Diet Doctor Podcast #10 —  Dr. Sarah Hallberg

Diet Doctor Podcast #10 — Dr. Sarah Hallberg

August 3, 2019 35 By William Morgan


#1Welcome to the DietDoctor podcast
with Dr. Brett Scher.
Today is my pleasure be joined
by Dr. Sarah Hallberg.
She’s the medical director at Virta Health
and medical director at Indiana University
where she runs a weight loss and diabetes
management clinic there.
And you’ve probably heard of Sarah
because of the amazing work she’s been doing
along with the folks at Virta Health
with their scientific data and their studies
which is really upended
the way we see diabetes.
Diabetes has always been taught as a disease
that is chronic, that you just manage.
But what they’ve done
is they’ve disrupted that whole concept
to now show we can reverse diabetes,
we can normalize people’s numbers
and get them off their medications
while helping them feel great.
So I’m so excited to have her on
to discuss the work they’ve been doing
and to discuss some of the maybe downfalls
of the study the way it was conducted
and maybe some of the problems
with applying it to real-world scenarios.
But these are the issues that we deal with
on a on a regular basis.
And you can see from her energy
and her knowledge
that she is a fantastic advocate
in this field.
So I really hope you enjoy this interview
with Dr. Sarah Hallberg.
Dr. Sarah Hallberg thanks so much for
joining me on the DietDoctor podcast today.
#2Thanks so much for having me.
#1So you’ve been very publicly well known
in the low-carb sphere
ever since Virta Health came out
with their study,
first their 10 week study,
then their one-year study,
but in case anybody doesn’t know you,
give us a little background about
how you got to this point in your career
that you’re basically upending how we treat
and see diabetes.
#2Well, I got to this point
through a little convoluted path
which in hindsight was the best way
to get there.
I started out my career
as an exercise physiologist,
I have my master’s degree in that
and worked for a while in cardiac rehab.
Actually I got into a fight
with a cardiologist,
that is the moment that I decided
I was going to med school.
So I didn’t want to go since I was five.
And then I worked to primary care
for a while
and then was approached by IU,
Indiana University Health,
which is where I’m still currently the medical
director at the obesity program there,
approached me about starting
the obesity program,
so I had to figure out what to do.
Like, “How do you solve the unsolvable
problem?”, is what I always used to say.
And so I spent a long time
reading everything.
I mean I read literature for a year
to try to say, “What can we do?
Why does nothing seem to work?”
And what I really realized then
was that the advice that I had been giving
for almost 20 years at that point
was really not based in evidence,
that I just took what everybody told me
and thought it was fact
and went on and gave
that misguided advice to my patients.
It was a real, “Aha!” moment of… “Holy cow,
I’ve been contributing to this problem!”
And so from day one we opened the clinic
at IU, as a low-carb clinic
and quickly the focus changed from obesity
which was the original intention of the clinic
to diabetes because that’s what
we were seeing the biggest impact in.
I mean, you know, what was impossible,
people’s diabetes going away.
And at that point it was not in the literature
this was not a thing, if you will.
And I got really mad
because, you know… how can this just be
for the patients at my small clinic?
We did a small pilot study
then I had the great fortune of running
into Steve Phinney at a conference
telling him I wanted to get funding
for a larger study and the rest is history.
#1Well, that’s fantastic.
Now what I find most remarkable is that
you saw what other people don’t see
or at least you acted upon it.
And so what was different for you?
Because so many physicians out there
are trying to treat obesity,
so many physicians out there
are trying to manage diabetes.
But somehow you were able to see
the difference
and say, “What we’re doing isn’t working,
and here’s what we need to do.”
So many people don’t take that next step.
So I guess where I’m going with this
is what’s different about you, how do we get
more people to take that next step
and realize that there’s more out there?
#2Well, I had a really wonderful
opportunity
to have a moment to take
some soul-searching so to speak.
I mean I had this opportunity
where I really had a year
to decide what we were going to do.
And, you know, spent all this time
reviewing the literature
and had that moment where I realized that
I had been doing the wrong thing for people.
And I was able to pause and just say,
“Oh my goodness, you clearly are
at a fork in the road at that point.”
Do I continue on with sort of the easy path
that we know is wrong,
but is what’s readily accepted?
Or do we consider trying something that
there sure seems like there’s more evidence?
I mean this was a number of years ago,
so there wasn’t as much evidence for it
as there is today.
I mean black-and-white almost difference
in the two times.
But then you say, “What is my goal?”
And clearly my goal– and I think most
healthcare providers say,
our goal is to help people,
is to really help people.
And I knew from my almost decade
in primary care
that what I was doing was
frustrating people with a low-fat advice.
I knew that, I saw it, I had those moments
where people were like, “But I’m doing it.”
In my own self I doubted,
I did like so many other providers did
that said, “If you were just listening to me.”
I had those moments along the way
but I knew that I was just frustrating them,
I knew that everybody–
that couldn’t be happening
with all the people that we were seeing.
#1Isn’t it convenient how we put it
on the patient, that is their fault,
that they’re just not doing
a good enough job
instead of questioning
the advice that we’re giving?
#2Absolutely but it just seemed so–
it couldn’t be that
all these people were wrong,
it couldn’t be the advice,
because I hadn’t taken the time
to go back and read
until again I was setting up
the obesity program.
And then you just look
at all the facts in front of you
and you say,
“I know it was frustrating people,
“we’re way getting worse
and we’re continuing to do the same thing.
Look, there’s evidence
for a different way of doing it.”
And ultimately you got to have
your moral compass
and check, “What is my goal?”
My goal is to do the best thing I can
for my patients.
So again I had a little advantage over–
the situation presented a good advantage
and my experience in primary care gave me
I think what I really needed
which was so much experience with
frustration from patients standpoint to say,
“We’re not going to do it
that way anymore.”
#1And then fortunately you get connected
with Dr. Phinney
and as you say the rest is history.
And the rest is actually rewriting history
because med school, residency,
fellowship, clinical practice,
you are taught you manage diabetes,
you adjust their insulin doses
almost always adjusting up,
you add oral medications, you manage,
you don’t reverse,
you don’t take them off medications.
And now it’s a different story,
it’s a completely different land out there,
it’s a completely different world for diabetes
largely based on the study that you did.
#2Well, isn’t it a wonderful time
for diabetes in diabetes care?
Because what excites me
more than anything
is when you look at a patient and say,
“You can reverse your type 2 diabetes”,
you’ve given them so much probably most
importantly control back in their life.
#1Right.
#2Because they felt
like they had just lost all control.
They continued to get worse
and so it’s an exciting field to begin,
it’s an incredibly rewarding field to be in,
just a great time to be in this space
and really be able to see patients
transform before your eyes.
It’s an honor to be able to accompany them
on that journey, it really is.
#1So let’s talk about the study briefly.
At the one year mark there was
83% compliance with the diet,
people who still stayed in it,
the hemoglobin A1c reduced
from 7.6 down to 6.3,
94% of people either lowered
or got off their insulin
and there were improvements in CRP,
triglycerides, HDL,
in the ALT, the liver function test.
Now the LDL-C went up by 10%,
but with no change in ApoB,
which is the more important marker.
So these are revolutionary stats coming
from a dietary management for diabetes.
So you would think
everybody would be getting in line,
lining up and saying,
“Yes this is what we need to do
to make the standard of care
to treat type 2 diabetes.”
But that’s not the case…
people aren’t lining up.
#2It’s not a pill.
So you say a couple of things
that it’s just so shocking…
you know, over 50% of the adults
in this country have diabetes or pre-diabetes
and what I say is,
“What if that was an infectious disease?”
What if over 50% of the adults
in this country had an infectious disease?
What would we be doing collectively?
This would be
like the world most nonpartisan thing.
We would be all coming together
and we would be doing anything
and everything that we could to battle this.
But it’s got to do with food
so we’re able to ignore it
and then the solution isn’t a pill.
It’s food again.
And somehow with results this remarkable
we’re able also to say, “Okay… move on.”
And it shocks me, it truly does.
And this is a fantastic solution for people.
They don’t have to have surgery,
don’t have to take yet another medication
and it’s not just the diabetes that reverses.
I mean people feel better.
It’s remarkable the improvements
people have in their overall quality of life.
So I’m just excited to keep doing the research,
plugging away, continue to talk about it,
because I think our solution to our current
health epidemic is in front of us.
#1So there can be a couple
of different pushbacks on the study.
It wasn’t randomized,
it was only one year,
it involved a very intensive management
with very high touch.
This isn’t something where you see them
in the office every six months.
Is it applicable to the real world?
Those are all sort of the pushbacks I guess
that people would give to this study,
that I’m sure you’ve heard
hundreds of times if not more.
So how do you address that to say this is
still evidence that applies to the real world?
#2So first of all as far
as the non-randomization goes,
my pushback to that is no it wasn’t randomized
because we were doing a long-term trial.
And if you don’t include
peak patients choice in it,
you’re going to get a huge drop out.
I mean patients are the number one people
who get to choose what they do, right?
I mean we can’t be telling them.
So we allowed patients to choose;
“Would you like to go
into the intervention arm
or would you like to continue on
with standard of care?”
And so you know that is a critical piece
without question
to the long-term sustainability.
And that goes to another point you had
which is generalizability.
“Do I think everyone in the world who has
type 2 diabetes will choose to do this?”
I don’t think,
but I think a lot of people will.
And so this is geared towards the people
who are interested in reversing their disease,
who don’t want to have surgery
in order to do that.
And the idea that
that’s not a big percentage
of the people who have type 2 diabetes
is crazy, of course it is.
#1And that’s what I find so interesting because
when I talk to friends in endocrinology,
one of my good friends
runs hormonesdemystified.com,
you know, his main pushback is,
“Everybody should be doing this,
but in my personal experience,
just a small fraction actually want to do it.”
And that’s what so frustrating,
how do we get people over that hurdle
to understand how important this is
and want to do it?
Because we’re so ingrained in our society
that we need our grains,
no pun intended,
that we need our carbs,
that is too much of a sacrifice
to do this type of diet.
But on the other hand you could say
it’s too much of a sacrifice to lose a limb
or have kidney failure
and yet there’s this disconnect there.
So how do you see us
getting more people over that hump?
And it has to start sort of in the community
with regular doctors and everyday doctors
and not from Virta Health.
So do you how do you see
that disseminating?
#2No one is going to choose to do it
who doesn’t know it’s an option.
That’s the absolute bottom line.
And so in many of my talks that I give
like in grand rounds and going to speak
to various physician groups,
I talk about diabetes reversal.
I mean in the take-home message is always,
“it is a reversible condition”.
I mean you can do it with bariatric surgery,
you can do it with extreme calorie restriction
or you can do it
with a low carbohydrate approach.
No one should be choosing
which one of those choices patients make
other than the patient.
But if they don’t know
that it’s a choice,
if they don’t know that there’s actually
something that they can do about it,
of course they’re never
going to choose that.
So the number one thing
we need to work on is just the concept
and allowing people to understand
that type 2 diabetes–
it’s very important to make sure we clarify
it’s type 2 diabetes,
is a reversible condition
especially if you start early.
So we just need to continue
to work really hard.
And I call on everyone,
I certainly call on healthcare providers
to talk to their patients about that.
But I call on the general public too.
When you know someone, you know,
they probably don’t have any idea
that this is something
that they can take control of
and that they can reverse.
And I think the more and more
that we get the word out
and I do think
we’re making a difference in that.
#1Sure.
#2The more we can continue to work
and get the word out
that this is something
patients can take control of themselves,
the more people will choose it.
#1Now what about governing bodies
and guidelines,
you know, the American Diabetes Association
and the European version of that
and even, you know, family practice
guidelines for managing diabetes,
why has this not taken those–
made them totally revitalize their guidelines
and include a low-carb diet?
Is it simply because Pharma influence?
Is it because they think more data is needed?
Is it because they’re concerned
about the LDL or the saturated fats?
What kind of resistance
are you getting there and why do you think?
#2Well clearly I think
there was resistance there
since my TED talk was
“ignore the guidelines”.
But since that time we have made
some good moves
in the sense that just recently
in the last few weeks
the American Diabetes Association
and their European counterparts
did come out with new recommendations
and they are now including low-carb
as a recommended eating pattern,
which is a move in the right direction.
I don’t know that it’s a strong as a move
because they still for example have DASH
as a recommended eating pattern
and the amount of evidence for DASH
for type 2 diabetes is basically nonexistent.
In fact in the one study that they cite
triglycerides actually worsened
in the intervention group.
So the evidence is there,
I think they’re starting to pay attention to it,
the governing bodies if you will
because the amount of evidence
is just overwhelming.
For example there are 25 randomized
controlled trials
looking at a low carbohydrate intervention
for type 2 diabetes.
Five meta-analysis.
You know, how many for the DASH study?
Two.
So there’s no comparison anymore.
Mediterranean diet – very few.
I mean there’s no eating pattern
that even comes close to the amount
of randomized controlled trial evidence
that there is for a low carbohydrate diet.
And I’m going to offer again
that we need to look beyond
just randomized controlled trial data.
There are additional other studies
in the low carbohydrate evidence-based
including ours that are longer-term
and maybe not controlled.
And once again when we’re looking
at long-term sustainability patient choice,
i.e. not randomization,
is just going to be a key component.
#1Yeah, it brings up a great question about
evidence and scientific research in general,
the randomized controlled trial
versus the observational trial
patient choice trial as you say.
For a drug a randomized trial is great.
#2It is… perfect.
#1But for a lifestyle choice
that you have to buy into,
randomized controlled trial
may not be the best choice.
And this is the better way to go yet,
where we’re so ingrained in our brain
that it has to be randomized
to be the highest level of quality.
And you bring up some good points,
maybe that’s not the best approach for this.
Because we want to know,
does this work in the real world?
#2And does it work long-term?
#1Yeah and what your study showed
is clearly the model at Virta,
works long-term.
Other studies have shown
maybe even outside that model
that a low-carb diet works.
But now your model
has that higher level of touch.
#2Yes.
#1It’s got the technology behind it
and it’s got sort of the best of both worlds,
the medical science and
sort of the Silicon Valley tech flare to it.
Do you think that is scalable
to the hundreds of millions of patients–
well, the millions of patients
that we need to help reverse this condition?
#2I do and I think that’s the key.
And the point that you made earlier was
this is a high touch situation
and that’s not what we’re normally doing.
But wait a minute,
that’s what we need to be doing.
Because let’s face it,
making a lifestyle change is hard.
If it was easy, everyone would do it.
So people who are embarking on this,
who have the goal
of reversing their type 2 diabetes
need to have a lot of support.
And so the remote care model that
we are utilizing at Virta is giving them that.
And so yes this is the way
that it can be scaled,
because you can do away
with the brick-and-mortar,
you can make it very convenient
for patients,
they can get their information,
they can get their medication changes,
they can get their support
and their questions answered
when it works for them.
And so yes, does the higher touch
cost more money
than going to the dietitian
every other month or something like that?
It does but it saves money,
because with the dietitian we’re just
continuing we know adding more medication
if we are seeing them–
especially I should say all dietitians,
if they’re recommending the standard
of care low-fat approach,
we know that that causes progression
of disease and more medication over time.
Yeah is more intense but very needed
when you’re doing something
as difficult as a lifestyle change.
If you’re doing that you can pull people off
of medications,
you can get rid of a disease
that is financially crippling this country.
So the high touch is absolutely needed
and can be scaled
and can be done financially
in a cost-saving model.
#1So why aren’t insurance companies
banging down your door to save money this way?
#2Well, I think that that is beginning.
So, I think as we see again
our continued results
we’ll be seeing more and more people
being able to offer Virta to their employees
or their insured populations.
And so as you brought up too
that it was only one year,
but we are looking forward
to the publication of our two-year data,
so it’s been recently submitted
and as you know it can take a while
to go through the actual
publication process.
I can’t get into the details of it
but what I can say
is that we were really excited to show
that our results are sustainable
and that’s really exciting.
#1Now, when you present data like this,
so you generally present the average…
everybody does it,
you present an average…
but what’s helpful to know is
do most of the people hit those averages
or there are huge swings?
Do some people reduce their A1c
from 8 down to 5.5
and others go from 6.8 to 6.7.
Some people have spikes
in their LDL
and some people have declines
in their LDL or their ApoB.
Can you give a sense of what kind of variation
you have across that mean in your data?
#2Sure, there’s some variation,
but actually much less than you would think.
So what we see is that most people
are getting better, sure with an average,
some people are a little below
and some people are certainly a little above,
but let me bring up one of the important
questions that you just post,
which is with the LDL-cholesterol.
Like the average ApoB didn’t change,
but there were patients
who had skyrocketting ApoB.
And actually when we compared them
to the control group,
the variance there was not any different
than what we would expect
or what we saw with the control group.
So in other words we didn’t see
these huge rises out of a couple of people
that would give us reasons
to be concerned.
So the variance was about what was seen
with standard of care.
#1That makes sense because
the patient population you’re working with
is overweight, they’re diabetic
and the patients that we see
those rises in ApoB
tend to be the leaner, healthier,
nondiabetic individuals.
So I think that’s an interesting dichotomy
if we use your evidence
to say nobody gets a rise in ApoB.
Obviously that’s not true,
there are certain subsets that do
and it looks like that’s
a fairly safe subset.
But do you have a policy at Virta
how to address that if it does happen?
Because it’s controversial,
there’s no one right answer.
And when you have a big company
and you have protocols in place,
you have to be a little conservative
I would think about that.
#2Yes, we do,
I mean we definitely take any change
in any biomarker that may be concerning
incredibly seriously and we act upon.
So we definitely– and I’ll tell you,
when we have a rise in LDL,
whether it’s someone who is healthier
or someone who has metabolic disease,
I sit down and we have
a huge discussion about it
and I prescribe statins very often
in that patient population.
I want my patients
to be better in everything.
I want all of their risk factors
to be controlled.
And that’s absolutely my goal.
#1Yeah and I think it’s a good perspective
if they still have metabolic disease.
It’s not like diabetes and metabolic disease
go away like that, it’s a progression.
So an elevated ApoB
as they are still on that progression,
they still have insulin resistance, they may
still have elevated inflammatory markers,
that’s a completely different situation
than someone–
these classically mess hyper responders
who have actually know insulin resistance,
their inflammatory markers are perfect,
their HDL and triglycerides are perfect,
those are two different scenarios
that need to be approached differently.
#2Yeah, I can say confidently
in the patient population that we treat
we don’t often see a rise
in LDL-cholesterol.
Anyone that does, what’s important
is each individual patient to all of us.
I mean each individual patient to be treated
as an individual and not as an average.
So anyone who deviates
from what normally we see
is something that we get on top of
and that we have a discussion
with the patient and we treat.
#1What about other side effects
or adverse effects of the diet people point to?
You know, gallstones or even kidney stones,
or G.I. distress?
What have you seen that is really
something that can happen
and what have you seen
that is just people putting out information
that really has no basis in reality?
#2I mean the “side effects” are that people
feel great and they lose weight.
Those are the big side effects.
So a lot of these other things
are just chatter.
So from a gallstone standpoint, people think
they can do it, they don’t have a gallbladder.
Oh my gosh, so many of our patients
don’t have gallbladders, they do fine.
And gallstones are caused
from a low-fat diet,
because the gallbladder isn’t squeezing
in response to fat that’s consumed.
So you know we certainly wouldn’t expect
formation with gallstones
with a low carbohydrate high-fat diet.
And kidney stones,
I mean do we see patients who have had
a history of kidney stones get a kidney stone?
Sometimes.
But do we see patients getting kidney stones
who don’t have a history of them a lot?
We don’t.
I think in the literature
there is very little about this in adults.
In kids there’s about a 5% chance of forming
a kidney stone with a ketogenic diet.
that’s what the literature–
So we don’t have any evidence
of the risk increasing in adults,
but it’s also never been well studied
and I can just tell you that I haven’t had
a big problem with it in my practice.
#1Do you have any people that you see
for intake or any protocols
that say if on intake
patient has X, Y, and Z
they are probably not a good candidate
to enroll in this?
#2So in other words who is not
a good candidate for a ketogenic diet.
And really we’ve only come up with one.
And that is anyone who has
hyperchylomicronemia
should absolutely not do a ketogenic diet.
So they have to be
on an almost no fat diet.
But that’s one case
every 1 to 2 million people.
Otherwise I’ve done this in patients who
have had liver transplants, kidney transplants,
I mean I’ve utilized it across the board.
And the hyperchylomicronemia thing
is something you would have to consider
seriously in a child,
but as an adult, I mean the adult
would know about it already,
because these are people
who get pancreatitis all of the time
and it can actually be a fatal disease,
it’s genetic.
So usually you’re not surprised
by a case of that.
#1Now with the rise in type 2 diabetes
in teens and adolescents
is that something you’re starting
to see as well?
Does Virta focus
only on adults at this point?
#2Only on adults at this point,
but yeah I think we’re going to eventually
have to expand,
especially if we continue
with the trends we’re currently seeing,
because of course type 2 diabetes
is not an unheard of case to see
in an eight-year-old anymore
and that’s unbelievably concerning.
#1What about bone loss?
Actually that was another side effect
I was going to ask about,
because that’s out there
in the chatter world
that there you risk increase bone loss
especially in elderly women on a keto diet.
#2Well, I’m smiling because…
hold the phone on that.
#1Oh, you have some data
coming out on that too?
#2The data is coming out.
#1Excellent, now another topic
that gets a lot of attention
for type 2 diabetes and weight loss
with some very good results
is intermittent fasting
and time restricted eating.
And just saying intermittent fasting
can mean anything from a 16 hour fast
to a 16 day fast and
so it gets a little confusing
and I know there are some people within Virta
who are not proponents of fasting,
but I think the devil is in the detail
when we talk about what kind of fasting.
So is there any discussion about fasting,
any use of fasting or time restricted eating
in your protocols?
#2When someone tells me
that they’re fasting
my absolute first question is,
“What does that mean?”
So I think there’s data
on time restricted eating
and if patients want to do that
I think that’s fine.
So I would like to see us do away
with the word fasting,
unless we’re really talking
about long-term fasting,
which is not something
that I recommend at all.
Time restricted eating,
where patients keep their food intake
during certain hours of the day,
I think that’s fine, you know, they’re not
going 24 hours without food or protein.
I don’t support that idea at all.
But time restricted feeding
for people who choose to do it,
I think is a very reasonable thing.
And again there’s some data
to support that.
So it’s something that we would talk
to our patients
to make sure that they’re doing
appropriately,
but if they were interested in,
then we would support them in doing that.
#1And the concern with going 24 hours
is that from the protein loss,
muscle mass loss mostly?
#2Yes, and then refeeding syndrome too,
which is a real thing.
So we don’t support that.
There needs to be data behind that
and I think the only data that exists
right now is from George Cahill
from many decades ago
and supports the idea that we have
muscle loss when we do prolonged fasts.
#1Yeah, I think that’s where the data
gets really confusing,
because it’s what type of patient population
are you talking about?
Are they already thin and lean or are they
obese with plenty of fat stores to lose?
What’s the duration
and how you measure it?
And I think it gets very conflicting.
So I can see why Virta would say, “Until we
have more evidence saying this is safe,
let’s stay away from it.”
But then you have people like Jason Fung
and Megan Ramos at IDM program
who are using it with great success
and safely.
And I want you guys to get together,
I want everybody to sort of agree on this
and I guess it’s not going to happen
for the time being.
#2It’s not.
I mean at Virta we are going to only practice
things that are evidence-based.
And so we will wait for evidence and
we’re open to any evidence that comes out,
but we are an evidence-based practice
without question.
#1So what about exercise
and the use of that?
Because that can be a double-edged sword
for some people as they’re trying to lose weight
and if they are not ready for exercise
it can cause injuries,
sometimes it can spark hunger,
but yet at the same time it can be
a very important part of long-term health.
So how do you incorporate exercise
recommendations into your program?
#2So the best time to get someone to exercise
is when they ask you about exercise.
So in other words it’s not from day one.
Because you’re asking them
to make a huge lifestyle change
if you are telling them
that they have to eat differently
and now they have to exercise too
and that’s overwhelming.
So again my background
is in exercise physiology.
I want everyone to exercise,
I mean exercise is fantastic.
But when do you get people exercising?
And when you get people exercising
where they’ll stay exercising
is when they come to you
because they’re feeling better.
Because they know that they are healthier,
they have more energy,
they’ve lost weight,
the pain in their joints isn’t as bad.
That’s when you can get someone exercising
and they will stick with it.
And there’s no set time for that.
It’s not like, “It’s been six months,
you need to be exercising.”
No, because for someone it might be
a couple of months
that they want to start exercising
and for some people it’s a year.
I mean each person needs to make
their own choice
on when it’s going to be right for them and
we’re absolutely here to encourage them.
#1That makes a lot of sense.
And thus the benefit of that high touch
frequent follow-up personalized care
you can get an idea
of when that timeframe is.
Again not seeing them every six months,
once a year or something like that
where you’re not going to have
a good time frame
on how they’re feeling
and how they are progressing.
#2Right, because what if they want
to exercise at, you know, three months
and you don’t see them again
for six months?
You missed your opportunity to talk to them
and engage them and help them.
Because what do you do?
You need to be there
with good advice and support.
And again when that comes for patients,
we want to be there
at the moment that it comes for them
to be able to support them
and guide them
and help them make it something
that can be sustained
as part of a new healthy lifestyle
going forward.
#1Now in addition to your positions
as chief medical officer at Virta health–
#2Actually I’m not that.
That would be Steve.
#1I apologize, that would be Steve…
Remind me again.
#2I am medical director.
#1Medical director at Virta
and then at IU,
you’re also very involved
on the policy side of things
and trying to get guidelines change.
Tell me about some of the work
you’re doing there
and what you see as what’s coming
on the horizon?
#2Well yes my partner in crime there is
the wonderful Nina Teicholz as you know.
So Nina has done some unbelievable
amazing work in DC
as far as trying to get
our guidelines changed.
And I help her out.
And one of the things was that I just
recently got to go and give a testimony
at a Congressional briefing for the working
group called Food As Medicine.
And so I gave my discussion about diabetes
and how is it that we’re not doing more,
here’s a solution that can help.
And so we got really great response there.
So I’m excited very hopeful
that again we can see guidelines changed.
Of course the American Diabetes
Association guidelines,
we are seeing evidence of that already.
But we’re poised for the 2020
dietary guidelines coming out soon.
I mean 2020 is not far down the road.
And so we are really looking forward
to hoping that they focus
on evidence-based medicine.
We are supporting many evidence-based
candidates on the committee
and again we just continue to work
in that direction.
Evidence-based policy is what we need.
#1It’s such an interesting term to use
because if you asked the people who were
involved in the last guidelines
is this evidence-based… They would shake
their heads and say, “Yes, it is.”
I mean I think it’s clear they believed
they were following evidence-based guidelines,
but there a lot of holes in that and
the quality of the evidence was poor,
but yet that’s what they believed in.
So how do we get them to change,
if they already believe they are following
evidence-based guidelines?
#2It’s very clear that they did not.
So the national Academy of Sciences
was very clear
in their report and recommendations
about the dietary guideline process.
So one of the things that Nina
and the Nutrition Coalition did
was actually get Congress to mandate
what was really the first peer review
of the dietary guidelines,
the 2015 dietary guidelines
by the National Academy of Sciences.
And they appropriated $1 million
to that effort.
And the report came out
in just over a year ago, September 2017,
and basically said that the dietary guidelines,
what impacts so many Americans,
is not based on rigorous methodology.
And has to be reviewed
and completely re-structured.
And so again we have
the recommendations there
and what we’re really working on right now
is to make sure
that those recommendations
from the National Academy of Sciences
actually get put into action.
#1So when you were testifying, you said
you were testifying in front of Congress?
#2Yes, it was a Congressional working group
called Food As Medicine, correct.
#1So I would hope they wouldn’t have
such a strong bias going into it,
that they would be–
you know, they are not scientists,
is not like they’ve made their career defending
a certain guideline or certain way of eating
so that they would be more open to it.
Did you find that they were
a little more receptive
than when you talk to a group
of endocrinologists or a group of researchers,
or a group of people who are already
involved in the American dietary guidelines?
Did you find a different reception there?
#2No, because I actually feel like I get
a really reasonable reception
even from physicians.
When you pause with them for a little bit
and talk to them, most of them–
of course there’s always exceptions,
are interested,
and you could see them
kind of reflecting on it
and then they agree
that it really makes sense.
And the same thing happened
at the briefing.
So there was a lot of interest in it,
a lot of people asked for my slides afterwards.
So I’m hopeful that, you know,
is this one thing going to be
the end-all be-all change?
Absolutely not we need to continue
to work to do things like this,
chip away if you will at the old dogma
of how we treat and recommend nutrition
to people and we will get there.
#1And how much is industry
and Pharma fighting this?
#2I think what we’re seeing
as far as industry goes is there is some shift.
I’m not saying that there hasn’t been
barriers due to industry, due to Pharma,
But with industry at least you’re seeing
some companies
began to shift to the whole foods idea
and at least put some thought…
I don’t think they’re doing enough,
no arguments there,
but put some thoughts to this direction
and how are they going to survive
in a world where the consumers are asking
for something different.
And I hope at the end of the day at some point
they become an ally in getting good food,
but there’s no question that they’ve been
contributing to the problem for a while too.
#1Absolutely.
I know we are short on time today
because you have to run downstairs
and give your talk.
I appreciate you giving us time this morning
so thank you so much.
I know you’ve got
a two-year data coming up,
what else is on the horizon
and get people excited about
and where can they go
to learn more about you?
#2We have a number of papers actually
that are going to be coming out.
So two-year data, we’ve got a liver paper,
a sleep paper…
We’ve got a really exciting data
coming out.
And so yes to learn more,
you can go to Virtahealth.com
we will always be putting up
all of our published papers there
for people to be able to read.
And keep watching,
I think the field is changing
and I think we’re going to see guidelines
really start to be impacted soon.
And like I said, I am excited…
it’s a good change, it’s a needed change.
#1That’s fantastic, thank you
for all your work and your advocacy.
It’s wonderful to see
the whole field change
and know that we can start to reverse
this condition of type 2 diabetes.
#2Thank you for having me.