The personal blog of Peter Attia, M.D.

Is Type 2 Diabetes Reversible at Scale?

Is Type 2 Diabetes Reversible at Scale?
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If you’re reading this, you probably know that I’m obsessed with longevity. But to really understand longevity, you must understand metabolic health, insulin resistance and, by extension, one of its end-results: type 2 diabetes (T2D). Though my medical practice does not focus on type 2 diabetes, I have taken care of several patients with T2D over the past few years. When I was in medical school I was taught many things about T2D, but one stands out most: T2D is incurable, I was told. Once you have it, you’ve always got it, and the best one can do is “manage” it as a chronic—but irreversible—condition.

But is this really true? Asked another way, is T2D reversible?

My obsession is partly due to my personal journey to better metabolic health, which I’ve documented elsewhere on this blog, and spoken about publicly. But those facts alone, don’t fully explain why I wanted to be involved with Virta Health (I’ll get to them shortly). T2D is a massive societal problem that has the potential to literally bankrupt countries: More than 29 million Americans have T2D and more than 80 million are pre-diabetic. And whether you view it through the lens of population health, or the lens of an individual patient, T2D is perhaps the biggest healthcare challenge of our generation.

At the population level, T2D costs Americans more than $300 billion per year: one of every three Medicare dollars is spent on T2D, and one of every six healthcare dollars is spent on T2D. At the individual level, patients and payers (employers and insurance companies) spend thousands of dollars (often more than $10,000) in annual expenses for medications and procedures with significant side effects, and much higher risk of developing cardiovascular disease, cancer, Alzheimer’s disease, blindness, amputation and kidney disease.

The traditional approach—which is clearly not working—is to “manage” this chronic condition with medications and the ever-ubiquitous “eat-less-avoid-fat-exercise-more” lifestyle interventions. At best, this approach only slows down the progression of the disease. Furthermore, many diabetes drugs have their own side-effects and diabetes management has a dismal diabetes reversal rate of about 1%.  To date, the only clinically proven way to reverse T2D has been bariatric surgery, which is costly and not without risk. If one great thing has come from bariatric surgery, besides the obvious help to those have been successfully treated, it is that any physician or scientist paying attention to the results can’t help but notice that the reversal of T2D in these patients post-operatively seems uncoupled from their weight loss. In other words, adiposity, while correlated with T2D, is not likely the cause.

Every doctor has his (or her) “Patient 0”—the one who really got him (or her) thinking. I’d like to introduce you to mine, RB. When I met RB, he was a 37 year-old Mexican man with a family history of T2D who had a “high” glucose level on a screening blood test. His two-hour oral glucose tolerance test (OGTT) is below.

You don’t have to read these for a living to see this isn’t ideal. As you can see, his fasting glucose was 258 mg/dL and his fasting insulin, 30 uU/mL. When given 75 g of glucose, his glucose rose to 344 mg/dL at 60 minutes and 408 mg/dL at 120 minutes, all the while his insulin level fell from 30 to 24 to 23. These numbers alone confirm the diagnosis of T2D. But if we needed more evidence, his HbA1C was 9.7%, corresponding to an average blood glucose of 232 mg/dL (today the diagnosis of T2D is defined by HbA1C >= 6.5%, but I much prefer to use OGTT).

Ordinarily, for a patient with this degree of disease and beta-cell fatigue, I would have opted for at least two drugs, metformin (cheap) and a DPP4 inhibitor (not cheap) and most doctors would have gone straight to insulin, as well. However, due to the patient’s financial circumstances, we opted to only use metformin and dietary modification. The patient worked very long hours in construction and, frankly, was pretty much exercising all day, so there was no way adding more exercise to his day was going to work. If we were going to fix him, it had to be through nutrition. I spoke with one of my mentors, Dr. Naji Torbay, a remarkable endocrinologist who has the largest diabetes reversal program in Dubai and Lebanon, about this case. Even he thought it would be tough, but he’d reversed cases like this, so we gave it a shot.

What happened over the next 5 months surprised me, as even I did not anticipate the alacrity of RB’s reversal. Below is a snap shot of RB’s labs from March 1, 2016 about 5 months after the OGTT, above. On the right side you can see the results from September 28, 2015, including the HbA1C of 9.7%, the fasting glucose of 258 mg/dL, and the fasting insulin of 30 uU/mL (HOMA-IR calculated at 19.1).

As you can see, the HbA1C fell to 5.3%—that’s even below the threshold of pre-diabetes—and the fasting glucose and insulin fell to 102 and 10, respectively (HOMA-IR calculated at 2.5).

RB doesn’t have diabetes any more. RB will avoid the amputations that destroyed the lives of his family. RB will not die prematurely from heart disease in his 50s. RB got a new lease on life.

If you think I’m telling you this story to impress you, you’re mistaken. Countless doctors (though not enough) know how to do what I did with RB—it’s actually simple biochemistry, and if a former surgeon like me can learn it, certainly anyone can, as long as one has the ability to frequently and safely manage medications and guide necessary behavior change. But sadly, most people like RB don’t have this option, and even if I and countless other doctors devoted the rest of our lives to helping everyone like RB out there, we could not put a dent in this problem, which is where Virta Health comes in.

Disclosure: I am an advisor to Virta Health and I have invested in the company, because I believe their approach is the best one to solve this problem—not the other way around.

Is it possible to deliver systematic diabetes reversal results (like the case above) safely, sustainably, and at scale among average diabetics?

Of course, even with the correct biochemical/nutritional approach, there are number of challenges to make T2D reversal possible at scale:

  • Eliminating diabetes medications safely requires day-to-day (not monthly) careful adjustments by a physician. This is not how physicians work and would not be cost-efficient.
  • Anything nutrition related requires a very high degree of individualization based on health status, lifestyle preferences and other life circumstances. For the 1% DIY’ers (who probably disproportionally read blogs like this one) any extreme approach can work, but at a population level, it won’t be enough.
  • Both the patient and physician would need near real-time biomarker (e.g., CGM) data to adjust meds and the overall intervention. [By the way, I get asked all the time—mostly on Twitter—what CGM is…for those about to ask, here you go.]
  • All behavior change and lifestyle interventions have failed at scale because only a small fraction of the population is able to DIY through complex decisions in today’s environment and life circumstances. This would require a near real time “personal coach” who can address any situation (e.g., family struggle, travel, new job, holidays).

It appears that we may be a step closer to somebody solving this challenge. Today, the first results of a T2D reversal clinical trial were published in the Journal of Medical Internet Research that show a promising new way to look at T2D: it is reversible in a large percentage of average patients, safely and sustainably. The trial was conducted by Virta Health, an online diabetes reversal clinic, which uses technology and artificial intelligence to solve the above mentioned care delivery challenges. The entire intervention is managed by physicians and the nutritional approach is based on highly individualized carbohydrate restriction and nutritional ketosis (which I’ve written about extensively in the past and throughout this blog).

The trial took place in Lafayette, IN, in partnership with Indiana University Health.  A total of 262 women and men with T2D enrolled in the Virta Clinic. Average age was 54 (Stdev: 8); BMI 40.8 (Stdev: 8.9) and two-thirds of the patients were female.  The trial will continue for at least two years, and data from the first 70 days were published today.

After just ten weeks:

  • 56% of the diabetics enrolled achieved an HbA1C below the diabetic range (6.5%), while eliminating hypoglycemic medications
  • Almost 90% of insulin users had it either completely eliminated (close to 40%) or reduced
  • Mean body mass reduction was just over 7%, which is quite significant, but also shows that diabetes can be reversed before massive weight loss (i.e., it’s not the obesity that causes type 2 diabetes, which is consistent with the gastric bypass literature)
  • Patient completion rate was >90%, which is remarkably high in an outpatient-based intervention.
  • Reported feelings of hunger decreased from the pre-trial level (this seems to be a strong indication that will-power driven caloric restriction was not a factor in weight loss)
  • Importantly, there were no serious adverse events, no incidence of symptomatic hypoglycemia, and no incidents of ketoacidosis.

The trial is ongoing with one-year data expected to be published shortly.

Yes, this is only one clinical trial and 70 days is not very long, but these data force us to consider that there is another way to look at T2D: it is not a chronic condition that gets progressively worse. With the combination of the right science and technology, it can be reversed at scale and among average diabetics.  Clearly we need to look at the long-term success, and see many more patients succeed safely, but this is more promising than anything I have ever seen. I’ve seen some of the preliminary 1+ year analysis and the results look very impressive.  I look forward to sharing them as they become publicly available.

If you are interested, you can learn more about Virta and their diabetes reversal science here. I’m excited to be a very small part of this organization and I look forward to the day when every patient with T2D at least has the chance to try an approach that can potentially reverse their condition.

 

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About the Author:

Peter Attia, M.D., is a physician in private practice in NYC and CA. His practice focuses on longevity and healthspan. His clinical interests are nutrition, lipidology, endocrinology, and a few other cool things.

Discussion

  1. Michael  March 7, 2017

    Boom
    No…… KBoom
    Peter – great to see this happening . I am a family doc and have been trying to do this on my own sans software and tech. Looking forward to hearing more about and from Virta .
    Soon as you mentioned Indiana I thought Sara Hallberg could be in on this . Saw her on the website along with Volek and Phinney . These are the folks I learned LCHF methods and approaches from.
    Thanks for the update.
    We front line, conventional structure practices need all the help and encouragement we can get. – very much like the “average ” patient
    Thanks again

    Mike

    (reply)
    • Peter Attia  March 7, 2017

      Great to hear, Mike. Sara et al. have done excellent work, and this is only the beginning.

    • carson  May 14, 2017

      Agree with Mike completely, I’m also a family doc and have been able to cure diabetes in the motivated patient with similar recommendations. Its incredibly gratifying to achieve such results especially at very low cost for my patients. Thanks for all sharing this article and thanks for all you do!

  2. Benas  March 7, 2017

    Thanks for the article, Peter.

    I am wondering, I’ve seen plenty of people go low-carb and reduce their HbA1C, blood glucose levels and so on and say they’ve “reversed diabetes”. However, T2D is basically carbohydrate intolerance, can a low-carb diet fix it? If these people started eating lots of carbs again, would their problems come back? If you need to stay on a low-carb diet for the rest of your life, I don’t think you’ve cured/reversed diabetes.

    On another note, since you’re mentioning bariatric surgery, here’s a few studies. They suggest bariatric surgery affects intestinal microbiota, intestinal barrier permeability and thus how many bacterial endotoxins (LPS) get through into the bloodstream to cause inflammation. There might be a very strong connection between gut microbiota/plasma LPS and diabetes.

    https://www.ncbi.nlm.nih.gov/pubmed/23835694 – Plasma lipopolysaccharide LPS is closely associated with glycemic control and abdominal obesity: evidence from bariatric surgery. reduced LPS levels after bariatric surgery were directly correlated with a reduction in HbA1c. Our findings support a hypothesis of translocated gut bacteria as a potential trigger of obesity and diabetes, and suggest that the antidiabetic effects of bariatric surgery might be mechanistically linked to, and even the result of, a reduction in plasma levels of LPS.

    https://www.ncbi.nlm.nih.gov/pubmed/27228236 – Bacterial Lipopolysaccharide, Lipopolysaccharide-Binding Protein, and Other Inflammatory Markers in Obesity and After Bariatric Surgery. LPS and LPB decrease after bariatric surgery. LPS receptor CD14 and mRNA expression toll-like receptor 2 (TLR2) and toll-like receptor 4 (TLR4) also reduce following surgery. Changes in LPS and LPS components after bariatric surgery are shown to be linked to the surgical technique of the procedure and restriction of caloric intake

    https://www.ncbi.nlm.nih.gov/pubmed/24713521 – Bariatric surgery significantly decreased the serum level of LBP. Serum LBP levels were higher in obese patients than in the normal weight patients (49.9±15.7 vs 25.2±7.5 ?g/mL) at baseline and significantly decreased to 35.1±22.6 ?g/mL after bariatric surgery.

    (reply)
    • Covadonga jimenez icaza  March 8, 2017

      Commenting about microbiota , i would like to know Dr Attia’s viewpoint . I had to do some study on the subject and most of the articles i read were comming to the same conclusion, when you eat mostly vegetables, cerals and short amounts of meat , the Bacteriodetes increase over Firmicutes and on the contrary , experiments eating only meat, chease and animal products increase the Firmicutes which are found in obese people. More variety of species are found in the “green” diet also
      I have been 2 years on ketosis and everytime i try to give up fat and add up more vegetables (sound healthy,uh?) I gain some weight. I lost 22 pounds with the keto diet very easily, but what about my microbiota, what does it prefere for luch?
      i would appreciate your comment Dr.
      carnivourus vs green https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3957428/
      Study with Burkina Fasso Vs Italian Kids https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2930426/

    • Peter Attia  March 8, 2017

      Longer discussion. I’m not especially impressed, though, at the causal relationship.

    • Birgit  March 9, 2017

      I am also curious if it is necessary to make a distinction between reversal and remission of type 2 diabetes. I had been under the assumption that long-term/permanent remission is possible but that reversal is not. I assume reversal would imply normal blood sugar even when eating more carbs then in ketosis (although less than SAD diet)?

    • Ben  March 29, 2017

      Great stuff. If I may, I just wanted to point out to those folks that state that diabetes cannot be reversed, I’d encourage them to look up the words “reverse” and “cure” in the dictionary. Reversal is not the same as cure. The word “reverse” is associated with a temporary state, whereas “cure” is associated with a permanent state. As a type II diabetic following a low-carb way of eating, my diabetes has been reversed, but not cured. Were I to abandon a low-carb way of eating and go back to a high-carb Standard American Diet, my reversal would stop, and the disease would progress once more.

      So diabetes can be reversed with a low-carb diet, with the reversal dependent upon one’s adherence to a low-carb way of eating. I hope this helps clarify the matter for some folks!

  3. Mike  March 7, 2017

    Bro –

    You complete me. I’m happy to see you post more and get out on the Interwebz with some hustle. Have you looked at Roy Taylor’s research on the PSMF (protein sparing metabolic fast) / Ketogenic crash diet?

    He’s written some interesting stuff, people are even able to get back to moderate carb diets once they are done. Here’s a 6 month follow up from his crash diet:

    http://care.diabetesjournals.org/content/early/2016/02/24/dc15-1942.short

    (reply)
  4. Palak  March 7, 2017

    Hi Dr. Attia, I believe you previously commented on preferring to build a small number of Ferrari’s with your nuanced longevity work vs. undertake the challenge of more population-based health. If that’s accurate, has your mindset shifted and any particular trigger for such a shift?

    (reply)
  5. Ben Greenfield  March 7, 2017

    Fascinating. I love this. Did they look into mechanism of action here…upregulated glucose transport or pancreatic cell regeneration or anything like that in this study?

    (reply)
    • Peter Attia  March 7, 2017

      Not in this study.

    • George J.  March 9, 2017

      Hi Ben,

      IIRC – which I may not – Ludwig remarked in one of his many talks that once the insulin is normalized & the inflammation stays down, some folks actually do heal at both beta cell & hypothalamus. Others for unknown reasons aren’t that lucky. Maybe you could get him to talk more around his thoughts & experience with this and what the mechanism could be.

  6. Norm  March 7, 2017

    Hi Peter,
    Great success for RB.
    1. I wanted to ask if an OGTT was done post intervention as OGTT doesn’t look good while in ketosis for many folks?
    2. For diabetics, perhaps there is no other choice than ketosis, however, as you have said not everyone responds well to ketosis, have you come across non-diabetic folks whose glucose tolerance gets worse with dietary fat especially saturated fats? If so what’s the counter strategy?

    Thanks

    (reply)
    • Peter Attia  March 7, 2017

      1. OGTT was done in ketosis
      2. Longer response needed…but can’t do now.

  7. Andy  March 8, 2017

    Hi Peter,

    What’s your opinion, or what resource would you point me to regarding the following about prediabetes?

    (patient is a 36yr, normal weight individual (5’9/160lbs). A1C 5.6%, fasting between 98-105. Post-prandial numbers range from 120-170 depending on carb amount. 23andme showed the TCF7L2 gene). Fairly sedentary lifestyle, though hits the gym 2x a week for light cardio (20min) + some lifting. Eats lower carb, but not super low carb. (Maybe 120g per day?). First noticed the high fasting at age 28 and A1C seems to have been stable since then.

    1. In prediabetes, are beta cells already dead, or is it still simply a state of insulin resistance?
    2. For someone this young-ish, would you jump on metformin early? 2 endos recommended “just watching it”.
    3. Do you believe it’s actually fully reversible, or only temporary? (Reading the articles you’ve posted now for more info)

    There is of course room here for more exercise that can help, but there are obviously other genetic factors influencing things as well.

    The next thing I plan to try is some 2-3 day fasts per Dr Longo.

    (reply)
    • Colleen  March 21, 2017

      I have a very similar situation. Just 3 days of IF (8 hr feeding window, with a little coffee but no food making it 10 hr) brought me to normal FBG (80-85) reliably in 3 days (from 95-108). Something Rhonda Patrick said about the body expectIng 12 hr downtime clicked with me, as i was only consuming very small amount of food outside say 10hours but over years of that apparently even this small shift has done a lot. It’s been about 2 months and I am planning to look at postprandial soon.

  8. Matt P  March 8, 2017

    Hello Peter,

    I enjoyed your visit on Patrick O’Shaughnessy’s podcast. When discussing caloric intake/disposal, your referenced an “oral glucose tolerance” test as one the five important tests people should have run. What are the other four tests?

    Thanks,
    Matt

    (reply)
    • Peter Attia  March 8, 2017

      Lp(a)-P, LDL-P, IGF, apoE genotype, but so many more, of course…

  9. wab mester  March 8, 2017

    I’m excited to see what these guys roll out. One question about the study, though. What’s the deal with CRP?!

    (reply)
  10. Cheryl Miner  March 8, 2017

    Would Virta be able to help Type 1 diabetes patients?

    (reply)
    • Peter Attia  March 8, 2017

      You’ll need to ask them.

  11. Brennan  March 8, 2017

    One quick comment, Peter. I noticed you made a couple references to the chicken-and-egg problem when it comes to diabetes vs. body fat/obesity. Does it really matter which causes the other? Just about any successful treatment for T2D will reduce body fat to some degree, and weight loss will improve insulin resistance and lower blood sugars in diabetics without any other treatment (unless you consider caloric restriction itself the treatment). It seems like a moot point to argue one way or the other regarding which causes which, because they are so tightly interrelated. Maybe it’s interesting from a biochemistry perspective, but I think it’s somewhat of a distraction from the real issues. I’m not asking this question rhetorically – perhaps there is a reason why it is important to make the argument whether body fat increases insulin resistance or whether insulin resistance leads to increased body fat. In my opinion it could be one or both depending on the individual. I just don’t see the reason for distinction when the treatment in both cases is so similar.

    (reply)
    • Peter Attia  March 8, 2017

      I think it does matter because while your observation is correct–most people lose weight when resolving IR/T2D–the cause/effect confusion results in many patients being told to lose weight via methods with lousy efficacy (eat less, exercise more vs. eat less of certain foods…).

  12. Clyde  March 8, 2017

    Given your knowledge today, would you have made the same decision to do a surgical residency at Johns Hopkins? As I am learning late in life, sleep deprivation has many bad consequences, more noticeable in the short term (reduced fine motor skills, memory loss, poor decision making), but also longer term (weight gain, hypertension, depression). If not for yourself, how would you mentor or advise a younger engineering or medical student on what would be a healthier career choice than slogging through a medical residency? Asking for a friend! I’ve enjoyed your blog and video and podcasts.

    (reply)
  13. Beau  March 8, 2017

    I look forward to the economic implication analysis hinted at in the second to last paragraph of the JMIR report. Needed to achieve widespread adoption and spur competition. In the works?

    I wonder what MED of support team (and other overhead and back-end costs) will be possible in coming years. How much of the necessary adjustments can be diverted to automatic algorithms, and how much will still require a clinician? On a related note – some experienced T2DM pts largely manage their own insulin dosages and check in with their docs here and there – surely that is a more dangerous proposition than taking care of one’s own BHB and blood glucose with the help of a smart app. What kind of supervision taper can be expected?

    Anywho, exciting stuff. Thanks for the write-up. Saw Dayspring’s tweet, read the paper, glad to see an insider’s view.

    (reply)
  14. Jay  March 8, 2017

    The answer is simple: we have to get off our butts and move more through the day, say NO to processed junk food and take a few core supplements like vitamin d3 and k2 and probably magnesium. It’s really that basic. Unfortunately,
    too many are addicted to crap living.

    (reply)
    • Peter Attia  March 8, 2017

      I don’t think RB could have moved much more, Jay…

  15. jimmy  March 8, 2017

    Can you get any more granular wrt to RB’s treatment by you?
    Did you manage RB’s glucose with CGM? Did you see him every 48h?
    Did you inform what to and what not to eat?
    Do you think he could have achieved this success via diet alone? Is it more about having that constant cheerleader influence (ie Peter Attia – sort of a kinder Gunnery Sergeant Hartman).

    (reply)
    • Peter Attia  March 8, 2017

      No CGM, just frequent finger stick. Very clear dietary recommendations, consistent with this paper.

  16. Joanie  March 8, 2017

    I must be confused…why are insulin levels decreasing as blood glucose levels rise if the patient is insulin resistant? Shouldn’t he be producing MORE insulin to cope with the glucose load given for the test?

    (reply)
    • Peter Attia  March 8, 2017

      Yes, he should have, but in late state T2D the beta cells get fatigued.

  17. Sam  March 8, 2017

    As someone who sells a DPP4, this brings great joy to me. I’m constantly harping on diet/exercise but the reality is the patients aren’t receiving the correct information. From obese endocrinologists to Dietician’s still preaching low fat I don’t see this improving much. Many of the clinical trials that support these agents both in the DPP4 class and outside the class are extremely weak. Most data shows on average a one point drop in A1C accompanied with a slew of side effects you have mentioned along with many others. It’s encouraging to see yourself and a company like virta showing strong results and sharing the truth. Keep up the outstanding work Peter.

    (reply)
  18. Hank  March 8, 2017

    Great post.
    Love the “link” to explain the CGM!
    A not-so-subtle hint.

    (reply)
    • Peter Attia  March 8, 2017

      So glad someone got that… If I had a dollar for every time I was asked.

  19. Craig  March 8, 2017

    Were RB’s excellent numbers at 5 months while still on metformin? I’ve heard of some people taking metformin just for a longevity benefit, even with no obvious blood sugar issues.

    My own n=1:

    I was informed that I was prediabetic, weighed about 200 lbs, fasting blood sugar around 100, AIC around 6.4. I went on a low carb ( but probably not ketogenic) diet and lost about 40 lbs. While I was losing weight, my AIC and fasting blood sugar were pretty good. Fasting blood sugar got down to maybe 85-90, and I had a few AIC readings in the 5.5-5.7 range.

    However….. once my weight loss stopped (I hit the dreaded plateau), my fasting blood sugar drifted back up toward 100, and my AIC drifted back up to 5.9 – 6.0. In retrospect, it seems like it was the calorie deficit that really helped. Once my weight loss stopped, it seems like my liver still wanted to pump out too much glucose. So I’ve wondered if a low dose of metformin might be something to consider (knowing of course that you can’t offer me medical advice).

    As a post script: I did drift off the low carb diet, and eventually regained most of the weigh. Some came back as fat, some as muscle, largely from following the Starting Strength program. With the weight regain, my numbers have gotten slightly worse, but not as bad as they were before I was doing the heavy barbell work.

    (reply)
    • Peter Attia  March 9, 2017

      Yes, still on metformin at 5 months.

  20. Gretchen  March 8, 2017

    I’m sure this program works, but I suspect it’s not cheap. How many insurers would pay for it?

    I think a simpler approach would be for physicians to buy loaner CGMs. Patients would pay only for sensors. If a patient had real-time feedback on the effect of various foods, even without 24/7 counseling, I think it would make a big difference.

    Right away would be too soon. Most people are in shock when they get the Dx. But after a couple of weeks they should be ready for a CGM. They wouldn’t use it forever, just for a month or so to work out a good diet for themselves. Then perhaps for a few weeks later if they weren’t making progress.

    Another approach would be “diabetes buddies,” assigning newbies to a patient who had had success. I suggested this to the local CDE, and he said, “I don’t have time to do that.” How much time would it take?

    I think it’s sad that so many fitness people are using CGMs when the people who really need them can’t afford them.

    I’ve becone a cynic. No wait! I’ve always been a cynic.

    (reply)
    • Peter Attia  March 9, 2017

      It’s a hell of a lot cheaper than having diabetes. Cost of administering the program is about 20-25% the cost of average medical cost for a patient with T2D.

    • Gretchen  March 9, 2017

      Peter, I agree 100% that having high BG is more expensive in the long run than some treatment that would result in long-term remission. Sadly, insurance companies don’t agree. When people change insurance plans, the cost for the treatment that company A paid for may produce savings for company B. And insurance companies don’t care about your health. They just care about their bottom line.

      Obviously, single payer would eliminate this problem, but with the current administration, we’re heading toward no payer.

    • Peter Attia  March 9, 2017

      I think Virta will be working to change this.

  21. Lewis  March 8, 2017

    Hi, Peter.

    56% reversal vs the 1% typical? Those are impressive results!

    Question: When someone under NK or VLCHF diet (T2-diabetic or otherwise) is about to do an OGTT only ONCE, would you typically recommend them to get out of ketosis 3 days earlier? Yes, this would avoid a “false pre-T2D” result as happened with your organ-donating friend. But doesn’t it also masks the “actual data”? The underlying questions seems to be: which results would lead to a more reliable interpretation, and whether results under NK could be correctly “translatable” to the not-under-NK ranges.

    Occurred to ask me because you recommended to your friend to stop for 3 days to see the “normal” results, but RB did it under NK. What is the rationale of when to pick one or the other?

    (reply)
    • Peter Attia  March 9, 2017

      Tough question and in my limited experience depends on physical activity. For someone like RB (i.e., very active b/c of his job), they do fine on OGTT without carb re-feed. For those less active, typically 3 days of 100-150 g/day CHO is needed to avoid the artifact “physiological insulin resistance.”

  22. Joel Kehle  March 8, 2017

    Once you saw improved results in RB’s test results did you take him off of metformin? What’s your opinion on metformin as a prophylactic with regards to T2D and more broadly, life extension. Thank you.

    (reply)
    • Peter Attia  March 9, 2017

      Depends on patient. Sometimes quick taper off; sometimes on for life.

  23. Josh  March 9, 2017

    Hi Dr Attia,

    As a shiny new physician and someone who comes from an athletic background myself, I think what you are talking about super exciting. I have one question about your proposed challenges though…why would patients following these rigorous lifestyle changes need CGM? I am assuming you are worried about hypo’s? is this a legitimate concern with lifestyle changes? also, dont we know from plenty of previous studies that tighter BG control leads to more adverse outcomes in diabetics? Great reading, and thanks!

    (reply)
    • Peter Attia  March 9, 2017

      Actually, in T2D patients not on insulin I don’t worry about hypo as much as using the CGM to teach the patient about the relationship of meal to BG.

    • Beau  March 9, 2017

      I think the tighter BG control adverse outcomes have much more to do with concomitantly more aggressive medication use, not with the BG per se.

  24. Nurse Dave  March 9, 2017

    Well, Doc – you finally got on a topic I had to address. My n=1 experience tended to match your experience with RB almost point-by-point. I was in pretty serious financial straits, morbidly obese, Dx of T2DM ca.2005. Couldn’t afford the Dr.’s visits to pay for my glimperide Rx renewals, and started digging into lifestyle changes that might help. I was taking prerequisite courses for entry into nursing school, and my prof for A&P was lecturing on fatty acid metabolism. She started discussing the relationship between triglyceride storage in adipocytes and insulin, and I had my own little epiphany on the matter – namely, what if the T2DM and the obesity were being driven by the same metabolic defect? As often happens, life sidetracked my flash of insight, but about a year and a half later I revisited the idea long enough to get as far as a controlled short-term self experiment. I tried a cabohydrate-restricted diet for 24 hours, and when I pushed myself into temporary hypoglycemia at hour 18 via dietary intervention alone
    I knew I was on to something. Fast forward to the present: completed the first round of nursing school with honors, HbA1c webt from 7.4 at initial Dx to a most recent one of 5.1, FBG typically in the mid-80’s to mid 90’s, weight loss of 125 lbs. and a lipid profile that even managed to surprise my PCP (HDL of 81, Triglycerides 85, LDL 95 & Total cholesterol of 190). In short – basically, I just saved my own life. So, yeah I’d say that management of T2DM is feasible, but reversal? Really, only time will tell.

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  25. Birgit  March 9, 2017

    This last comment, about using CGM to teach the patient surprised me. I went on keto in 2012 after starting to read your blog and also started reading some stuff and seeing video by Dr. Richard Bernstein. Buying a cheap meter and test strips at big box stores is so easy and inexpensive that I always advise people just to do that, so unless they are on lots of insulin and have to worry about hypos it seems that this would be far easier than a CGM.
    I have considered starting a low-carb/keto support group locally though to be able to help people through the initial difficulties and to advise them to talk to a low-carb friendly physician if necessary.
    The sad thing is that CGM’s are not typically covered for pre-diabetes when a

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  26. Antti  March 9, 2017

    I am a Finnish MD and done for years among other things work with DM 2 patients. I have more than 2000 patients who are drug-free remission. It’s not a big deal, only what they need is bit right type info. I wrote a book how to do it and more people have access to the same situation only reading the book. I also have a Clinic in net and it is easy to operate through it. Inkinen is an engineer from Finland and “borrowed” the idea. I think this should be in the hands of professionals and not to give amateurs to spoil the thing.

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    • Mikko  March 10, 2017

      Antti – I think there are an impressive collection of professionals (PhD’s, MD’s, Surgeons like you) involved in Virta Health. Why not join them instead of complaining they borrowed your idea and are not professionals. I don’t think you were the first to come up this idea.

  27. Kara  March 9, 2017

    Just curious… I’m I just a weird outlier or is it common to see fasting insulin INCREASE after being ulc for an extended period of time? My diet was tight. Ate this way for over 3 years. Lost well for over a year, maintained the second, weight slowly started creeping up 3rd year. Ingrated med Dr ran a bunch of labs and my fasting insulin was up to 16!!!! Tsh was at the top end of normal. I creased carbs *some* (60-80 range) and it is back down below 10. Problem is I felt better with it lower. This range is hard and everything has to be measured/weighed. And I’m grumpy hungry. So question… is the common and is there a way to get balance? Ulc is how I had planned to eat for the rest of my life.

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    • Peter Attia  March 9, 2017

      Fasting insulin alone can be misleading. When extreme changes (like my patient here), it’s helpful, but no value in seeing change from 95 to 105–cortisol can easily do this. Reaven showed fasting insulin more closely correlated with steady-state plasma glucose (gold standard for IR) than HOMA-IR–implying fasting glucose actually *hurts* the calculation in non-diabetics.

  28. Dan  March 9, 2017

    Have you seen this from last spring? Doc L. directed me me to it. Will be interesting to see what else they might glean from working on proving it.

    Medical Hypotheses 93 (2016) 87–92
    Fructose surges damage hepatic adenosyl-monophosphate-dependent
    kinase and lead to increased lipogenesis and hepatic insulin resistance
    Alejandro Gugliucci

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  29. Jannie  March 9, 2017

    Peter,

    Tracking BG 24×7 teaches one a hell of a lot about the effects various actions, foods, etc. on blood glucose. Not that I need to tell you. ?

    The cost of the more sophisticated monitors make it prohibitive for most, though.

    About a year ago I started wearing a CGM sensor from Freestyle, called the Libre. Lasts 2 weeks, costs less than $50 locally and can be read with a smartphone. Purely a monitoring device but perfect for 99% of use cases.

    I’m not T1 or 2 but use it as a ‘fuel gauge’ for training and to check effects of various foods, supplements, etc. A great source of data! ?

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  30. Eric  March 9, 2017

    The ADA has a new CEO. Meet the new CEO, same as the old CEO. The basic philosophy is go with whatever the USDA recommends.

    One of two things are going on here. Either the ADA cannot admit that they have been giving horrible advise for decades, or they are just placating their Big Pharma donors (like the king of insulin – Eli Lilly), or their Big Packaged food donors, who make billions off of diabetes. It’s one or the other, or perhaps both.

    Can I call the ADA a criminal organization?

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    • Colleen  March 21, 2017

      Yes

  31. Maryanne  March 9, 2017

    I am a healthcare professional and work to help patients manage their diabetes. I have been following a ketogenic diet since locating your blog in October, with great success. While I am not currently encouraging my patients to follow a ketogenic diet, this is all very interesting to me, and I applaud the efforts toward researching this topic. I’m hopeful that one day this will be an ADA standard of practice for diabetes management.

    One nagging questions comes to mind: are we truly observing ‘reversion’, or is this ‘remission’? I would be interested to see the effects of a high-CHO diet following this state of ‘remission’. Since restricting CHO intake is reducing pancreatic B-cell stress, when we reintroduce the stressor aren’t we back in the same boat? I have seen, first-hand, how diet/exercise/medication compliance results in a reduction of insulin/medication requirements (by de-stressing the pancreas and improving insulin sensitivity). Inasmuch, we never tell patients their diabetes is ‘gone’–even if they have a “normal” A1c/fasting BG, as there is still the baseline pancreatic insufficiency (in most cases) which usually resurfaces when challenged.

    So, is DM2 ever ‘reversed’ or are we just removing the stressor and placing the patient in ‘remission’? Could this perhaps be based on the extent of their disease?

    I would obviously love to hear that reversal is possible, I just am not making the connection…any insight/explanation would be helpful.

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  32. Justin  March 10, 2017

    Dr. Attia,

    Would you say ALT (SGPT) or AST (SGOT) are decent indicators of whether one has fatty liver? I was watching a Dr. Lustig video where he said ALT was a good indicator of fatty liver disease. If so, what numbers on those tests would be concerning to you? Thanks.

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    • Peter Attia  March 10, 2017

      Yes, but not always. ALT/AST can be in the mid-20s with NAFLD present and can be in the 50’s or higher without. Like Rob (and we’ve discussed this at length), I believe “normal” LFTs are in the 20s or lower, despite the current reference ranges.

  33. Neil Cooper  March 10, 2017

    How do I get an appointment at Attia Medical?

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    • Neil Cooper  March 11, 2017

      Does anyone know?

    • Neil Cooper  March 15, 2017

      ?

  34. charles grashow  March 10, 2017

    http://www.dimensionsmagazine.com/news/art3.htm

    Dr Naji Torbay, who treats people with weight problems at the American University Hospital, prescribes amphetamines as part of an overall diet plan but never for long periods.

    Any thoughts?

    (reply)
    • Peter Attia  March 10, 2017

      Yes, but too nuanced for a comment.

  35. Matija  March 10, 2017

    So what’s the bottom line. Is ketogenic diet only option for people with diabetes and prediabetes? Is it good enough just to en whole foods or just lower carbs to some extenc bt not near ketosis threshold?

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  36. Blaire  March 10, 2017

    Hi Peter,
    What was the Metformin dosage for RB?

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  37. Nancy  March 10, 2017

    Thank you for your work with Virta! My brother is T2D and I have pre-diabetes. We’re both using low carb to reduce and control this, although not successful yet in a reversal. Many of my close female relatives in their late 70s are developing MCI, dementia and a cluster of close relatives have died from pancreatic cancer. Would love to see work on Type 3 Diabetes and genetic links.

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  38. Justin  March 10, 2017

    Another OBSERVATIONAL study came out today with news screaming scary headline “Is going gluten-free giving you diabetes? New study links diet with the disease.” Sigh. A whole 13% increase too. Meaningless.

    “Gluten-free diets adopted by growing numbers of health-conscious consumers enhance the risk of developing Type 2 diabetes, scientists have warned.

    A major study by Harvard University suggests that ingesting only small amounts of the protein, or avoiding it altogether, increases the danger of diabetes by as much as 13 per cent.

    The findings are likely to horrify the rising number of people who are banishing gluten from their daily diet, encouraged by fashionable “clean eating” gurus such as Jasmine and Melissa Hemsley.”

    “The study was observational, meaning participants reported their gluten consumption.”

    http://www.telegraph.co.uk/science/2017/03/09/gluten-free-diet-boosts-diabetes-risk-major-study-suggests/

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  39. Brian Miller  March 10, 2017

    Hi Peter – I also enjoyed your podcast with Patrick O’Shaughnessy. Have you ever examined Type 1 Diabetes? Your comments on the podcast about examining gene markers and the impact on developing certain diseases intrigued me. The scientific community seems to be lacking in the area of diagnosing causes of Type 1 Diabetes. I am wondering if utilizing artificial intelligence and compute power (such as IBM’s Watson Health) has the potential for identifying the root cause of Type 1 Diabetes and could potentially lead to a cure. Any thoughts?
    Thank you

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    • Brian Miller  March 10, 2017

      FYI – I happen to be an ultra-runner (completing several 50 to 100 mile events) and there is an interesting trend in ultra-endurance events (which you are probably aware of) utilizing ketogenic diets to “force” the body into utilizing fat as a fuel source alternative to carbs.

    • Peter Attia  March 10, 2017

      T1D is a very different disease and I don’t have as much insight. See Jake Kushner at UT.

    • Jim  May 16, 2017

      Dr. Bernstein Pioneered using a KD to manage his symptoms since the 1970’s. At 82, he likely the world,s oldest living T1 diabetic. His book “Diabetes Solution” goes into great detail on how to successfully treat T1D. He and many of his T1 patients keep their A1C in the 4’s. He also treats T2 diabetics. I am not diabetic, but have for many years been interested in the subject. I am still amazed how many of my friends and family, too who believe their doctors who tell them to shoot for a 7.0 A1C. I have given away many copies or Bernstein’s book over the years to T2 diabetics, and, not one has changed their behavior. It seems medication, eventually insulin, and a moderate carbohydrate diet with low fat, and low protein is fine with them. Dr. Bernstein was near death when he discovered a research paper where dogs with induced T1D were successfully treated with a strict fat and protein diet. At this time his wife a practicing doctor, managed to purchase a BGM only available at hospitals. Using the BGM DR. B determined that his blood sugar levels were wildly out of control. He eventually determined that his max amount of carbohydrate was about 22 grams per day. He went from death’s door to a full life using a KD and other practices along the way. It’s a truly inspirational story. Check out his website.

  40. charles grashow  March 10, 2017

    charles grashow March 10, 2017
    http://www.dimensionsmagazine.com/news/art3.htm

    Dr Naji Torbay, who treats people with weight problems at the American University Hospital, prescribes amphetamines as part of an overall diet plan but never for long periods.

    Any thoughts?

    Peter Attia March 10, 2017
    Yes, but too nuanced for a comment.

    Is that your way of avoiding the issue?

    (reply)
    • Peter Attia  March 10, 2017

      No, Charles, it’s my way of saying I don’t feel like writing another blog post right now. I hope that’s ok with you. If not, I’m happy to stay up all night tonight to work on it for you.

    • charles grashow  March 11, 2017

      So snarky are we – yes – why not stay up all night? You might provide us with a valid reason why your mentor uses speed in his practice!

    • Lade  March 13, 2017

      Would you all please be respectful, kind ( suprise!! he is a human being ), and appreciative toward this man: who has an all-in-constant-focus Career ; goes home to be the best Husband and Father he can be ; works out vigorously as an Athlete ; has the Needs we all have for rest, relaxation, fun, peace and solitude ; generously, has and is, in generousity, putting his knowledge, experience and critical thinking analysis of both aucourant information as well as replying to neophytes at their level out here ( no small feat ). Has it occured to you that he is possibly making the healthy, wise decision to pull back a bit ,for his own mental well being, from this time consuming project? Were he to stop entirely, yet leave the site up for our sakes, I would continue to feel only gratitude .

      Kudos Dr. Peter Attia

    • Colleen  March 21, 2017

      My solution to Charles would have been to not post his second comment, but I Guess it just shows PA open to the discourse. I can respect a person or say they are great but it is not the same as endorsing everything they have ever done or said.

  41. KJ  March 10, 2017

    I was just having a conversation with a doctor about my Mom. She had adult onset diabetes. She is highly adverse to RX medication and decided to work on it with diet and supplements. For the last three years, her A1C has been in the normal range. Her endocrinologist said at her last appointment that he could not say “You are cured” because there is no cure for diabetes. But he also said he would have a hard time proving that she was, and under oath would not likely be able to say she was diabetic.

    I applaud your work and keeping us informed. Thank you.

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  42. Mike L  March 11, 2017

    Does fasting help maintain a healthy metabolism?

    (reply)
    • Colleen  March 21, 2017

      Yes

  43. Omar  March 12, 2017

    Hi, you wrote that ” To date, the only clinically proven way to reverse T2D has been bariatric surgery”. How about the studies of université of Newcastle an their next study similar to yours. Snipet from their page:”we have demonstrated that in many people who have had type 2 diabetes for up to 10 years, major weight loss returns insulin secretion to normal”. I cannot imagine that you are not aware of their two publications or more about diabetes reversal.

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  44. Justin  March 12, 2017

    Dr. Attia,

    I was just curious, approximately how much EPA+DHA do you intake per day?

    (reply)
    • Peter Attia  March 13, 2017

      Dose is irrelevant as it depends how much salmon I’m eating. Goal is RBC DHA/EPA level of 8-10%.

    • Naren  March 14, 2017

      Thanks for sharing, Peter.

      I used to wonder what the goal should be; reference ranges in test results suggest EPA: 0.2 – 1.5% and DHA: 1.2 – 3.9% but I believe those could just be population averages and not necessarily ideal levels?

  45. Martin  March 13, 2017

    The virtahealth blog mentions this very recent study/publication: http://diabetes.jmir.org/2017/1/e5/, with some well known names in the author list.

    I wonder if/why NuSi never(?) considered launching studies in this area, instead of supporting the nonsensical experiments by Hall et al.

    It’s also related to Gary Taube’s latest book. Do you still have any (professional) connections?

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  46. David  March 15, 2017

    Patient is insulin resistant but confused as to whether pre-diabetic. A1c 5.8-5.9 & fbs of 94-95 unchanged last 5 years before and after LCHF (Hyman EFGT 5/4/15 to current, avg 40-50 g carb/day). Excellent results for trig/HDL going to 68/66 from 4 @1yr, no hbp ever, bmi to 23 from 26.5, small LDL-p to 212, etc BUT no improvement A1c or fbs. Patient broke down last week and got first glucose meter and did lots of testing for typical meals resulting in projection of 101 average bg, not 130 indicated by A1c. Have you ever seen someone where CGM or representative metering indicates much LOWER avg blood glucose than A1c formulae?

    Where is the cutoff point for avoidance of atherosclerosis progression (patient has Agatston score last August 166, concentrated in widowmaker and a family history CHD) and other diabetic complications? Patient metering is 95-120 for vast majority of LCHF meals and had 96,145,92 (fasting/60min/90min ) after 100 gram carb cheat meal, with bg hardly ever going below bedtime and awake readings of 96. Do you believe like Jenny Ruhl in Blood Sugar 101 studies quoted that staying under 140 at all times will avoid most complications? Are Virta costs effective or necessary for borderline patients like the one mentioned here?.

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  47. Attia-fan  March 19, 2017

    Dr. Attia: Sorry for being off-topic, but I am a little alarmed that you have stopped talking about the ketogenic diet altogether even when talking about diabetes.

    I never had any issues with being diabetic or even pre-diabetic. However, I was around 150 pounds overweight until I discovered your blog around 3 years back. Got convinced by your writings here to try the ketogenic diet and have been doing that for 3 years now. Lost around 135 pounds in 1.5 years and have maintained the loss for over a year now. I understand that you are now working on longevity etc. but would like to know if you have changed your opinion on the ketogenic diet? My blood work is all fine but it is a little disconcerting that you almost never publicly talk about ketosis anymore. I follow you on twitter etc. If you have changed your mind on the ketogenic diet – would be helpful to find out.

    Also, want to emphasize that your writings on the ketogenic diet have changed my life. I know you don’t get paid for this blog, so THANK YOU from me and from countless other people who have lost weight and become healthier because of your blog.

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  48. Jim  March 20, 2017

    Dr Attia,
    Have you written any articles that explain why blood glucose levels may rise drastically on a ketogenic diet? I have a friend who was warned he was pre-diabetic with a A1C of 5.6. I recommended a ketogenic diet, as I have had great results from it. After 4 months he has lost 26lb and is feeling good but went for an updated A1C and it was 7.6. Can you become or advance to being diabetic while on a ketogenic diet? He is still over weight and fairly sedentary, tends to stay in stress-mode and is usually up all night working while taking short naps during the night and day. Can stress (cortisol) cause such high BG levels when consuming a very low carb diet?
    Thanks for pointing me in the right direction.

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  49. Stephen  March 21, 2017

    Since Lipase is an enzyme involved with the absorption of fats, would an HF/LC diet have anything to do with an elevation of someone’s Lipase level on their Hepatic Panel?
    TIA

    (reply)
    • Peter Attia  March 23, 2017

      Only if there is pancreatic dysfunction.

  50. Sebastian  March 23, 2017

    Dr. Attia,
    Incredibly grateful for all the information you have shared with us, you have improved mine and many lives around me.
    I am curious to know if having coffee in the morning hinders the benefits of IF? I’ve been doing IF for about 4 years, mostly because I feel like I function better fasted, easier to follow macros, more flexibility on the diet, plus it’s very convenient not having to prepare/eat food early before going to work. But I still want the other possible benefits, autophagy, insulin sensitivity, etc..

    (reply)
    • Peter Attia  March 23, 2017

      Probably not, but maybe.

  51. Dean B  March 24, 2017

    I’ve shared with you on Twitter some basics in the past but I wanted to share more info. I was diagnosed with T2D in May 2015 with an A1C of 11.7, Fasting Glucose of 223, TC of 247, Trigs at 211, HDL 41, LDL 164. My doctor handed me a test kit and a prescription for Metformin. He also said “eventually you will be taking insulin, everyone does”. Worst day of my life! I hate needles!!!!!

    Most recent tests are: AIC of 5.6, Fasting Glucose 117, TC 153, Trigs 58, HDL 51, LDL 90. NO Metformin. I’m sure my numbers are even better now. I get new lab work soon.

    The solution: No bread, pasta, rice, potatoes. Real food only. Meat with fat, Eggs, Veggies, limited berries, butter, heavy cream. Basically Keto!

    All of this was accomplished doing research on everything Attia and others you reference! You, Dr. Peter Attia, saved my life! You have to have self discipline but how I feel today is all the motivation I need to continue.

    Thank you so much!!!!!!!!!!!!!!!!!

    p.s. I changed doctors. My new doctor said he’s never seen this before but keep doing what I’m doing.

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  52. Andrew  March 24, 2017

    Hello Dr. Attia,

    Thank you so much for sharing the wealth of knowledge from your personal journey and research. I was just curious what is the best way to book a consultation appointment?

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  53. Diane  March 28, 2017

    Thank you for mentioning Virta Health. I was so excited to find out more about them on their web site. I live in an area of Colorado without good forward thinking doctors who know how to treat T2D, as you do. I was ready to jump on their bandwagon, when they told me they only take people under 70. I can’t tell you how disappointed I was. I am a very fit young LCHF 74 year old who just has a BG/IR problem. Any thoughts from you as to their reason for this?

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  54. Justin  March 28, 2017

    Dr. Attia,

    Do you think diet sodas containing artificial sweeteners such as aspartame, sucralose, acesulfame potassium, etc., contribute to body fat gain or interfere with losing body fat, assuming someone is eating the same number of calories and types of food they usually eat when not drinking diet soda?

    (reply)
    • Peter Attia  March 30, 2017

      I touched on this in a previous post, I think the one on artificial sweeteners.

  55. Tom  March 30, 2017

    Peter, PLEASE write your book – your material is the first place I turn with any health questions. Recently my wife had bloods showing ‘high’ cholesterol. I read your entire series on cholesterol now she is WELL within the healthy range.

    Thanks.

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  56. Kelley  April 2, 2017

    Wow – Virta Health looks like an amazing organization – I realized my doc (who is brilliant) is an advisor! I did have a question in relation to IR- I have read a few scientific articles claiming to prove how fat and protein cause IR by inhibiting the glucose transport pathway. If this is true, how do low carb/high(er) fat/normal protein diets work to decrease insulin levels and blood glucose? I wear a dexcom and see a rather large rise in blood glucose after I eat protein and to a lesser degree fat, but I am not entirely convinced that there isn’t a bigger part of a picture that isn’t being taken into account…what are your thoughts on this?

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  57. JL  April 5, 2017

    I’m pregnant. A nurse told me that ketones will make my baby stupid. I’m nervous. Let me know your thoughts?

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  58. Peter  April 6, 2017

    The grandfather of my girlfriend is a type 2 diabetic and used to be severly overweight.
    He complained about being hardy able to get his bloodsugar below 200.
    The diabetis expert at his doctor´s office recommended a diet that consisted soley of carbs – pasta without fat in the sauce, milk rice with sugar etc..
    I could convince him to give keto a try instead.
    After the second meal on the first day of his diet his bloodsugar was 105…
    After 10 days he did not need his nighttime insulin shot anymore. Seems sensible to me as he allready had a tumor removed from his liver.
    Long story short – happy to hear that more people will have access to a quality dieatary intervention instead of pumping insulin into their bodies.

    (reply)
    • Peter Attia  April 11, 2017

      Kind of frustrating, isn’t it, Peter? What if he was just given this advice at the beginning? I’m sorry he had to go through so much, but glad you were there to help him.

  59. Tatiana Romanova  April 6, 2017

    Aloha Dr.Attia!
    Our teacher Dr. B.L. Rassovsky told once, that the best way to get a patient to loose weight is to brake his jaw. It was a mental model of a true situation: when a patient has his jaw immobilized and eats only liquid food, in couple of weeks he looses an efficient amount of pounds. My question is: Having these real people with immobilized jaws, doomed to starve for a while, could we find out, when does the satiety click in their brain, while patents are on unusual diet. Is the brain chemistry involved in this case? does its profile improve/change within two- three weeks (I mean neurotransmitters)? does it correlate with new insulin sensitivity/C-peptide level, glucagon? How about cortisol level (are patients stressed by the situation during healing)?
    When we were getting into ABCs of diabetes, we were told, that there is a kind of diabetes that can manifest because of change in the brain activity after stress for example, not because the changes in pancreas itself. How much the brain chemistry imbalance would contribute into insulin resistance, does it change during immobilization. Are there any changes after returning to the usual diet?
    Psychologists are ambivalent about food addiction- does it really exist, or not. I think, some answers you could get from collaboration with neuroscientists.
    Thank you for TED talk about possible sequence: insulin resistance-> obesity. It makes sense.

    (reply)
    • Peter Attia  April 11, 2017

      The broken jaw question is basically one of putting someone on a full liquid diet, which is different from fasting. The composition of that FLD can vary greatly and will likely determine the efficacy (in resolving metabolic derangement) and misery (to the patient). It basically comes down to fuel partitioning. The sooner the patient’s RQ comes down and their obligate dependence on glycogen is mitigated, the better they get.

  60. Stephen  April 7, 2017

    On the standard blood test my insurance coverage allows, they test for Oxidized LDL.
    Is that of lesser or greater significance than the insignificant (when not related to LDL-P) LDL level?

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  61. Van  April 11, 2017

    Peter
    Totally unrelated but are you available for a consult on a biotech company? If interest please email me. Many thanks and sorry to everyone for clogging this space.

    (reply)
    • Peter Attia  April 11, 2017

      Sorry, Van…my plate is really full.

  62. Nicole  April 11, 2017

    Hello Dr. Attia,
    I am very excited to follow Virta Health’s progress! I am wondering if you are aware of -and more significantly – are you able to speak about any pressure you and/or any colleagues may be feeling from “Big Pharma” in response to a very patient friendly – non- pharmaceutical based reversal of T2D?
    Thanks and best of luck!

    (reply)
  63. Van  April 11, 2017

    no worries. thanks very much for coming back. sorry to stuff the comments box. BTW really appreciate the stuff you put out there for people. wish you all the best, van

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  64. Dean B  April 12, 2017

    Hi Dr. Attia,

    Any suggestions or can you refer me to articles/videos that you consider helpful in preventing Dawn Phenomenon?

    Thank you!

    Dean

    (reply)
    • Peter Attia  April 12, 2017

      No, but I wonder if it’s cortisol-mediated.

    • Dean B  April 13, 2017

      I don’t know what Cortisol-mediated means but I’m about to start researching it. Thank you!

  65. Sam  April 12, 2017

    Hi Peter,

    I came across some analysis of studies that claimed/showed that LCHF diets raise blood glucose because insulin was not being excreted to reduce it. This seems to be a major arguing point for low fat and/or vegan proponents. Does *this sort* of high blood sugar (seemingly not an effect of insulin resistance) pose any health risks? Does avg. blood sugar become lower the longer you’re on a LCHF diet? Also, I can’t figure out why blood sugar would be so high on a ketogenic diet, when you’re eating low carb and lower protein.

    I did several keyword searches on your site, but can’t find any place that you’ve addressed this. If you have, or know of a good video or article answering this question, please feel free to point me in that direction in lieu of writing an answer. Whether you can answer my question or not, thanks so much for posting your articles over the years! I came across you, your site, fasting, ketogenic and LCHF diets due to Tools of Titans (fyi) and couldn’t be more stoked!

    (reply)
    • Peter Attia  April 18, 2017

      With LCHF studies always check the following: what species? What is the actual dietary composition of the “LC” part?

  66. daniela silva  April 15, 2017

    Very interesting this article, you explained very well about it, I do not understand very well about it, but after my uncle died of diabetes I am interested in this subject, and your article came to calm very well.

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  67. Sousa  April 15, 2017

    Hello Dr., I watched several of your videos about dietary fat and ketosis, and I must thank you because this really changed my life. I lost from 110kg to 85kg, and being a science lover it was your videos that convinced me that low-carb is the way to go. My blood works are great, and I reference you whenever a discussion about this topic ensues.

    Thank you from Portugal.

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  68. alan reeves  April 15, 2017

    Hi Dr Attia, I’ve been doing keto for last 11 months ( properly testing glucose and ketones only the last 4 weeks . ) I see my morning glucose level is 5.6 , after I eat breakfast ( eggs , cheese , ) it’s 4.8 . I’m 44 years old and train weights 5 times a week , currently 5.11 and 84.8 kg at 9% bodyfat . I’ve lost 22 kg on this diet .

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  69. Karl  April 16, 2017

    What’s your take on the Prof Longo’s latest publication in ‘Cell’? Its premise is so transformational, it’s being discussed by nutritional biologists, biogerontologists, and stem cell scientists.

    The title is, “Fasting-Mimicking Diet Promotes Ngn3-Driven ?-Cell Regeneration to Reverse Diabetes.” In plain English, it means that a specific, temporary low-calorie diet activates pre-natal gene codes to grow beta or ?-cells.

    I agree with you a slow low carb / ketogenic approach is an effective management protocol for T2DM having implemented this diet in multiple patients. HBA1C doesn’t lie either. I can tell imediately if the patient has been following the programme or not.
    But this new paper indicates that T1DM can be reversed with consecutive implementation of the fasting mimicking diet for 3 months. This raises some interesting propositions. If we can stimulate Beta cell regeneration in the pancreas, what is the diet FMD doing to other organs? Is it all SIRT gene enabling? Is this RepleniSENS? and does it induce ApoptoSENS?
    If you believe the paper, and follow with its premise, then do we need to implement this protocol in our overall geronprotection regime?

    (reply)
  70. Oren  April 17, 2017

    Hello Peter. As a PhD student of biology the JMIR Diabetes research you linked to above really pisses me off.
    How can one claim to perform a medical dietary study where the important part of the methods is purely behavioral – “eats fats to satiety”. No statistical reports whatsoever on the actual composition of individual diets, hence chance of reproducibility. No negative controls (a baseline is not a control for an interventional study). One can publish in “JMIR” as one may as well simply publish on the blog, how am I supposed to evaluate this study anyway…? This is a blunt at-your-face demonstration of how financial interests may corrupt scientific ethics, wouldn’t you agree?

    (reply)
    • Peter Attia  April 18, 2017

      This is not meant to be the definitive statement on the topic. It’s called a pilot study.

  71. John  April 17, 2017

    Hi Dr. Attia. I’ve been in the anti-sugar camp for a while now, and I generally don’t worry about how much fat (both plant fat and animal fat) I consume. So, I’m curious to know what you think about Dr. Michael Greger’s (author of How Not to Die) position that insulin resistance is caused by a high-fat diet (which leads to increased fat levels in the blood, which in turn leads to increased fat levels inside muscle cells). https://nutritionfacts.org/video/what-causes-insulin-resistance/

    This isn’t just academic curiosity. I’ve been prediabetic for a long time and I’m trying hard to avoid type 2 diabetes.

    Thank you

    (reply)
    • Peter Attia  April 20, 2017

      There’s a difference between physiologic and pathologic insulin resistance (IR).
      A high-fat diet–or fasting (i.e., a zero-fat diet)–can lead to IR in muscle, sparing more glucose for the brain in the short-term.
      A high-fat diet–or fasting–can reduce IR, and a low-fat diet can increase IR, in the long-term.
      IR locally can help partition more fuel globally.
      IR can save life (starving, rapid blood loss), create life (pregnancy), and take life (T2DM and other chronic conditions). It can be both a normal physiological response and a pathological condition.

  72. daniel vaz  April 18, 2017

    Peter thank you so much for sharing the wealth of knowledge from your personal journey and research.
    Really a very rich and very good text

    (reply)
  73. Stephen  April 18, 2017

    Anybody read Mark Hyman’s recent book “Eat Fat, Get Thin”? He mentions Dr. Attia on one page, concerning NUSI.
    Any positive or negative opinions? It’s obviously written for the layman, like me.

    (reply)
    • Michael  April 22, 2017

      Mark Hyman is a gifted communicator . He also oversees a marketing empire of information for patients . He advances many interesting ideas regarding nutrition , most of which are in the book “Eat Fat”. However, he also pushes ideas about vaccines and “complementary medicine ” that I just cannot agree with – see his website .
      BTW, Mark did a web conference he called a “fat Summit ” that features an interview with Peter. In that , I think you can gain a sense of how Mark emphasizes marketing over knowledge. I have not listened to that piece in several months but my memory is that Marks questions to Peter just were not very well thought out.

    • Stephen  May 3, 2017

      I guess no one’s read Hyman’s latest book. While it’s heavily LC/HF,
      his final stance is what he calls the ‘Pegan’ diet; the best of the Paleo + Vegan.
      Surprisingly, he comes down hard on dairy, claiming that it contributes to obesity, diabetes, heart disease, dementia, and cancer.
      He limits dairy to grass-fed butter, or ghee.

    • Stephen  May 3, 2017

      Sorry, Michael; I just read your reply. Thanks!

  74. Marie  April 21, 2017

    New study claims a 3 times higher risk of stroke from drinking one diet soda a day, but somehow no increased stroke risk at all from drinking a sugary soda a day. Also “prior studies have linked diet soda intake to stroke risk.”

    https://www.sciencedaily.com/releases/2017/04/170420162254.htm

    It’s a behavioral study (followed 4000 people for 10 years from the Framingham Heart Study’s Offspring and Third-Generation cohorts. Probably safe to disregard?

    (reply)
    • Marie  April 21, 2017

      I wanted to add that I found some of the previous behavioral (not controlled) studies showing increased risk of stroke from drinking diet soda. They also found no increased risk from drinking sugary soda:

      2015: 30% increase in CVD events including stroke and MI in those drinking 2+ diet sodas a day (study of 60,000 women): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4371001/

      2012: 43% increase in stroke in those drinking diet soda daily. No increase in those drinking sugary soda. (study of 2564 adults in Northern Manhattan Study):
      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3514985/

      Is there a certain number of behavioral studies where one could say she needs to change her habits (if she were drinking a diet soda a day for example)?

      Also, I heard you say once that you drink a diet soda every once in a while. How often?

      Thanks.

    • Peter Attia  April 21, 2017

      Probably…who drinks diet soda?

    • Marie  April 21, 2017

      People with diabetes, haha. I know I heard you say in a video you have one every once in a while, maybe it was just once a year, not sure. So you never drink them now?

    • Peter Attia  April 24, 2017

      Exactly… I still prob drink half a diet coke a month. Or not.

  75. AJ  April 21, 2017

    Hi Peter,
    Per your recommendation, I painstakingly got my doctor to include some extra lab values during my annual physical. Unfortunately, he went so far as saying these lab values are unnecessary and that research scientists/doctors who hype up these values are engaging in what he called “mental masturbation”. lol

    Anyhow, it turns out that my Lp(a) value is very high at 126. I’m only 32 but my dad had a severe stroke when he was relatively young (late 40s, early 50s). Should I be concerned at my age? It doesn’t look like there is anything I can do other than wait for the apo(a) antisense drug.

    Also, I just want to say thanks for blogging about your self experimentation and being honest about their being no one-size-fits-all approach to diet and health. I really appreciate the nuance in your perspectives and it’s been interesting to see you change opinions over the years.

    Also, my wife is a 3rd year med student at NYMC and we live in Stamford. If you are ever taking on new patients in the NYC/Westchester area, please let us know…

    (reply)
    • Peter Attia  April 21, 2017

      AJ, you should absolutely be seeing a lipidologist who understand why this should not be ignored.

    • AJ  April 22, 2017

      Thanks Peter — do you have anyone you can recommend in Fairfield/Westchester County?

    • Peter Attia  April 24, 2017

      Check with Richard Bernstein.

    • AJ  April 23, 2017

      Also, I read that niacin is sometimes used to lower Lp(a). Would it be a good idea to take niacin at my age?

    • Peter Attia  April 24, 2017

      It does, but it has not shown efficacy in reducing events.

    • AJ  April 24, 2017

      Dr Attia, I couldn’t find a lipidologist with that name in the Northeast. I did find a doctor with that name who runs a diabetes practice in Mamaroneck, NY. I called his office and they said he only takes patients who have read his book and have diabetes.
      Are you referring to a different Richard Bernstein? I don’t have diabetes but rather slightly elevated LDL and a very high Lp(a) value of 126 nmol/L.

      Appreciate your help, Peter. Thanks.

    • Peter Attia  April 25, 2017

      I thought you were looking for a diabetologist. Look at NLA site for lipidologist.

  76. Neil  April 25, 2017

    Hi Peter,

    Have you done any research on the effects of ketosis on circadian disruption and/ or do you know anyone who has? Shift workers are susceptible to T2D, cardiovascular disease, obesity and metabolic disease. I wonder if a ketogenic diet would be a good prevention to disease, but also, as new evidence is showing circadian disruption mutes gene recognition, would a ketogenic diet help boost energy by activating AMPK? Have you ever heard of Metformin used for shift workers? Can it be used for prevention and performance?

    Thanks for your comments if you have time.

    Neil

    (reply)
  77. Justin  May 14, 2017

    Hi, Peter! Quick question… is there a nutrition degree/ diploma/ certification program that you would readily recommend to Nutritional Therapists looking to further their knowledge? My own search has been frustrating as most programs I’ve come across are centered around textbooks citing studies that are decades old. Are there any cutting edge nutrition programs out there based on the latest science?

    (reply)
  78. Arthur  May 19, 2017

    Hi Peter.

    First, thank you for sharing your knowledge and passion.

    I have two questions about your IHMC lecture and your RQ during your metabolic chamber experience.

    1. What would have been the likely your RQ graph during 3 hours bike ride instead of 45 minutes?
    I observed that within 45 minutes your RQ fell from ca. 0.88 to ca. 0.83 meaning a fall from ca. 60% carbs energy to
    ca. 45% energy from carbs.

    2. Let’s assume that you eat ( within 5-10 min) a bar of milk chocolate on “empty liver”. 60g of refined carbs but still within liver glycogen capacity. And just after that you begin your bike ride with the load of 200 watts. What will be the likely RQ graph within 3 hours in that case? Refined carbs, although within glycogen liver capacity, will surely raise insulin and inhibit lipolysis immediately…

    I’m trying to estimate and optimize my fat loss rate and amount of needed carbs, setting out boundary cases. I’m very well adapted for fat burning.

    Once more thank you for all.

    (reply)

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