, you know, we got a lot of, well, people can't sustain it. So then we put out our one year results. And of course the sustainability is incredibly high. You know, 83% is just virtually unheard of in a nutrition adherence. And then, you know, when we get our two year results out, it's just, it's going to become increasingly difficult to make the argument that this is not sustainable because our adherence has been so high. And I want to just make a quick comment on that too, and goes back to the whole idea of study design and randomized controlled trials versus a controlled

trial, but not randomized because we allowed patients to self-select. One of the biggest problems, if not the single biggest problem in nutrition studies, is difficulty with monitoring adherence. Yeah. Right? Right. Because... How do you know they're actually eating what you say they're eating? Exactly.

So this is the intention, but what really happened. And in order to figure that out, we have always, this is always, relied on food diaries, which are notoriously inaccurate. Yeah, I would say my patients will estimate what they eat in half and overestimate how much they exercise. Right. I mean, it's just it's human nature. Like this is not like we can't fault people for this. Right. They want to they want to, first of all, adhere to what you're asking them to do. But the ability to do that is not always 100%, right? And so food diaries have been the way we've relied on measuring adherence. And with our study, we had an absolute marker of adherence, and that was their beta

hydroxybutyrate levels. You don't get elevated beta hydroxybutyrate levels unless you're, number one, starving, which our patients clearly did not, or number two, restricting carbohydrates and increasing fat. And so we are certain— You can prove that they were eating that diet because their blood test proved it. Exactly. And so, you know, that right there in and of itself puts away the single biggest problem with nutrition studies in general that we have been able to overcome with the measurement of that biomarker. And it's one of the few diets where you can prove that. What about the 40% that didn't reverse the diabetes?

Well, so the 40% who didn't reverse the diabetes, I would say a couple of reasons. Number one, very important with the patient population that we took, because if you look at other type 2 nutrition intervention studies what you'll find is that they exclude patients with insulin they only want new diagnosis of type 2 diabetes and our average length of time with type 2 diabetes in our patient population was eight years these were not new diagnoses. And we had a very large percentage of our patients who were on insulin. And again, as we talked about earlier, the longer you have type 2 diabetes and are dependent on insulin, the less likely you are to be able to make adequate insulin later on. So

that was a big factor, right? So many of our patients that we took into the study just couldn't make enough insulin on their own. We, in other words, didn't catch them early. And that's an important lesson to learn for as we move this forward. You know, who needs to be intervened upon? And the earlier is clearly better. Now, we do have some long term patients who have been able to successfully get off of the insulin and reverse their type 2 diabetes, but it's not going to be 100% in that population. And do they give them exercise too? Oh yes, absolutely.

So exercise is going to be key to long-term, right? The difference with averted treatment is we let patients know they don't have to start exercising from the beginning, and that's not what they have to do to reverse their type 2 diabetes we want to focus on the nutrition first get people feeling well losing weight and then introduce exercise right and the other reason that it's not a hundred percent is people still i mean we have great adherence right you know our are 83%. But 17% maybe not. Right, you know, didn't or struggle or people may be, you know, having a period of time where they're not doing as well. And then, again, due to the support that we're able to give them, we can help them get back on track.

But sometimes for some people, everyone is different. It may take a couple times on the saddle before this truly becomes a lifestyle. And that's why the length of the trial is so important, right? So we're wrapping up two years here. But what's going to happen at three and four and five years, and what we think is that we can really instill this as a true lifestyle, right? Not a diet. And that's helping people through those bumps in the road where maybe their nutrition

isn't as good as they would like it to be, but you don't abandon them then, right? You surround them even more with support. So how long do you think it'll take before Medicare and insurers will pay for a digital healthcare program that reverses diabetes? Because if that happens, it's a game changer. It is a game changer. I don't know the answer to that. I think, again, that things are moving so quickly right now that if you had asked me that a couple of years ago, I would have said, I don't know, not in my children's lifetime, probably. And now I say, you know, I think that it may be right around the corner. I won't be surprised that that's not far off anymore. Pretty exciting.

All right. So you are queen for a day and you get to change something in our health care system, our food system. What would it be? Okay, so let me walk you through the progression of what I would like it and then the ultimate prize, right? Where the prize where I can... You're queen, the ultimate prize, right? The prize where I could... You're queen, you get anything you want.

Yeah, where I could say that we've done it. So step number one is kind of what I talked about earlier, which is just the acknowledgement of reversal, right? That reversal is possible and needs to be given as an option to patients when they have metabolic disease. Number two... Become standard of care. Become standard of care.

Number two is physician education, right? We need to re-educate physicians or actually I shouldn't say re-educate because physicians actually are not getting nutrition education period. So we need to educate physicians. So we need to have a educated from a nutrition standpoint workforce, right? Which is the healthcare providers. So that would be number two um and then number three is complete change of the guidelines right where they endorse a low carbohydrate approach and actually recommend it and then how do we know that we're really there that we've accomplished everything i'll tell you in my uh view it's two things farm subsidies when we start seeing tomatoes and broccoli being

subsidized we've done it like that's success right because we've come full circle then right and we are going to actually start subsidizing things that are healthy for the planet um and and for the people in it and i think that's really important. So great. Yeah. I mean, I mentioned it before, but, you know, there's the beginning of this movement of food pharmacies for prescribing food for diabetics. And Geisinger did it and they reduced their health care costs by 80% a year.

Absolutely. And got a lot of people off their meds and same thing. But it wasn't even acute genetic diet. It was just like getting them off the junk, teaching them to eat a little rough food. Imagine what we could do if we went all the way. Absolutely, absolutely. I mean, this is the right thing to do.

It's the right thing to do for so many reasons. You don't just look at it being the right thing to do for reason X or reason Y. I mean, it's the right thing to do, and it's the right thing to do and it's the right thing to do urgently. And it's a very hopeful message because the single biggest driver of so many crises is obesity and chronic disease related to it and diabetes. And for you to say we have a cure. I won't say cure. I'll say a reversal. Right, right.

To say we have a reversal is huge, right? And that message has to get out there. So anyone who's listening, you know, who is, I'm sure if they're listening to your podcast, they're not hearing this for the first time. But, you know, tell your family, your friends, your neighbors that are struggling with type 2 diabetes that reversal is something that they need to discuss. They need to demand to discuss with their healthcare provider. So where can they go to find out about your study and can they print it and bring it to their doctor? They absolutely can. And I would encourage them all to go to virtahealth.com. That's V-I-R-T-A health.com. And there they can read our blog,

which is written by experts in the field. They can have access to our papers and our research and other research as well. So, you know, it's a good landing place for more information. And that's right. They should be printing out these papers if their physician is resistant to it, bringing it in and say, I need support on this. Yeah. And the other thing I would say is that, you know, if you're type two diabetic, a quarter of them aren't diagnosed. And if you're pre-diabetic, 90% are not diagnosed. So it's important for you to figure out if this is a problem and how to diagnose it.

And I'm sure if you go to your doctor or check out my books or Sarah's work, you'll find out how to actually figure this out. And it's not that hard. This is our biggest problem and it's got a simple solution. So thank you. A non-pharmaceutical solution. Imagine that. So thank you, Sarah, for being on our podcast,

Doctors Pharmacy, A Place for Conversations That Matter. If you're listening and you love this conversation, please leave a comment, a review. We'd love to hear from you. And share with your friends and family on Facebook and subscribe on iTunes, wherever you get your podcasts. And we'll see you next time on The Doctor's Pharmacy. Thanks for having me, Mark.