Ketogenic Diet for Diabetes with Sarah Hallberg, DO

welcome everybody to functional medicine Grand Rounds today we're really delighted to have Sara Hallberg dr. Sara Hallberg who I've known for a little while I've mired for a long time and is doing remarkable research and work in reversing type 2 diabetes metabolic diseases using food as medicine particularly a ketogenic diet and published number of studies this year looking at both the cardiovascular locations as well as the outcomes on reversing diabetes and and one for the company that's very disruptive and in a word disintermediating which is a big word but it means it's disrupting the healthcare system by doing services that the healthcare system might or could or should probably do but doing them outside of the healthcare system through a digital platform then involves coaching and support and medical supervision and is published on that work and she's the medical director of Verta health corporation which is a company that's designed to deliver healthcare services around metabolic disease online using support and coaching and medical supervision and it's developed the first clinically proven program to reverse type 2 diabetes she'll talk about that she's a physician an exercise physiologist a passion for helping people be healthy through diet and exercise she's supervising all the team of physicians and the clinical strategy she's also the executive director of the nutrition coalition which I'm on the board of as well it's a nonprofit organization that aims to strengthen public and policymakers education about the need to improve nutrition policy so it's founded on a comprehensive body of conclusive science where science is absent and to encourage that additional research so she's a low carb enthusiastic Hallberg practice which increases by living a ketogenic lifestyle so welcome dr. Halbert thank you so much I am really glad to be here thank you so much mark for inviting me so today we are going to cover a lot talking about ketogenic diets mostly for type 2 diabetes but I am going to do a little bit about obesity as well and we've got a lot of slides to cover so I'm gonna go through quickly but then I'm happy to answer any questions at the end so here are my disclosures and I also want to disclose again mark already alluded to it my personal bias because I think that it's really important for us to be discussing our personal bias when we talk about nutrition and nutrition research because my personal bias is definitely low carbohydrate nutrition now that being said I was probably Dean Ornish's number one fan some years ago ok I spent over a decade preaching a low-fat diet and was pretty close to being a vegetarian absolutely ate no red meat for again a very long time my two oldest children didn't have you know any kind of meat until they were much older and why did I convert because I had the opportunity to spend an entire year supported by Indiana University health with my nose in the literature trying to figure out how we were going to going to start the obesity program at IU and in doing all that research I realized that there is a lack of evidence for what we have been telling people for so long eat a low-fat diet right eat less and exercise more that's what we always tell people and so I came about it just with really having that opportunity to take a deep dive in the literature and when you do which is so hard in the busy lives all of us health care providers lead it's amazing what you find ok so our objectives here today and we'll kind of go through all these I won't go through them individually right now so let's start off with exploring the state of the problem with diabetes and obesity I mean the question is why am I even here today right we know that we have a huge problem we are in the midst of an unprecedented epidemic of diabetes and obesity in this country and I'm sure I don't have to convince all of you of that because you see it showing up in your offices every day but again when you really look at it graphed out it's really staggering and what we see here is that the most concerning is if we look at the extreme obesity right I mean extreme obesity was something we didn't used to see several decades ago and now you can't miss it right it's all over the place and of course these people are suffering significantly going back this is also a huge problem and becoming worse again in children and if we know that the children who are obese early on have a just almost guaranteed and struggle with this lifelong so we've got to address it and we've got to start addressing it in the youth as well and diabetes I'm it's staggering over half of the adult population in this country now has diabetes or prediabetes over half and of course that doesn't include everyone with insulin resistance you add just insulin resistance on this the numbers are even higher and the last day to here on this this was published in JAMA was 2012 data we know were worse now so I mean we have to do something not only again does this impact the lives of all of these people who are affected by this we can no longer afford this take a look at what happened in just six years here to the cost of this it is breaking us we have to do something the time is now all right so let's talk about what a ketogenic diet is and the physiology behind it because I get asked all the time people who read on the internet they get these ideas of what a ketogenic diet is and oftentimes they're wrong then they have problems and they think the keto diet doesn't work right well well understanding exactly what it is is a key ok so here in a quick nutshell a ketogenic diet is a low carbohydrate diet generally under 50 total grams of carbohydrates a day and that's really important because a lot of times people use net carbs we choose not to do that because it becomes confusing for patients it's just total carbohydrates under 50 grams a day for metabolically well individuals however for the patients that I take care of who are not metabolically well who have the insulin resistance the pre-diabetes and the type-2 diabetes we generally at least need to start even lower so we counsel our patients to start at under 30 total grams of carbohydrates a day and then we adjust that and personalize it from there so what we see is that many of our patients if not right away can eventually tolerate even higher carbs like up to maybe 50 grams a day or so but again we start at that under 30 grams and then depending on their results blood sugars ketone levels we can help counsel them to add carbohydrates in depending on their personal tolerance adequate protein not high protein so one of the other things that you see online all the time is that this is a high meat diet it cannot be a high meat diet okay it absolutely can't in fact it doesn't even have to contain meat for people who choose to that's fine but they cannot consume high amounts of meat because that is the excess protein is anti ketogenic so what we have to do is adequate protein or what I like to call it is just adequate protein or moderate protein and usually for us it's 1.5 kill up milligrams per kilogram of ideal body weight so it's the one time that would go back to the height weight charts and take a look at those to help us dose our protein and then they take fat until they're full so the idea is to fill in with fat to satiety and so the idea of talking about satiety all the time when following a well formulated ketogenic diet is really key one of the things that we see is people say well on the internet it said I have to have 80 percent fat so at night I realized I didn't have enough fat so I just started zooming fat for the sake of consuming fat right and that's no you don't need those excess calories okay you take the fat to fill in until you feel full we don't want people walking around being hungry right that's a certainty that this is not going to be a sustainable plan and the fat sources include saturated fat but also high in MUFAs so we have our patients on a lot of olive oil and avocado oil and macadamia oil okay so why does it work and it important to understand this is to kind of go back to the real basics and there are four macronutrient classes and three of them are food so we'll focus on those of course it's carbohydrates fats and proteins and you know when we talk I'm sorry what alcohol is a macronutrient yep uh-huh alcohol is a macronutrient yeah yeah and you can have alcohol certain kinds on a well-formulated ketogenic diet but right now we're gonna focus on the food and when we hear people say a calorie is a calorie is a calorie right that idea that mindset completely ignores hormonal responses okay we all know how important hormonal responses and individual hormonal responses are to the way we function in general and okay and the hormonal response is when it comes to the macronutrients are no different so let's take a quick review how do we use these macronutrients well we use carbohydrates as energy and fat we use as energy but there's other important aspects too fat to protects our organs insulation fat soluble vitamins for protein again the list is you know longer yet again and the important thing when we look at these three categories is how many of these three categories are essential for humans to function well we know we have essential fatty acids right we have to consume those we have essential amino acids but who's ever heard of an essential car no you have it why because it doesn't exist okay they are not something that's essential do we consume them yes on a well-formulated ketogenic diet are you gonna consume them yes are they essential no all right so going back to those hormone responses right a key hormone here is going to be insulin because we know even before we get those elevated blood sugars before someone gets into that pre-diabetes and then diabetes range what we see is insulin is elevated in type 2 diabetes associated with insulin resistance and those elevated insulin levels can go on for years even decades before we have a problem with the blood sugar starting to rise and so we have to ask ourselves well of these three macronutrients what causes insulin and then eventually glucose to rise and although I stress all the time individual variability individual responses personalization is key there are certain things that are pretty consistent with humans and our hormonal response to these macronutrients are one of these things when humans consume carbohydrates it causes our insulin and blood sugar to rise okay protein is variable but the most important thing is what happens when we consume fat the macronutrient that we have been counseled to avoid for so long there's no insulin and blood sugar response to fat and that fact right there is key to why fat needs to be part of a science-based nutrition plan for people who struggle with metabolic disease alright so is it just the hormonal response right that makes a ketogenic diet make sense and have an effect and the answer is no there are other there are other aspects as well in one of the big ones is the inflow in response so this is just one study there was another wonderful one looking at how beta-hydroxybutyrate the active ketone also influences our genetics actually and our histone deacetylase complexes to decrease inflammation but this was just another one looking very specifically at the mechanism of how beta hydroxy butyrate decreases inflammation and when we talk about cardiovascular risk right we know inflammation is involved in every step of the pathogenesis of coronary artery disease so getting control of inflammation is going to be key too so an important part again of the mechanism and I'm going to talk more about our research later but I just wanted to show you here our one-year results of a large group of patients with type 2 diabetes 262 to be exact and what happened at a year our patients the intervention patients are in blue our control patients are in grey which are the usual care group with inflammation at a year so we saw some significant decreases so the c-reactive protein at a year dropped by 40% in the patients who are following a well-formulated ketogenic diet yes uh-huh okay so going back again and looking here on comparing the advice that we've been giving for decades to a low carbohydrate nutrition plan and what it looks like for simplicity we put it up there as a pie chart but remember the pie chart can vary a lot we don't want people stacking up at fat with fat at the end of the day ok just as a general idea and our low-fat approach over the last few decades ok which have of course ruled our nutrition advice during the time of this terrible epidemic our counterintuitive ok when it comes to the actual human nutrition physiology here and a low carbohydrate plan makes sense with our physiology so in other words the advice that we are giving our patients we have to put it put ourselves in the seat of our patience okay the advice that we are giving our patients essentially has caused them to try to work against their own physiology right and then it doesn't work the patients get frustrated and what do we do we blame them because they can't work hard enough against their physiology what we need to do for our patients is help them get the physiology on their sides and right here is a very easy way to illustrate how they can do that by changing their macronutrient ratios all right so really quick I know again everyone here is well versed in this but the question is what is carbohydrate intolerance or insulin resistance right and so I like to use this diagram because if we go back to the low-fat diet right people are saying it's healthy carbohydrates that we want to eat and I think everybody would acknowledge that most people have been told right that whole a brown rice excuse me is a healthy car right it's something that patients with type 2 diabetes are instructed to eat often but if you take a cup of brown rice what we see is that there are 45 grams of carbohydrates in it if we convert those to sugar actually that winds up being nine teaspoons of sugar that these people are getting in and now you take someone who has a high carbohydrate tolerance okay or someone who is not insulin resistance they're still gonna mount an insulin response to the carbohydrates remember those graphs carbohydrates cause our insulin to go up but it doesn't have to be that much of an insulin response okay because their body is responding well to that insulin okay their insulin sensitive but if you take the exact same food and someone with a low carbohydrate tolerance or who is insulin resistance what we see is that the insulin response that they have to mount to the healthy carb okay is very high and insulin is our fat storage hormone so of course we add on to this on to the insulin resistance it's a problem now with obesity okay because they've got these really high levels of their fat storage hormone around all the time and so again the difference high carbohydrate tolerance low carbohydrate tolerance and I tell my patients with the low carbohydrate tolerance all the time I'm sorry this stinks for you okay but it is what it is and we have to manipulate what you're eating to help you work around it and so again our approach to these patients right so to someone with type 2 diabetes again going back to our standard of care number one we've been telling everybody to eat a low-fat diet working against their physiology and then our plan medication wise is to increase their insulin even more let's think about that right we got a prop person whose problem is high insulin levels to begin with and what we do with a patient with type 2 diabetes right they eventually wind up with insulin or they take medications that cause their insulin levels to go up okay I mean this is not a solution okay this is akin to putting a band-aid on a bullet hole at best okay because we know what happens the next time we see that the patient with an approach like this those medications need to be upped right and then the next time upped and then what happens to these poor patients right they just put their head down and they say I give up all right and and that's not fair okay so one of the questions that we get all the time and concerns people have is wait a minute if I'm not eating carbohydrates how am I gonna get any energy remember when we saw that table at the beginning carbohydrates can provide energy and the answer is our patients get lots of energy but they're getting it from a different source now remember because insulin is our fat storage hormone when we're consuming carbohydrates which cause our insulin levels to go up it's sort of the same as putting a big lockdown on all of our stored fat so we lock we can't access it right because the insulin is saying store store store for a rainy day but when we decrease the carbohydrates and we can decrease insulin and holy cow now all the sudden we have access to two sources of energy the fact that we're consuming but the fact that all the sudden is unlocked by that decrease of insulin and so these two sources of fat in the liver are converted into ketones okay and ketones as it turns out are a wonderful source of energy and actually the preferred source of energy for some really important parts of us like our brain and our heart and our skeletal muscles so not only do our patients have the energy that they need they have a consistent flow of energy and again probably all of you have personally experienced the carbohydrate rollercoaster even those who are metabolically healthy right you get that surge after you eat and then you have that trough right and so you have to eat again to get energy and then you fall again but with utilizing fat for energy of course we've got even if we're not eating fat we've got all the stored fat so we have this much more consistent energy source and that helps in the way that people feel as well okay so this is straight from the American Diabetes Association guidelines right which again the eating patterns that they recommend are - diet Mediterranean diet and plant-based diet and what do they all have in common they're all low-fat the Mediterranean diet definitely can be done higher fat and I think it is a great choice if it is done in a high fat manner but as a general rule they're all low-fat interventions and so this is what they say straight from the guidelines total amount of carbohydrates eaten is the primary predictor of glycemic response for a disease whose problem is elevated glycemic response right so here's one of our patients now this is a patient I love this his CGM data because this is a patient with very long standing that continue excuse me continuous glucose monitor is that is anybody using these with their patients or seeing their patients with these okay I love the continuous glucose monitors I just I think they are going to be the game changer once and for all on this because patients have access to what's going on to a degree that they never had before and they can say oh my goodness I can't eat that so this is the graph from a CGM for one of our patients who had very long-standing diabetes who presented to us on insulin with insulin dosing over a hundred units a day which for the patients that I see is actually on the low end of the insulin okay we see regularly patients with over 200 units a day all the time this patient had over 100 units for years and this is him off all insulin okay off all insulin and look at that curve why because he eliminated or decreased significantly the carbohydrates he was in taking and of course when we remember total amount of carbohydrate eaten is the primary predictor of glycemic response we can get to this glycemic response these little bumps that he's having these little prolonged bumps that's protein he's reacting the protein okay but it's hardly an excursion there okay so do our patients eat no carbohydrates no that is another one of these misconceptions around a well-formulated ketogenic diet well you can't eat carbohydrates not true okay our patients are eating carbohydrates in fact we really press patients over and over five servings of non starchy vegetables a day okay and then they also get nuts and seeds limited berry fruit dairy but what are they not eating and this is really important and I use this like GPS all the time I tell my patients just remember what you don't want to be eating okay grains potatoes and sugars these are the I'm sorry beans most of our patients with type 2 diabetes cannot tolerate beans it depends again on what eventually their metabolic flexibility that's the word I like to use becomes remember I said everybody starts out at under 30 grams and then we can build and see individual responses to see can they add more later and beans would be definitely one of the things that they could add later if they can tolerate it but beans do cause a blood sugar excursion and our patients with type 2 diabetes and some can tolerate it some can't okay but grains potatoes and sugar are things that even our patients who regain some metabolic flexibility these are the kind of things that they just need to stay away from all right so is it crummy food then I mean can you have to suffer through eating a well-formulated ketogenic diet I mean no and this is one of the keys to sustainability number one you want to give them what works with their physiology instead of against it and then you want them to enjoy it okay so this can be full of wonderful foods and again the idea of going under 30 grams of carbohydrates a day seems daunting and people think they can't do it until they actually take a look at what that looks like it actually is good and there are incredibly diverse ways that you can eat this way so we work with a lot of different cultures as well okay and you can you can help personalize this so that anyone can eat this way it doesn't matter what their food preferences are and it doesn't matter what their family traditions are you can make this fit okay so history of a ketogenic diet and the associated risks and benefits this is what it used to look like I know this is not perfectly clear but my friend Osama Hamdi gave this to me and dug it out of the Harvard archives this is how we used to manage this right we used to do these carb tolerant test I mean just talk about high maintenance here to figure out patients with diabetes how many carbs they could eat okay and you know the origin of low carb diets actually began with doctor Joslin himself okay in one of the first patients he treated interestingly with a low-carb high-fat diet was his own mother who had type 1 diabetes and of course way back when type 1 diabetes was quickly fatal right except for his mother lived 13 years with type 1 diabetes because she followed his advice to eat a low carbohydrate high-fat diet um and this is from medical textbooks way back when when we used to get it okay when we didn't have other choices I mean take a look at what's on here this is a well formulated ketogenic diet okay that's what they were instructing people to eat this is not new this is not new then what happened well we discovered insulin and heavens knows I am NOT saying insulin was not a wonderful addition in medicine I mean it saved countless lives of patients with type 1 diabetes right we couldn't do without it but it became a way to mismanage type 2 diabetes okay that's what it that's what it wound up doing so absolutely essential we need it for type 1 we utilize it to mismanage and forget what we used to know when it comes to type 2 diabetes and so again oops is right how can we now back out of our old advice okay and get everyone to embrace the idea that we can truly use food as medicine all right what about the risks are there any risks I get this question all the time is there anyone who you shouldn't put on a ketogenic diet yes one patient who has familiar hypo hyper chylomicron emia should not go on a ketogenic diet they have to eat an extremely low fat diet the incidence of this is one to two out of every million okay otherwise I have patients with transplants on it I have all kinds of patients on a ketogenic diet okay kidney stones honestly we don't see this in our clinical practice it has not been well studied in adults the incidents and children is about 5.4 percent but theoretically it's a risk for adults to increased LDL P or a poby I will say that this appears to be confined to metabolically healthy individuals because when we look at all the studies and piece in patients who are metabolically ill what we see is that there's not increase overall in LDL P arepo' B halitosis is temporary it's very temporary gall bladder the only time we have problems with gall bladder is when people have been eating a low-fat diet for so long in their gall bladder is full of stones theoretically if you then start a high-fat diet and you're now causing squeeze of the gall bladder you could um get a stone lodged but interestingly I have never seen that I have thousands of patients the only time we see our patients getting gall bladder issues is when the starting of the squeezing of the gall bladder uncovers a calculous cholecystitis which would have probably happened anyway we just maybe ramped up the timeline they tolerate it fine after cholecystectomy so them I mean if we think about it you know in the obese and metabolically ill patient population which is who I take care of I mean it's I don't know the exact number but it's probably close to 50% of them have already had their gallbladders out and they all tolerate it mm-hmm some people who may feel like oh I can't maybe I got a little diarrhea we may just have them say don't eat so much fat at once right we want to increase it through the day but honestly we just don't see a big issue with this it's not a big issue and other symptoms you hear about headaches fatigue keto flu that's just a sign that their sodium levels are low and that these people need extra sodium alright so what are the benefits okay of you know ketosis and the black are all the things that we know are have been shown clinically in research studies to be a benefit of nutritional ketosis the ones in blue are kind of the science is emerging there but we certainly can't say definitively that it's going to be benefits so there are a lot of benefits already known and it'll be really exciting with some of the research on some of these other very specifically neurologic disorders come out what more we're going to be able to stay say about this metabolic state this is not news the the concern about this is sadly enough this article was in 2003 and here we are right all these years later and we still haven't changed our tune you know pushing back against the status quo is just hard let me tell you and but we have to go back to the basics which is what we are saying and what we have been saying our status quo is failing our patients miserably okay we have to look at a new or I'll say old approach okay so I'm going to really go through this quickly I think there you're gonna have access to the slides you can go over I I've actually eliminated a lot of the studies here but I'm gonna sum them up in a later slide so we're gonna kind of go through this quickly for the sake of time but this was a study looking at a three arm low carbohydrate Mediterranean and low-fat diet um and again this was done a while ago this was back in 2005 a two-year randomized control trial a good in size 322 patients adherence check out the adherence rate okay it was like almost 85% that is unheard of right in a nutrition trial and so of these three groups we have the low fat the low carb Mediterranean here's what they did important to note that the only group who was not calorie restricted here in these three arms was the low carbohydrate group okay because we don't have two calorie restrict people on a low carbohydrate nutrition plan to make it successful and what happened well this is a graph of obesity okay our excuse me weight loss and we can see again low carbohydrate nutrition plan did work the best but also an especially for me we look at the much smaller cohort of patients with diabetes and what we see is that at two years the only group that had a significant decrease in the a1c still was the low carbohydrate group and what we see is actually that glucose went up in the low-fat diet again not surprising it's fighting against their physiology okay so this is great because this was actually a metabolic ward study okay ten patients with type 2 diabetes hospitalized day one through seven they had their usual diet and then for two weeks they were switched to a low carbohydrate diet a true low carbohydrate diet this actually was under 20 grams of carbohydrates a day and so what happened in that short of a time period I mean it's pretty remarkable okay glucose and insulin plummets and it plummets fast and once again this is really important for adherence for patients because they don't have to wait until some like you know time in the future for them to be able to see the results they can see these results quickly and in fact when it comes to medication reductions they can see them the next time they go to the pharmacy it's amazing okay so I'm just gonna again sort of go through this this is a twelvemonth comparing moderate carbohydrate which is the typical ad a plan to low carbohydrate again low carbohydrate wins out and in weight as well and so this is a two-year randomized control trial this one was interesting in they did a low carb and low saturated fat group and at two years the blood Sugar's were about the same but the medication reduction was significantly greater in the low carbohydrate group and they had these patients on the continuous glucose monitor and the low carbohydrate groups had much few had much fewer excursions okay so they were much flatter at the end so some critical important things there okay so then this is also low-carbohydrate has also been compared to a low glycemic index plan again low carbohydrate outperforms that as well and this is an interesting one because it looked at a ketogenic diet in two arms one arm was patients who started out with type-2 diabetes and the other arm were people who started out without - or metabolically well and what we see when we compare the two is it works in both and at the end of the 56 weeks these patients were meeting up right the patients with diabetes were really matching up with the patients who did not have diabetes at the start of the trial and we see here when we talk about body weight and we talk about cholesterol there were again improvements in both groups yet another one this is a 32 week trial comparing a DA method versus a low-carbohydrate with the low carbohydrate arm doing significantly better this is one looking just at metabolic syndrome again you can see the pie charts with what the patients ate the intervention arm was getting physiology on their side and we see that with the results so again improvements in insulin resistance scores and also after genic dyslipidemia and here these two groups were calorically identical so they did actually control four calories in this and low carbohydrate arms and better metabolically um so there have been a number of systemic review and meta-analysis looking at these and they are generally very positive to low carbohydrate interventions but it's really important also to deep dive into some of these meta analyses again this is one here which said yes low carbohydrate does better than our standard of care but when we look at the force plot here and we look at the low carbohydrate one what we it looks like they're okay studies did better in the low carbohydrate arm but there are a couple studies there that didn't seem to do as well what is up with those studies why would those studies in the low carbohydrate arm not be as successful so we go to those studies and we see specifically the low carbohydrate arm was minimizing the intake of saturated fat and encouraging grains okay these were not low carbohydrate diets so unfortunately here the semantics do matter okay people will say low carbohydrate diets when you truly look at what the patients were eating it wasn't a low carbohydrate diet and despite that the low carbohydrate arm still did better but it was really more moderate carbohydrate and the second trial it's the same thing okay they were counseling patients to increase fat by 10 percent that is not a low carbohydrate diet okay again another this is actually an American Diabetes Association systematic review same thing when it came to the conclusions about a low carbohydrate diet but it said that they were short duration and in some cases were not randomized or had high dropout rates so hold tight on that thought for just a minute we're gonna come back to that and I just really quickly wanted to mention this study that got a lot of press when it came out and it talked about how ketogenic diets do not give us an advantage metabolically when it comes to weight loss that was the conclusion of the study and that was certainly the immediate tension that came from the study as well but it's really interesting because that's not what the data said so here we look at the weight data the problem with this study is it was not randomized okay everybody started out with the kind of standard diet that was supposed to keep their weight stable and then switched into a ketogenic diet but what we see is the weight did not remain stable initially okay they were unsuccessful in weight stability they were losing weight during the run-in period but then look what happened despite that they had already lost weight as soon as they started the ketogenic diet which is let me see here do I have a yeah so as soon as they started no can't see it on here soon as they started the ketogenic diet right here right they still lost weight right they still had weight loss and so what this wound up being depending on which method you want to analyze their caloric expenditures there was a 100 to 150 calorie difference advantage to a ketogenic diet and everyone's like well that is irrelevant it doesn't matter but wait a minute let's do the math on that okay let's just presume it to the lower end of that in a hundred okay if you look at that that lines up being ten pounds a year and what's the average weight gain over time and you know people are gaining about ten pounds right and so actually this is a hugely significant trial yet it was portrayed very different contrary to the actual data in the media okay so is there science behind carbohydrate restriction remember what that one meta-analysis there the systematic review said there's you know the studies are sure there's not enough randomization 20 randomized control trials for low carbohydrate in the treatment for type 2 diabetes 5 meta-analysis and 10 other published trials all supporting carbohydrate restriction for diabetes treatment how does it stack up against the other eating patterns recommended by the ABA there it is there it is okay so the concept that there's no evidence for this in the treatment of type 2 diabetes is false it's just false okay that is not what the studies the literature the data will tell us there is significantly more literature supporting low carbohydrate intervention for type 2 diabetes alright but wait a low carbohydrate diets gonna kill me right we just saw this last week my goodness gracious we can't eat low carbohydrate diet because you will die alright so here is what you know again the media picked up right the media loves these kind of studies oh my god you know the sky is falling okay so let's take a look at this problem with this study number one it was not a clinical trial this was a prospective cohort study okay and there are multiple issues with it multiple I'm not gonna go into all of them I'm gonna give you some of the high points so nobody in this trial was consuming a very low carbohydrate intervention yet they extrapolated this again look at look at the risk here it just continues to go up go up go up but except for there was no data on that they just said hey let's just keep the line going right there's nothing to support that low carbohydrate high death rate they didn't have data on those people all right and the other effect is that again this is a pro spective cohort study they had two time periods where they surveyed these patients about what they were eating and so they were relying on diet records okay diet records are notoriously problematic and here's a really good example of why they're so problematic in this study the average patient 45% female 54 years of age BMI of 27 okay the patient reported calorie intake was 1600 calories a day what does someone with that general description need to stay weight stable okay they need 24 to 2600 calories a day to stay weight stable where are all the calories what we're missing 800 to a thousand calories in the patient-reported intake we're missing how can you say anything about the data when this is really typical of what happens when we utilize the food records in these prospective cohort studies and again so here this is a study looking at okay if we take what the prospective cohort studies say right relying on the food records and we compare it to when the question at hand was actually tested in a clinical trial this study found that the prospective cohort study was correct zero out of 52 times another study by John I&E Dee's at Stanford did find better he found that they were correct 20% of the time okay but these are the studies that the media loves okay and so we have to be incredibly cautious and one of the other problems not necessarily this data set here but most of the data sets when we look at these prospective cohort studies the data sets are locked down no one else can have access to analyze it which is a really huge problem as well okay so I really want to quickly talk about our study ongoing it was done the first two years in conjunction with IU again where I'm still the medical director of the obesity program oh yeah okay I should have said that too right again so many things to point out I just don't have time with this study but yeah the low-carbohydrate group was more likely to be smokers have type 2 diabetes and not exercise but you know irrelevant whatever it'll still kill you apparently so ongoing study at Indiana University so we took a look at a large study this was almost 500 patients altogether almost 400 of them were in the intervention arm given a well-formulated ketogenic diet and there almost 100 in the control arm which was they were treated with standard of care by the diabetic educators in the endocrinology department of the almost four hundred two hundred and sixty two of them had type 2 diabetes the rest of the 116 had pre-diabetes and we're going to be publishing the pre-diabetes papers soon I'm also really excited because the data I'm gonna show you is the one-year data and we are going to be submitting the 2-year data very soon for publication so I'm not going to be able to present that today but I'm just excited about getting that out as well okay so what happened with our patients at a year okay a 1c reduction really dramatic okay and dramatic fast but then it continued to improve throughout the first year and again the patients were improving their a1c but they were doing it while they were simultaneously getting rid of medications okay the medication decreases were profound a hundred percent of patients off self on e area ureas 94% percent of the patients who began the trial on insulin had the insulin decrease or totally eliminated just imagine what that does to the quality of life and the financial life to one of those individual patients in that group the I don't know the exact end but you can see here it's a pretty significant amount of them so I mean in the the end of fun stuff I'll tell you right now so we're in over three years into this trial now and just last week actually was the week before last we took another patient completely off of insulin so for some people it takes a little while all right but we still we still are getting rid of it even today and of course this leads to lower cost too when you're taking people off of that medications they cost less do patients stay engaged because one of the other criticisms that we get is you know they can't stick with it it's not sustainable actually um 83 percent retention at a year don't tell me that's not sustainable and weight loss not our primary goal in this study but patients lost anyway average of 12% body weight at a year and you see we didn't have typical nutrition intervention for weight loss we're at 3 to 6 months we went back up again alright so again we not only published the diabetes data we also have a publication on the cardiovascular risk factors and what we see is significant 22 out of 26 risk factors improved well what is the one risk factor that did not improve and that is the LDL C did go up by 10% however the LD LP and the April be better predictors of cardiovascular risk in this population specifically actually went down not statistically significant but the important part is those concerns that everybody has that the LDL PA poby will go up did not happen so the four that didn't improve I can't remember specifically what are the ones that didn't improve sorry can I can I can we come back to that later okay sorry I present this data so much and that's a really good question I should know the answer to 10-year risk scores improved and again did not got worse in the control group liver functions we actually have a paper in review right now looking at fibrosis scores and the improvement in liver function and did they actually eat a ketogenic diet one of the problems in nutrition research once again is we rely on those food records right to determine if people actually did what you instructed them to do except for this trial here we used beta hydroxy butyrate levels that we were measuring okay and they had elevated levels of beta hydroxy butyrate I will tell you they were eating what we asked them to okay we have again the serum data to rely on which is fantastic okay and feedback loop we're going to talk about that right now review how to support lifestyle changes so you know every once in a while you can get someone who you can give these really general like that very first slide you want to be less than 30 grams you want to have moderate protein and you want to fill in with fat that's all you have to say to a few people and they go home and they do it and they do it forever and it's perfect okay that is the exception not the rule okay most people need support they need long-term support and they need support from many angles they're battling our society right now and all of the carbohydrates all over the place and so this is how we supported our patients okay we supported them from many different angles we supported them because they each got their own health coach okay and they actually interacted with that health coach over two times a day initially they all got their own physician so that way the physician can decrease the medication safely okay and effectively they had a patient community that they could get support from they had a resource an entire resource pool where they could learn about everything from cholesterol to protein to what to bring to a fourth of July barbecue and they had biomarker tracking so they were able to follow these biomarkers which included weight blood pressure and patients with a history of hypertension blood glucose and also ketones over time okay and now what's really cool is in my community in Lafayette Indiana we actually have a sixth one that we don't see represented here and that's because in my community we have hit a critical mass of patients doing this so there is now community support because the restaurants in town like the big Italian restaurant you can get any of their pastas with zoodles okay I mean the restaurants are accommodating to this the grocery stores are accommodating to this everybody knows somebody doing this so we had something we didn't have to create which was just the community support and we can do this in other communities as well you have to give them advice that works okay you have to not continue to tell them to eat less and exercise more and that is it so I'm sorry I ran close to time so we don't have as much for questions but I wanted to get it all out so thank you very much [Applause] [Music] um hypokalemia so so we don't generally see that as long as patience again are taking an adequate sodium right we want to so the concern with that is because initially with a low carbohydrate diet you diurese okay and you can spill out all kinds of things when we increase the sodium right we're not gonna die or eise as much and that can definitely help the other thing too is we do have most of our patients on magnesium as well but as far as the hypokalemia goes we don't generally see this because we check labs you know all the time in these patients so as long as we're pleading sodium keeping them from diary seeing quite as much and as long as we put them on magnesium which we do if anyone has any kind of muscle cramps we instantly put them on magnesium and realistically I mean most of the US population are on or not a ketogenic diet should probably be taking magnesium because we used to get it right from our fruits and vegetables and things and now they're all growing in magnesium depleted soil so don't usually see it but those are just a couple of other like electrolyte things that we take seriously yeah [Music] yeah so that's great a question and so you have to be on top of them right I like to say what my expertise is is I am an expert D prescriber that is that is my like medical expertise and so this has to be it's an art as well as a science so we decrease our patience even believe it or not the ones who have uncontrolled blood sugar when they start we decrease their medications before they start dietary changes and then we're on top of them and oftentimes we are adjusting insulin in some patients on a daily basis and then when do we like relax a little bit we relax as soon as we get them off of insulin and celfon areas right and so we you know my philosophy is remove the self Ani area first okay because I think it's just in general bad for patients and the reason I remove it first also is because it makes patients feel good they can get off that Salani area either before they start dietary changes or within a week or so and like score that's a big win from that for them at the beginning right down one medicine already and then the next thing we go after is the short-acting insulin because if they are eating a well formulated ketogenic diet they shouldn't need it right that's Neill coverage and then the last thing we work on decreasing is long-acting insulin okay that being said in some of our patients we will decrease all three of those things before they start dietary changes in some cases right and so it can be challenging because the fact of the matter is when a patient presents to you you don't really know the degree of in Slovenia that they have okay some of these patients with long-standing type 2 diabetes are just not producing that much insulin so it's really hard to create an algorithm for this because everybody is a little bit different [Music] oh yeah yeah and actually that was demonstrated by Cahill you know many decades ago that when you have elevated levels of ketones right that that is used by the brain okay and so people can write instead of getting these hypoglycemic reactions they can tolerate lower levels and again I don't want anyone on insulin with with a 50 okay but what we see is that can happen in patients who are not on some of these concerning medications and we don't really worry about it that much okay yeah great question we don't know so do I think that a paleo or like a higher fat Mediterranean diet can be used successfully absolutely will it have diabetes reversal rates right like how do i define reversal define reversal as an a1c below 6.5 of all diabetes medications with the possible exception of metformin because that's got indications outside of type 2 diabetes will you get there in as many people on a higher carb then intake the answer is I don't think so I don't think so right when we there's actually a study that looked at a typical Mediterranean diet and a very low carb Mediterranean diet and the low carb Mediterranean diet did better but but do I think that that's an option for some people who came in maybe not as metabolically unhealthy absolutely and so what role specifically does the beta hydroxy butyrate play well again we know that it helps with inflammation okay does it have to be elevated for us to have this reversal or is it just because the carbohydrates are decreased so much I don't know no one knows it's a great question it's one that needs more study I think the thing is that there is so much emerging science on beta-hydroxybutyrate with other advantages and this is kind of what I talk to my patients I I you know I tell them I don't know I don't know the answer to that I know the lower that we go in carbohydrates the better result we're gonna get with the type 2 diabetes that the studies that are out on beta hydroxy butyrate are incredibly exciting with other things that they can benefit us does it have to be for the type-2 diabetes we don't know exact account I believe are going to play a role in diseases but I think that they're going to play a much more main role in diseases like neurologic conditions and maybe cancer I don't have as much confidence that we're gonna find a place for them in metabolic diseases because I want my patients to be making ketones from their stored fat you know not we don't know is exactly this ketones gonna decrease the production of endogenous ketones which would be countering you know productive we just don't have the answers to that yet so my advice to patients is no exact escy tones right now okay metabolic ketosis is definitely not going to be a problem potentially a really key part but we don't know for sure did that answer I know like I I'm leaving you with someone knowns but that's where we're at right now with the science [Music] yeah newly diagnosed diabetes you know what their insulin production capacity intact I mean we know that they obviously a diagnosis have a significant decrease but enough to help them with carbohydrate restriction they definitely do better however in our trial and this was really different comparing compared to other childs that have looked at this we took really ill patients with long-standing diabetes the average length of time and our patient population was over eight years and so it doesn't mean that these long-standing patients can't see success and you know again if every patient who walked in the door you know had a number on them or a way to easily get it you can do these two our insulin glucose tolerance tests to try to assess that but it's a bit cumbersome it's really the key at - it's the key to to helping patients develop a realistic goal at the beginning because obviously if they are producing almost no insulin the goal changes right the goal changes - I just want to decrease your insulin I want to help you lose weight I want you to get off the roller coaster and the blood sugar roller coaster especially with a low carb diet but our goal is not going to be removing the insulin however I will tell you you know I'm just specifically thinking of one patient 20 years of type 2 diabetes almost all of that on insulin totally off insulin now for two years and so these these cases definitely happen a lot and a lot of times if we check insulin levels in these patients you know there's that they're still sky-high despite their long-standing diabetes so but you're you're absolutely correct the earlier that we catch these people the better off that they do and the insulin opinio remains a big problem in the reversal success uh-huh so so it started out daily okay and then we did it you know patients were pushed to do it at least one a week so they were can you know yeah right exactly we only used yeah the true beta-hydroxybutyrate levels you know that is a really exciting provocative question like can especially in our adults like can what can we do with a lot of cases right can we can we reverse the course of Lada and you know the jury's still out I think we really need to see more research being done in that field I will tell you anecdotally that I believe we can okay based on patients that I've taken care of but clearly you know anecdotes aren't going to get you very far we need good research on this because I I think that answer is really important no I mean we saw the typical things and really they're pretty matched with the intervention you know we did have a couple of patients in this population who had newly diagnosed coronary artery disease same with the control group I mean to be expected in patients with type 2 diabetes a couple people diagnosed with cancers you know same thing in the control group I mean we didn't see anything that was unexpected in these people right now and that's again a big concern and and and also tell you again not only did we not see it in this trial but when we look at my I you population you know where we have thousands of patients we're not seeing you know the complications that people are concerned of like I said you know we just don't see these gallbladder issues right we don't see any increase in kidney stones where we're not seeing them [Music] yeah that is a great question and and actually we've had a lot of interest in our data set and taking a look buy a lot of electrophysiologist wondering can we impact this because I mean probably because we're improving sleep apnea right and and that can help with afib we don't have any hard data from this study but I think again with the interests that have been raised in the cardiology community around this we're hoping to be able to help get another study together on that specifically but just another one we have a paper that was just submitted specifically on sleep as well again because I think it's going to be central to this question it'd be City in general oh right ketogenic diet absolutely improves mm-hm right Yeah right I it correct we just we don't have the data on that yet but again I think it's a it's a big area of interest and I think we'll soon see a study get together on that but not in this in this trial we don't it's a great question though in a really important area I agree yes they do [Music] it's totally personalized at that point you know um so but we really encourage them to stay pretty low if they've had metabolic disease in the past even if right now they're you know normal glycaemia but there's a really huge difference between under 30 grams and under 50 grams right that that really is and and what we find is over time most of our patients can get up a little bit you know closer to that 50 grams and what we do is our encouragement is for variety so people do get bored because they get stuck in a rut and they do that like normally right I mean people get stuck in a rut no matter what they're eating and so as far as the behavioral counseling goes it's to get them out of the rut more than anything and so I'll just kind of on that line it's really interesting so you know a first year with the lifestyle change you know moving to a ketogenic diet is troubleshooting with patients teaching them adjusting medications you know all those kind of more medical aspects of it if you will in education aspects and then after a year it becomes the most important thing from one year on is behavioral health and this is one of those perfect examples I'm bored so I'm gonna fall away you've got to be on top of them saying hey have you done this let's go I mean like this is what I do with patients as I sit through and I say tell me exactly what you're doing now right and we walk through their day of what they're typically eating and again it's it's into some sort of routine okay and we go through each meal and I say okay how could we give you variety here and not increase the time and it's amazing how you can do that when you sit through and troubleshoot with each person but if you did this you'd increase the variety and you'd actually be spending less time in the kitchen or preparing things and but you need to be pushing them on that like it's kind of one of those things where people may be able to counsel and that exact person may be able to counsel someone else to teach them how to do it but they have trouble with themselves so they need someone to come to them and say yeah hey look or they have a life crisis and then you have to counsel them through that that's what happens one year on yeah huh again we don't really see the potassium drop I mean I will tell you in in a few patients who came in to us with a known history of hypokalemia I'll put them on a schedule where we sort of obsessively monitor that and I've done that a number of times and I've just you know no I have not seen it all right people swear that they're gonna have potassium problems I always have potassium problems and we'll put them on weekly checks for a while nothing yeah so I guess I have a little concerns on that because the problem here right yeah so so the difference today right versus then is the is the societies that we live in really right so in the paint in the times when people were in ketosis they were in ketosis through forced right there were force ketosis things weren't available right and nowadays that never happens we don't have like this time where McDonald's is not still sitting on the corner you know the gas station is full of all this kind of junk and so the problem that I see and again it hasn't been well studied so this is just my this is my opinion is that if we try to do that during those non ketosis periods we're going to be increasing insulin levels again and what patients are going to have trouble with is to get back on track and we see that we fight with patients again of you know getting them back in ketosis if they've gotten off track because their hunger increases their cravings increase and it's harder to restart so that's my real concern that situation but again I'll point it out as I have already numerous times I mean there are many aspects of this that need more research and that is one of them and I'll just mention for a minute like people talk about intermittent fasting as well and so we get questions about that and the first thing that I say to a patient when they say that their intermittent fasting is defying that for me what do you mean by intermittent fasting okay and if they say I only eat twice a day I'll say okay that's really more time restricted feeding and good that's working for you do it there's actually evidence to support that if they say well I don't eat for seven days I say right because I mean actually you know the evidence that we have on that does not support that actually says that that's going to be detrimental in the long term to their lean body mass so what we say is no more than 18 hours of fasting okay but if you're doing up to 18 hours of fasting or you get into you know the time time restricted feeding I think that's I like that term much more because it's really very specific to what they're doing you know I if that's working for you great [Music] mm-hmm yeah absolutely thanks so much are you showing up and and listening to this provocative conversation about that we're gonna have also an interview after which will be online and recorded so you'll be able to get a little deeper into some of the nuances of this and the question so really appreciate it thank you [Music]

Channel: The Institute for Functional Medicine

Views: 277,898

Rating: 4.7824044 out of 5

Keywords: CCCFM, Cleveland Clinic Center for Functional Medicine, Sarah Hallberg, Ketogenic Diet, Keto Diet, The Institute for Functional Medicine, Type 2, Type 2 Diabetes, Mark Hyman, Virta Health, Grand Rounds, IFM

Id: I23sr16DqTw

Length: 73min 22sec (4402 seconds)

Published: Tue Sep 18 2018