Dr. Sarah Hallberg - 'Low Carbohydrate Diet for Type 2 Diabetes Reversal'

[Applause] thank you so much thank you Ken and how can I start without thanking Jeff and rod I remember it was just a few years ago we were in this tiny room was anyone there right this tiny room in Breckenridge and here we are today so thanks to all their hard work and I am so honored to be here with everyone today so we're going to talk about type 2 diabetes and actually I hope that when I'm done here I can convince everyone that low-carbohydrate does work for type 2 diabetes and type 2 diabetes reversal but I'm not gonna have to work that hard on that fact but that it's not the only way and that all of us who care for patients do need to understand that there are other ways for people to go about the idea of reversal and we need to always remember that the ultimate choice about what a patient does for their health is theirs and what we so important so important I think it's lost sometimes along the way but our jobs are to be educated on all the options and to really be able to have a patient-centered discussion now I fully believe or I wouldn't be here today that most people will choose low-carbohydrate as an option because of all the reasons we know but not everyone will and that's okay so let's go through it first my disclosures I do work for Verta health and I am an adviser at Adkins and I have a major intellectual bias major and why do I have this intellectual bias because I've cared for thousands of amazing people who have had life-changing results and you know what you can't ignore it so I declare it and I hope that we can get to a place in medicine where we can be forthright with our intellectual biases because it's the one that is the most powerful and the one that we hide all right so you guys have seen the slide if you've seen me talk before you know we got a problem over 50% of the adults in this country have diabetes or prediabetes so what would we call that we would call that urgent maybe emerge it but is it even worse the answer sadly is yes so here's a new study that came out to say okay over 50% diabetes or prediabetes those are people who actually have problems with their glucose but we all know that there are plenty of people who are insulin resistance and still have normal glycemia and actually the amount of those people blue even me away so looking at n Haynes data recently what do we see 12.2% of the adults in this country are in optimal metabolic health what does that mean wait a minute 88% warrant one in ten and when we look at the normal weight people right we think they're all fine the normal weight people less than a third of them we're in optimal metabolic health health is that urgent is that emergent no it's panic time it's panic time and here's my question what is it going to take for the collective to care about this if these people were spontaneously combusting everywhere would we pay attention is that what it's gonna take this is beyond an emergency folks one in ten of us are healthy metabolically nine in ten of us are in trouble we've got to do something so talk about the group of wonderful people who are here at this conference what can we do about it we can talk about what we can do whether you're a health care provider whether you're a patient we need to be talking about this fact type 2 diabetes is reversible I like to think of it like this when someone is diagnosed with type 2 diabetes what they get put on in our healthcare system is a one-way street a one-way street and we can throw medicine and we can throw all kinds of stuff at them and we may slow them on the one-way street maybe 230 miles an hour from 50 but even if we slow them for 30 miles an hour for a little while what's gonna happen a year later they're gonna be not at 50 probably they'll be at 60 miles an hour but the point is they're still gonna be on a one-way street right it doesn't have to be that way we can open another lane to get them going the opposite direction we can free them from the one-way street and we have to understand the options to do that the options to open the second lane and discuss it with patients and let them know they have a choice there's a way for them to regain control so how three clinically weighs proven in the literature to reverse type 2 diabetes bariatric surgery a very low calorie diet and a low carbohydrate diet three ways in the literature well documented so let's talk about bariatric surgery first here's the thing folks it works it does work up to 80% short-term remission and in surgery we've moved away from the gastric bypass surgery for the most part and are doing the less invasive sleeve gastrectomy the 10-year remission rate is somewhere between 36 and I have on here 83 percent but that really was attained from one study in the 90s and no one's ever been able to replicate that degree of long-term remission so probably somewhere in the 30s and then I'm gonna talk a little bit more about the Stampede trial it went out to five years it's probably one of the best known surgical intervention trials looking at diabetes remission and at five years it was 29% but they had a very conservative definition so they were trying to get in under 6.5 they were pushing to get it under 6 so that's an important factor as we evaluate these things it works but right there's a surgery risk I mean many people will come saying there's no way I'm gonna have surgery and again remember patient choice that's their decision there's complication risk and there's a big cost we know that but I think the most concerning thing is does it really solve the underlying issue so if mom or dad has bariatric surgery is it gonna change what happens to the kids does it prevent the next case have we really gotten someone to so embrace the idea of nutrition changes along with it that we can help impact the next generation that's probably a big concern that we need to think about however is bariatric surgery appropriate for some people it is and anyone who cares for people knows this is what's going to happen some of the time people are gonna try a nutrition intervention it's going to fail them they'll wind up with surgery and the flip will happen surgery will fail some people and they will wind up in our nutrition based clinics and they'll thrive so we just have to help people figure out what's the best place for them but we have to also acknowledge the most robust data exists with bariatric surgery and it can be successful for some people alright so how about very low calorie diets they've been studied for diabetes reversal since the 1970s and if we look at some of the most well-known trials we see you know one of the differences is the degree of calorie restriction you know we go everywhere from like 3 to 400 calories a day up to look ahead which went up to 1,800 for some people so the calories differ but again they're pretty low in general and that's an important thing to discuss with people if they're going to be working on reversal or remission as their goals what does this actually mean when it's applied practically now of course the calorie restriction to this degree doesn't last that long 3 to 5 months on average the question is can it work long term and there's consistent issues with all of these studies with weight rebound when that extreme calorie restriction ends and so here's a good look at that and the rebound that we get so what I've got here is I've gotten a number of different studies ok so some with extreme calorie restriction and then I've got two low carbohydrate studies one the study by Tay at all so I'm probably many of you are familiar we've gotten 2-year data on that and then also we have our Verta I you which is the blue bar and then everything else are the very low calorie diets and what you can appreciate from this graph is boy when you're on that degree of calorie restriction you lose weight really fast okay no one's gonna argue with that it works in the short-term but the problem is and it's well documented in the literature when we lose weight that fast we tend to have a more extreme rebound afterwards and so you can see that in this graph here and take a look at the bottom of the graph which looks at a 1 C and what you can see is when you have that extreme calorie restriction you do lower a1c really fast but take a look at down the road what happens the a1c is not sustainable either so this is the biggest issue when we talk about these very low calorie diets so in summary they work really well in the short term the question is the rebound and what's going to happen long term so now let's go to my favorite of the three and I'm sure many in this audience which is low carbohydrate diets so this is not just a few studies ok low carbohydrate diets have been incredibly well studied for diabetes 22 randomized controlled trials 10 meta-analysis 10 non randomized trials look at this this is a big one there are a lot of studies with a lot of people in them that have lasted a long time so it's not just that we have as the ABA has liked to criticize in the past you know short studies with just a few people I mean we've got robust data here so a couple of the things when we're evaluating these studies that we have to keep in mind the degree of support given with all these trials differs widely you know once a month in-person groups you know do people actually go to those yes or no you know are people calling them at home what kind of supports and I think that that we're gonna find out with that or with very low calorie the support given is going to be critical and what it appears is that the degree of carbohydrate restriction matters and this was very specifically pointed out in a recent meta-analysis the lower you go on carbohydrate restriction the better the diabetes remission and reversal rates and I don't think that really surprises anyone that's kind of basic physiology here ok but when we evaluate all of the low-carb studies who are at least call themselves low-carb because one of the low-carb studies for example that didn't show really good reversal rates didn't perform that good compared to the control diet called themselves low-carb when it was really 40% carbs so we need to be able to categorize these differently the lower the carbohydrate levels the better the results have turned out to be so we just want to keep that in mind so now I'm gonna jump to our trial and talk a little bit about our new two-year results as well so I think many of you probably are familiar with this trial so I won't stay too long on this but just quick summary this is a five-year trial and I'm really excited because we just started like last week our three point five year data collection so numbers are starting to roll in yes so I can't wait to be here next year and talk about three point five years and and we're gonna have a whole number of other studies coming out of this that are really exciting to discuss in the future but this was a big trial okay four hundred and sixty five people total and of those in the intervention group two hundred and sixty two of them had type 2 diabetes the others in the intervention group had pre-diabetes and we will be reporting on those later this year and one thing I'm gonna say here and then I'm going to come back to this really important point the average time patients enrolled old in our study had diabetes these were all type-2 diabetes was 8.4 years we had a number of people who had diabetes for 20-plus years now one important thing is if you look at the bariatric surgery literature where this is again best discussed is that one of the risk factors for reversal or not being able to attain reversal is length of time with diabetes so just want you to keep that in mind as we go through the rest of this talk so our primary outcomes were body weight metabolic syndrome criteria which again is what we're gonna be reporting on in our pre-diabetes paper and type 2 diabetes status so here it is two years what happened we sustained the results we sustained the results and so I mean this is very exciting so we reverse type 2 diabetes and we were able to keep people in reversal we went from 60 percent at two years to 54 percent over half the people in the trial maintaining diabetes reversal that's huge just for one moment imagine that was a drug right do we need another drug come on we need food we need proper food it works and the medication reductions they're staying incredibly robust right so these are people who are maintaining a lower a1c and still staying off drugs and I gotta tell you something so exciting and that is in the last six months in the last six months so this is three years after these people started I have taken three people who have a diabetes duration of 15 to 20 years off insulin three years it took three years for them to get off insulin but they did it and it begs a unbelievable question what's going on with the recovery they didn't get off like many of our patients do in the first couple of weeks they had diabetes for so long and came into the trial on huge doses of insulin but they were able to stick with it and at three years they came off insulin I mean you know those of us who work with these patients all the time it's so rewarding to tell someone that they don't have to take insulin anymore but I will tell you nothing has been more rewarding than to tell someone that after three years of their hard work and their diabetes of 15 to 20 years you're done man you're done it's so [Applause] we need to understand that better but it's exciting and so with all the medication reductions that we're having we're saving a lot of money this makes sense financially - let alone the quality of life that we're giving to people so 46% at a year in the medication cost reduction okay so let's go back to this summary big picture things ninety-one percent at two years of insulin users had decreased or totally eliminated their insulin right 91 percent at one year we were at 94 percent I'm calling that sustained success and 74 percent were retained and that number is amazing we all know the physicians in this audience you prescribe a medication to a patient there's no way they're coming close to 74 percent still taking that medication at 2 years no way yet we were able to sustain a lifestyle take change at that degree at 2 years and what's the average weight loss 10 percent average weight loss at 2 years so these are big sustained numbers and let's take a look at the new data that we have coming out part of it's already been published part of it is in review what happens to liver fat because we know fatty liver disease right is taking over just like type 2 diabetes it's a problem in quality of life and it's a huge problem in cost in this country so here we are with liver fat scores 12 months down two years down further huge and let's take a look at this this is all the liver related biomarkers including what we have over here second to the right that is central abdominal fat and how much it went down at two years so what we have is across-the-board improvement in these markers of liver health whether we're looking at the liver function test we're looking at fibrosis scores I mean they all improved and this is a paper that we just had released I encourage everybody to read it this was just published in BMJ open looking very specifically at all of the markers of liver health and the graph on the right basically is showing that liver function improves and it is related to the improvement at a1c so in other words if you're a 1c dropped further the chances are your liver function or markers of your liver health improved more that probably doesn't surprise us and here's another paper that we just published within the last month sleep we all know how important sleep is and to us ourselves right and to our patients and so patient reported sleep improved significantly in patients with type 2 diabetes and also patients with pre-diabetes and the interesting thing is the patients with pre-diabetes improved even more what happened in our control group over the time period they got worse that doesn't really surprise us because they were on the one-way street and they're just progressing so one other important thing is our feedback loop utilizing beta-hydroxybutyrate as a marker of adherence it's something that I think is so important that sets this trial apart from other trials because we weren't relying on what patients reported they ate we were able to really know exactly what they were eating because if they had ketones they were restricting cars and they had restriction and ketones and that was maintained so they're still doing it oh but it's not a randomized controlled trial so we can dismiss it right as it has been dismissed by so many oh yeah the results are good but it's not a randomized control trial I'm not gonna talk to you okay so let's talk about this because we just had this week the release of the two year results of the direct trial anybody know about the direct trials this was in UK and this was a very low-calorie intervention aimed at diabetes remission so again it's a really important trial for everyone in this room to know about it's important when we talk about diabetes reversal in remission it's an important option for our patient patients and so we cannot dismiss this trial it is very important the result release got a huge hubbub but let's talk about the comparison of the direct trial and our trial the direct trial was cluster randomized ours was controlled what does that mean in the differences here's what it means patients self selected and knew the intervention they were getting ahead of time it's the same thing now if they were cluster randomizing it and the practices that they were choosing all had to get into the trial that's one thing but they didn't the patient's self selected in our patients self selected in it's essentially the same thing except for we had two sites and they had multiple we had endocrinology practice as the control and we had my medical weight loss practice and at IU as the intervention patients self selected in both direct study again had multiple sites where we had the two we were able to measure adherence like I talked about directly and with certainty by beta-hydroxybutyrate and the remission and reversal criteria the direct study it's a little unclear because here's what it says defined as hemoglobin a1c less than six point five after withdrawal of anti diabetes drugs at baseline independent of status at twelve months I'm not sure what that means and also their original one that said that it has to have an a1c below six point five two time points at least two months apart and it's very unclear if that actually happened maybe it did but we need a little clarity on that we are very strict in what we are saying reversal is in our study a 1 C less than 6.5 without diabetes specific medications which allows metformin and here's the deal with metformin it's indicated for conditions outside of diabetes and here's a really important question that we have to ask all the patients who had type 2 diabetes are at risk for developing it again we have a medication that is benign and cheap and will decrease their risk for reoccurrence of course they have to keep up with the nutrition - so whose choice is it to stay on metformin is it the choice of the study to tell everyone that they have to get off of metformin because it makes the numbers look better we want to be able to say that this was off all drugs because that's would be the best idea if you're looking at the study group as a whole but I'm the doctor for everybody in the study and the numbers at a whole are great but I am responsible for all the individual data points that make up the study and it's not my decision to pull them off a drug that may have benefit for them so the discussion with every single person is here's the deal with metformin you can go off or you can stay on let's have a risk-benefit discussion and the choice is yours and my question is is it ethical to just pull everyone off because it makes the study look better or should we be mandating that in anyone who has had type 2 diabetes and therefore is at risk for developing it again needs to be able to have the choice at the patient level where it belongs so it's really important we think about that and did patience in the direct trial take insulin no it was an exclusion criteria did we take insulin patients oh yes we wanted them and how many years did people have type-2 diabetes in the direct trial the average was three years in our trial 8.4 and for those of you who care for people with type 2 diabetes that's two different diseases we know it so how did we stack up then so let's look at these three options for a reversal so the sleeve in the bypass no data is coming from the stampede trial very low calorie diet is coming from the direct trial and the purple the low carb is coming from our trial so let's take a look at this we know when it comes to a1c surgery as I said up to 80% short-term reversal plummeted they had much higher a1cs to start with but let's take a look at once we got down and these curves here if you take a look the low-carb got the a1c lower and it's maintaining that a1c we're now tracking right with surgery or below important how about weight let's take a look at ours remember I said 8.4 years we took the sickest of the sick take a look at where our weight started off compared to everyone else including surgery our patients were sicker which makes this even more important and quite frankly remarkable so what if you take and pull ours down let's say okay maybe we started at a lower weight we're really tracking right with surgery here we're tracking right with surgery now does that make surgery not a good option it doesn't for some people but what I'm gonna say is that low-carb can do the same things it's really important that we understand that and low-carb is now that's under dove care we are not some fringe diet new guidelines out last October endorsed low-carb by the ATA in the EAS D as a recommended eating pattern and the new ad a standard of care and I'm super pleased to report that they cited our trial when they made the change pudding low-carb as a recommended eating pattern and acknowledged that low carbohydrate is the only eating pattern that can have removal of medications that's big right this is we are not fringy the evidence doesn't allow that anymore we our standard of care so how did the eating patterns stack up with the other eating patterns that the American Diabetes Association still recommends here it is with all and we we've done a systematic pull of all of the data of all of the research and here's how the research stacks up randomized control trial and meta-analysis in the light blue other trials in the dark blue and it's no wonder the standard of care changes the evidence is there and I don't know if anyone knows this but the Department of Defense the VA have been recommending low-carb for over a year now and we look here and say the carbohydrate intake as low as 14% recommended by the VA and the DoD that's important and one thing I really want to point out is how the VA and the DoD came about in creating their guidelines so I've got some important points here they use the u.s. PST F methods they're considering upgrading to grade which is a really fantastic guideline for guidelines they have a policy of transparency and they did a systematic review so here's someone who didn't do those things this is the a seee or the clinical endocrinologists so this is actually from their new guidelines when it comes to nutrition plant-based now notice that even though this is from the new guidelines this slide is actually from 2015 they haven't changed anything because of course there's been no new science out there right 2015 I mean why would we bother looking we know what's right and so here is a really important thing that looks at what happens when you do a systematic review and you follow guidelines for guidelines versus when you don't this is a study from the ACP or the American College of Physicians when they change their hemoglobin a1c goals last year what they did is they took the major diabetes guidelines and they graded them and what we see here is what is dead last the AACE followed closely by the ad a because there's not rigor in the development these are not things done with systematic reviews when we look at the VA and the DoD here it's very high ranked because they followed the guidelines for guidelines we have to ensure guidelines are based on rigorous evidence review it's critical especially when we're talking about diabetes the crazy epidemic in this country and around the world so doing proper scientific review is critical to getting good guidelines so let's remember three ways to reverse diabetes surgery very low calorie diets low carbohydrate diets talk with your patients the decision is theirs thank you [Applause]

Channel: Low Carb Down Under

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Keywords: Low Carb Down Under, LCDU, www.lowcarbdownunder.com.au, Low Carb Denver 2019, #LowCarbDenver, Type 2 Diabetes, Virta Health, Obesity, Bariatric Surgery, Low Carb High Fat, Very Low Calorie Diet, Low Carbohydrate Diet, LCHF, Diabetes Reversal, HbA1C

Id: Q_6dKfHApC0

Length: 34min 17sec (2057 seconds)

Published: Sat May 18 2019