In Categories: Science & Research

Over fifty percent of adult Americans now have diabetes or pre-diabetes and there are no signs of this epidemic slowing (1). Diabetes has long-been considered a chronic and progressive disease. Treatment of diabetes usually involves recommendations for lifestyle changes, and when lifestyle interventions are insufficient, medications are prescribed to manage the disease and slow progression (2). Unfortunately, many diabetes medications are costly and some come with undesirable risks and side effects, such as weight gain and increased risk of severe hypoglycemia (3,4). And despite these treatment efforts, the remission rate under this usual care model is extremely low (0.5-2%) (5). However, with the right treatment, reversal of hyperglycemia and insulin resistance is possible (6)!

Virta takes a novel approach to diabetes care. We employ a technology-enabled continuous remote care model with individualized guidance for achieving nutritional ketosis. Each patient has a remote care team —a health coach and a medical provider —that continuously customizes their care. Patients also receive behavioral support and encouragement from their coaches and an online community of their peers. We hypothesized that this comprehensive care model would improve health for patients with type 2 diabetes, allowing them to actually reverse hyperglycemia and insulin resistance while removing medications.

To assess the safety, efficacy, and sustainability of the Virta Treatment, we put our treatment to the test in a clinical trial. We enrolled 262 adult volunteers with type 2 diabetes who chose to receive the Virta Treatment. For comparison, we also enrolled 87 adult volunteers who chose to receive Usual Care for type 2 diabetes, including appointments with their physician and consultations with registered dietitians regarding nutrition and lifestyle changes.

At 1 year, participants who received the Virta Treatment saw clinically-significant benefits in their health outcomes, such as decreased HbA1c and weight, all while discontinuing 63% of diabetes-specific medications (7). And while we are very excited about the results after 1 year, we understand that this lifestyle change requires a long-term commitment from our patients. Therefore, we decided to extend our 2-year clinical trial out to 5 years. We are closely following the clinical trial participants to learn more about our care model.

Here we take a look at the 2-year health outcomes of participants in the clinical trial, which were published in Frontiers in Endocrinology, a peer-reviewed journal. At 2 years, 74% of the original 349 trial participants remained enrolled in the trial. We are excited to share that trial participants receiving the Virta Treatment showed ongoing clinically-significant health improvements at 2 years.

Reversal of diabetic hyperglycemia without use of diabetes-specific medications

The terms Reversal and Remission have both been used to describe regression of hyperglycemia and insulin resistance, but they are defined slightly differently:

Reversal = Sub-diabetes level glycemia (HbA1c <6.5%) that is achieved without diabetes medications or only with metformin.

Remission = Similar to reversal, but requires that no diabetes medication (including metformin) be used and that it is maintained for at least 1 year.

Here at Virta, we focus on Reversal. The reason for this is that we believe that it is not in every individual patient’s best interest to arbitrarily stop metformin. Patients who have a history of diabetes remain at increased risk of developing diabetes again, even after HbA1c normalizes, and metformin has been shown to decrease this risk (8). Therefore, we discontinue metformin only due to side effects or patient request.

We are thrilled that 55% of Virta Treatment participants still enrolled at 2 years achieved Reversal!

Clinically, it might also be important to consider the percentage of patients who achieve Reversal among the total number of patients enrolled at the start of the trial. Those who discontinued participating in the trial or did not complete tests at two years are assumed to have not met Reversal criteria. Using this rigorously conservative approach, 38% of the 262 participants who began the trial met criteria for Reversal at 2 years.

At 2 years, participants who received the Virta Treatment maintained reductions in diabetes-specific medication use. In fact, average daily insulin dosage further declined at 2 years.

The average daily insulin dosage for Virta patients began at 81.9 units/day at baseline and dropped to 15.5 units/day at two years.

Trial participants on the Virta Treatment also continued to show clinically-significant improvement in HbA1c from baseline to 2 years.

Sustainability

You may have noticed a slight increase in HbA1c between years 1 and 2. We also saw a slight increase in weight (5 pounds on average). This is an issue for any lifestyle change intervention. Many brilliant researchers have spent their entire careers working to improve sustainability. Most lifestyle intervention studies see regression towards baseline values within the first year, and then major, if not total, regression to baseline at 2 years. After 2 years in our study, our participants’ average reduction in HbA1c and weight was about two times that of comparable study populations (see below) (9-12). In this trial, participants’ average ketone levels (which indicate adherence to a low-carbohydrate diet) remained significantly increased over baseline at 2 years, meaning that overall participants continued to restrict carbohydrates at 2 years. This provides evidence of long-term sustainability of this lifestyle. We can’t be certain about what has led to our study participants maintaining improvements at such a high rate. We believe that it is likely a combination of a satisfying diet that does not require calorie counting combined with the continuous support and monitoring with individualized recommendations for carbohydrate restriction.

Impact beyond type 2 diabetes

Safety is our top priority at Virta. In addition to diabetes, we monitor other aspects of our participants’ health to ensure other health risks are unaffected, or even better, improving! Our goal is to make patients healthier overall.

Not only can the Virta Treatment be delivered without negative impact on other aspects of health, it also improves other health conditions that commonly co-occur with diabetes such as inflammation, insulin resistance, dangerous (atherogenic) changes in blood lipids, and fatty liver disease. Among Virta Treatment participants still enrolled at 2 years, 75% had lost at least 5% of their body weight and 50% had lost over 10%. This is in contrast to the Usual Care group, who showed no significant improvement in their diabetes status or other health markers.

Take-home points

  1. Participants receiving the Virta Treatment had long-term clinically-significant improvement in glycemic outcomes alongside reduced medication usage.
  2. A high percentage of participants receiving the Virta Treatment met criteria for remission compared to what we see under usual care and even in other intensive lifestyle interventions (12,13).
  3. Participants receiving the Virta Treatment sustained clinically-significant weight loss at 2 years.
  4. The Virta Treatment is safe. Participants had improvements in risk factors for other health conditions.

15 Comments

  1. Avatar

    i am on Medicare. i was diagnosed as diabetic. i am not anymore after a year on a ketogenic diet. i wish my Medicare doctor was interested in the Virta approach which i am following on my own with significant positive changes.

    Reply

  2. Avatar

    I have been eating a low carb diet sincediagnosis Augut 2016 .At diagnosis my Hba1C was 10,3% it has not been under 5.7% for two years , I am on a ketogenic diet, though not alwys in ketosis. All other markers have similarly improved.

    Reply

  3. Avatar

    Is it possible to halt or even reverse the progression of micro and macro vascular complications of Type 2 Diabetes by maintaining A1c levels below 5.6 without the use of diabetes medications?

    Reply

    1. Virta Health

      Thank you for your question, Birgit. We have many anecdotes of reversal of neuropathy, retinopathy, and nephropathy in people with T2D following a well-formulated ketogenic diet but there are not objective data (ie, published peer-reviewed studies) to provide evidence that this is true.

      Reply

  4. Avatar
    Pradeep Awasthi July 11, 2019 at 5:19 pm

    The experts of virta group are seriously working on different possibilities of reversing type II diabetes through well designed protocol where patients gets trans theoretical model of treatment to expect better quality of life with longer life expectancy.

    Reply

  5. Avatar
    JAMES M. ALLEN July 14, 2019 at 9:59 am

    I am a long standing diabetic of nearly 20 years. I have never taken medications except Insulin. I was originally overweight but now I am thin. I still have high blood sugar except when I rigorously eat low carb and engage in regular exercise. I am encouraged by these postings and I need to start a program to reverse my diabetes and complications .
    Regards,
    James M. Allen

    Reply

  6. Avatar
    Peter Delannoy July 24, 2019 at 4:43 pm

    I was diagnosed prediabetic on January 23, 2019. A few weeks after that I found my way here and started a ketogenic diet. In five months and one week I reduced my A1C from 5.8 to 4.9. My average fasting glucose adjusted from 109 to 80. My lipid profile is trending to match the results published in the one and two year study.

    You guys rock!

    Reply

    1. Virta Health

      Great work, Peter! Thanks for sharing your story!

      Reply

  7. Avatar

    Any suggestion or thought that the continued drop in daily insulin dosage over two years means increasing insulin sensitivity and if those who remain on it are type 2 transitioned to type 1 diabetics?

    Reply

    1. Virta Health

      In our patient population, the decrease in insulin requirements would be due to carbohydrate restriction. Typically, exogenous insulin will result in decreased insulin sensitivity over time. As for your 2nd question, type 1 and type 2 diabetes are two completely different conditions and therefore patients cannot switch between the two.

      Reply

  8. Avatar
    Alexis Espinosa August 25, 2019 at 3:03 am

    Hello,
    Thanks for proving that standard of care does not help nor cure diabetes. There is no doubt that the best results published so far about treating diabetes T2 are yours. Thanks a lot to Virta, Sarah, the team, Volek and Phinney. You rock!

    But there is some kind of “credible” people out there still saying that Fat is not good for our health and even claiming that saturated fat may be the culprit of diabetes. I refer mainly to the comments of S. Joshi, Cyrus Khambatta (mastering diabetes), Michelle McMacken and the “Forks over Knives” people. Indeed, they already wrote a scientific letter complaining about your paper (https://www.mdpi.com/2072-6643/11/7/1620/htm?fbclid=IwAR21YW2fqIv3Asu-ANtyH42MQmEQ33jr8c-p1HKXp1H6U95QQkw_2D4PYNs). In my opinion, they are closing their eyes, brain and ears to the truth you have presented, but they are still causing confusion to the public. And this confusion grows with their own claim of diabetes reversal and their use of plant based low fat delicious diets. (They really look healthy and delicious, though.)

    Their main claim that is causing me confusion is their comment about ketogenic diets reducing glucose tolerance. They say: If you have a glucose tolerance test after following a Ketogenic diet, you will dramatically fail! I was not believing this, until I saw the response of Dr. Hallberg accepting this phenomenon as a known fact (https://www.mdpi.com/2072-6643/11/7/1644/htm?fbclid=IwAR35B1Zm_QZRETSfsl66EzrK0eHJo_SEzSyrDzzXWhmL8zOYzN3QAnzUPJY#B1-nutrients-11-01644).

    So, my main two questions are:
    1) How should we interpret the “failure” of the glucose tolerance tests? Or rewording it, what would be the right protocol for performing that test? Should I change to a No-Keto diet (but still healthy) for a week or two and then perform the test? Or is this test really not the right test to focus on? (Possibly, it is something like a test called: alcohol tolerance test, where the healthiest person is supposed to be the one that resists three shots of tequila in a row without getting drunk. Then, of course, the people more used to alcohol will do better, but that does not mean to be healthy. And, of course, someone under treatment to cure cirrosis will not perform well on that test either). But I would really would love to have a comment back from you about this. By the way, they really refer to scientific papers showing insulin production and sensitivity being damaged by saturated fat: https://eje.bioscientifica.com/view/journals/eje/180/5/EJE-19-0022.xml,
    https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1462-8902.2004.00356.x
    Can you please also comment on them?

    2) It has been proven, there is no doubt, the standard of care is terrible, horrible, no good! But what about the best of the best plant based, whole foods, “curing” diet? Like the one suggested in “mastering diabetes” or in “forks over knives”. Could those diets be curative too? It would be amazing if you can produce some other studies involving this “curative” diet and comparing the results against virta. I think this would be a fantastic piece of science because it would help to finish once and for all with all the bad names this people is still giving to Keto. Please test it, and test it with scientific eyes, allowing the best plant based diet to give its own results and then evaluate. Please!

    Thank you very very much, and I hope you can give some comments back here to reduce the level of confusion and to perform further tests to eliminate ALL sources of confusion about pros and cons of keto diets to cure type 2 diabetes. And pros and cons of whole food plant based diets to cure type 2 diabetes

    Many thanks,
    Alexis

    Reply

    1. Virta Health

      Hi Alexis, in regards to your first question, it depends on the purpose of the glucose tolerance test. In many circumstances, it may not be necessary to complete it and regular glucose monitoring can be an appropriate substitute. For your 2nd question, a ketogenic diet and a plant based diet do not need to be mutually exclusive. It is possible to consume both and we have many patients (and employees) who do follow both and are very successful. While we do not have any plans to study a plant based ketogenic diet, there may be others who would be interested in that research.

      Reply

      1. Avatar
        Alexis Espinosa October 11, 2019 at 3:48 pm

        Thanks a lot for your response. I really appreciate it.
        Can you please expand a little bit more on my question 1? My point is: If Dr Sarah Hallbergh is recognizing herself that the failure of the glucose tolerance test is a fact for those who follow a ketogenic diet. This is confusing to me.

        How do we really know if the ketogenic diet is affecting/not affecting our body capacity to process glucose? What this vegan researchers are claiming is that, when the keto diet is over, we will be worse than before! This is confusing, and it has been published in scientific papers. We do not want to be worse than before! We want to be better!

        Now, with the keto diet, we look better, we feel better, glucose levels are down. But they still claim that we are worse and refer to the scientific proofs about keto guys failing the glucose tolerance test. Then, how can you really respond to that attack from the vegan researchers? How should the capacity to process glucose should be measured?

        I agree with you that continuous glucose monitoring is good, as it tells us our glucose levels and we can feel happy to see them down and under control.

        But I agree with them that the control is somewhat arbitrary, as the carb/glucose income through diet is really low. I agree with them that what we finally want is a body that can control glucose levels even if we eat fruit (in a healthy reasonable way).

        So, what is the response, the real effect? Is keto helping the body to be able to regulate glucose better for a future intake of a normal healthy dosage of fresh fruit within a healthy lifestyle? Or is it making things worse as they claim? How do we know?

        Reply

        1. Virta Health

          Type 2 diabetes can be reversed through nutritional ketosis and limiting carbs. As previously mentioned, if our patients were to begin consuming carbs at a level above what they can tolerate (“a normal healthy dosage of fresh fruit” perhaps), then their blood sugar would increase. What can happen in the short term is they may have a larger spike in their blood sugar initially as their body hasn’t been releasing large amounts of insulin because it hasn’t been needed. This is referred to as physiologic insulin resistance. If they were to continue consuming carbs over their personal tolerance level, they could expect to have the same issues with blood sugar levels as they did before. We know that our patients have impaired insulin sensitivity and so this is managed by restricting carbohydrates so insulin needs are lowered.

          Reply

  9. Avatar

    I’ve jumped on LCHF diet just a bit more than half year ago. Feel significant improvement with no doubt.
    In first I was having some abdominal fat despite running half marathons and doing some weights. Once I’ve stopped carbs fat’s gone whether training plans did not change at all.
    In second I’ve stopped feeling hunger. I can eat once a day or two and even not remembering about eating at all. When I was packing myself with carbs hunger was literally banging at my door every 3 4 hours. 24 hrs fasting was like a real challenge to me.

    Reply

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