Dr. Sarah Hallberg (Live) on Ketogenic Diets and Diabetes

– Hello Welcome to our Facebook Live question and answer session

I am Dr Sarah Hallberg, and I am one of the medical directors here at Virta Health, and I'm also the primary investigator of our large clinical trial looking at a remote supported continuous care intervention utilizing nutritional ketosis as a treatment for type II diabetes and pre-diabetes And I am thrilled to be here with Dr Catherine Metzgar – Thanks, Dr

Hallberg As Dr Hallberg said, I'm Catherine Metzgar, and I am a member of our clinical team here at Virta, and I work directly with patients during their time in the Virta treatment So please list your questions today in the comments below the video, and we'll try to get to as many as we can in the next hour – It's really important too to note that this is not intended to be individual medical advice

The thoughts that we share today do not replace any advice from your primary care or specialty physicians – So our first question to get started, – So our first question to get started, how does ketosis and Virta's treatment affect heart health and cardiovascular risk? – Well, Catherine, that is a really great question and one we get all the time And the exciting news that I have to share is we recently published a paper on this exact topic So our paper looking at our one-year results and cardiovascular outcomes again was recently published, and I encourage everyone to follow the link and read it for themselves, but let's talk about some of the really important highlights in the trial So Catherine, of all the risk factors that we looked at, and there were 26 altogether, the Virta treatment improved 22 of those

So from a big overview standpoint, that's pretty remarkable But now let's look a little bit more at some of the granular details here about things that patients are asking about So one of the really important things is that patients who have insulin resistance, pre-diabetes or type II diabetes very often struggle with something called atherogenic dyslipidemia, and let's pause for a minute and break that question down or break that term down Atherogenic dyslipidemia means essentially atherosclerosis causing cholesterol And so what is this atherogenic dyslipidemia? What it is is increased triglyceride levels, decreased HDL or good cholesterol and LDL particles that are very small and dense

This is really the hallmark of atherogenic dyslipidemia, and once again important to stress how very common it is in the insulin resistant patient population So what happened with atherogenic dyslipidemia in our trial? Catherine, the results were really remarkable Triglycerides decreased by almost 25%, HDL or good cholesterol went up by almost 20%, and those small dense particles, what they did is they became large buoyant LDL particles So it's really important also to note that there's no medication that can do this – Pretty awesome

– This is just by changing what? Your eating, can drastically improve something that is a big cardiovascular risk for this patient population But one of the other important things that we get questions about all the time is, I know that my diabetes may be reversed, and all these other improvements may occur, but what's gonna happen to my LDL cholesterol? Well again, we looked at this very specific question in our one-year cardiovascular risk outcomes paper And what happened? Well, LDLC or LCL cholesterol did increase slightly However, and this is really important, when we look at cardiovascular risk factors in a insulin resistant patient population, what becomes a much better marker of risk when it comes to LDL is LDL particle number So how many LDL particles are there? Another term for this is the apoB

This is really looking at how many particles there are that potentially could cause problems with heart disease And what we saw is that these were unchanged through the year, and that is really important So the question that we get asked all the time, I mean the really root question is, I can make all these other things better like my diabetes, like my liver function numbers, but am I making some of my cholesterol worse? And the answer from the paper is no Again, the LDLP or apoB did not change over the year, so that is a really important take home point from the study So that's specifically looking at cholesterol

So what we see is dramatic improvements in atherogenic dislipidemia, no change in those really important LDLP or apoB numbers, and we see a really big improvement in blood pressure, a key risk factor for cardiovascular disease And here's the important point Not only did we get to see patients blood pressure significantly decrease, but they were taking less medication for it So we were making it better while being able to remove medication, so again a critical risk factor The other one that is really important to make note of is inflammation because it is important for everyone to understand that at every phase of the development of cardiovascular disease, inflammation plays a key role

So what happens to the inflammatory markers with any intervention is really important And the best one to look at specifically cardiovascular risk is one called C-reactive protein And Catherine, in this study our patients decreased their C-reactive protein by 40% So again, another really important cardiovascular risk factor made better by the Virta treatment – Awesome, thank you, Dr

Hallberg So our next question, can you point to any clinical So our next question, can you point to any clinical evidence of ketogenic diet's anti-inflammatory benefits? – Yeah, so let's go back to what I was just talking about before, the C-reactive protein, and the dramatic decrease We know that that is an improvement in a cardiovascular risk factor, and then that's an improvement in systemic inflammation overall And we actually have this number supported by a decrease in our study in patients' white blood cell counts because that actually, people think of white blood cells, and they think of elevation in sickness, but the other thing is there can be an elevation in chronic inflammation as well So not only did we see the C-reactive protein decreasing by 40%, but we saw out patients' white blood cell count drop as well

– For our next question, if I'm following a low carb diet, – For our next question, if I'm following a low carb diet, and I start eating carbs again, does that make the fat I've been eating have a negative impact on my cholesterol and heart? – Okay, so what we're talking about really there is, the question is geared towards the past fat that someone has consumed when they're eating a low carb diet, and the answer to that is no, that's not gonna negatively impact their cardiovascular disease risk But what they're talking about doing then is going back to our standard American diet, right? Eating fat and eating carbohydrates, and what we have plenty of evidence for is that that combination is a problem So I would really reframe this a say, okay, I was eating low carb and high fat, and I was doing better Maybe now I wanna add a little bit more carbs into my diet again, but we have to really be cautious about ensuring that those carbs that are added are not exceeding any individual's carbohydrate tolerance, because if you increase carbs over your carbohydrate tolerance and add fat in, what you've done is gone right back to the standard American diet that has failed us for decades – I think that's a really great point, Dr

Hallberg, because it talks about, or it speaks to a little bit how we really try to personalize the Virta treatment to each patient's carbohydrate tolerance levels Thank you for that If you're just joining us, we wanna welcome you to Virta Facebook Live Q&A with Dr Sarah Hallberg Please put your questions in the comments below the video, and to get notified of future Facebook Lives and events, follow Virta on Facebook

So with that, our next question, can you provide any So with that, our next question, can you provide any clinical that the ketogenic diet is helpful in preventing cancer? – So there are a lot of trials ongoing here as a potential adjunct cancer treatment So by adjunct I mean in addition to traditional cancer treatment So in order to answer that question and as a prevention for cancer, there would have to be a really long what we call the hard outcomes trial And I think that honestly we're probably pretty far away from that, but we're not that far away of finding out how a ketogenic die may play a role in cancer treatment, because as I said right now, over the next few years we're expecting many of the ongoing trials in this very area to get published and really help with some insights into this question insights into this question

– For our next question, what are the possible side effects of coming off of insulin when your body does not produce enough C peptide? – Well, let's go back and first talk about C peptide and exactly what is C peptide, because many patients who are getting the Virta treatment may have their C peptide levels checked, and why do we do that? We do that because it gives us a really good idea of how much insulin their pancreas is able to produce So when a patient is first early diagnosed with type II diabetes, on average 50% of the cells in their pancreas that produce insulin have actually died already at the very beginning of the diagnosis because they've been over used for so long They essentially tucker out And so people would initially think okay, look, if I wanna take a look at insulin levels and how much insulin my pancreas is able to produce, we'll just draw a insulin level, and that actually is really problematic in giving us answer to the question of how much insulin is my body able to produce because our insulin levels are very dynamic through the day They're up and down and up and down, so if you're just checking an insulin level, you're not really sure if you're catching a high one or a low one

But they're also metabolized differently So insulin is metabolized in the liver very quickly, but insulin is released along with something called C peptide, and it doesn't have these peaks, troughs and quick metabolism issues that come with insulin So when we're looking at someone's insulin producing ability, what we usually check is a C peptide It tells us how much insulin they're able to produce So how that we understand C peptide a little bit more, let's go back to that question and say how is that going to influence my ability to get off insulin? Well, if your C peptide is zero, meaning your body is not able to produce any insulin any longer, you will not be able to get off of insulin completely

That is a condition called insulin apenia, and it's very similar to type I diabetes where patients aren't producing any insulin It's just that the cause is different In type I diabetes this is an autoimmune process, and in type II diabetes where someone develops low or zero C peptide, meaning they can't produce insulin any longer, it's essentially from pancreas burnout Now people who follow a strict low carb diet who are still producing some insulin, meaning they have maybe a lower but still present C peptide, possibly still have the ability to get off insulin or maybe all but a very small basal insulin Again and that's something that would be very personalized and needs the assistance of a physician

And that is one of the reasons why we have a physician, a Virta physician, assigned to each patient in the Virta treatment, so that we can help patients not only remove medication safely, because that is critical, but also at the beginning take a look in patients who are taking insulin, at the C peptide to give them some realistic expectations about what can be accomplished and potentially at what rate So this is a really important question because C peptide for anyone who has type II diabetes over a long period of time, and has needed exogenous or insulin that's injected, a C peptide can be really helpful in predicting how they will be able to get off insulin, of if – Thank you So our next question, how often is it okay to eat keto So our next question, how often is it okay to eat keto approved fruits and foods containing erythritol or other sugar alcohols? Would you say daily or less than daily? – I would say that it really depends on each individual, and I know that that can sometimes be a frustrating answer, right? Meaning that there's not one simple answer for this, but you know, the fact of the matter is we are all different, and what one person can do does not mean another person is able to do and have the same effect So this is one of the areas where a Virta health coach comes in as a critical piece of the puzzle, because your Virta health coach can help work with you to develop your own carbohydrate tolerance level, and also that can lead over to sweeteners as well because some people, it seems that sweeteners can stall weight loss some, and in other people it seems like they can have quite a bit of sweeteners and not ever have an issue at all

And so it's something that we need to experiment with, and you need to have someone to work with you and support you through trying to figure out what your tolerance is What we can find is that most people, most people can consume at least on occasion sweeteners Other people though, the answer may be that they can have them every day So again, individualized, personalized It's such an important key part of keeping people in good metabolic health and making the lifestyle changes to do this sustainable

– And one of the cases that Dr Hallberg mentioned is the sugar alcohols or erythritol or other sweeteners can stall weight loss So we would be looking at how often are is when including these foods, and how does that impact their other metrics like blood glucose and ketones as well – Absolutely, thanks for saying that That's a really important point

– So the next question comes from an individual So they say I've been following a keto eating plan, but my weight loss has slowed even though I have more to lose I struggle with increasing my calories, and I still believe it's necessary to keep calories on the low end between 1200 and 1500 calories daily Would increasing my daily calorie goal speed up my weight loss? – Increasing daily calorie goals, no, probably not I would say the most important thing is to make sure that you're not hungry because that's that sustainability piece that is key

And if you're not hungry, pushing yourself to eat beyond that would not be a good plan for the long run So a couple of things that I would say to that Number one, a weight stall for a while is very normal So first you have to say, is this truly a plateau or is this just my body's pause period for a little bit? And bodies seem to adjust to a lower weight So we see this in most everyone

So my first recommendation is to be patient on this, and it may take a while for your body to essentially reset So a pause in the weight loss sometimes can be very normal And if you're not regaining weight, I like to tell people think about this What you're doing right now is you're practicing maintenance, and it can be very hard in the long term for people to maintain the weight that they've lost ever more so than to get down to a specific weight So practicing is something that is a really important part of the process for everyone

Now if your stall in weight loss continues on, one of the other things I would do is to go and spend a week really specifically weighing and calculating everything because, and you know I'm guilty of this too, all of us here at Virta who follow the Virta treatment sometimes can fall into these traps where we say oh, that looks like a cup of tomatoes And even people who have been doing this for a long time, I encourage everyone to pause at least every couple of months and spend just a few days literally weighing and counting everything to make sure some things haven't snuck back in And the other thinkg that I would say is has exercise changed? Have you started exercise? Or have you stopped exercise, because sometimes that can impact it Believe it or not, especially in women, what we see often is when they begin exercise, which why wouldn't they? They're feeling better, they've lost that initial weight, they're ready to start moving What happens is that can actually cause a prolonged weight plateau

Now that initially sounds like it could be a problem, but in reality what's happening is they tend to be building muscle And so their body composition is changing, but they're just not seeing it on the scale So believe me, if that's occurring, continue on and embrace that longer plateau, and start to pay attention to things like, wait a minute, my pants fit a little bit differently And you may get cues here that you're doing just fine from things other than the scale – I think those are some excellent tips for getting through that weight plateau and thinking about the perspective from that

If you're just joining us, welcome to our Facebook Live Q&A with Dr Sarah Hallberg If you have any questions, please just add them in the comments below the video, and we'll get to them throughout the hour And to get notified of future Facebook Lives and other Virta events, please follow Virta on Facebook Can a ketogenic diet help fight yeast infections? Can a ketogenic diet help fight yeast infections? – There is not any data on that

We do not have any clinical trials on this You know, yeast infections usually are caused by they can be in warmth, so warm places in the body, you know, people can get them anywhere from underneath their breasts to underneath (mumbling) to vaginally And again, sugar does feed yeast infections So I think that the basic science is there that this may truly be a help, but we cannot promote that because we just don't have rigorous clinical trial evidence for this So what I say is try it if you're battling yeast infections, and see if this is something that helps

– For our next question, how concerned should I be about – For our next question, how concerned should I be about high LDLP numbers if my HDL numbers are in a normal range while I'm in nutritional ketosis? – So LDLP is again going back to what we talked about a little while ago, a much better assessment of cardiovascular risk than LDLC And so if someone has got really great improvements decreasing triglycerides, increasing good cholesterol, but struggled with an elevated LDLP, what do they do? And this is not a solidly certain answer yet We don't, there has been no evidence one way or the other 100% So this is one of those places that you really need to work with your physician on So again, the Virta physicians may ask other questions

What are other risk factors that you may have, and how are those controlled? Or this is another place where we may say let's go ahead and get something called a coronary calcium score to assess is there really any burden of cardiovascular disease already present But once again, this is an individual call, and this needs to be worked out one on one between patients and their physicians And Virta physicians are all very, very expert in this area to be able to ensure that they are doing whatever we need to do to promote cardiovascular risk factor reduction for each and every patient individually – So do you say it's fair that it's not just one number that's driving that you're in bad health or great health? It's really a big picture of everything – Absolutely, it is, Catherine

There's not one biomarker when it comes to cardiovascular health that we can point to and say if this is good or if this is bad, you're in the clear or you're doomed It's not like that You know, what we have is we have a whole bunch of things that we know are associated with increased cardiovascular risks, and we have to look at the larger picture You can't get lost in the forest for the trees So each one of those and taking a look at the whole in each individual patient is really important, and that take personalization

– I think that's an excellent reminder because it's very easy to get caught up on that one number Would you say there are any specific drawbacks or benefits to following a ketogenic diet for post-menopausal women? – So I would say there's a lot of advantages to following a ketogenic diet for post-menopausal women And you know, what we know is that post-menopausal women do tend to struggle more with their weight, and it tends to be central weight And so again, a ketogenic diet can improve things for post-menopausal women just as it can for pre-menopausal women and men of all ages So if someone is struggling with those post-menopausal weight gain, especially in those specific areas, I would really encourage people to consider a ketogenic diet

And as far as drawbacks goes, no, there's no specific drawbacks there I mean this is a great patient population for this to be implemented with – What could be the cause of a strong heartbeat when someone's in ketosis? Are there any suggestions of supplements that might help with that? – A strong heartbeat So I would presume that that just means something that one can feel more, that it's not necessarily a racing heartbeat or a feeling of a skipped heartbeat So if I'm taking that question literally, that it's just something you can feel more, here is the likely cause

Someone has lost weight, and literally they can feel it easier So when people lose weight, and there is actually is truly less there, right, they can be more sensitive to feeling their hear beat So a strong heartbeat per se is probably not a problem Maybe a sign of your success Now if that goes into a racing heartbeat, a skipped heartbeat, again that's something that I would see their physician for

– Thank you If you're just joining us, we have Dr Sarah Hallberg here for our live Facebook Q&A Please put your questions in the comments below the video, and we'll address those throughout the hour today And to get notified of future Facebook Lives and other events, follow Virta on Facebook

So jumping to our next question, do you have any plans So jumping to our next question, do you have any plans or timelines on publishing the two-year results of the Virta Health Clinical Trial? – Ooh, that is a great question, and I'm super excited to answer that because well, let me say something before I answer it, which is we have just had an amazing group of truly pioneering patients who have participated in our large clinical trial I mean we all, all of us, not just at Virta, but people around the country should really pause for a moment, and let's just tip our hats to this group of people who have participated in this trial that I really think is going to be part of a nationwide change So if any of our clinical trial patients are watching, you know a big thumbs up to you True pioneers And we are just wrapping up now the two-year results

So we're having the, by the end of this month we will have gathered all of our data for two years, and so it just becomes actually analyzing that data and writing the paper And that seems like okay, we can do that in a couple of weeks, but let me tell you, it's a process because there is a lot of statistical analysis that needs to take place, and a lot of writing and rewriting, and it actually takes a really long time to get a paper published because they go through a peer review process So what is a realistic timeline? Well, we are very hopeful that this paper can get out before the end of 2018, but don't hold me to a promise on that because again, it's dependent on many variables there that all have to fall into line But we are really excited to get those results out, so we're gonna be doing everything we can to keep that process moving forward I actually can't wait for that day

– Me either – It's going to be fantastic, and I am really excited to share with the world again what's possible when it comes to treating this epidemic – This next question is a very common question – This next question is a very common question I get from patients How should I approach fat bombs? Are they a snack, or are they an addition to a meal? – So again, I'm gonna go back to that frustrating answer first, which is, it depends It can be very individual

And so for some people it's a great snack For other people they can have it as part of a sweet treat right at the end of a meal, but you have to be really cautious, and remember this Fat is fantastic We know that we need to have a larger percentage of fat in our diet, but fat is not a free food So just because something is containing even exclusively fat does not mean more is better

So we have to police things even like a fat bomb So I'd say work with your health coach on this to find out what's going to be the right amount or cadence, like every day, or do I do this every other day? Is this a once a week treat for me, depending on how your body is reacting And then really, you know, how is it best for you? Is it one fat bomb in the afternoon, and I'm great until I can get home and have time to prepare dinner? Because for some people that may be the perfect place to put a fat bomb For other people, they're done with dinner, but they just want that small bite of something sweet, and they make a small fat bomb For that person, that may also be perfect, too

So again, individualized on this, but remember, fat is not a free food – I think that's an important point as well because it's very easy to overdo those fat bombs, and then while you may have amazing ketones, your weight is probably going to stall as well, so they can definitely go a little too far if you're not careful, so that personalization piece is very important Thanks for those tips, Dr Hallberg – Absolutely

And the artificial sweeteners are what's causing diabetes in the first place What would your elevator pitch be to answer these critics? – Okay, so let's go back to the sweetener part first, and then let's talk about the long term aspect of this We've got two questions here, and I think they're both excellent questions, and I wanna make sure that we treat each of them individually So my feeling about sweeteners are honestly we don't know how much sweeteners or the very long impact of sweeteners So I take this in, this is my view on sweeteners

We want to be able to use them as little as possible, and we use them really as a tool to make this intervention sustainable because you know, when it comes to sugar, sugar for anyone with diabetes is going to lead to long term problems And so we want to be able to keep people away from utilizing sugar to make foods palatable But to tell someone who really enjoys sweets that, well this lifestyle intervention, you can never have anything sweet for the rest of your life, that's not going very far, okay? But I'll say a couple of things, which is number one, if when people are early on beginning the intervention, and they spend even a few weeks early on without eating anything sweet, you know, meaning even staying away from those sweeteners for a short period of time at the beginning, their taste for sweet things will change And you know, you have to try it to truly believe that because I get that comment from people all the time I can't believe I couldn't eat X, Y or Z any longer because the sweetness was overwhelming to me

So right there that's gonna enable you to be able to decrease any sweetener use significantly And then I just say use sweetener sparingly to make things sustainable, okay? The long term answers to sweeteners we don't know, but we have pretty good evidence that processed carbohydrates, including sugar and their impact on metabolic health for patients with type II diabetes, pre-diabetes or insulin resistance is negative, so we have to keep both of those things in mind Now long term impact of this, what we know is that long term impact of our typical dietary guideline associated dietary recommendations has been a failure, has made people sicker So we have great evidence on this in ketogenic diet in studies out to 56 weeks already And again, with the improvements in metabolic health, including the huge risk factor for so many diseases, cardiovascular disease, cancer, that is type II diabetes, long term if we are able to reverse people out of that disease pattern, we can say with confidence that they're getting healthier

– Are some artificial sweeteners better than others? – Are some artificial sweeteners better than others? Specifically what are the benefits or the effects of saccharine or glycerine or other artificial sweeteners like that? – So artificial sweeteners, there are many different categories, if you will There's sugar alcohols, and then there's what we call the saccharine These are the chemically created, non-nutritive sweeteners And so let's talk about sugar alcohols first So sugar alcohols end in o-hol

You can always kind of pick them up on a food label xylitol, erythritol, neanotol, sorbitol, those are all examples of sugar alcohols, and they can all actually impact blood sugar a little bit differently And so it's important if you're trying out a new sugar alcohol that you check your blood sugar to see what the reaction is for you But the ones that tend to have the least impact by far on blood sugar, which is key here, are going to be xylitol and potentially erythritol Now with sugar alcohols, especially in higher doses, people can tend to have some GI issues, so that's another thing to keep in mind as well

So experiment with them when it comes to your blood sugar and your individual tolerance of them But we tend to recommend a lot of the sugar alcohols overall because of that, and actually xylitol, let's take a quick look at xylitol itself And that is one of the interesting things that people don't realize is right now everybody who's watching this, Catherine and I, we're making xylitol right now Our bodies make xylitol So again, what we're doing is we're ingesting something that we're also making, and so that's one of the reasons that we recommend that

Our bodies are used to that xylitol is found, erythritol too, a lesser degree, naturally in fruits and even vegetables So again, that's high on our recommendation list, but everybody needs to check out their individual tolerance of them Now the non-nutritive sweeteners, those are ones that have no calories, and they don't by themselves have an impact on blood sugar And that's been shown in multiple studies

So let's take a look at Splenda, for example Splenda doesn't, over a patient population, increase blood sugar Once again I'll always say check your own individual blood sugar, but it tends to not have an impact That being said, it's a chemically created compound So if you're using something like Splenda, I would use it sparingly

And what you'll notice with these non-nutritive sweeteners is that in their liquid form it'll say no carbohydrates, no calories But when you get them in their powdered form, that's a different story Why? Because they had to add something called bulking agents, which are carbohydrates, to make them powdery so that you can use them for example in baking recipes So there's a big difference between the liquid forms of these and the powdered forms And one other sweetener that I'd like to draw attention to that is a non-nutritive sweetener, but is little bit different is stevia

So stevia is just from a stevia plant In other words, it's not chemically created Now that being said, stevia is available under many different names, and some of these the stevia leaves are highly processed and some aren't So a good idea is if you're choosing stevia, you wanna take a look and research what brand that you're buying so that you can get the least processed stevia Or if you wanna be completely natural about it, grow some stevia

Now stevia and utilized straight from the plant can have a little bit of licorice taste to it Some people really enjoy it, and for some people it makes it a little less tolerable So those are my comments about sweeteners Sugar alcohols, put them into non-nutritive sweeteners, but the non-nutritive sweeteners are different in a liquid form than they are in a powdered form And always when introducing any kind of sweetener, check your blood sugar

– If you're just joining us, welcome to our Facebook Live with Dr Sarah Hallberg Please put any questions that you have in the comments below the video, and we'll address those during our last 20 minutes or so And to get notified of future Facebook Live events and other Virta events, make sure to follow Virta on Facebook All right, here's a really good one, All right, here's a really good one, and I think the answer's gonna be it depends, but maybe you can shed a little more light for us, is how do you know what your personal carbohydrate tolerance level is? – So that's a great question, and it depends

No no, but let's answer that with a little bit more detail here, okay? So what I like to say is that people can develop different metabolic flexibilities, okay? So let's just take someone who does not have type II diabetes, pre-diabetes, never had an issue with blood sugar, no family history of it, they obviously have a higher carbohydrate tolerance And now that may not last forever because if they utilize that high carbohydrate and eat lots of sugar and refined carbohydrates, they very well may develop a lower carbohydrate tolerance for insulin resistance But that is at one end of the spectrum of carbohydrate tolerance At the other end of the spectrum of carbohydrate tolerance when it comes to type II diabetes is someone who has had very longstanding diabetes, and as we talked about earlier has overworked their beta cells in their pancreas and truly is unable to produce enough insulin Those people are at the other extreme end of carbohydrate tolerance, so there's a big spectrum here

And where, most people fall in the middle of this spectrum, and where exactly in the middle do you fall? And the first thing I'll say is that may change, okay? So in other words we may find someone who's at the lower end of carbohydrate tolerance, and as they implement a Virta treatment, they improve their insulin resistance, which is very nicely documented in our one-year clinical trial Insulin resistance scores dropped dramatically They may actually shift themselves to having a higher carbohydrate tolerance Now I'll tell you right now anyone who improves their insulin resistance, if they go back to eating a high carbohydrate tolerance, they will develop problems again So this is helping back people out, but it's not curing them, and that's a really important point to make

If we implement the Virta treatment, someone does it just for a while, goes back to a high carbohydrate lifestyle, they will have recurring problems at some point So important to remember that as we think about that sustainability piece But in figuring out exactly where in the carbohydrate tolerance spectrum you are at any given time, keeping in mind that that could change, it's really going to be following your blood sugar And if you have a Virta health coach, they're gonna be key in helping you with that because they're gonna be watching your blood sugar And say you try a new food

What's your body's reaction to it? Are you doing really good, and your blood sugars have been in the 90s, and then all of a sudden you went out to a new restaurant and had a sauce on something, on your dinner plate that night, and all of a sudden the next morning your blood sugar was 180? Whoa! That was over your carbohydrate tolerance And even though maybe the food choices looked good, it was probably something in the sauce that you weren't aware was put in there, and most of the time unfortunately that winds up being sugar So it's just going to be following those blood sugars And you know, I'd like to take an opportunity with this question to point out something that I think is going to be key in the type II diabetes community, and that's going to be the advent of continuous glucose monitors that are now available to the type II diabetes population So continuous glucose monitoring is exactly that, what it sounds like

It's monitoring your blood sugar not when you prick your finger and you check it one, two, even more like four or six times a day, which is helpful, but we've got big parts of the day, including overnight where we are not sure what's happening with your blood sugar We're just checking it at specific points in time during the day And continuous glucose monitors have that available, but they have been so expensive that they've really only been implemented for type I diabetes But now there's a new continuous glucose monitor available called the Libre, and these are very inexpensive And I've been utilizing them in some of our patients who have found them to be incredibly helpful at just this, determining their carbohydrates tolerance because they can watch the line through the day instead of just points on that line to see exactly how they're reacting to certain food

So I think finding everyone's individual carbohydrate tolerance is very important Working with your Virta health coach and following your blood sugars when you eat anything new is going to be a wonderful way to make sure that you are personalizing your carbohydrate tolerance threshold for where you're at right now – Great answer to a great question – Great answer to a great question What amount of dairy or lactose is allowed on a ketogenic diet? – Well, for most people that is a great source of additional fat and often protein, okay? Sometimes we will have patients who have issues with dairy, and maybe the lactose in it

It may be other aspects of the specific proteins in dairy, and so it's one of those things If people are really struggling, if they're having some sort of side effect, which oftentimes is GI, they could try removing dairy for a few days to see if that could be the issue, but I would say that's the exception for most patients instead of the rule So for most patients the answer to how much dairy can you have in a day is how much is it taking to get you full, as long as you're making sure that you're meeting your protein requirements for the day – Our next question, what are your thoughts about upping your carbs to 50 to 100 grams a day after achieving type II diabetes reversal or your goal weight? – So it all depends on what your individual carbohydrate tolerance is, right? – Nice follow up question there – Yes, yes, it's a perfect, thank you very much for this question

So again, let's go back to that spectrum idea, right? So someone started out at the very carbohydrate intolerant end of the spectrum, and they've done a great job with this and they've worked their way up They very well may be at the 50 to 100 range That's totally possible For other people, they're not They're gonna fall maybe at the very low end of that, and they can do 50, but if they go above that, they're gonna run into issues

So you're gonna have to just check your blood sugar, but that is not like unfathomable range for some people Some people can regain what we like to call metabolic flexibility, or they can tolerate higher carbohydrates, potentially even in the 50 to 100 range But the other important thing is if you are one of those people who can get into that 50 or 100 range, you always wanna be asking about the quality of the carbohydrates that you're adding in, because if you're at 30 and doing great, then you moved up to 50, and you're still doing good and we're gonna experiment with going higher, if you're adding those in with refined flours, I mean you're gonna get into trouble quickly If you're choosing to add more carbohydrates by choosing berry fruit or choosing to eat more nuts, those are gonna be foods that are gonna allow you again more flexibility So be cautious not only of what your specific gram number is, but exactly what are the foods that you're choosing to increase the carbohydrates if you're able in your diet

– Do you have any evidence of neuropathy improving – Do you have any evidence of neuropathy improving with diabetes reversal? – Well, we see this anecdotally often in the clinic, and patients will report an improvement, but can I claim that this is absolutely a treatment for this? No, because once again we don't have rigorous data on this So it's one of those other situations where I say look, this is probably good for a lot of things in each individual case that we have good data on Try it out, and if the neuropathy is improving for you, wonderful You don't have to wait for the rigorous clinical data, but to be able to say to the masses you should do this for that specific treatment, we have to wait for the data It's really important to say that we as a company, the Virta treatment is being driven by data

So we are continuously getting more data, but what we are doing we are only gonna be promoting things that we know are truly evidence based And like I said, there may be plenty of good evidence based reasons to try the Virta treatment, and for some people that may also improve their neuropathy, which is fantastic – If you're just joining us, welcome to our Facebook Live with Dr Sarah Hallberg Please put you questions in the comments below the video, and we'll try to get to as many of those as we can today

And to get notified of future Facebook events and other Virta events, make sure to follow Virta on Facebook And we have just about 10 minutes, so we'll try to get to as many questions as we can because I know there are a lot of good ones out there All right, here's another common one that I get All right, here's another common one that I get from a lot of patients So I've noticed I'm losing hair on keto Is this normal, and what can I do about it? – So I can be, and it's very important to say what we should really turn this into because what is much more true is I'm losing hair with rapid weight loss because it probably has nothing to do with the diet itself

It's the fact that the diet is causing weight loss And we do get this question a lot, and here's how I like to explain it to my patients in a way that they can really understand And that is when women have babies, they don't go home from the hospital with hair loss, right? But what they will find is that when that baby is four, maybe six months old, all of a sudden they're starting to lose hair, and that's because giving birth is a big shock to the system, right? I mean it's obviously a good one, we all love it, but it is a big shock to the system Weight loss is the same way It's a big shock to the system

We love it, we wanna have it, but again weight loss is likely to occur four to six months after the beginning of a period of rapid weight loss, and that's because the hair grows in phases So what I tell patients here is be patient Let the phase pass, and then the hair will come back If people are really worried about it I'll say, start taking some B-complex vitamins I mean I don't think there's gonna be any problem with patients doing that

Whether or not that's gonna help, hmm, it might, but the bigger thing is you just gotta give it time and let that phase pass – Next question, what effect can a well formulated ketogenic diet have on osteoporosis? – So I'm gonna say table the answer to this question because we have data on this that we have not analyzed, but we will and intend on publishing, looking at dexa scans in our patients in our large clinical trial So right now the evidence on this is scant to non-existent essentially, and so we have the ability analyze some data right now and put these results out So I'm gonna have to say hold on this because I wanna share, one again ensure that all my answers are evidenced based answers, and we will have the answer to this soon – What does the research tell us about ketogenic diets – What does the research tell us about ketogenic diets for thin people with type II diabetes? Specifically would a ketogenic diet be a good option for diabetes reversal for people of southeast Asian descent? – So the answer to that is yes

And so patients of southeast Asian descent do tend to develop diabetes at a much lower weight than in many other parts of the world, and so they may not have 100 pounds to lose, but it doesn't mean that changing the content of the diet won't lead to successful diabetes reversal just as it would with any other patient population So I would really encourage people of south Asian descent to consider this as a treatment for type II diabetes, really important – Is a ketogenic diet an option for a patient with – Is a ketogenic diet an option for a patient with a family history of hypercholesteremia? – Absolutely, and like I said again let's go back to the cardiovascular risk paper that we just published, looking at improvement in 22 out of 26 risk factors And so having a family history of hypercholesterolemia does not preclude anyone from participating in a lifestyle change that includes nutritional ketosis But once again, I'm gonna go back to say everyone is different, and this is one of those things that you need to have a physician who is following with you to help make sure that you're able to make personalized choices and treatment plans as you move forward

We at Virta want everyone to have their cardiovascular risks as reduced in all aspects as possible – How often if at all would you repeat a CAC? And can you tell us what a CAC is? – Yes, CAC is a coronary calcium score And so coronary calcium scores are a really great way to help people make decisions, giving them another point essentially, remember we don't wanna miss the forest for the trees, and sometimes that can happen when it comes to cardiovascular risk reduction We wanna be able to have as many data points as we can, and somebody's coronary calcium score can be a very helpful point here So in other words, if someone's had high cholesterol all their life, they go on a lifestyle intervention like the diverted treatment, and their cholesterol stays elevated instead of going down like it does with many of our patients, or potentially even goes up, and they have a coronary calcium score of zero, that's a really different place than someone who has had a lifetime of high cholesterol and has a very, very high coronary calcium score

So a coronary calcium score is a CT scan People go in, they can usually be had for very low prices I know in our area Indiana University Health offers them for $49 It's a very quick test, in, out, and what the CT is looking for is calcium, calcium in the arteries that supply the heart with blood And so what a coronary calcium score should be is zero

In other words, no evidence that heart disease that has developed into coronary plaque or calcium Now anyone who has a positive coronary calcium score, even if it's low positive, using and checking this over time, one of the big things that's going to be a factor there is statin medication use because anyone with high cholesterol who then has a positive coronary calcium score, if they get started on a statin, their coronary calcium score actually has the potential to increase, but that doesn't necessarily mean that that's a bad thing because calcium in that plaque shows us that it's stable And I'm gonna go here and digress just a little bit into coronary artery disease physiology Many people think of a heart attack as a clogged tube, right? So you develop disease in your arteries, and they get smaller and smaller in diameter until one day they close, and that's actually now what happens with heart attacks and coronary artery disease progression to an actual event What happens is there's a degree of disease in an artery, and for whatever reason there becomes a piece of this plaque that's unstable

It gets kicked off, floats downstream, blocks the flow of blood, and that causes the heart disease, excuse me, the heart attack So what we wanna do is someone has any degree of disease is we wanna stabilize it, and when you stabilize it that can actually be seen as an increase in the coronary artery calcium score, but that can be mean in many people stabilization of disease, so that's really important But I love the coronary artery calcium score in people as again an additional data point And we can have a really good discussion together at what that person's individual risk factors are, and what is our next logical step And it's a decision that should always be a shared decision

I think this is so important I will never say here's a prescription, you need to take it because taking a new prescription, that's a really big decision to be made, and it should be made as a team It shouldn't be one person dictating what another person does It should be to say let's put your, let's put all the ducks on the table, if you will Let's talk about your risk factor, and let's come up together with what our treatment path is going forward

– Do you need to be in ketosis for the low carb, – Do you need to be in ketosis for the low carb, high fat diet to be effective? Or can eating keto-ish be acceptable or successful? – Well, that's a great question, and honestly the jury is out I think that what we know about ketones are they can be incredibly important in helping people know that they're doing it right, right? Because if they have ketones, what does that mean? It means that they're using fat for energy, and they've got it They're implementing the lifestyle intervention well If they're doing keto-ish, and they don't have that to judge, I mean it's really a little bit more difficult to say how am I doing today? Was this food choice a good one for me? Or did I just make a choice that's negative on my metabolic health? So I think they can be really important there And we're just beginning to understand the benefits of ketones, so I think more and more data is coming out on this, and I would not be surprised within the next few years if we really get a much more firm stance saying ketones are critical in health

There have been studies recently that came out that show ketones very specifically decrease inflammation Once again, going back to remind everyone, key component of all stages of cardiovascular disease formation, inflammation Some really nice studies showing that ketosis specifically with elevated ketone levels lead to decrease in inflammation In the other one there was even longevity studies that came out, and yes, it was a mouse study, but I think it really opens up questions I mean where is the possibility for ketones to play in so many aspects of disease? And we mentioned it briefly before

Right now there are ongoing a lot of trials with ketones specifically in cancer and in many neurologic diseases For over 100 years in fact, ketogenic diets very specifically needing those ketones present, treats epilepsy So I think that we're gonna find out much more on exactly what else besides metabolic health improvements we may get as a benefit by following a true ketogenic diet and implementing that as a lifestyle – So stay tuned More info to come on ketones over the next couple of years

– Yes, absolutely, absolutely – So we have time for just a couple more questions So with that we'll go to the next one So is it dangerous for someone that's living with So is it dangerous for someone that's living with type II diabetes to do ketogenic diet without measuring all of those biomarkers and just following the basic rules? – It can be That's the really quick down and dirty answer, it can be

It can be very dangerous if you are not working with a physician Why? Because medications that patients take for diabetes are intended to lower their glucose And if you're making lifestyle interventions aimed at lowering your glucose, you can enter into a potentially really dangerous double whammy That's why everyone entering into the Virta treatment plan not only gets their health coach who can help personalize their food choices, but they also have their own Virta physician who is ensuring that they are adjusting those medications appropriately, safely, but also getting them down so that people can successfully reverse their diabetes and get rid of some of their medications So it is so important to have a partner in a physician who's working with you on this

And I can't stress that enough because if we get those blood sugars to drop too quickly because no one is helping with medication adjustment, that can be incredibly dangerous – So thanks everybody for joining us today To get more information, follow Virta Health on Facebook, and check out our research, much of which Dr Hallberg referenced today at virtahealthcom/research

So thanks, Dr Hallberg, for joining us today I learned a lot, I hope everyone else learned a lot, and we'll see you back here next time – Thank you so much for joining us I really appreciate it, and I'll be excited we'll be doing more of these in the future