NOAKES: WHY VIRTA HEALTH STUDY IS GOLD FOR DIABETICS
Picture: NOAKES FOUNDATION
By Marika Sboros
You’d think all doctors and dietitians would join Prof Tim Noakes and many others in welcoming robust new evidence showing that a simple dietary change really can reverse type 2 diabetes.
In other words, evidence showing that diabetes doesn’t have to be chronic, progressive and degenerative. And that diabetics don’t have to face an increased risk of heart attack, blindness, limb loss and declining mental function.
Physicians at the Virta Health company in the US have shown just that in a peer-reviewed study just published in Diabetes Review. Led by Virta medical director Dr Sarah Hallberg, it is a one-year trial showing that a low-carbohydrate, ketogenic diet puts 61% of patients with type 2 diabetes into remission.
That’s big. It shows that patients have a choice: to accept or not to accept conventional wisdom on diabetes. Yet many have been quick to attack the research and undermine its conclusions. Noakes has written a letter to a Cape newspaper (scroll down to read it below), explaining why the study really is a watershed. He looks at why it gives diabetics and their families renewed hope.
And why, in essence, type 2 diabetes is “a condition of choice”.
Dr Jeff Stanley
A common criticism is that the study is not a randomised controlled trial (RCT), the so-called “gold standard” of modern science.
Co-author Dr Jeff Stanley deals a knockout blow to that one. The Virta researchers haven’t claimed that their study is an RCT. And ethical, funding, financial and other constraints mean that RCTs are notoriously difficult to do in nutrition research these days.
Stanley points to an RCT by University of California, San Francisco researchers published in the Journal of Medical Internet Research last year shows similar results.
Others have tried criticising the study because they claim that low-carb, ketogenic diets are “dangerous fads”. They do so without providing any evidence, robust or otherwise, in support of that claim.
And when all scientific health argument fails them, critics attack the study on environmental grounds. They claim that low-carb diets hurt the planet.
The Virta researchers are undeterred.
Stanley rightly says: “This approach works, and we will help millions of people reclaim their health.”
Stanley also pays tribute to visionary Virta founder, Finnish billionaire type 2 diabetic Sami Inkinen. Inkinen is also co-founder of the leading online real estate company Trulia.
In a tweet, Stanley says of Inkinen:
“He could be on a beach after selling Trulia for $3B, but instead started a company that is changing/saving the lives of people with t2 diabetes.”
A Canadian-led study, of which Noakes is a co-author, has also shown strong evidence of low-carb, high, healthy fat diets for “diabesity”. That’s doctors’ term for the twin epidemics of obesity and diabetes. That study’s message goes further than that. It also looks at obstacles to nutrition science research.
In fact, there is a wealth of evidence showing that LCHF diets do work for diabetes. That raises the question why so many doctors and dietitians still don’t recommend it.
Here’s what Noakes had to say about the Virta study in a letter to the editor of the Cape Times on February 15.
His letter is headlined: Dangerous fad diet (low carbohydrate ketogenic) puts 61% of patients with type 2 diabetes mellitus into remission in 1-year trial.
To the Editor
In 2013, my colleagues and I published The Real Meal Revolution (RMR). The central theme of the book is that persons with insulin resistance (IR) – the underlying biological abnormality in Type 2 Diabetes Mellitus (T2DM) – enjoy substantial health benefits when they restrict their dietary carbohydrate intakes to between 0-150 grams per day depending on the severity of their IR.
Whilst the book and the eating plan it promotes became an overnight success with the South African public, just as rapidly influential medical colleagues and dietitians across the country dismissed it as a dangerous diet fad that causes harm.
The unrivalled success of the book and the challenge to dietary convention that it poses, soon became a unifying provocation for the subsequent 4-year, multi-million rand investigation into my professional conduct by the Health Professions Council of South Africa (HPCSA).
Click here to read: Noakes verdict: he won battle but war goes on
On Wednesday, February 7 2018, the medical journal, Diabetes Therapy, published a peer-reviewed scientific paper (1) reporting the findings from the first year of a 2-year study of the use of remote care (telemedicine) for the management of type 2 diabetes mellitus (T2DM) undertaken by the Virta Health company in San Francisco.
The key focus of the study was to ensure that patients with T2DM develop a state of continual mild ketosis by eating a severely carbohydrate-restricted diet (<30 g/day). This is the same diet prescription promoted for the management of IR and T2DM in the RMR and all my other nutrition books. In fact, the RMR was used as a patient resource for dietary information in the Virta Health trial.
The study initially enrolled 262 persons with T2DM for the intervention trial; at the end of the first year, 218 remained in the study giving a retention rate of 83%. A further 87 T2DM patients who continued to receive conventional care (insulin and/or other anti-diabetic medications; non-ketogenic high carbohydrate diet) were also followed for 1 year.
Ninety-four percent of T2DM patients on the intervention trial had either reduced or ceased their insulin use at the end of year one. The use of other anti-diabetic medications excluding metformin fell from 57 to 30% and no patient was still using a sulfonylurea drug at the end of the trial. In contrast, medication use increased by 9% in the group receiving conventional care.
Click here to read: ‘CCure’ for type 2 diabetes? A doctor’s journey
Despite reduced use of anti-diabetic medications, 61% of subjects on the intervention trial “reversed” their diabetic markers, especially glycated haemoglobin (HbA1c) values, to below those considered diagnostic of T2DM.
As a result, these patients are technically “in T2DM remission”. This does not mean that they are, or ever will be “cured” of T2DM since re-introduction of a higher carbohydrate diet to persons with severe IR/T2DM will rapidly reverse these gains.
However it might logically be expected that persons “in T2DM remission” will be much less likely to develop T2DM complications in the future, provided they continue to restrict their carbohydrate intake to <30g/day.
Other benefits included an average 12% (14kg) weight loss, decreases in systolic and diastolic blood pressures and in all blood markers of IR and inflammation. In contrast, most of these markers deteriorated in the usual care group.
The authors conclude that a North American with T2DM who stops using insulin will save $10 000 per annum for the rest of his or her life.
The importance of this study is many fold. First, it disproves the depressing medical opinion that T2DM is a chronic progressive disease with a dismal future. Instead, it shows that T2DM can be effectively managed with a quite simple dietary change.
Second, it shows that, in essence, T2DM is a condition of choice.
Patients can choose to eat <30 g/day of carbohydrate and so minimize their risk for developing any of the disease’s myriad complications. Or they can continue to eat an unrestricted carbohydrate diet, in which case it is probable that they will develop the complications of T2DM regardless of how much medications they use.
Third, it confirms that the cause of the current T2DM/obesity pandemic is clear. It was the adoption of the high carbohydrate diet mandated by governmental agencies and vigorously promoted by medical and dietetics organizations around the world since 1977.
Every month another 15 000 South Africans develop T2DM. The Virta Health study proves that this is unnecessary. This tragic epidemic can be stopped. Persons with IR need to understand that eating a diet in which carbohydrate intake is unrestricted will likely lead to T2DM and all its tragic complications.
This is as we described it in RMR in 2013.
- I am co-author with Prof Tim Noakes of Lore of Nutrition, Challenging Conventional Dietary Beliefs (Penguin 2017). I am contributing author to Healthy Eating, The BIG Mistake by Dr Verner Wheelock (Columbus 2018)
- Follow me on Twitter @MarikaSboros
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Has anyone actually seen this study reported in ANY mainstream media? Here in the UK there is a deafening silence, just as on the Noakes Trial, Gary Fettke etc. yet whenever a vegan breaks wind in the general direction of a microphone it is front page news.
Well done Tim. keep up the great work.
Great piece Marika – I have a query about definitions.
Professor Noakes in his paper in Brit Journal of Sports Medicine in Jan gave these definitions of high. low and keto carbs.
In the officially recommended diet, carbohydrates provide at least 55% of your daily calorie intake.
In a LCHF diet carbohydrates make up less than 26% of daily calories (about 130 grams)
And in a very LCHF (ketogenic) diet carbs provide less than 10% of your daily calorie intake or between 20 and 50 grams.
In this post the carb level in the intervention group was less than 30gms a day – so they are on a ketogenic rather than low carb diet.
But many of the discussions of treating diabetes with diet refer to a low carb diet – defined as around 120 grams,
So is Noakes’ position that in fact the only way to reduce diabetes with diet is to use a ketogenic rather than a low carb one?
Noakes makes it clear – many others dont – that to keep the benefits of his keto diet patients will have to be eating like for life – i.e less than 30 g of carbs. Presumably that is an extrapolation. Accounts suggest that many will find that very if not impossibly challenging.
Do exogenous ketones have a role to play here?
regards Jerome
Hi Jerome, received this reply from Prof Noakes – with apologies for the delay!:
Dear Jerome,
I apologise for the inordinate delay. However, now that the trial has ended and I’m finally in real retirement I’m doing all sorts of things and so my emails have been slightly ignored. However here are my responses:
I think that the Virta health study proves that the only diet that will sustainably reverse or put Type II diabetes into remission is one containing less than 30 g of carbohydrate per day. That’s the diet I’ve been following for seven years and which finally put my own type II diabetes into remission. I have reviewed other papers written by other authors showing that a dietary intake of 130 g of carbohydrate per day in persons with type II diabetes has a small effect in improving glucose control in patients with type II diabetes but that the effects are nowhere as powerful as those reported in the Virta health study.
So I think the evidence as we have at present is that you must cut your carbs to an absolute minimum and that should be below 30 g per day if you want to put Type II diabetes in remission in a majority of patients. I’m not saying that a diet providing hundred and 30 g a day of carbohydrate would not be beneficial but it lacks the potential to put patients into remission.
I’m really not sure that it’s a difficult diet to follow as I tweeted in the past, I followed my dad’s progression from a vigorous powerful man to someone whose body was wracked and ruined by his Type II diabetes treated incorrectly with a high carbohydrate diet. Watching him die has in retrospect taught me that if you have type II diabetes your choice is either carbohydrates or strokes, renal failure, blindness, peripheral vascular disease leading to amputations. Once you’ve seen that cutting sugar and carbohydrates from the diet is rather simple. What frustrates me is that people don’t understand that type II diabetes is eminently manageable on a low carbohydrate diet, but it’s an absolutely fatal condition on a moderate to high carbohydrate diet.
I suspect that ketone bodies have a role to play as I’ve seen in myself that taking exogenous ketones rapidly drops my blood glucose concentration. I suspect that this effect will be used in future as a form of treatment for patients with type II diabetes.
With my very warmest regards and again sincere thanks for your ongoing support, sincerely,
Tim Noakes
To me, the “Dangerous Fad Diet” is the low fat, high carbohydrate diet pushed on people as “healthy” by the very professionals who should have known better for these many decades.
What Marika and I have learned is that our most vociferous critics usually have absolutely no training in or understanding of, or in fact any real interest in hard science. Yet these “quack watchers” are for ever accusing us of being quacks etc. The truth is that the real quacks are those who continue to promote the low fat diet. The Virta Health study is perhaps a key study. No longer can anyone say that healthy grains and healthy (low glycemic carbs) cure type 2 diabetes. Now we know for certain that the promotion of high carbohydrate diets (plus insulin) for persons with type 2 diabetes is tantamount to medical malpractice.
I believe that there is more exciting evidence coming out in the next few months further to establish that a low carbohydrate diet is safe and effective for the management of insulin resistance/pre-diabetes/type 2 diabetes. Since the majority of many populations are insulin resistance, this indicates that the low carbohydrate diet has a very wide application (as we perhaps already know).
Many “low carb” studies have obviously been fixed, since they do not achieve the results we see anecdotally (such as in the ADA Forums going back now over fifteen years). What I especially like about Virta’s papers is that they demonstrate the sort of outcomes that are commonplace in the Real World. While the ADA were claiming that diabetics must “eat more starch” and that “medical nutrition therapy” could only improve A1c by up to 1.9%, there were hordes of diabetics routinely achieving drops of 5 – 8% and sometimes as much as 13% IN THEIR OWN FORUMS, yet these were never studied. Let alone the concomitant improvements in BP, trigs, HDL etc.
Your trolls have no idea how to achieve this, and no desire to do so.
Meanwhile here in the UK this has taken the media by storm, as discussed by Zoe Harcombe
http://www.zoeharcombe.com/2017/12/reversing-diabetes-type-2/
Most dieticians agree that starvation using vegan chemical gloop is preferable to eating your fill of low carb Real Food. Yet strangely some are claiming this will lead to Eating Disorders. You Could Not Make This Up.
Probably most of these people are too young to know that there was ever a time before there were “epidemics” of obesity, diabetes and other metabolic disorders. And some of the diabetics who were put on low carb diets decades ago back when it was Standard Operating Procedure are now dying not of diabetic complications but of old age. Try living to be 89 and having diabetes for 42 – 43 years WITH NO PROGRESSION. Impossible on a low fat diet. Maybe the likes of you, David Unwin, Virta et al. will live to see this happen again.
Dr. Noakes
I can still remember my marathon days – when you promoted carbs and more carbs.
Then I can recall you being on the Discovery Health advisory panel – advisit and rewarding Discovery Health Members to eat Fat-free.
The ketogenic lifestyle has been around for 70 odd years.
Took quite a while to discover that in South Africa – by none other than the previous fat-free advocates.
Educate your fellow medical fraternity – no time to make money out of regurgitating keto info in books to the public.
It breaks my heart that I have been watching my husband destroy his health (T2 Diabetes) over the last 20 years. I chose to follow a ketogenic diet (religiously) even though I am in excellent health but my husband just rolls his eyes because his heart specialist tells him that statins and a handful of diabetes medication is better for him since he is not interested in giving up his bread and wine (or pizza and pasta. He is Italian!) I love it that you are educating the medical profession because maybe then more people will listen.
Christine, I agree that progress will be limited until the medical profession opens its mind and sees the low-fat diet for the historical aberration that it is.
I have a friend with type 2 diabetes and it saddens me greatly that he eats bread and sugary junk simply because he likes it so much. It baffles me that he will harm himself in this way, despite my sometimes blistering warnings. I think that deep down he finds it convenient to follow bad medical advice that allows him to eat sugary rubbish and supposedly deal with the problem with medication.
This week whilst buying a curry and checking there was no added sugar, the lady who served me told me that she was losing her eyesight and losing feeling in her legs because of diabetes. She said, “You could kick my leg and I wouldn’t feel it.” She takes insulin four times a day and admits still eating junk.
I pointed her to Professor Noakes work and that of Dr Sarah Hallberg. It’s all so sad and so needless, particularly for my friend and your husband who have been warned.
My big eye opener (pun intended) was when I took my late mother to the opthalmologist. They wheeled in a huge woman. She was in a wheelchair because of her missing leg, and was obviously there because she was going blind.
The wheelchair was too wide to fit through the door to the doctor’s office, so he and his equipment had to decamp to a room with double doors.
Obviously a medical success story, NOT.
Any day now, men in white coats will come and take him away to a mental hospital, where he will … Oops, sorry, – getting confused with that pesky ‘Semmelweiss’ heretic…
Read Dr Bill Lagakos for a good explanation of how Insulin Resistance is on a spectrum and for other reasons why people may stay in DM2 despite dietary changes. The necessity of good sleep and circadian health changed my life for the better. The Banting community champions the fast result rapid weight loss changes, but not necessarily the lifestyle revolution necessary for sustained results. LCHF is good, but medical keto is not sustainable over a long period for most sunny South Africans. Need I state that I am a Paleo and Epi-Paleo fan, too?
Wow! “Condition of choice” really hits the nail on the head. And keto is “dangerous” to whom, except those profiting off of the status quo? Great article.