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

[The sound of a bell] 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 prevent complications, but often it still 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.

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. Yeah. 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. 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 health care 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. No fact. 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 prevention is in my background and was something I was always interested in. And I wound up doing primary care as an internal medicine physician. Again, preaching what everyone taught me, which is low fat is the way to go. And I was frustrated.

To lose weight and to prevent heart disease.

Just for everything. It was the way to do it. It was universal. You have any problem, low fat diet, exercise more. And it was depressing. 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. All I do is prescribe medications. And quite frankly, it was. It was demoralizing to me professionally.

We're basically pharmaceutical.

I was a 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. I 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. 'Cause, you know, we built it from scratch. And it opened as a low-carb clinic.

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 could 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, of course, the big fat nothing. Yeah, you know, you get the cricket in the back of the room, right? Like this was not happening with some few, as you know, notable exceptions. 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 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. 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.

So, if you add a lot of psyllium to your Wonder Bread, it doesn't work?

No, that's right. That's right. Because I would say that the number one important thing about what we do is that it's a whole foods based diet.

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 on your diet.

So you could have three cups of broccoli?

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, right. Maybe that would be less intimidating.

Right. You're eating a high carb diet.

High carb by volume. I like that.

I always say, 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 gonna use that.

Please.

Can I, can I, please do.

Because it is an act, I mean, and 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 can't do that. But as I just said, yes, you can. You can do that and still stick with your carb limit. 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 not. 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, 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, is spoken like someone who's never given up bread. Because wait until you taste bacon cooked brussels sprouts or some of the things.

I saw someone who made a macadamia keto bread the other day and I thought that was really good.

I mean, you can do so much with a whole foods, low carb, high fat meal plan. I mean, the diversity can be immense, which is great and important because then it can reach across other cultures as well. So it can work with our kind of standard American fare, But we can also modify things for different cultural backgrounds as well that could still stick with the same premise, low carb, high fat, moderate protein.

Hmm. So is that keto or are we talking about some variation of that?

No, it, 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.

And that means you have to measure their blood level with a finger stick and it has to be over 0.5.

Well, 0.3. Yes, we're not 100% sure. 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 what we see is that 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 gonna 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.

And that affects a lot of people. What about people who are overweight who don't have diabetes?

Are they also insulin resistant or 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. Exactly.

And I think that that is true for this.

Yeah, I think that the longer term 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, you know, then pre-diabetes and into type 2 diabetes. So, you know, 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 pre-diabetes, this is what you need to do to reverse out of that condition, easier it's going to be for them.

But 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 higher levels of beta hydroxybutyrate, you know, is 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 two diabetes, you need the pound of cure.

Right. That's right. That's right. And can we avoid that, right, by catching people earlier?

And then can these people, once you sort of reverse the type two diabetes and they get healthy and they're more metabolically resilient, can when 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. If you go back to the way you were eating, it's going to come right back. 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. Bad idea, right? What are those 30 grams? What do we want to be adding in?

Sweet potato, maybe.

Or berries, that would be another one. More 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 so 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 other 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 that who have never seen this for themselves, And they're likely to not believe you. But it's so profound and it's not.

Just like- and we see it routinely in clinic and in my practice. I've seen it. It's amazing.

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 the root cause of this problem, and it literally can resolve itself in a matter of days to weeks.

So I want to, 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. Right. Went to the doctor and found out he had pre-diabetes 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 Follick. the art of low carbohydrate living, which I've read, which is 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, it actually provides a structured way for type two diabetes to be reversed using a ketogenic diet. And it also is done virtually, meaning it kind of subverts the healthcare system. It dis-intermediates the healthcare system so 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 type 2 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. It'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 Virta and also to sort of answer the question about why only 60%? If people were doing it right, why wasn't it 100%?

Great questions. Well, first of all, yes, Sami's story is quite remarkable. And I love his story because 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, he brings that passion. If this can happen to me, this elite athlete who does everything right, 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. How is this presenting itself to all these other people? I mean, if this is unfair and ridiculous for me, I am not alone. And so, I just have to put a shout out for 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 Voloch 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, this 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 Verti 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. I mean, at the multiple times a day. Multiple times a day, correct. And so, you know, 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 Skip the pasta. 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 when 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 the 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 long standing type two 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.

So what do you do? You take them off the oral hypoglycemics and 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 wanna make sure that they're adjusted down gradually and safely. But again, as we already talked about, 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? Because physicians, I mean, we all were taught how to prescribe medications in medical school. We weren't 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. But they may see them, but it would be on a virtual platform. Virtual platform. Right. Mm-. 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 Fourth 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 explain to them why what we're saying makes sense. 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 is the plan.

That's right.

I think that's the concern is how do you scale up because we've got so many diabetics, so much need and how do you build it and how do you get reimbursement? It seems like 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 the 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 this 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, 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. And I mean, which is completely counterproductive for someone with diabetes. And 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% 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 and 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.

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. And I mean, pharmaceutical companies have no interest in reversing type two diabetes, it would go against their business model.

I remember being at a diabetes conference, a nutrition conference, and I saw this giant kind of poster and banner that said, Cure for Diabetes. And then I walked over and there was a bariatric surgery, a promotion, and I was like, oh, okay. Yeah. I would say, 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. And that's huge. 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 it's not the-- Within weeks, by the way.

Within weeks. 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. Um, 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. Um, 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 two diabetes.

People criticize the study and say it's not randomized, meaning if people self-select into the study, they're motivated, they want to do it, whereas the average person may not.

Well, and I agree. That is the criticism that it's getting, but I'm going to push back on that in many ways, and I have forcefully, because you cannot tell someone to start a lifestyle that they're not interested in doing. 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 gonna 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 wanna do that. They want to have control of what the lifestyle 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.

And, 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're more likely to be overweight if your friend's overweight than if your parents overweight. So the data is there on how our social networks drive our behavior. And if all your friends are eating 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. And I think that's key to the Virta treatment. That is key. It's one of the things that we recognize and have built support for. Because you're absolutely right, telling someone to do something and then having them go out into the real world into their personal communities, their friends, their neighbors, their workplace, which is a big problem for people. family gatherings 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. 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 a really important. Like I always say diet is a four-letter word. We don't do diets. we do lifestyle. And 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.

All right, so let's go into the biology a bit. Because people are like, well, how does this work? And how do you all of a sudden eat 70% of your diet as fat and lose weight and reverse your diabetes because it seems so counterintuitive? Right, because fat's supposed to make you fat and 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 all had in first year medical school. 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 I'll tell you that 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, pushing a low-fat diet, even for type 2 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, oh, that makes sense. Of course, why are we doing it the other way again? You know, 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, 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 five 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, 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 sugars.

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 2 diabetes. And if we go back again and remember, okay, carbohydrates cause insulin and blood sugar to go up. It's 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. Fat.

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 that we know cause heart attacks.

Right. I mean, insulin is a huge problem. And if we back up from just prescribing more insulin for type 2 diabetes, and this is what I encourage all physicians to think about, wait a minute, what you'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 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 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 two diabetes?

One in three Medicare dollars.

Probably if you add in pre-diabetes, it's probably two in three Medicare dollars.

Yeah, and I think the numbers, the numbers in 2012 were 255 billion a year in this disease and the new numbers are over 400. $100 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.

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 is, 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 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 healthcare 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 hyper-kyphomicro- anemia. 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 should. 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 another thing with our-- what does that mean? Exactly. That's-- 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 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 through. What about the whole fiber issue and, 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- Dr.

So you get like 50 grams of fiber through that? Dr. 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-hydroxy butyrate. Yeah. 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 nutritional ketosis.

It gets in your gut. Yeah.

Incredible. So how do you see all this playing out? I mean, 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... Dr. Julie Are there major medical.

Centers where they're using ketogenic diets for.

Treating type 2 diabetes? Dr. Justin More and more and more. I mean, 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. 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. Dr. 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 2 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.

Blood pressure, cholesterol, all things like that.

Blood pressure goes down, blood pressure medication use goes down, inflammation decreases, and LDL-P or ApoB is really important cholesterol numbers don't change. So we've got all these improvements with that LDL-P and ApoB not increasing as people would think. Now there's a slight increase 10% in LDL-C in our patients, but again, especially in people who have metabolic illness, The ApoB or LDL-P is a much better indicator of cardiovascular risk.

Dr. Yeah, a lot of the diabetics have actually normal LDL but the particles are terrible.

Dr. 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 uncontrolled LDLP 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 talk to each other about, okay, it'll happen. It will happen. You know, I think we're going to get there. I think we're going to get there. And all of a sudden, the discussions with providers in this field have changed to, we're there. It's happening. The change is now. And 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 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 one that we're talking about.

The dietary approach to stop hypertension, which is sort of low fat, more plant-based.

Correct.

Low lean meats. Yeah.

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.

We have no- what'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. 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.

I mean, even the US Dietary Guidelines, because you know, obesity, I mean, there's one in two Americans has pre-diabetes or type two diabetes and then 70% overweight and many of those probably also have insulin resistance.

Insulin resistance.

Yeah, 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, you know, when a mother has gestational diabetes, you know, 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, you know, 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.

I, 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 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 allow 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 has always relied on food diaries, which are notoriously inaccurate.

Yeah, I always say my patients will estimate what they eat in half and overestimate how much they exercise.

Right, 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 wave 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- you- can prove.

That they were eating that diet because their blood tests proved it. Yeah. 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 two 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 are 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 successfully get off of the insulin and reverse their type 2 diabetes, but it's not going to be 100% in that population.

And, have they given them exercise too?

Oh, yes, absolutely. So, you know, exercise is going to be a key to long term, right? The difference with the Virta 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 introducing exercise. Then get them moving. Right. And the other reason that it's not 100% is people still, I mean, we have great adherence, right? You know, our 83%. But 17% 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 of 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 health care 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 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. 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 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 and for the people in it. And I think that's really important.

So great. Yeah, I mean, I mentioned it before, but 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 a ketogenic 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, you know, reason X or reason Y. I mean, 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. Or 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 insistent 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 podcast. And we'll see you next time. on the doctor's pharmacy.

Thanks for having me, Mark.