Dr Jacob Wilson PhD on Keto//OS Ketogenic Dieting FAQ Diabetics Blood pressure Type 2 diabetes

hi this is Anthony Flatt from anthonyflattcom and today's video i want to give you a resource to answering some of the questions that I get in the comments and an email and messages and and so forth and there's about twenty really good questions that dr

Jacob Wilson covered a couple days ago in a live Q&A video that he did and i'm going to include the link to that video in the description of this video but I want to kind of go over just real quickly what he talked about and when he talked about it and i'll include the timeline in the description as well but this video is just to give you an idea so if you if you see some things on here that are of interest you can go watch that video you have to watch the entire video you'll be able to go right to the point where he talks about the thing that you're most interested in so let's go village real quick there's about 20 of them so in this video that dr Jacob Wilson did first thing you talked about was ketoacidosis in diabetics that was at the two-minute 22nd mark then he talked about blood pressure at the four-minute in 12 second mark talked about type 2 diabetes at the seven-minute 12 second mark using a full pack or half pack of keto OS we talked about that at the seven-minute in 30-second mark weight loss i talked about it the eight-minute 28-second mark cancer he talked about at the 10-minute in 20 second mark going off of ketones you talk about 11 minutes and 42 seconds mark too many ketones you talk about it the 12 minutes and 29 seconds mark sleeping issues he talked about at the 13-minute and seven second mark checking level options he talked about at the 13-minute 40-second mark using ketones and all when you're already following a ketogenic diet you talked about that at the 16 minutes 55 seconds mark inflammation in wound healing he talked about at the 18-minute 40-second mark upset stomach you talked about at the 19-minute a 15-second mark multiple sclerosis and muscle loss he talked about it the 19 minutes 58 seconds mark a hyperthyroidism he talked about it the 21 minutes to second mark drinking alcohol and using ketones you talk about it the 21 minutes and 43 seconds mark intermittent fasting he talked about the 22 minutes and 31 seconds mark crohn's disease he talked about it the 23-minute 40-second mark dehydration he talked about it the 24-minute 26-second mark and autism we talked about it the 34 minutes 44 seconds mark and stress he talked about at the 35 minute mark so that gives you over 20 different topics that he covered if any of those are of interest to you i know i've gotten questions on almost all of those i want in one form or another so whichever you're interested in just go to that point you can certainly wants the entire video but the goal here is to give you a resource with some timelines that you can jump to the sections that you're most interested in I'm all include this list also in the description so you can read it if you follow along with the ones I just covered and then if you don't get your questions answered in that video and you still have questions feel free to email me Anthony Anthony flat calm and i'll do my best to answer your question or help you get a resource that will answer your question so i hope you find that useful just want to make this quick video to to kind of Mark the things that are covered by dr Jacob Wilson in this little live Q&A video we get a couple days ago and I think you'll find it very useful as a great video is very useful to me so i hope you enjoy take care

Why a Ketogenic Diet is Dangerous for Diabetics

Alright my friends This is very important for you guys to pay attention to whether you're diabetic or not

A Ketogenic diet is disastrous for your health long term Please, if you or anyone you know is on a Ketogenic diet warn them There are three end term results to a Ketogenic diet: diabetes, heart disease and cancer Those are the three things you're signing yourself up for a long term Maybe in the short term you experienced some weight loss and you experienced your blood sugars, you were able to keep them stable but long term that fat is gonna build up in your arteries and cause either a heart attack or a stroke and your insulin resistance in the meantime is gonna go through the roof because all that fat gets absorbed into your muscles and it's your liver and then it doesn't need to absorb any more glucose

And you need those fruits and carbohydrates in your diet because they also come jam-packed with vitamins, minerals and phytochemicals that your brain needs for healthy development and function and all your cells need These are vitally important nutrients that your body needs and if you're just living off fat it is disastrous for you long term So, please, check out my program "How to Feed a Diabetic" I will give you all the information that you need to understand that more deeply and really get that concept into your head Vitally important for your long-term health

You can always check out my website feedadiabetic com for more tips like this one or to check out my "How to Feed a Diabetic" program that is jam-packed with nutrition information to get you and your family back to healthy again

Ketogenic Diet vs. Low-Fat, Plant-Based, Whole-Food Diet for Type 1 Diabetes: Rebecca’s Story

What was so crazy to me is that the results were immediate I mean, literally within days, I started having to take less and less insulin, and I was eating more and more carbs

I feel so energetic, and I can remember things now, a lot better I have more mental clarity, less mind fog, I had so much mind fog I feel encouraged because my metabolism is responsive now 340 my total cholesterol and now it's 130 something My LDL was 227, and now it's 59

I would say my relationship with food has radically improved because I feel freedom now [Music] I got diabetes when I was pregnant, I got gestational diabetes, and I had it with both of my boys I have two boys, I have five kids now but I only birth two of them, so I got gestational diabetes and then it went away in between both pregnancies, and they told me that it would most likely come back way later in life as type two, but it came back like three months after my second son was born I woke up one morning and I can hardly see, I went to the emergency room and my sugar level was like 500 Some people said you can eat whatever you want, just take insulin to cover it

It was just this big general "eat whatever you want just dial it up", you know Then other people, if I was having trouble maintaining it would say "well, you know it's the carbs don't don't eat too many carbs" I never ate fruits, because I thought it was the enemy to me, so I lived on meat, cheese, nuts, hard-boiled eggs, that's all I ate, and I tried to keep my carb intake less than 20 grams a day That's what I did every day, less than 20 grams of carbs a day, but my favorite thing in the world was a latte and that's 11, so there you go I had 9 left for the whole day, you know But even though I was doing that things kept getting worse, I kept gaining weight, I kept developing more odd sensitivities to foods, I was exhausted, I couldn't think, I had zero mental clarity, my A1c kept going up, I mean and I really thought I was going to end up having to live on cardboard, because I had to keep limiting more and more foods, you know, and everything kept getting worse

It was really depressing Most of the 16-17 years I didn't eat any fruit, and ate mainly animal fats and nuts I thought if I'm only in my early 40s and I am exercising this much discipline, and things keep getting worse what is my future going to be like It was scary because it wasn't as if I was a person who was just reaping the results of obviously poor choices, I was doing exactly what the doctors told me to do, perfectly almost, you know, I never veered Then I think I was just getting really discouraged, and I had a friend who, a friend who went to this doctor, so he started saying things to me like you need to eat fruit, and I was thinking no, he said well just try it, just start trying to add in more whole foods, more fruit and see what happens

Then he told me about Robby and Cyrus Since I had diabetes and he knew they had type 1 diabetes also, he said you've got to listen to these guys, so I started listening to everything they did I watched the summit and I was so inspired, between listening to Robby and Cyrus, listen to every single one of those summit talks, and then just trying it What was so crazy to me is that the results were immediateI mean literally within days, days, you know, I started having to take less and less insulin, and I was eating more and more carbs

A week went by it was ridiculously more carbs, I mean it was so fun I felt like I had just entered a candy shop with all that fruit, because a banana? I never ate a banana, but I mean bananas are like the best I never let myself feel full before because I was counting every calorie, and now I'm stuffed all the time, I mean, if I don't even have to worry about it, I don't even have to think about calories It's wonderful, it's so freeing Now I typically eat for breakfast, I usually have fruit, a big bowl of fruit some days, if I'm working then I make a smoothie, like with spinach and bananas and sometimes I put raw cacao in it

Sometimes, I like to do oats like oatmeal with water and berries and cinnamon and bananas I try to do a lot of raw honestly, so that's breakfast Then lunch, I usually try to do a salad with just a ton of different vegetables, all kinds of vegetables, whatever I've got in the refrigerator Sometimes, I add a grain like quinoa, rice to it, always beans, I love love beans, I eat tons of beans I need to have a plate of all kinds of raw vegetables, it feels kind of like tapas, you know, just like all kinds of raw vegetables and hummus, and avocado, salsa

It's a lot of raw vegetables and fruit Then I love potatoes, I love to cook some potatoes and cut those up with parsley with my evening vegetable plate I feel so energetic, and I can remember things now a lot better I have more mental clarity, less mind fog, I had so much mind fog I feel encouraged because my metabolism is responsive now

I feel like I have more influence over how I feel now, because everything's responsive and working more like it should Even eating less than 20 carbs a day, I would have to take between 18 to 20 units of insulin a day, so when I started eating a lot more fruit, I was a little nervous, but now as I incremental increased my fruit and vegetables, now I eat probably upwards of 130 carbs a day and I take 13 units of insulin a day, so it's crazy the change I used to, my cholesterol was what did I say 340, my total cholesterol and now it's 130 something My LDL was 227, and now it's 59 I dropped 10 to 15 pounds of weight

My HbA1c went down from seven point three to six point one This isn't a matter of six months, I started changing, I started experiencing radical change within a couple days, and then it just kept going For the longest time, I honestly was afraid I was going to be a beanpole, and I didn't want to be a beanpole, and it did it leveled out and I'm not a beanpole, it's good, but for a while I thought And then I thought for a while, maybe I would just be healed completely of my type 1 diabetes, but not yet, maybe soon Something else that's so encouraging is I get so excited about the nutrients I'm eating now

What I think is horrible is to realize that for 17 years, I virtually ate zero nutrients, that is both infuriating and alarming, and it's so exciting to realize that every single thing I put in my mouth now is doing something positive for my body, and keeping me healthy I still think about food a lot, because food is really good, but I would say my relationship with food has radically improved because I feel freedom now I am living so much more fully now, truly, it's so inspiring Yes, eat plants! Eat lots and lots and lots of plants [Music]

Dr. Stephen Phinney and Dr. Amy McKenzie on Ketogenic Diets and Diabetes

– Welcome to our Facebook Live Q&A today I'm doctor Amy McKenzie and this is doctor Stephen Phinney

We are researchers here at Virta and collaborators on quite a few different research studies together Today we're gonna answer any questions that you might have about diabetes, heart health, ketogenic diet interventions, anything you can think of Please list your comments and questions below the video and we'll get to as many as we can – And as we answer questions today, we want you to remember that we cannot give specific medical advise, so our answers to questions will be general rather than specific And for specific medical questions, we would refer those to your physician

– Our first question today is "How does Virta's treatment affect heart health?" This is a very relevant question because we just had a new publication come out today in Cardiovascular Diabetology that really focused on this So we had published maybe two months ago now, we had published the one year Type II diabetes outcomes We showed that A1c improved We showed that glycemic control was better, insulin resistance was better, weight improved And in this paper we really focused on all the different risk factors around cardiovascular disease

– And that's important because in the diabetes paper published two months ago in Diabetes Therapy, we noted that although a whole group of diabetes-associated risk factors got better, one of the more controversial changes is that the LDL cholesterol level in our patient group as a whole rose slightly but statistically significantly We felt it was important to take a much closer look at the full range of heart disease risk factors And that is what's encompassed in the peer-reviewed paper that we had published just today and can be accessed through our website – Yeah, so to give kind of a brief overview of what we've showed in that paper, Steve mentioned the rise in LDL and LDLc in the group on average, but there are a few markers that some researchers believe might be a better predictor of cardiovascular risk or at least equal to LDLc So those are LDL particle number and apo B

Those two markers statistically were unchanged at one year in our cohort of patients And then, we also looked at the particle size Some believe that small, dense LDL particles might be more atherogenic than the larger particles And our small dense LDL particle number actually significantly decreased at one year And the whole, the particle size of all the LDL particles increased at one year

So in terms of looking at the whole picture of risk, we certainly saw that increase in LDL that a lot of people get concerned about But when you put all of the markers together and consider the whole risk profile, we're definitely getting an improvement in a lot of different risk factors And we still are concerned about LDL, but we see a lot of improvements in other ways – Understand that the test that we use to measure LDL particle size and number is a new test, it's not universally available It's a predominantly a research-based test

And there are a couple of different ways that these can be analyzed, and the medical practice community has not arrived at a, kind of a uniform recommendation for these values So this is a research test that we did And it may not be available to the average person through their primary care physician For instance, I saw my physician a few weeks ago and asked, and I get my health care through Kaiser Permanente here in California, and I asked if they could run a LDL particle size and number for me and they said "no, we don't do that" But, it's important that other factors that we did look at, such as HDL cholesterol, which is so-called good cholesterol and triglyceride values, then those are part of a standard lipid panel

When the ratio of HDL to triglycerides goes up, that is, you have more HDL relative, proportionately to triglyceride, that is correlated with an improvement in LDL particle size and number So, again, we've looked at, I think we had 18 different cardiovascular risk factors in this current paper, and those were included in that So the point is, this is a very complex area, it's an area of active research But what we want to provide is a broader perspective of all the parameters, rather than focusing in on what we have with the cholesterol-diet-heart hypothesis where the focus for a couple of decades has been just on the LDL The true picture is much more complex than that and we want to get into some of those details

– Sure And there's evidence even to say that the picture is more complex from that, from the Imbarac trial, because they put people on STLT2s They saw LDL go up but they saw cardiovascular mortality decrease – Dramatically, yes – 38% I think, maybe

So, there's definitely something to say where there are other factors at play, and it's not all about one lipid marker in terms of cardiovascular risk So we'll find out someday – So before we get into specific questions, do we wanna talk about the range of risk factors? – Sure – That we looked at, responses such as hypertension, inflammation – Yeah

I think also when we're talking about different risk factors and looking at the whole risk profile, inflammation is also an independent risk factor for cardiovascular disease Many consider it or hypothesize it be an under, potentially an underlying cause So we looked at a few broad markers of inflammation in this study, we looked at high-sensitivity C-reactive protein and white blood cell count And both of those dramatically improved The CRP response especially was pretty astonishing at one year

And then blood pressure as well, blood pressure significantly increased, and the really cool thing– – No, it actually decreased – Sorry thanks, improved, decreased So blood pressure decreased, so it improved And because of this we actually had to de-prescribe medications for the patients because they didn't need the medication anymore So that's a really unique finding too

– So a lot of patients moved from the hypertension, borderline hypertension area to normal blood pressure with a reduced total medication use in the population Which is a very unusual finding, 'cause usually the way with standard medication treatment for hypertension you have to give more medications to get better control – Sure – We got better control because nutritional ketosis and the Virta treatment that embraces and supports that is such a powerful metabolic tool – So, that's a little bit of a recap on our cardiovascular risk factor paper that just came out today in Cardiovascular Diabetology

You can go to our website virtahealthcom/research and you'll find a link to that paper there And then we'll have certainly more information coming out from Virta tomorrow about that Check back tomorrow and we'll have some more information for you Our next question, "Is it okay to eat one to two "meals per day with half of your protein needs in each, "or is it better to space out your protein?" – That's a good question, and actually kinda leads to the concept of time restricted eating

– Yeah – We actually did a blog post a couple months ago entitled To Fast, or Not to Fast And in that we point out that there is actually a fair amount of published research on time restricted eating As long as people don't do total fasting for more than 24 hours, certainly skipping one, or even two meals per day, when the composition of those meals is appropriate, is safe and for some people turns out to be an effective tool And so yes protein doesn't have to be eaten in three equal portions, it can be eaten in two portions

And there are some people who find that they eat one meal per day, so they're basically fasting, from basically dinner, let's say one evening, til dinner the next evening, and that, as long as that is interspersed with adequate nutrition including adequate vegetables for potassium and other minerals, and fiber on the non restricted days, it can be a healthy way to follow a well formed ketogenic diet – Sure, protein is important, so it is important to make sure that you get it in, and meet all of your needs And then if you, if you are in a situation where you're eating protein in this way, where you're kind of lumping it all into one meal, and your ketones don't go down, don't be too surprised 'Cause that might also be a factor too So depends on what your goals are, but it is definitely really important to get in all of your protein

Next question "Is keto safe and, or recommended if you have no thyroid? "And is there a risk of low TSH "if you do keto without a thyroid?" Doctor? – Yeah, it's a good question Again we have to be careful not to give specific medical advice, but in general terms, taking thyroid medication can fully replace what the thyroid gland normally does And it's important to point out that the thyroid gland doesn't make active thyroid hormones It makes a precursor, called, we just say it's, it's a precursor, it has four iodine molecules on it

Active thyroid hormone has three The thyroid makes the one with four, your liver takes away one of those iodines to make the three So you can take the thyroid hormone by mouth, and then the liver does the final step, and can regulate much of that process And TSH is a useful test because that's a measure of what the brain perceives in terms of what the liver's doing And so that can be used by your physician to help judge the dose of oral thyroid medicine as prescribed

So again this is something that has to be managed between you and your primary care physician We can't give you specific advice for that – Great, so if you're just joining us, I just wanna welcome you to the Virta Facebook live Q and A I'm Dr Amy McKenzie

This is Dr Stephen Phinney We're here to answer your questions about diabetes, heart health, and ketogenic interventions If you would like to be notified of future Facebook lives, or events, please follow Virta on Facebook Our next question is, "Can being in a state "of ketosis enhance your athletic performance?" I think this is something near and dear to our hearts

– Yeah, wow Do we have an hour to– – Yeah, I think we could spend a lot of time on this Our collaborator, Jeff Volek, that is at Ohio State, and also a co-founder of Virta, he actually has been looking at this a lot lately in his research Back at Yukon, a few years ago, he brought in 10 high carb athletes, and 10 keto adapted low carb athletes– – These were elite, ultra runners – Yeah, elite, ultra runners, that do ultra marathons, or some of them were triathletes

So it was elite, ultra endurance athletes And 10 of them were keto adapted, and 10 of them were on a high carb diet He brought them in to run for three hours And looked at all of their performance during that time, and then during recovery Probably not surprisingly, the low carb, keto adapted athletes had higher peak rates of fat oxidation, and a higher mean rate of fat oxidation throughout their run

But the really interesting thing is that, when it comes to athletic performance, people seem to be concerned about muscle glycogen And they're worried that if your low carbohydrate, and keto adapted that you're maybe gonna run out of muscle glycogen Feel like you hit the wall and not be able to perform So they did muscle biopsies in this study And what they found was that the keto adapted, low carb athletes and the high carb athletes had the same amount of muscle glycogen

And that it followed the same pattern even in recovery So after the three hour run, and then also two hours into recovery, muscle glycogen was all the same – But the difference between them was because the keto adapted athletes were burning fat at twice the rate, providing 80 to 90% of the fuel during their endurance run at race pace So as Amy said, they ran them, had them run on a treadmill three hours, in the lab – In the lab, staring at a blank wall

– The Keto adapted athletes mobilized muscle glycogen at the same rate But they, it appears that they recycled it They didn't burn it all the way to CO2 and water So it's like, you know, basically recycling that same carbon, so they didn't need to eat a lot of carbohydrate in their diet in order to regenerate and maintain muscle glycogen stores But from a parental perspective, how many ketogenic enhanced diet performance, one thing that the endurance athlete tells is that when they're keto adapted they're much less likely to hit the wall

That is how the central nervous system begins to shut down saying you aren't providing me enough glucose to keep my brain functioning So A, they can go for longer periods of time And it appears to be that because the brain can function very well on ketones, and is not glucose dependent And so for events lasting longer than three or four hours, when normally, again a full iron man triathlon, they have to eat continuously during the running and the cycling legs of those events One was that the athletes find they need to eat far less calories in the race in order to sustain performance

So that's one aspect that's beneficial And the other is what we call power to weight ratio That many athletes find, no matter how hard they train, they can't train themselves down to an ideal, low level of body fat Say under 10% And for some athletes getting under 10% is really important in terms of the power to weight ratio

And they find that when they adapt a well formulated, ketogenic diet they're better able to achieve that optimum percent body fat that optimizes the ratio of muscle to muscle weight to body fat weight And again for those athletes, oftentimes they will train on a high fat, low carb diet to get ideal body composition down And then they can add back what they call strategic carbs, either immediately before, or during an event in order to optimize glycogen as well And again this tends to be athlete specific Each athlete needs to have some guidance, but their own experience in figuring out what works best for them in terms of the degree of carbohydrate restriction, and the amount of carbs that can be used strategically to maintain optimum performance

– Yeah, and I think we've talked a lot about resistance training, or endurance training, but I think resistance comes up a lot too I think there was a study recently, I hope I'm not miss remembering this I think it was out of Donovan and Stephen's group, or he was involved in it somehow But they looked at 10 weeks of western diet compared to a ketogenic diet, and similar gains in terms of strength and power during that time And also similar losses of body fat and muscle gain between the two groups

So it doesn't appear to impair performance in any way – And not to get too far ahead of the data, Professor Volek at OSU is, has completed the data collection from a study they did with a high carb versus a ketogenic diet in a group of student athletes where they did a intensive resistance training program And hopefully those data will be reported this year But it will I think, emphasize the benefit in terms of resistance training, and maintaining lean body mass and optimizing power to weight ratio – Sure, I think power to weight ratio is really an important point

Alright, our next question "Are there any benefits of fasting "that you can't get through a well formulated "ketogenic diet and what do you think about "autophagi and apoptosis?" – These are hot buzzwords right now in the research community There's a lot of research been done with basically animal models And what people talk about autophagi and apoptosis is basically changing either, you know, regenerating cells, aging cells, regenerating with– – Yeah, it's kinda– – Replacement cells, and also– – It's kinda the cleaning system – A cleaning system, but also cleaning up internal cellular machinery, particularly involving things called mitochondria

And mitochondria are those little furnaces inside cells that actually do the oxidative energy generation That's where oxygen is consumed, along with either fat or carbohydrate to replace the high energy phosphate ATP, and creating phosphate And so that machinery constantly has to be repaired And there is evidence that periods of fasting can enhance that process – Several

There's been less research with well formulated ketogenic diets done long enough to actually look at that And again the turn over of cells, and the turnover of mitochondria, that is how frequently it is replaced is measured in weeks or months, not in a day or two – Sure – And so particularly for human, you know to have human specific results it takes rigorously done studies And there aren't that many groups who have been able to sustain ketogenic diets long enough to really look at that

And again, stay tuned, because that's an area where Dr Volek and his team are on the forefront of doing that research – Yeah, I think, I'm certainly not an expert in this area But I think, autophagi can be stimulated by reduced insulin, increased glucagon, inhibition of mTOR So I know a lot of the research is in fasting

And ketogenic diets tend to mimic that from a metabolism standpoint in a lot of ways So I would assume that you would be able to get some similar benefits out of doing it for a long time Alright, "Have you tested apo E genetic expression "in study subjects, and does it have any "predictive value in identifying "so called LDL hyper responders?" so we did not include genetic testing in this research study so unfortunately we can't draw any conclusions, or make any statements about that My understanding of apo E is that one variant of that, apo E4 is very highly associated with increased cardiovascular risk – And increased LDL

– And increased LDL, yes So in this case, in terms of identifying the LDL hyper responders, this is a very complicated question 'cause my first question is what is an LDL hyper responder, and also if it's a genetic component, if they have apo E4 they probably had a high LDL to begin with before changing their diet So perhaps, we don't have any data that would be able to answer that question But I would think that I would see high LDL in that person before they would even begin dietary changes – So the simple answer is, we haven't tested it

– Yeah – In terms of doing the genetic testing on our Indiana University Health research population But the other point is, that increasingly the cardiovascular risk area is moving away from a focus just on LDL So we think of LDL as one tree in the forest – Yeah

– And then we will be putting up a blog post in the next day or two, basically summarizing what we have in our research paper So making it a little more digestible for the non science reader to point out that when we look at a bunch of other factors like inflammation, like hypertension, that when we look at those other risk factors, so many of them improve independent of LDL that even we assume that even people with the apo A4 genotype would probably still then get a net benefit from the ketogenic diet, even if their LDL doesn't respond as dramatically or in the same way as the other groups do in terms of particle size and number – Sure, I just spent some time at the National Lipid Association conference and the opinion of a lot of clinicians there is that they like to use a non HDL So even with LDL being a target they have, they tend to also have a target of non HDL And National Lipid Association promotes that, so I think the idea of relying on more than one marker is certainly catching on in clinical practice

So if you're just joining us, we just wanna welcome you to the Virta Facebook live Q and A This is Dr Stephen Phinney, and I'm Dr Amy McKenzie If you like this event, and you wanna know about more in the future you can follow us on Facebook by following Virta Health

Our next question says, "Is it possible "for a person to have a really high "hemoglobin A1c and yet have decent triglycerides, "meaning 150s or lower?" Suppose it's possible – It's on average the higher a person's, or the less controlled a person's Type II Diabetes is, so the higher their hemoglobin A1c would go the more likely they are to have what we call atherogenic dyslipidemia which involves a low HDL and a high triglyceride So on average high triglycerides and high hemoglobin A1c values go together But people vary wide, quite a bit from one another And it's very possible that somebody could have a triglyceride under 150 which is the upper limit of what is considered normal

We like 'em under 100 – Yeah And still have a high hemoglobin A1c The other factor is triglycerides can go down very quickly when you cut down dietary carbs If their hemoglobin A1c – Very quickly

value takes three to four months to change So one might see triglycerides plummet in the first, say month of a well formulated ketogenic diet – Sure – And the hemoglobin A1c is gonna tag along quite a bit behind So typically we wait anywhere from four to six months after people make the change to a low carbohydrate diet before we do that testing so that the hemoglobin A1c can, which is a slow responder catches up to some of the factors which respond more promptly

– Sure (chuckles) So this comment is, "Hi, Amy "Congrats on the award" Thank you very much "Is there a rough estimate of when "two year Virta results get released, "and are coronary artery calcium scores "being calculated as well?" – Tell us about the award

– Oh gosh I mentioned the National Lipid Association And we had submitted an abstract there– – With you as first author – Yes Definitely a team effort from the whole group

We submitted an abstract focusing on the cardiovascular risk factors and their response at one year to our intervention And also we took, because of this concern about LDL, we also took a closer look at the change in LDL over time So we compared early to late change in LDL And what we saw is that people who had an early rise in LDL, either LDLc or LDL particle number, in the first 10 weeks, later saw a decrease in a similar amount And those who had an early decrease had a later rise

So there's a lot of you know, potential explanations for this One is probably, partial to Dr Phinney with, in this case, so if somebody has an early rise in LDLc, and they're losing weight, a lot of weight, a significant amount of weight in that time, there's a chance that their cholesterol will go up during that weight loss, right? – Correct – And then it will go back to normal following weight stabilization – And that appears to be because, when people carry a fair degree of extra body fat it soaks up cholesterol

When you lose the body fat it has to be mobilized So there's a transient mobilization phase So again, we don't draw conclusions even after three or four months if people are losing weight, from the actual, the measured cholesterol levels We wait usually til the end of a year Most people have stabilized their weight by that time

And that gives us a more steady state measure of the cholesterol distribution within the circulating lipids But there was a young investigator award, and of the abstracts submitted to this national meeting Amy was the recipient of that award Congratulations doctor – Thank you (chuckles) Definitely had some good mentors along the way to get there

So thank you Yeah, so we presented this at the National Lipid Association conference last weekend Feel free to write to us and ask us more questions – And the other question is when are we gonna release our two year data – So two year data

We're two years into the trial now, can you believe it? – We're more two years in, but we recruited people over about an eight month period And the last people recruited two years ago have now completed their two year time point So we're collecting the data, and we're analyzing that We can't tell people about it until we have it accepted for publication – Yeah

– And again this is sometimes pretty controversial data, and it takes awhile, but we hope by later this year we'll have that data published in the peer reviewed literature and be able to share it with this audience – And then in terms of coronary artery calcium scores, we did not include that as part of the research study Although I know that sometimes it's used in the course of clinical care But unfortunately not part of the research study We did do carotid intima-media thickness measurements

– That's an ultrasound of the carotid artery to look at the thickness of the lining of the artery And at one year we did not see any threatening changes in the population on the ketogenic diet in spite of the fact that they're eating a lot more fat than our parallel control group So that's reassuring that it wasn't getting worse And we're hoping at two years that we'll may be able to see a difference between the control population and our intervention population – We'll test it and find out

– Um hm – Alright, our next question is, "What definitive total cholesterol numbers "that are healthy for men and women?" Oh, "what definitive total cholesterol numbers "that are healthy for men and women?" Sorry, I can't read today "And can you more clearly elucidate LDLp, "small LDLp, LDLc, HDLc, and what one should look for?" – First point is, these are not standard tests that are available to all of us – But the LDLp, yeah – So particle size and number still remain research tests

And if you can get them done, then you would need to talk to the physician that you went through to have them ordered to be done In terms of total cholesterol numbers, again that's turning out to be one tree in the forest There are a couple trees in the forest And again, we have no reason to, dispute the total cholesterol and calculate LDL values except the have to be viewed in the context of a wider range of risk factors But we can't get into specific numbers for individuals at this point

– Yeah Alright, so if you're just joining us we just wanna welcome you to the Virta Facebook Live Q and A You have Dr Stephen Phinney and I'm Dr Amy McKenzie

We're hear to answer your questions on diabetes, heart health, and ketogenic interventions Our next question is, "Has research been done "to determine if there's a point at which "high amounts of sodium supplementation "can be dangerous or unnecessary?" So there's a paper that looks at sodium consumption and mortality, right? And this is– – There's been a lot of research on it – Well I'm thinking of one I think you know what I'm talking about, Donald– – Donald, and then (interrupted) Journal of Medicine from 2014 If you go on our blog we have a posting on sodium intake and adrenal, and the why adrenal fatigue is not a real medical issue

And this is discussed in that paper as we've referenced there Sodium is obviously a very controversial area And people have almost, let's say, let's say very intense convictions, including dispute among measuring scientists So this is not a resolved area as yet But in the study published in the New England Journal by this group, it's a international research consortium studying lifestyle factors, and health outcomes in a couple 100,000 people in 17 different countries

– sure It's a massive study called the PURE, P, U, R, E, that's the acronym, study And they, rather than asking people how much salt did you eat yesterday, they actually took a urine, got a urine sample from people From over 100,000 people and then looked at sodium excretion at that time point and their subsequent, assuming that the day before they'd eaten their usual, whatever their usual salt intake would be Inaccurate if you were dealing with a few people But when you have 100,000 people it gives you a good measure of range of sodium intake

And then they looked at health outcomes for four years afterwards The total mortality and coronary disease, that is heart attack risk for people was a U shaped curve And the bottom of that curve, where the risk was lowest, was between four and five grams of sodium, not salt Four and five grams of sodium intake per diet When people went down to the value of where the current US recommendations are at 2

3 grams per day, there was actually a measurable increase in risk And under 23 grams, again these are people in multiple cultures, in many different countries But consistently there's a rise when you restrict sodium severely And as one increases sodium intake past six or seven grams a day, then the risk also begins to go up

Now there are some regions and some cultures where people eat a lot more sodium, and there is evidence that that can be dangerous, for instance some fishing villages in Japan, where the sodium intake may be in the 10 to 15 gram per day range, that can be associated with increased risk of stroke and even heart disease So again, this is not a blanket permission to eat vast amounts of salt But keeping, particularly when somebody is on a ketogenic diet which enhances the kidney's ability to clear extra sodium, it appears that the beneficial range for people who don't have significant heart or kidney, already have significant heart or kidney disease, the beneficial range is in the four to five gram per day of sodium intake range – Yeah, I think an important takeaway from this is that it's always in context It's always for an individual person

You have to consider all the different things that they have going on And we can't give a blanket, across the board kind of recommendation But, – If somebody has fluid retention, or hypertension– – Right, have to be much more careful– – Requiring diuretic therapy We get people onto the ketogenic diet and get them keto adapted, and typically we withdraw the diuretic medication Then we then begin to gently add back the sodium to optimize their circulatory reserve, their wellbeing, and their function

So again this has to be individualized, and there aren't, as Dr McKenzie says, you can't give blanket recommendations And we're not doing so here – Alright, our next question is, "Too many calories, and too much fat, "what is your take on these issues, "and the low carb, high fat way of life? "Will hitting your fat macros lead to weight gain?" Hmm, well I'm gonna start with saying, basically what we just said Is that it's very individual, and I would say, what's your goal? Is your goal to lose weight? Is your goal to maintain weight? Is your goal to build strength and muscle? All of these different factors are going to change what your macros may be

At Virta we handle this a little bit differently And we really focus on, you know, it's, we're trying to treat Type II Diabetes We really focus on carbohydrates, getting an adequate amount of protein, and then in terms of the fat, we don't count calories, and we don't prescribe a certain amount of fat We really teach you about hunger and satiety And we encourage people to eat fat to satiety

– So we try to stay away from macros because when somebody comes to us, and they carry extra weight and they wanna lose weight, what's coming in is different than what the body's burning That's how people lose weight And so again, this is as Amy said, we individualize carbohydrate intake to a restricted level where they can get into nutritional ketosis We guide them to eat protein in moderation But enough to maintain lean tissue and function, but not to over eat protein

And then, we counsel people to eat fat, add fat to satiety What that means is to trust your instincts – Yeah – And so often, people, when they're eating a high carbohydrate diet, they don't get that sense of satiety And they're surprised at hey, I, there's still food on my plate and I'm satisfied

And we coach people through that process And one's natural instincts after a significant weight loss is that the body will basically give a person signals, yeah, eat a little more fat But A we don't counsel people to eat a specific amount of fat, and we definitely don't tell people to eat more fat to make your ketones go up because that doesn't work Ketone production is a function of how much carbohydrates you eat, which is the biggest driver Keeping it low enough to maintain the liver in a state where it produces ketones

Not overeating protein Which protein is not a very potent suppressor But it's a moderate suppressor of ketone production And then the other factor that brings ketones up moderately is adding a moderate amount of endurance type activity And if people haven't had the energy level, and they don't have the lower extremity and back problems that prevent exercise, then exercise can be a factor was well

– Yeah, and that's for many of our patients It's been a really successful component, just getting moving in terms of a walk after dinner or something like that Been really helpful for a lot of people – But we don't encourage to purposely add a specific amount of fat to the diet Only to add fat to the point where that meal, that day they have adequate sense of satiety, that they're not constantly thinking about, and obsessing over food

– Yeah, I certainly hear people say, well if I add more fat will my ketones go up But as you mentioned it's not much of a main driver And then if you have that thinking, then you're potentially getting more calories than you really need and potentially stalling weight loss if that's your goal– – Again the process of keto adaptation gives the body permission to burn fat at twice the rate, and at least initially, it doesn't care whether it comes from inside, or from the mind – Alright, now our next question, "Is there a protocol for using the ketogenic diet "as an adjunctive therapy in the treatment of cancer?' Working on this – Again a hot topic

– There's a lot of animal research going on There have been a fair number of human case reports, and small uncontrolled studies have been done There is now a lot of interest in doing controlled, larger cohort studies And again not stealing Dr Volek's thunder, but he has one underway at Ohio State University

But to my knowledge there are no published protocols at this point for treating specific forms of human malignancies or cancer with a ketogenic diet And that you know, hopefully that will be forthcoming, and with high quality research within the next few years – Yeah I think when we were at the Global Symposium for Ketogenic Therapies they were discussing this, and talking about using ketogenic diets in treatment, as an adjunctive therapy for glioblastoma But it was a few case studies, or a case series But yeah

– Again, it takes, as we've discovered, and at Virta, it takes a lot of education and support for people to know what to eat and how to sustain a well formulated ketogenic diet And there's a potential application for vertigo going forwards in providing our continuous remote care to support these kinds of studies – Sure – But, again that's something we look forward to in the future – Alright, so if you're just joining us, we just wanna welcome you to the Virta Facebook live Q and A

We have Dr Stephen Phinney here with myself, Dr Amy McKenzie And if you would like to tune in again, and join our future events, you can follow Virta on Facebook Our next question says, "Many have great concern "about eating protein and fat if they have kidney disease, "or if their doctor warns them that a ketogenic diet "may cause kidney problems, can you address this?" – Yes

– Yes I would say the risk to kidney function from dietary protein intake, is based more on a presumption than on data When protein is eaten in moderation there is very little evidence in, when people have normal, or even modestly impaired kidney function that it will negatively affect the kidney function In our one year data from the IUH study that we published a couple months ago, the commonly used measure of kidney function is something called serum creatinine And that's a product that's produced metabolic in the body and has to be cleared by the kidneys as a waste

And the level of creatinine over the course of a year in people with preexisting Type II Diabetes, so the kidney's are already being challenged by their diabetes The creatinine level went down slightly, but statistically significantly, in the context of a well formulated ketogenic diet So we saw no evidence at one year of any negative effects of moderate protein in the context of carbohydrate restriction and circulating ketones And we will have, hopefully data from two year, that we'll publish from two years as well So again it's, this is not a high protein diet

That, really we have to emphasize that Protein is eaten in, as when we say moderation it's in a range that if you're talking about macros in terms of what the body is burning in a day, we're providing 10 to 15%, at most 20% of the daily energy intake of protein Some people advocate higher protein intakes with carbohydrate restriction, let's say with the Paleo diet And that does not appear to be necessary We don't know whether that's safe or not

But certainly at the levels that we counsel people to do this, we have every evidence of improving kidney function, and no evidence that there's a negative impact on renal health – Alright I'm pretty sure this is a question for the physician "Could diazox– – Diazoxide – "Be helpful to ketogenic dieters?" I have no idea

– It hasn't been studied – Can you tell us what diazoxide is? – It's a therapy that's used in acute care medicine for people with severe hypertension – Okay – It does have metabolic effects that might be beneficial But it's a prescription medication

And I don't know of any evidence that it would be any better than naturally occurring ketone production But again, it's an area where I don't wanna speak from presumption, and I don't know published evidence that would support its use – Okay "Do we need to supplement iodine "since we are using sea salt? "If so, how much?" – So most commercial salt is supplemented with iodine– – Iodized salt – Because if people don't get enough iodine they can have impaired production of thyroid hormone because it has, each molecule that the thyroid makes has to have four iodines on it

In the past, in areas where people aren't close to the ocean where sea food contains a fair amount of iodine, even if sea salt doesn't Iodine depletion can lead to what's called goiter The thyroid gland hypertrophies because it wants to make more But it doesn't have enough of that mineral – Sure

– If somebody eats, takes a standard, basic multivitamin, – Multivitamin That contains plenty of iodine Much of the salt is used in food preparation is iodine supplemented, so again prepared foods will have it, and even if one chooses to eat a version of sea salt that's not been iodine supplemented So we don't have any evidence that folks eating a well formulated ketogenic diet and using sea salt rather than commercial supplemented salt will see an iodine deficiency Theoretically possible

We do counsel people that a seven cents per day, standard, low iron multivitamin is a very, very inexpensive insurance policy that will do no harm and cover some of these basic issues were they ever to become a factor – Sure Our next question is, "What is the maximum limit "grams of carbs for weight maintenance?" This is a very challenging question "What is the maximum limit of grams "of carbs for weight maintenance?" It's a very challenging question to give an answer to broadly I think it depends on the person

– Sure As Jeff and I, I think, if that coined a term, certainly promoted the concept of diabetes as a form of carbohydrate intolerance And diabetes is a disorder of, Type II Diabetes is a disorder of predominately insulin resistance When people reverse that with a well formulated ketogenic diet they can increase their carbohydrate tolerance At the other end of the spectrum, there are people, and we know people who eat a lot of carbohydrates on a low fat diet, and remain very thin, and very healthy

They have a very high carbohydrate tolerance So we range, as humans from very carbohydrate intolerant, that's Type II Diabetes, to those skinny high carb people who seem impervious to even a high intake of refined carbs They're highly carb tolerant So humans vary in a range And then we vary with age

And I would say 30 years ago I was much more carb tolerant than I am now And so you know, for me, 50 grams a day of carbs is about all my metabolism will handle without having health effects But other people can handle 100 to 150, 200, so again, it has to be highly individualized And so we don't have rigid prescriptions And at this point people really have to find through coaching and a bit of trial and error what works for them

And that's what makes the Virta treatment complex, and why it makes it difficult to put it into a standard cookie cutter approach – Yeah, definitely individual to each person what their goals are, what their insulin resistance is Definitely have to work with each person individually Our next question says, "Are there discreet groups of people "who tend to be at greater or lesser risk of losing "muscle mass if protein intake is too low? "How about groups of Type II Diabetics "who react differently to different levels of protein?" Hmm – We do know that people vary in their protein needs

There have been very rigorous studies done in the context in a quote, balanced diet And actually when I was a graduate student at MIT, oh, many decades ago, some of my teachers there were doing studies to measure precisely how much protein the average, normal person needed – Um hmm – I don't wanna cast any spurgeons, at students at my alma mater But they were using MIT undergraduates as their normal subjects, and some people from Harvard might say that those weren't really normal people

Just a little bit of Cambridge politics there, sorry But what they found is that keeping the protein intake very low, down to the point where the people were just hanging on to their existing lean body mass, was a specific number But some people were doing just fine at that And other were losing these tissues So the group average doesn't represent what the individual needs

So there is quite a bit of human diversity in terms of their protein needs We also know that that protein need goes up with aging That older people tend to be less able to maintain lean body mass when protein is restricted And then illness, particularly inflammatory illnesses can increase protein requirements And certain medications will increase protein requirements

So again, there's a lot of variability The number we've chosen to focus on, which centers around an intake of what we call 15 grams of protein per kilogram of reference weight, which is, it basically makes some assumptions about how much lean body mass a person has We pick that number because for the vast majority of people that we've tested that turns out to be a adequate amount of protein, with some buffer But not so much that it suppresses ketone production

And so again, but we, our coaches will work with people if they're struggling to get their ketones up in a good range They can dial back a bit from that level of protein Other people, if they're doing resistance exercise and wanna build lean body mass they can add a bit more, as long as it doesn't compromise ketone levels So again, it's individualized through our biometric monitoring and our coaching – Yeah, one thing that I was really surprised about when I was working clinically was, patients who gained lean body mass once they started doing a ketogenic diet

Can you talk about that a little bit? – Well we've seen that in metabolic work studies That some people come in, perhaps because they have been doing restrictive dieting for an extended period of time And again, when you restrict calories, the body becomes less efficient in the use of protein So people that are constantly restricting, trying to lose body fat may end up also compromising lean tissue – Compromising protein

When we get them on a well formulated ketogenic diet the fascinating thing is satiety goes up They no longer feel like they're restricting But they're eating fewer calories And yet they gain lean body mass And that implies that there is something about the nutritional ketosis that enhances the body's ability to build and recover lean tissue

And we hear that from athletes as well Particularly on the recovery point Again areas that we see evidences there, but we really haven't had the resources to study it rigorously – Our next, who Oh, sorry

We have time for two or three more questions So please ask yours in the comment section under the video "What is the best time to test "for blood ketones to verify ketosis?" we've gotten quite a lot of these, it depends questions today Sorry, this is another one of those it depends questions So I apologize

It really varies between people In general I would say most people have lower ketones in the morning, and higher ketones in the early afternoon, evening, generally kind of in the before dinner, dinner time range But I've definitely seen exceptions to that rule too So I think this is something that it's good to test a a lot of different times and see where you are at different points in the day It's also good to test at different time to understand how your body reacts to food, how your body reacts to exercise, and you can really understand how you work with this

But then ultimately it's up to you, and it's up to you and how your pattern works, and really what you're looking for – In the past we thought that ketones primarily were just a good replacement for glucose to feed the brain Which means you had to have them there all the time, 'cause your brain is burning energy continuously, minute by minute, and so we thought ketone levels should be up in a good range all the time And now it turns out that ketones, particularly beta Hydroxybutyrate has almost a hormone like action signaling various cells in the body to do things, and some of those come through changing gene activity as an apo genetic effect And that maybe something, that if one gets up into it, an effective apo genetic signaling range at some point during the day, the benefits will carry on

And so there's more to be explored here But as Dr McKenzie implied – I can't wait for that People vary at different time points in a day And you know, if you wanna get positive feedback, and see a good quote, you know, a higher level – a higher level

Test yourself typically in the afternoon after it's a half hour, from anything from a vigorous walk to working out in the gym it will probably go up – But if you wanna know your lowest you test at your lowest time point So it depends on what, it really depends on you and what feedback you want to get So our next question is, "Have there been "any updates to the literature around taking "exogenous ketones for general health, "energy, and neurological disorders "since your March blog post?" I don't know if I've seen anything recently– – There really hasn't, I haven't seen anything that enhances what we already know Again there are, this a very active area of research with ketone supplementation

And research being done at Oxford – Yeah – Dr D'Agostino's group at University of South Florida and Jeff Volek at Ohio State University all have active protocols under way And as the range of ketone supplements that can be consumed, the range of formulations is increasingly available, and particularly as the cost comes down we'll– – Yeah that too

– Hopefully have an understanding of how best to marry the exogenous ketone usage with also enhanced endogenous production by appropriately restricting dietary carbs – Our next question is, "How do you address "those doctors who advocated whole foods, "plant based diet to restore insulin sensitivity "and thus control Type II Diabetes, "and also decrease insulin needs for Type I Diabetics? "It seems their way of eating "is the complete opposite of a ketogenic diet" – The answer is, not necessarily One can do a, definitely a low carb, and even a ketogenic diet as a vegan vegetarian It's easier to do as a lacto ovo vegetarian where the majority of one's food is coming from non meat sources, and particularly from plant sources

And I actually was, I participated in a symposium recently in Chicago where there was a advocate of total fasting for a duration of like two or to three weeks, followed by a plant based diet And he presented evidence of reversing Type II Diabetes with that approach The total fasting was done in an inpatient setting This is obviously, would be a very expensive way of using this kind of therapy And his data was impressive in terms of the people he selected to present

But these are people who chose to A, pay the money, and B, go through the fasting And at the end we agreed very collegial that there are some people who are well suited to do it that way And there are many people, and certainly we found quite a few of them in the Lafayette, Indiana area who were able to do it with the Virta program The two are not mutually exclusive And so in the future as, particularly as there are rigorous studies done with the plant based diet, because up til now it's been more anecdotal and ideological than science based

But as people demonstrate what percent of people who are recruited into such an intervention can succeed at that, not just for months, but for years, we'll be able to offer people, basically a menu of options rather than saying this is the way to do it And I don't think there's one carbon, or one cookie cutter approach that fits every human being's metabolic needs – Yeah, and I also think there's preference, and lifestyle choice too, is that you have to, we were talking about doing something sustainable You have to choose something that's going to work for you both in terms of health and your metabolic needs, and your lifestyle, so you have to kind of find the balance between the two And for some people it might be one direction, and for some people it might be a different direction

Definitely have to consider what the patient's goals and values are – Agree – Next question says, "How will I know "if I am no longer insulin resistant?" That is a challenging question to answer We could tell you about your glycemic control You know there's certainly a range of understanding your blood glucose, and how much your blood glucose varies in terms of you know, what is your average blood glucose over a period of time when measured by A1c

In terms of insulin resistance, I guess the gold standard would be the clamp? The glycemic clamp? – There's actually a sign, a research test where you infuse insulin in one arm and you infuse glucose in the other arm and you see how much glucose it takes to overcome the effects of insulin – Sure – The more standard approach is to do either a fasting insulin, and a fasting glucose in the morning and that is a calculation called– – A homeo– – Homeostatic measure of insulin resistance And that's something that can be done by any physician It's a standard test with just one blood test

If you wanna be more rigorous you could do a, and we don't advocate this, have people drink either a 50 or 75 grams of glucose and measure the body's insulin and glucose response over either two hours, up to five hours But the home IR is a pretty good test– – Yeah, it's been validated against– – It's been validated in our, what was the reduction in home IR at one year? Was it like 60%? – I don't remember off the top of my head It was significantly reduced Unfortunately I don't remember the number – It was a very large reduction

– Yeah – And so those are the ways, but if you were taking diabetes medication for Type II diabetes, and you're off those medications, and your blood glucose control is better, and your hemoglobin A1c is down significantly you're markedly, you've markedly improved your insulin resistance That you can know for sure – Definitely So thank you so much for joining us today

If you'd like to have more information on ketogenic interventions and their effect on diabetes and heart health, follow Virta Health on Facebook, and check out our research on virtahealthcomresearch – Thank you

Keto diet shows success for local diabetes patients




A TYPE TWO DIABETIC IS 25 POUNDS LIGHTER SINCE STARTING THE KETO DIET IN APRIL BEFORE THAT, JUSTIN SAYS IT WAS DIFFICULT CONTROLLING HIS WEIGHT SOT JUSTIN SHIRLEY, KETO DIETER: "I love fried foods, I love eating out But I knew being a type two diabetic, I couldn't do that anymore" SOT ASHLEY PORTILLO, REPORTING: "A blood screening from late march shows Justin's results consistent with diabetes

And since the diet? His results show normal readings His doctor even recommending he stop taking his medication for a week" SOT JUSTIN SHIRLEY, KETO DIETER: "I was amazed that on this diet, I can control my blood sugar, I can lose weight, I can have a better lifestyle" BUT ONE THING DR GOPAL WANTS PEOPLE TO KEEP IN MIND IS THAT THE KETO DIET IS STILL CONTROVERSIAL

SOT DR JEGAN GOPAL, BARIATRIC SURGEON: "Long term consequences of the keto diet, we have some idea But in terms of what it does in terms of diabetes, heart disease, liver disease, we don't have that data yet" ASHLEY PORTILLO, KRIS 6 NEWS STEPHANIA IF YOU WANT TRY THE KETO DIET, DR


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

Dr. Sarah Hallberg: Is it dangerous to reverse diabetes with keto without physician supervision?

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

How to KETO: Avoid, Beat & Control Type 2 Diabetes, naturally

So your blood sugar levels are normal but what about your insulin levels? In this video, we talk about the ABCs of reversing type 2 diabetes naturally and Hey if we're meeting for the first time, my name is Lynette and I'm here to help you get back to the pink of health and be beautiful naturally and today I'm on a quest to find out how to A – avoid, B- beat and C – control type-2 diabetes naturally just by choosing the right foods and talking about foods, what foods do we avoid? Remember previously we talked about how carbs turn into sugar in our bodies so very simplistically if diabetes is the passing of sweet or honey tasting water then by reducing the amount of carbs you actually reduce the amount of sugar that's freely roaming in your bloodstream So why is there sugar in your bloodstream? Because you eat too much carbs

There's too much rice, too much noodles, pasta, breads, potatoes things like that and plus you don't really exercise, you don't have time and so you don't expend all of that which you've eaten and what happens is all of these get converted to sugar and get stored up as fat and that's what you call a decrease in insulin sensitivity You end up feeling hungry all of the time and you have cravings for carbs and it's a vicious cycle you know because insulin is the hormone that tells you when to eat when to stop eating On top of that, insulin is also the key that unlocks our cells to tell it to take in sugar to either use it as energy or to store as fat and so if you think about it insulin is actually that which keeps your blood sugar in perfect balance So when you eat too much carbs, you actually cause your pancreas to overwork and when it overworks, it has to produce more insulin to cope with the high amounts of sugar that's in your body and it's worse if your cells are not taking in the sugar, that's how you end up having sugar floating about in your bloodstream and that's dangerous because that's something called insulin resistance and that can lead to pre-diabetes and eventually Type-2 Diabetes Now what I find most disturbing about insulin resistance is the fact that it is one of five risk factors that increases your chances of getting heart disease and stroke so you really need to pay attention if you've got insulin resistance, excess belly fat, high blood pressure, high triglyceride levels and low healthy cholesterol levels But what if you are skinny, you exercise, you eat well? It's best to confirm with the test so as for the insulin levels test to know for sure whether you develop health complications later or not If you are well and good that's great! Don't you want to preserve what you already have? Now according to Dr

Sukol, insulin is like money in the bank It is finite So if your pancreas has to constantly overwork to produce high amounts of insulin to cope with high amount of sugar in your body it's bound to go wonky at some point so why not start today don't wait till it's too late I challenge you cut out carbs from your diet Substitute it with 70% good fat, 25% protein and if you're on medication already consider cutting on your carbs as well so you reduce your dependence on pills as well Okay so that's a lot of information to take in I know You're most welcome to watch this video again or I'll see you in the next video!

Keto Diet and Type One Diabetes

Jacinda says, "is the Keto way of eating okay for a type one diabetic?" Really cool question, thanks Jacinda Type one diabetics are special breed of diabetics so in essence type one diabetics born with diabetes or they may get diagnosed when they're like five or six years old

Generally type one diabetics aren't overweight You know they're not generally overweight type two diabetics, not all type two diabetics are like hugely overweight, but generally is a bit of a rule of thumb I suppose So you have to be quite careful as a type one diabetic to manage your blood Sugar's well Because you can be prone to hypos more than a type two diabetic So keto has been studied in type two diabetics for losing weight and has been proven to be quite good

As has a low calorie diet of 800 calories or less has been proven to sometimes reverse type 2 diabetes entirely So there's lots of different ways of tackling type-2 diabetes with diet, but type one I would probably advise caution so if you are type one diabetic and you wanted to try something I would do it in partnership with your GP, and make sure that you're monitoring your Sugar's really closely Keto is high in fat low in carbohydrate, so therefore all of your insulin dosing will mean that your Sugar's will crash and burn and you don't want to go there because it will lead to a coma So just be careful with that Jacinda I would work really closely with someone

Maybe even a nutritionist