Reversing Diabetes With Nutritional Ketosis

In the US, 52% of the adult population is suffering from type 2 diabetes or prediabetes. Type 2 diabetes can be a devastating disease, and it is often mistakenly regarded as chronic and progressive, meaning that over time, it will only get worse. However, clinical trials have shown that type 2 diabetes can be reversed.

Defining diabetes "reversal"

Because type 2 diabetes is diagnosed based on elevated blood sugar, if your blood sugar remains normal without the use of diabetes-specific medication and you no longer meet the diagnostic criteria, you have successfully reversed your type 2 diabetes.

There are three forms of treatment for type 2 diabetes that have been demonstrated to reverse this disease. Bariatric surgery can sometimes reverse type 2 diabetes, but it is expensive, can have major side effects including death, and often loses its effectiveness after a few years. Very low calorie diets (also called semi-starvation diets) can lead to rapid weight loss and diabetes reversal, but can only be followed for a few months, after which weight maintenance and continued diabetes control are difficult. The third treatment is a well-formulated ketogenic diet, which is nutritionally complete and can be followed for years.

The terms “reversed” and “cured” mean very different things. Type 2 diabetes can be “reversed” but not “cured” because the disease will come back if long-term behavior change is not successfully maintained. There are still several points of debate around the term “reversal” -- in particular, how long HbA1c and medication reduction success have to last for the diabetes to be considered reversed. Since diabetes reversal is a relatively new term, there is no universally accepted definition by the scientific community or agencies like the American Diabetes Association or American Medical Association. Thus many medical professionals are still unaware that reversal is even possible.

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Virta's definition of diabetes reversal

Maintaining an HbA1c below 6.5%, with the elimination of all diabetic medications removed (except for metformin)

Metformin is excluded from these reversal criteria because it is not diabetes-specific—many patients choose to stay on this medication for reasons other than blood sugar control.

What is Nutritional Ketosis?

Nutritional ketosis is a natural metabolic state in which your body adapts to burning fat rather than carbohydrates as its primary fuel.

Ketones are made from fat in the liver, and provide energy to fuel important organs like the brain, heart, and muscles. Ketones also play a newly discovered role to reduce oxidative stress (aka free radicals) and inflammation, both of which are key underlying causes of type 2 diabetes.

Given this dual role of ketones as fuel and metabolic regulator, nutritional ketosis is now understood to be the most effective treatment option for sustainably reversing type 2 diabetes. It is clinically proven to directly reduce blood sugar (as measured by HbA1c), improve insulin sensitivity (as measured by HOMA-IR) and reduce inflammation (as measured by white blood cell count and CRP). Since type 2 diabetes is a disease of high blood sugar, insulin resistance, and inflammation¹, nutritional ketosis is an effective diabetes reversal tool because it can improve all three.

Entering a state of nutritional ketosis requires changing what you eat. Every food is made up of different components. The major components are carbohydrate, protein, and fat.

Carbs

Chains of various sugars, most of which get digested to produce glucose

Protein

Made up of 20 different amino acids

Fat

Long chains of carbons called fatty acids

Blood sugar increase

High

Moderate

Very Low

Used as energy?

Can this be used as a source of energy?

Yes

Inefficiently

Yes

Because foods contain such different levels of each macronutrient, different foods will have very different impacts on your blood sugar. Eating foods that contain a lot of carbohydrates will elevate your blood sugar significantly more than eating foods made up of predominantly protein or fat.

Once a person has type 2 diabetes, even whole grains and fiber-rich carbohydrates will cause a large blood sugar increase. Because some fiber is not digestible, it will slow the absorption of carbs slightly, but not enough to make a big difference in someone who is insulin resistant. Eating carbs makes your already chronically elevated blood sugar even higher. This pattern can be thought of as carbohydrate intolerance.

Even whole grains raise your blood sugar
Even if the carbs you eat are whole grains and contain fiber, the blood sugar impact is similar to other carbs. Because fiber is not digestible, it will slow the absorption of carbs slightly, but not enough to make a big difference.

        
Brown Rice
45 g carbohydrate
3.5 g dietary fiber

        
White Rice
45 g carbohydrate
1.2 g dietary fiber

Fat is a source of energy that does not raise your blood sugar

Unlike carbs or protein, fat cannot be broken down or converted into glucose efficiently. Furthermore, fat does not require insulin to get into cells to be used for energy, thereby bypassing the problem of insulin resistance. In fact, high insulin levels impair the body’s ability to use fat for fuel, driving it instead into fat cells for storage.

To adapt your metabolism to using fat as your main source of energy, dietary carbohydrates must be reduced to below your unique tolerance level. When you do this, your blood insulin level will come down, giving your body increased ability to burn both the fats you eat and those which you have in storage. For most people, this means switching from the standard recommended high carb, moderate protein, and low fat diet to a high fat, moderate protein, and low carb diet. Fat adaptation does not happen overnight - it can take anywhere from 3 to 6 weeks for most of its benefits to occur, and possibly longer for the full benefits to occur.

Carbohydrates are not essential (with an important exception!)

You may have heard in the past that you “need” carbs for energy - but basic biochemistry and decades of clinical studies demonstrate otherwise. Carbohydrates are actually the only dietary macronutrient not required by the human body. There are certain essential amino acids that we need from dietary protein and essential fatty acids that we must consume from dietary fats, but no one has yet discovered a carbohydrate molecule that we can’t make within our own bodies. Furthermore, fat is not inferior to glucose as a fuel - your heart and brain actually prefer ketones as a primary fuel source.²

The exception where dietary carbs are necessary is if a person is currently taking diabetes medications associated with the risk for hypoglycemia such as insulin or a sulfonylurea. In this case, dietary carbohydrate reduction has to be closely coordinated with the reduction or withdrawal of these drugs under expert medical supervision.

Protein in moderation

Moderate protein is a key component of nutritional ketosis. While protein is a critical component of any diet to provide the amino acid building blocks required for cellular growth and repair, protein is unable to efficiently provide energy, as the amino acids have to be converted into glucose first. This also means that chronic excessive consumption of protein can raise blood sugar and raise blood insulin levels, which reduces ketone production and impairs weight loss.

Fat is safe in the context of nutritional ketosis

A common concern about following a carbohydrate restricted diet long-term is the eventual need to increase dietary fat intake. For decades now, Americans have been told to restrict fat as a way of not only decreasing the risk for obesity, but also decreasing the risk for cardiovascular disease. This theory has been refuted.³ Consuming high amounts of dietary fat is clinically demonstrated to be safe as long as carbohydrates are restricted. The theory that fat is responsible for heart disease and cholesterol problems has largely been disproven.^4-9

Macronutrients in Perspective

There are tons of diets out there, and some focus on lowering carbohydrate intake. But a well-fomulated ketogenic diet is the only one that can put your metabolism into nutritional ketosis.

Reversing type 2 diabetes with nutritional ketosis

Nutritional ketosis can sustainably reverse type 2 diabetes by directly reducing blood sugar (as measured by HbA1c), improving insulin sensitivity (as measured by HOMA-IR) and reducing inflammation (as measured by white blood cell count and CRP). If you are able to consistently and safely maintain nutritional ketosis (which can be measured with a simple at-home blood test), diabetes reversal becomes much more likely.

Because nutritional ketosis can lead to rapid decreases in blood sugar and blood pressure, Virta strongly recommends getting medical supervision before making any dietary changes, especially if you are on medications for blood sugar or blood pressure. A medical provider can help you safely reduce your medications so that they don’t drive your blood sugar or blood pressure too low. Both hypoglycemic (low blood sugar) and hypotensive (low blood pressure) episodes can be very dangerous, and potentially even fatal. The Virta Treatment ensures safety through an outpatient protocol providing intensive nutrition and behavioral counseling, a digital coaching and education platform, and medical provider-guided medication management.

Reductions in average blood sugar

Diabetes is diagnosed by a fasting blood sugar over 126 mg/dL, or an HbA1c greater than or equal to 6.5%. Maintaining nutritional ketosis leads to lower average blood sugars, since eating fewer carbs means less overall sugar entering your bloodstream. Fasting and meal-time blood sugars can rapidly decrease in just the first few days or weeks of carbohydrate restriction. After 2-3 months, you are also likely to see reductions in your HbA1c, which is a measure of your blood sugar control over a 3-month period.

Fasting Blood Glucose improvements
(Sample Virta patient)

Virta patients enter nutritional ketosis through intensive nutrition and behavioral counseling and a digital coaching and education platform, and they are provided with medical provider-guided medication management.

Reductions in diabetes medications

Diabetes medications all have the same goal—to reduce elevated blood sugar. The common classes include:

Insulin (both short and long acting, and even pumps)
Sulfonylureas (glipizide, glimepiride, glyburide)
SGLT-2 inhibitors (Invokana, Jardiance)
DPP-4 inhibitors (Januvia)
GLP-1 receptor agonists (Trulicity, Victoza)
Metformin (non-specific due to other uses)

When your blood sugar is no longer chronically elevated, these blood-sugar-lowering medications are no longer necessary. An ongoing study has shown that sustained nutritional ketosis can lead to the permanent removal of these medications.¹⁰ Medications that rapidly reduce blood sugar need to be removed first, such as insulin and sulfonylureas, sometimes in as little as 2 days to 2 weeks. Other medications like SGLT-2 inhibitors, DPP-4 inhibitors, GLP-1 receptor agonists, and metformin can be removed as long as you maintain normal blood sugar.

If you are on diabetes or blood pressure medications, Virta highly recommends that you get medical supervision before making any dietary changes.

Other benefits of nutritional ketosis

Nutritional ketosis has many documented benefits beyond improved blood glucose control, including:

Weight Loss

Ketogenic trials have demonstrated greater than 10% weight loss at 1 year.^11,12

Increases in energy and decreases in hunger

Subjective, self-reported measures of patient energy improve after patients adapt fully to nutritional ketosis.¹³

Improvements in cholesterol

Studies have shown decreases in triglycerides, increases in HDL, and increases in LDL particle size. These results have been replicated in multiple low carb dietary intervention trials, including controlled feeding studies.^14-16

Significant decreases in blood pressure

Many patients need to reduce or eliminate their blood pressure medications when eating low-carb.

Sustainability

For type 2 diabetes to be reversed, the improvements must be sustained over the long term. But not all ketogenic diets are created equal. You can get into nutritional ketosis using a protein-sparing modified fast or other forms of hypocaloric (very low-calorie) diets, but these interventions are very difficult to stick with long-term. Hypocaloric diets and diets following bariatric surgery require followers to adhere to extremely low calorie diets—between 800-1200 calories per day.

There are several indications that a well-formulated ketogenic diet, based on real, whole foods, can be sustained over the long term. Indigenous populations like the Inuit and Masai have been eating this way for millennia. Medical providers have been prescribing ketogenic diets as a treatment for epilepsy in children for almost a century. More recently, Virta Health’s clinical trial showed a 92% retention after 10 weeks and 86% after 6 months. In addition to the obvious incentives of improved diabetes control and major weight loss, the lack of caloric restriction and the associated reduction in hunger and cravings contribute to this high adherence rate.

Safety of Nutritional Ketosis?People with type 2 diabetes who are taking medications for diabetes or blood pressure should not begin a ketogenic diet without adequate medical supervision.

Reversing diabetes with nutritional ketosis is fairly simple in theory, but very complex in practice. A ketogenic diet causes rapid improvements in blood glucose, blood pressure, and changes in how the body processes electrolytes and minerals in important ways. To avoid problems with over-medication, these changes typically require daily medical provider monitoring of your body’s response to carbohydrate restriction in order to deliver prompt modifications and reductions in diabetes and hypertension medications. In addition, certain conditions such as prolonged QT-interval can make nutritional ketosis dangerous. This condition is uncommon, potentially linked to magnesium depletion, and can only be diagnosed with an EKG.

Citations

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