Dr. Sarah Hallberg – Type 2 Diabetes Reversal

– So, I’m here to talkabout my favorite subject, besides my children, and that is diabetes change. First, my exposures. And the problem. I know in this audience here, beings are well aware of this, but we are in the midstof a horrendous epidemic. So the last time this waspublished in a major periodical was in GEMA, looking at 2012 data. This was published in 2015. And over 50% of adults in this country have diabetes or prediabetes. I entail, it’s really striking. And the consequence of this is we can’t afford this anymore, okay? Of trend, the primary outcome is people’s quality of life, their portion of life isbeing really impacted. But when we look at what isreally going to drive alteration, unfortunately, we all know money talks. And take a look at what hashappened really over six years. I signify, we cannot affordto allow this disease to continue to spiral out of control. And here is the bottom line, type 2 diabetes is reversible. And, you know, foreveryone in this audience, this reality that type 2diabetes is reversible is everyone’s responsibility.So for those people whoare health care providers, it is all of your responsibility to let your patients know this. For people who are nothealth care providers in the audience, it’s your responsibilityto let your friends, your coworker, yourfamily members understand that they are not caught inan irreversible problem. They have their own alternatives on how to taken into consideration their disease.And they can back out of where “theyre starting”. All privilege. Okay, so, there are, actually, three clinically proven ways to reverse diabetes. Bariatric surgery, theliterature is quite robust. I mean, we do get reversal, and we get prolongedreversal in many cases. A very low calorie diethas also been shown to make form 2 diabetes. And a low-carbohydrate diet. Now, I bet no one willbe really surprised, especially at a conferencethat has low-carbohydrate in its figure that I’m gonnafocus on the third one. But it’s really important to understand that there’s not just one alternative. And that is becausepatients have a choice. All claim, so, what is not have evidence of diabetes reversal? Sorry, this looks likeit smudged together. And that is the standard of care. So a study at Kaiser Permanente, a really large study, looks at what happens. What is the amount ofdiabetes remission that occurs following the standard of care? And it doesn’t, okay? So what doesn’t work? We have three techniques that work, one doesn’t, yet we’re invariably talking and rehearsing the one that has miscarried us.It doesn’t make any sense. So, focusing now on low-grade carbohydrate. So, just really quickly now, why does carbohydrate regulation handiwork? Because we know it does, but what’s the physiology behind it? And, again, it’s thatdifferent macronutrients induce different glucoseand insulin responses. And when we remember, what is the problem with type 2 diabetes? The problem with form 2 diabetes is hoisted blood sugars, right? But even before the bloodsugars became hoisted, the pre-problem, if you are able to, is heightened insulin status. And it’s just so importantand truly so simplistic to understand that ourthree food macronutrients form very different altitudes in both glucose and insulin. Carbohydrates cause them both to go up. And it is really important, really important foreveryone to understand , not only the people in this room, that fatty does not cause aglucose and insulin response.And so if we want to instruct our patients to eat something that, actually, will control the root cause of their sicknes, and not just Band-Aid it as we do with more andmore and more prescriptions, we have to instruct them to eat what scientifically shapes feel. Everyone is an individual, and personalization iskey to sustainability. But although everyonehas individual foibles in their own physiology, what we see here as far astheir responses to macronutrient are just generalized to humen, to, actually, mammals. Carbohydrates will cause theglucose and insulin to go up, and fatty is flat. So fat must be a part ofscience-based recommendations for anyone who has type 2 diabetes. So, let’s talk about healthful carbs because our guidelines, again, that have disappointed us are full of recommendationsfor health carbs, right? Well, it’s okay, it’s a health carb. You know, I’m not eating white-hot rice, I’m eating a really healthful carb.It’s brown rice. So a beaker of brown rice with 45 grams of carbohydrates in it is gonna cause two reallydifferent responses in people dependingon if they have a high or a low-pitched carbohydrate endurance. And, clearly, when we’retalking about kind 2 diabetes, we’re talking about the person or persons in red-faced, the person who has a verylow carbohydrate tolerance. So ingesting these health carbohydrates are going to cause anexcessive insulin response. And, of course, we’ll go back to, why are cases with kind 2diabetes generally overweight and often morbidly obese? Because these high levels of insulin, insulin being our fatty storagehormone, stimulate questions. And what do we do? What do we all do? We blame the patient, right? They’re not following our direction. But we gotta go back and lookat this simple physiology.Wait, we really gave thisperson up for failure. So, again, this is from the American DiabetesAssociation guidelines. The total amount of carbohydrate snacked is the primary predictorof glycemic response. Okay, so let’s take alook at one of cases that I heard very recently. I pulled this CGM data just this weekend. So his starting insulin dosewas 210 contingents a day, which, if anyone who is seeingpatients with kind 2 diabetes, that’s what? Pretty usual, that’s pretty conventional. That is not like a patient whocomes in once in a blue moon. That’s, you are well aware, the patientat nine o’clock on Wednesday.And his starting A1C was 11.3. So this is three years into a low-carbohydrate, ketogenic diet. And this is his CGM reading. Insulin dose today, zero groups. He’s still on 2,000 groups of metformin. And his last A1C was 6.1. And I’m gonna predictfrom this glucose swerve, again, that I precisely drew. Oh, actually , no, thisis an old-fashioned one, I’m sorry. This is from April. His last-place A1C was 6.1, whichwas about four months ago. So pretty soon after this glucose curve.But “youre seeing” what happens when you remove the carbohydrates. So this chap had consistent ketones and a flat arc now. And I wanna stay on this for just a hour because I truly feel that the ability for us to give CGMs, the continuous glucose checks, to our patients with category 2 diabetes is going to be a game changer. Because when they canactually look at this and see this happening, and go, “Oh, my goodness, “I can’t eat this, ” you know, they’re gonnawind up pleasing ourselves. And what we’re gonna get there is another facet ofsupport for these parties, which is really exciting.Because when I throw aCGM monitor on someone, I am just super provoked asto watch what’s gonna happen. Because I’ll tell you, even in the patients who we’ve been working withfor a long period of time, formerly they have access tothat data in their hand, like the real time, andthey can see the curves , not only these simple degrees, I symbolize, it makes all thedifference in the world. Okay, so, many of you may have heard the study that came out recently, right? And for parties in this room, I pot a great deal of you had thesame response to it as me. Duh. Okay, so, this was pickedup by the media though and blinked everywhere. Oh, my goodness, even people who are well, who don’t have insulin resistance are having these daytime tides when we settled CGMs on them, right? So this is gonna, again, truly facilitate push carbohydrate restraint further.Because what we’re gonna be seeing, which we have not beentalking about in past, is this is a problem with everyone. So, since I have a CGM andI wear it all the time, I decided to do a little experiment. This is me deciding to sit down and have watermelon withmy minors in the morning. This is a health carb, right? Now, I have not yet been diabetes, Ihave no insulin resistance. My triglyceride: HDLratio is well below one. And my objective, the blue bar there, was in accordance with 70 to 100, okay? This spike, it was 170. 170. And I get asked a lot, like, “Well, how much were you actually eating? ” I’m like, “Like not much. “Like, I sat down and had a bowl “of watermelon with my kids.” This is me.This is a problem. So this was just last week. I was so riled by this that my brand-new project is I’m gonna come home and I’m gonna slap in a CGM oneach of my kids for 10 daylights.( gathering shrieks) My babies are just gonnaroll their gazes and depart, “Oh, my God, my crazy father again.” But I’m like, I wannaknow what’s happening. I make, we have low-carb children, but I don’t restrict outcome. And now I’m like, man, do weneed to restrict some return? I don’t know, but this isreally bothersome to me. Okay, so, how about this? When we talk in the public, away from this type of audience, one of the questions we ever have is there’s not enough suggestion, right? That, you are well aware, we haveto go with the guidelines because the guidelines arewhere all the evidence is.They’re evidence-based. So if you wanna comeup with this new idea, you just have to have much evidence to reinforcement us varying our access. And quite frankly rightnow, it’s not there. Anybody heard that before? Anybody had that assertion? There’s not enough exhibit. Okay, so let’s take a look at this. So looking at low-grade carbohydrateintervention as a medication for nature 2 diabetes.There are 20 randomized see tests, five meta-analysis, and1 0 other published contests, all patronizing carbohydrate regulation for diabetes treatment. Now, we all know that as a general rule, low-grade carbohydrate interventionis not put forward by the American DiabetesAssociation guidelines. I entail, the last iteration they said, “Well, maybe for three months or so.” Like, maybe we could do it short-term, but you can’t do it for long-term.So what do they recommend? The eating patterns that they recommend are the DASH diet, Mediterraneandiet, and plant-based. So let’s see how low-pitched carbohydrate compares to all the evidence of the recommended evidence-based eating patterns. There it is. So, now, the white-hot off-color, is randomized controltrials plus meta-analysis. And then when we supplemented inother clinical contests, here’s how low-carb loads up. And I would adore, take a pictureof this .( public laughs) And evidence it to anybody who tells you that there’s no evidence. And the thing is, I’m gonna be working on more and more diagrams of this because the other thing was, “Well, the studies weren’t long enough.” Actually, overall, taken together, studies and research on low-spirited carbohydrate had more parties and were longer. And there’s just more of them in general. So it’s just not true. Okay, so now I wanna go backto talking about evidence and waste some time talkingabout our ongoing study at Indiana University Health. So this was initially two time, and we have increased the timeof the study to five years. Non-randomized prospectivecontrolled study. And I’m gonna come back in a little while to talk a bit more about study layout. But we banked 465 cases. And in our active interventionarm, there are 378 of them, of which 262 had character 2 diabetes, and the remaining part 116 have prediabetes.The customary care arm were case banked from the same community, same, all at IU Health, but they were being givennutrition instruction by the diabetes educators. You can see here that the mean( sighs) of our patients was quite high. So these were not cherry-picked cases. And the other really importantthing about this inquiry at baseline is we wererecruiting all busines, representing, we weren’t puttingrestrictions on insulin or duration of duration with the diabetes. In point, if you see here the mean times that beings had character 2diabetes was truly long. These were really sick beings. If you compare that meanyears with nature 2 diabetes to other studies, includingother reversal studies, you see that our lengthof years with diabetes is enormously longer. Formerly again , not cherry-picked people.So our primary upshot was torso load, metabolic ailment criteria, and form 2 diabetes status. Secondary outcomes, welooked at a number of things, and we also still have enlisted samples that we’re gonna be doinga lot of amusing substance with. So what happened at a year? A1C increased, and it reduced significantly. We led from a starting average A1C of 7. 5 to 6.2 at a year. And a duo really importantpoints on this diagram, which is just how fastthis improvement results. And the reason that that is so important is because it motivates patients. We is important to remember at every single graph that any of us was put forward, there’s all these patientsthat even out those graphs. And they are all important. And for each of thosepeople as an individual, they wanna look answers that areactually meaningful quickly.They wanna be giveninstruction that works, and they wanna be able to seethe improvement very quickly, including, you know, one of my favorite things tohear from a patient is when they start at the clinic and then a month last-minute they say, “Oh, my gosh, I can’t believe it. “The very next time Iwent to the pharmacy, “my cost was reduced already.” So this speedy cease is important for each of those individual data points. But, again, we don’t see thedrop and then a comeback, right? We watch a endless declineout to a full year.And if we look at the grey-haired rail above, this is the usual care. So remember what kind 2diabetes has been called by many organizations, including the AmericanDiabetes Association. It is a chronic and progressive disease. And I agree with that statement if we’re expending standard of care. That’s what happens over season. We slowly get worse. So, again, it’s not just notthe A1C that was improving, it was the drugs thatwere also being reduced. 57% of prescriptions fordiabetes were finished. And if we look here, like sulfonylureas, which I consider for any of youwho work with these patients, like this is the first oneto get parties off of, right? I signify, it’s taxing the pancreas.They’re just, in my view, nightmares. But, regrettably, in general rehearses we turn to them all toooften because they’re cheap. We were to able toremove all sulfonylureas. And for insulin, 94% of the patients whobegan the visitation on insulin had the insulin decreasedor totally eliminated. And if you can see, the total elimination was really significant. But, you know, this croaks across to other classes of medications, too. And the one you verify notthat much of a change in it, the N there is metformin because metformin has indications outside of type 2 diabetes. And no matter how wonderful wemake their glycemic command, these are people who had type 2 diabetes, and they are at risk. And so I really feel like metformin is one that I have a risk-benefit discussion with the patients about. And I let them choice. I say, “We have reasons to believe “that this may behelpful in the long run.” And some cases are like, “Great, I can stay on it.”it’s not riling me, it’s super cheap.” And other cases areabsolutely, “I want off of it.” So I let the patients pick. And then you be understood that wedid computed some GLP-1 agonist. And the reason, clinically, that I do this is it’s a great bridge toget parties off of insulin. Because we know thosehigh levels of insulin are gonna impede their weight loss, and it also cause risksof hypoglycemic incidents. We truly wanna come beings off the insulin as speedily as possible. And that’s kinda my favourite lane to make love, is we switch them justto another injectable, and then we can get themoff of those over experience, extremely. But, certainly, we’ve reducedtheir hypoglycemic gamble soon. All claim, so not only dopatients get off of them, but, of course, thisdoesn’t surprise anybody, with that much reduction in drugs, we’re saving money as well.So remedy reduction at a year was 46%. Again, retain, this isjust medication reduction, this doesn’t yet take into account all the other cost affiliated that even off the over $300 billion a year now, such as abbreviated productivity, daytimes off of undertaking, infirmary expenditures, all those things. And do patients stay involved, right? Because in addition to the argument that there’s no suggestion for it, the second largest biggest argumentI get is people can’t do it. And so 83% at a year. Like, when we look at drugs that we write for our patients, there’s no way at a year 83% of them are still making those prescriptions. So this parties adheredto better than a lozenge. Don’t “ve been told” that’s not sustainable. Okay, so, our goal was not weight loss. Straight up, we told cases that’s not. If you do it, immense, that’s a wonderful benefit. But in spite of the fact that ourfocus was not on weight loss, people lost some of force. And as you interpret, we do nothave the six-month uptick that you see in mostweight loss tribulations, right? People lose weight forthree to six months, and then we go up again.But, now, we are allthe way out to a year and we aren’t continuingto lose on average, but we’re flattening outat a much lower rate. So in addition to publishing our one year diabetes-relatedresults, we also published a one year cardiovascularrisk paper as well. And this is my favorite graph probably from the whole trial so far. And it looks at all thesemarkers of cardiovascular probability, comparing our intervention to the control patients which are in gray. So we can see here, I signify, certainly, our interventionpatients rocked it( laughters) as far as cardiovascular risk disappears. What is the one, one exception where it got a little bit worse? If you notice here, LDL-Cdid go up a little bit.It went up by about 10%, which countless would consider very significant as far as increasing cardiovascular risk until you take a look attheir apo B and LDL-P. And Ron previously talkedvery nicely about this. And that in these patients, they can have a regular LDL-C or a slightly heightened LDL-C, yet their LDL-P and apo B can be sky-high. But that’s not what we were seeing here. We were examining theincrease exclusively in the LDL-C. Their apo B and their LDL-P, actually, was downed slightly. Wasn’t statistically significant. But the point is, we weren’tincreasing this risk. So, really, we had all these improvements. Yes, you can reverse your type 2 diabetes and improve all these other determining factor, and not be making other things worse.So that’s really exciting. And so how about their 10 -year risk score? We made a look at that, very. And, again , what happenedwith our intervention cases comparison with usual attend? It’s more of the same thing. And so liver run, you are well aware, another big problem and another big costassociated with type 2 diabetes is all the problems people get because of fatty liver disease. And so here we see asignificant improvement in liver run as well. So kinda to have a look, big picture overall, really, 60% of individual patients in the involvement limb at a year reversed their nature 2 diabetes, which means they had a glycemic self-restraint for the purposes of the diabetes threshold and we’re off alldiabetes-related prescriptions with the possible exception of metformin for the above reasons I discussed before. And, again, drug reducedwhile the improvement in A1C, weight loss, and improvementin cardiovascular risk factors. I signify, what’s not tolove from this, right? So here’s a question. And I know I’m running short on time, but I wanna make sure that I window-dressing this. Did they actually eatwhat we told them to? Because in any nutrition involvement, we’re giving them instructionsthat’s all well and good.But the issues to is, did they do it? And how have we tracked this? In all prior nutrition involvements, we rely on food records. What do we all know about food records? They smells. They smells, they’re not good, they’re fraught with error. And it genuinely utters, I believe this is actuallyone of the reasons that nutrition science is so contentious. Because no matter what someone publishes, someone could come up and say, “Oh, they didn’t really make love. “Your food record method stunk.” We can’t say thingsdefinitively up to now. So did they actually eat a ketogenic food? They did. Because we had a biomarker to follow. We followed beta-hydroxybutyrate. So our study is really odd. We didn’t use menu publications. Our cases didn’t have to write down everythingthat they were eating. We use this as a marker. And, yes, they were doing it.So I imagine not only is this, in and of itself, importantfor this particular study, the committee is also accompanies us to aquestion of study design. Because we did not do arandomized control visitation. And, you know, that’s often a disapproval. Oh, my goodness, everything needs to be randomized regulate trial. That’s the gold standard. And it’s the gold standard, and makes really goodsense for dope studies. But their own problems with nutrition studies is that the people haveto be invested in it, peculiarly if you’re planningon doing a long-term study. So if you all of a suddentake a group of people who let’s just say have been following a low-carb, high-fat diet, and you tell them all, “Well, we’re gonna put you in research studies, “and half of you are gonna haveto be vegan for five years.” Or, you know, or anything.That certainly significantchange to their diet. And they’re not invested in it. They don’t believe in that. It’s not going to work because you’re not gonnaget the compliance. So you require people who are invested in it. And this goes back to myargument of case hand-picked. Patients need to choose the intervention that they want to follow. And I think that that’s really important. So the relevant recommendations of randomizingthat is a little tricky. So how do you supportsustainable behavior vary? And patronage from numerous angles is critical. So the patients in our study, actually, had a ton of differentways of getting support. They tracked their biomarkersand we’re able to follow them. They all had a health coach, and they all had aphysician following them. In the trial, it was me.And they were able to coachbased on those biomarkers to help people and reallymake it personalized for them. They had a patient community, and they likewise had a ton of resources that they had access to. So the other thing you need to really have sustainable reforms, and you have to givepeople advice that works. And, cheers. And, again, we know fromthe graph how quickly not only this works and worksfor a long period, but, you know, parties are excited to eat this kind of food, extremely. The notion that people can’t stick with it because it’s boringand doesn’t tastes good is just not the case. Oops, sorry. So I just wanna end with this. Reminding everyone that there are three clinically proven ways toreverse type 2 diabetes. We need to be talking about this. We got to let cases is a well-known fact that they once again have see. Because telling a patient who is diagnosed with form 2 diabetes that they are stuck, that itis progressive and reversible, and there’s nothing to do about it makes the control away from that patient.And when you can tell them, “There’s something you can do about it, “you can reverse out of this, “and here are the ways.” And the most important thing is then to give cases the choice. And I clearly believe that most cases, when given the choice, are going to choose acarbohydrate-restricted plan, but if they choose one ofthe other ones, that’s fine. It’s not is about to be ever aone-size-fits-all for each patient. We have to respect that always. But the problem is that patients are not given the choice right now, right? They’re not given the choice because this is not being discussed. So I’ll go back to what Isaid at the very beginning. It’s everybody’sresponsibility in this room to make sure that all peoplewith character 2 diabetes know that it does not have to be a chronic and progressive disease. Give them the supremacy back. Give them the choice. Thank you.( gathering acclaims ).

food record method stunk

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