Sarah Hallberg, DO, MS The Virta Health Approach To Reversing Type 2 Diabetes 

Brian Mowll: Hello, and welcome back to the Diabetes Summit 2019. This is Dr. Brian Mowll, the Diabetes Coach. I'm a master licensed diabetes educator and IFM certified in functional medicine. I am your host for our sixth annual Diabetes Summit. Now, my next interview is with someone that you're going to absolutely love. She has done landmark, groundbreaking research on using low carb ketogenic diets to reverse type 2 diabetes, and help eliminate medications.

Brian Mowll: Her name is Dr. Sarah Hallberg. I'm really excited to bring you this interview as part of the 2019 Diabetes Summit. So, Dr. Sarah Hallberg is the medical director at Virta Health. As a physician and exercise physiologist with a passion for helping people be healthy through diet and exercise, she's responsible for providing medical supervision to Virta's expert team of physicians, and oversees the clinical strategy for the Virta Clinic participants.

Brian Mowll: As an expert on metabolic control and type 2 diabetes, Dr. Hallberg is also the executive director of the nutrition coalition, a non-profit organization that aims to educate the public and policy makers about the need to strengthen national nutrition policy so that it's founded on comprehensive body of conclusive science, and where that science is absent to encourage additional research.

Brian Mowll: A low carb enthusiast, Dr. Hallberg practices what she preaches by living a ketogenic lifestyle. You can learn more about her at VirtaHealth.com, or by checking out her TED talk called 'Reversing Type 2 Diabetes Starts with Ignoring the Guidelines,' which has been viewed 1.2 million times.

Brian Mowll: All right, so enjoy this interview with Dr. Sarah Hallberg.

Brian Mowll: All right, everybody. Welcome back here. I have with me a guest who I am very, very excited to interview. Someone that I've been trying to interview for a while. A very, very busy lady, and who's doing some incredible work. Most of you have probably heard of her. If not, you are going to be very impressed today, and you're going to want to do some research on the work that she's doing. That is Dr. Sarah Hallberg, who is doing some great research out at Indiana University with the Virta Health system.

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Brian Mowll: Sarah, welcome to the forum and the podcast. It's great to have you with me.

Sarah Hallberg: Thanks so much for having me. I'm excited to be with you today.

Brian Mowll: All right, excellent. So let's just dive right in. You've been really doing some great work there. I've talked about this for a long time. I think that there's a lot of people who have sort of come to the same realization, and who are trying to change things, but that is that our healthcare system is really the way it's been designed is ill equipped, I think, to handle chronic health conditions and diabetes. To me, type 2 diabetes is really the pinnacle of that. I look at type 2 diabetes as kind of the pinnacle of metabolic disaster.

Brian Mowll: We need ... The way I look at our current healthcare system is it's really designed to handle one off things. It's you come in, the average primary care physician that might be managing a couple thousand patients. They're going to try to solve whatever they can while that person's in the office, and move on to the next person. Diabetes just doesn't work that way. We need some continuity of care, and we need to sort of get in the trenches with these folks, and help them.

Brian Mowll: I think you've devised or helped to devise a system that's doing that. Would you mind talking a little bit about Virta, and what you guys are doing over there?

Sarah Hallberg: Absolutely. So, you're absolutely right about the way that the healthcare system is set up, and as far as it dealing with chronic diseases. I mean, we have a healthcare system that is set up to put out fires, right? And not to push prevention in any way, shape, or form. I mean, that's how physicians and health systems are incentivized. We are looking only at who's making the most money. In that, we lose sight of who is potentially saving the most money.

Sarah Hallberg: With healthcare expenditures run amok, I mean at this point, we have to start looking at who is saving the most money. So yes, diabetes and metabolic diseases is a perfect example of what happens when you have a system focus on again, putting out fires rather than prevention.

Sarah Hallberg: What I'd really like to say is when we talk about the diabetes and metabolic disease epidemic, we have talked it and utilized terms like 'emergent,' 'urgent,' 'unprecedented.' I'm going to introduce a new term that we really need to put into the lingo. That's panic.

Sarah Hallberg: We've known for several years that among adults in this country, over 50% have diabetes or pre-diabetes. But you know, there's a new paper looking at, all right, what about metabolic disease in general that was just published. What it found is ... I mean, unbelievable results. That is there's only about 10% of the population of adults in this country who are considered truly metabolically healthy. So newsflash, that's 90% of the people who aren't.

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Sarah Hallberg: That's beyond urgent. That's beyond emergent. That's beyond unprecedented. This is the time that we need to start panicking. I've said it before, but it bears repeating in that we had results like this with any infectious disease, what would be happening in the country? We would be panicking. We would be giving it its right place, as far as our priorities within our country. Of course we know it's not just this country, within the global. This is something that we have to do something about today.

Sarah Hallberg: But because it's metabolic disease, because it's something that's going to be impacting the lives of people, and therefore the expenditures in the future. I mean obviously the expenditures are hitting us now from people who have had problems in the past. But the worse we get, the more the expenditures are going to build. So we cannot put this off any longer. The panic needs to be appropriately addressed to this here and now, unbelievably out of control issue.

Brian Mowll: Yeah, you're totally right. The good news is that there are some real solutions. It's sad, almost, that more people don't know about these solutions. That's why I'm doing this. I know that's probably one of the things that motivates you to go out and speak, and share this message, and put up YouTube videos, and do everything you can to spread this message as well. But so far, it's spreading, but it hasn't penetrated into the mass of the population of people with diabetes yet. But, that's what we have to keep doing.

Brian Mowll: I know that you've ... I think you've created a system that has an answer, maybe not for every single person, but for certainly a large percentage of people, the results they're getting are incredible. So, would you mind maybe talking a little bit about the details of the model that you use?

Sarah Hallberg: Absolutely. So, really the model that we're using, and well, let me even back up a little bit before that is why has this not hit the mainstream, so to speak? What's holding it back? I think it's really all centered on this word, 'reversal,' because that makes everybody in the medical community a little bit nervous and scared, like a reversal, you can't reverse disease. Well, you can't with the standard of care model that we've been pushing for decades now.

Sarah Hallberg: But reversal of disease is possible, and this has been shown in a number of studies in the medical literature. So what we need to do is we need to start getting comfortable with this word, disease reversal. So one thing I always say, if there's one thing I could get out, it's for providers and for patients both to understand that this is a word that needs to come into our medical vocabulary. We need to be talking about it. We need to be educating ourselves as both consumers from a patient standpoint, and providers, to what does this word mean? What is it applicable to? What do I need to know to make sure that me, as a patient, or me as a provider, are communicating properly with my patients to discuss this as something that can be a goal.

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Sarah Hallberg: So Virta Health falls into a totally different category. We are not a diabetes management company. Okay, I mean the management companies are everywhere, right? I mean you Google diabetes app, and there are just hundreds of diabetes management apps. We fall into a totally separate category. We are a diabetes reversal program. That is our goal.

Sarah Hallberg: So again, new category, which is necessary in this again, panic mode that we need to be in. We have to start looking at this. We can't just manage 90% of the population. We need to set the goal at reversal, and that is exactly what Virta Health is doing. We're really falling into a niche of something that hasn't been available for, but it is critical if we're going to get ahold of this.

Brian Mowll: Yeah, I totally agree. I like the way I've heard you describe reversal before as backing people out of diabetes, baking people out of the situation that they find themselves in. I think that's a great way to look at it. That is really what you're doing when you're reversing is backing yourself out of wherever you are. I think that can be done. We look at liver disease, and certainly unless there's serious cirrhotic changes, then we know that liver disease can be reversed. There's other diseases that we're ... are commonly accepted that they can be reversed. I think that we need to start looking at certainly pre-diabetes, and even many cases of type 2 diabetes in the same way.

Sarah Hallberg: Absolutely we do. Again, really one of the things going back to the term 'reversal,' that makes people nervous is that they say, 'Well, you're not curing anyone.' No, and I don't know that anybody is claiming that. I mean, I suppose there are some people out there, but curing means that the disease isn't going to back, right? Reversing is the most appropriate terminology for exactly what we're doing because it's been widely accepted for decades now that once someone gets on the road or the path of type 2 diabetes, it is a one way street. You are going to progress. You are going to continue to get worse. Those facts are absolutely true with standard of care management.

Sarah Hallberg: But again, if we started hitting the root cause of the problem, the underlying insulin resistance with type 2 diabetes, and again, removing what is causing the disease problem, which is glucose and insulin elevation, then we can truly turn the one way street into a two street, flip a u-turn, and start to pull back. Again, that's why I think that the terminology is so incredibly appropriate for this. Again with standard of care management, the way that it's historically been, the only goal ... there's no goals of getting off the one way path. We try to put the brakes on it, at least temporarily, with maybe medical management. Okay, but it's just that. It's a temporary brake.

Sarah Hallberg: Unfortunately with medical management, that temporary brake is often followed by acceleration. Once we put the temporary brake on, maybe we're making the blood sugars better with insulin, but then the weight gain goes on, and we wind up accelerating the disease process, actually, at the end of the day. We have to stop with that mindset. We have to start, again, flipping that u-turn when it comes to this disease.

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Brian Mowll: Yeah, I love that. Great way to explain that. So, how do we do that in practice? What are the most important elements of putting somebody through a diabetes reversal program?

Sarah Hallberg: Well again, there are three clinically proven ways to reverse type 2 diabetes. Okay, and one of them is surgery. There's really robust literature on that. Another is extreme calorie restriction. There is evidence of that, although the long term evidence for this is lacking. Then there's carbohydrate restriction. We have a reasonable amount of long term evidence in that, and we are currently continuing to produce more long term evidence. In fact, we are going to be publishing our two year clinical trial results.

Sarah Hallberg: So, who is supposed to choose which path of reversal they would like to embark on? If, in fact, they do choose reversal. I mean, I think that many people will choose reversal, but it's going to come with effort no matter which of those three paths you're going to embark on. Quite frankly, the only person who should be choosing between the three is the patient themselves. No one should be saying this is absolute one, or an absolute other. That's why the education of providers is so critical sot hat we can make sure that a really good discussion is had with patients.

Sarah Hallberg: We at Virta believe, I think very fairly, that many people will choose carbohydrate restriction. Why? Because it doesn't need surgery. It doesn't require surgery. It doesn't require calorie restriction. Patients do seem to naturally pull back on their calories when eating low carbohydrate nutrition because that is so satiating, but it's not something they have to worry about. It's not something where you're counting your calories all the time, and trying to stay under some maximum. It requires not more medication, but in fact, less medication.

Sarah Hallberg: So again, what do we need? We need continued results with long term success, which we're about to add, and then again, we'll be adding even more as our clinical trial is going to out to five years. But carbohydrate restriction, you can say carbohydrate restriction, and some people can be absolutely successful with just a very brief education session. But that is the exception, not the rule. So the big question is how do you make sure that you're providing support to people who are working towards disease reversal utilizing carbohydrate restriction?

Sarah Hallberg: That's what we think at Virta Health, we have a real leg up on because with our remote care model, we're able to bring people many different layers of support, and bring it to them on their schedule based on their needs at the moment. We're providing a health coach for each patient. That health coach patient interaction and engagement is incredibly high. This is a high touch model because support needs to be high touch. If a lifestyle change was easy, everybody would do it. Okay, it's hard. There are challenges. People need to be supported through all phases of those challenges.

Sarah Hallberg: In addition, because safety is a important concern, especially when you have someone with type 2 diabetes who enters into a lifestyle change on a lot of different medications, each participant in the Virta

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treatment also has their own physician. So that they can almost in real time be making safe medication adjustments. By medication adjustments, and when you say medication adjustments to the medical community at large, what does that mean? It means writing another script, right? I'll tell you, I've been there, done that, because I spent almost a decade in primaries care. Then, I always say I was a legal drug dealer, just writing more and more scripts. What my specialty is right now is a de-prescriber.

Sarah Hallberg: The physician gets to come in. I mean, how great is that job? And come in, and tell patients wean off of their medications safely. So again, the safety built in with the physician oversight. You've got the health coach there for support. We also provide patients with an incredible community support system. Resources galore, and so again, it's not supporting patients from one angle because nobody's life is like one single thing, right? We have so many different aspects of our day to day lives. If we're going to make successful and sustainable lifestyle changes, we need to make sure that the support is coming from all over so that every part of our day to day lives can be supported, and not just presume again that one way will fix it.

Brian Mowll: Yeah, perfect. Makes total sense. So, I want to get into this low carbohydrate or carbohydrate restriction nutritional ketosis approach a little bit more; but before I do that, I just want to ask a question. This really isn't my question, but I know it's going to be on other people's minds. You listed several ways of reversing diabetes, including bariatric surgery, and severe calorie restriction, the work of Roy Taylor at Newcastle University, and then you mentioned the carbohydrate restriction model.

Brian Mowll: So a lot of people are thinking, 'Well, what about plant based diets? I heard that plant based diets can reverse diabetes, too, and there's a book about that,' and all this. What does the literature say about that? What have you come to realize in that area?

Sarah Hallberg: You can do ... First of all, couple of things. You can do a plant based carbohydrate restricted diet. We help people who choose to eat plant based do this on a regular basis. But, the typical way that plant based has been implemented before is as extremely low fat diet, which therefore is very high carbohydrate. When you really look at the literature for this, there is scant evidence that this can be successful. In any trial that does show some reduction in hemoglobin A1C, what you see is that there's extreme calorie restriction, right? There's a lot of calorie restriction going on, so it does fall in, in that way to one of the ways of diabetes reversal.

Sarah Hallberg: But again, it appears that calorie restriction is needed both for improvements in glucose control, and also actually improvements in most of the cardiovascular risk factors. Because when you don't have a calorie restriction involved, one of the things that typically happens, especially with any form of a very low fat diet, is that we see a worsening of atherogenic dyslipidemia, right? We see triglycerides go up. We see HDL cholesterol go down. We even see the size and

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distribution of the particles themselves shift into a more problematic pattern.

Sarah Hallberg: So plant based fall into two of the categories of diabetes reversal. It can be implemented as a low carbohydrate approach. It can be implemented as an extreme calorie restriction approach. But as far as plant based without one of those two things, there's just ... there's not the evidence for that in the literature.

Brian Mowll: Yeah, that's what I found as well. People will improve their blood sugar, but not get to the point of diabetes reversal, and eliminating medications. I haven't seen any studies on plant based diet that show people eliminating medications like your studies, and there's been other studies on low carb diets that have shown that as well. So that's pretty powerful.

Sarah Hallberg: On plant based diets, there are some medication reductions, but once again, they fall into that calorie restriction reversal.

Brian Mowll: Okay. All right, thanks for clarifying that. All right, so let's talk about nutritional ketosis and carbohydrate restriction in general. So, I know that you use a nutritional ketosis approach in your program, or at least in your study ... in your studies. I know that from listening to you that at least a good part of that reason is that you don't have to worry about food logs, and from compliance reasons, you can look at blood levels of ketones, and know whether a person's on track or not.

Brian Mowll: But aside from that, do you think it's ... is there something special about being in nutritional ketosis reverses being sort of right on the edge of that, but still following a very low carbohydrate diet that makes the results all that much better?

Sarah Hallberg: So, it sure appears to be. I think that the evidence is mounting, and we'll see a lot more evidence probably coming out within the next 12 months on the fact that beta hydroxybutyrate appears to be a really potent anti-inflammatory agent. As we know about almost all chronic diseases, if not absolutely every single one of them, is that information plays a key component.

Sarah Hallberg: I mean take cardiovascular disease, right? I mean, forever we've thought of this as just a cholesterol problem. But you know, one thing that is really important for everyone to know is that in the path of physiology, of the development of cardiovascular disease, what is like mandatory every step of the way? Inflammation. It is an inflammatory disease.

Sarah Hallberg: So yes, if someone is restricting carbohydrates and not in nutritional ketosis, especially if their type 2 diabetes is early on, can they be successful in reversal? The answer is yes. I mean, we definitely have evidence of that. But are we really hitting the whole disease when we enter into the idea of the anti-inflammatory properties of beta hydroxybutyrate? I'll also add to that the fact of the matter is, when we become fat burners, right? When we literally switch our metabolism, which is exactly what's happening when you have elevated beta

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hydroxybutyrate levels, then what you're saying is I am switching from being a carbohydrate based metabolism to a fat based metabolism. We also know that people get a lot less cravings, right? They're just not hungry all the time. That is playing, again when we look at the role of sustainability, that is likely a major factor in the sustainability aspect of this as well.

Brian Mowll: So there are several ways that I've seen this model taught. There's some disagreement about how you distribute the other two macro nutrients, being protein and fat. Do you have sort of a recommendation there? I mean, do you recommend a high fat diet? It's always going to be, of course, relatively high if you're reducing carbohydrates, but do you recommend 80, 85% fat in the diet, or somewhere up in that range, 75%? Or, do you personalize that per patient? What's your thoughts on that?

Sarah Hallberg: Yeah, we definitely personalize it. We don't really like to try to talk percentages. I know that that's kind of ... what do I say? It's ... enticing [crosstalk 00:26:15] ...

Brian Mowll: Right, right.

Sarah Hallberg: But we try to stay away from that. The way that we instruct patients at the beginning, and then of course, critical is the personalization aspect, which I'll come back to in a minute. But, how much fat that they're getting, and at what percentage of their intake is going to depend on what part of the journey they're on. Initially, we give patients the recommendation of restricting total carbohydrates under 30 grams a day. We weight base the protein recommendations. We're looking for moderate protein, okay? Or what we like to say is adequate protein. And why? Why not high protein? Not high protein because protein again, with the goal of nutritional ketosis can push people out of nutritional ketosis. We want to make sure that patients are getting enough protein so that they can sustain their muscle mass, but they don't need any more than that.

Sarah Hallberg: Okay, so we're setting a limit on total carbohydrates. We're making a personalized recommendation on protein based on their weight and gender. Then, they need to have more food in order to feel full, and what is the fill in? The fill in is fat. Okay, and initially that may actually be a lower percentage of total because some of the fat that they need, especially to make ketones, is coming from the stored fat as well. But of course, once they are weight stable, so later down the disease process, actually the percentage of fat in their diet is likely to increase, and in some cases, pretty significantly, because that fat that they need for energy that they're making the ketones out of is coming much more from the fat that they're consuming, rather than the fat that they're storing. Again, once they hit that weight stability.

Sarah Hallberg: So that's why we try to stay away, again, from a specific fat level. We talk about fat to satiety. One of the things that we talk about also is that fat is not free. Can you, even though fat is our macro nutrient we want to be consuming the most of, does it mean you can have as much fat as possible? The answer is no. That is you need to be careful that

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you're not consuming more than you need to get full. It's easy to take in 1200 calories of fat before six a.m. in coffee, if you really wanted to, right? But if you're doing that, did you need all that fat to get full? Most certainly you did not, right? So we have to make sure ... Again, this comes with the personalization. Fat is our macro nutrient of focus because it does not cause glucose and insulin to rise. But, we only want to be consuming it to satiety, not more.

Brian Mowll: Right.

Sarah Hallberg: It is possible to consume fat more than what you need. In that case, we can run into problems.

Brian Mowll: So how do you help people figure out what that level of ... I don't even ... I'm hesitant even to say calories, because I don't want people to think we're calorie counting, necessarily, but how do you help people figure out what their level of food intake is so that they're in that sort of energy deficient state? They can burn their own body fat.

Sarah Hallberg: Ah, so that's where our wonderful health coaches come in. That's where those biomarkers, including the ketones, are critical to personalization. So, a health coach will get a glucose reading, and a ketone reading, and weight reading on a patient. They'll be able to utilize all of those biomarkers to personalize, again, in almost real time.

Sarah Hallberg: So for example, if you are working on carbohydrate restriction and you go in to see your physician, and then go back to see them a month later, and you've lost five pounds, because of what, right? Or, if you gain two pounds because of what? What meal? What did it that month? When the glucose, the ketones, the weight come in, we can say what was the last meal? Right, let's troubleshoot this right now. Things went really well. What can be replicated? Hey, we went up, and you went out to a new restaurant last night. Let's go through that really carefully. Something didn't agree with you. So again, that personalization for long term success is really huge.

Brian Mowll: Yeah, that's huge. What else do the health coaches do to help people become more successful through the program?

Sarah Hallberg: Our health coaches are amazing. They help people with the education, and then with a key here, which is personalization. So our biomarkers that patients are putting in the app, we're paying attention to those. We're really honed in those because they are the key to personalization. I mean, number one, physicians use them to again, safely de-prescribe medication.

Sarah Hallberg: But most important is the health coach is using those biomarkers in almost real time to help guide people. This makes the carbohydrate restriction successful, but also sustainable. So for example, if you go into your physician's office and you're working on carbohydrate restriction, and you see them, and a month later, you see them again. Let's say you were successful, and you lost five pounds. Why? What happened? Why did you ... what went well that month that helped you

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lose those five pounds? Or, the flip side, what if you gained a couple of pounds? What didn't go as well? We can't pin that down to a specific time, or it's very, very difficult to do. In order to do that at all, you've got to have people journaling, which is again, something that enters in a whole layer of complexity that's not necessary.

Sarah Hallberg: Whereas when we get the biomarkers, the health coach can say, 'Hey, glucose went down. Ketones went up. What did you do for dinner last night? It went really well. Let's try to incorporate that in some other aspects of your meal plans.' Or, if it didn't go so well, 'Oh, you went out to a new restaurant last night, and you had this that was low carbohydrate. Well, let's go through their ... There was somewhere, hidden carbs. Let's troubleshoot this together.' Then it can really be an impact also for planning ahead. 'Hey, I've got a work party pitch in. What can I bring? What can I say to my coworkers, and encourage them to help me out with this? We have a family celebration that's really important to me. What do I do? Here's the things that typically will be there.'

Sarah Hallberg: That again, you can't say, 'Well, that falls into recommendation, category A,' and then give the same advice to everybody, right? Because what do they do for a living? How people are at the pitch in? What's their relationship with these people? Those are personalized aspects that you need to be able to know to truly advise someone, and advise that particular person.

Brian Mowll: Yeah, that's why the coaching model is so vital. As we were talking about earlier, when you compare that to the standard practice, and conventional recommendations that are made, it's checking in with your doctor a few times a year. Maybe you go to a dietician a couple of times who teaches, unfortunately outdated and I think, inaccurate information. Then, maybe you go to a diabetes education class, but they're teaching sort of just basic diabetes management. As you said, what you're doing is not diabetes management. It has a completely different goal, and you're looking for a completely different outcome, which is really the reversal of diabetes, type 2 diabetes, which is so vital.

Brian Mowll: When I look at this, you're doing incredible things. You're growing exponentially. I think the research you're putting out there is phenomenal into the scientific community to actually create an evidence base for this model. But, then we look at the ... how big of a problem diabetes is, and again, you talked about this earlier, 50% of our population with pre-diabetes or type 2 diabetes, 90% with metabolic issues. That's just here in the US. Globally, China, India, and pretty much every developed nation, diabetes is exploding.

Brian Mowll: So I guess the question is, is this scalable? Is there a way to start to shift the way that diabetes care is practiced, or the way that we're taking care of people with pre-diabetes and type 2 diabetes?

Sarah Hallberg: Yeah, you're absolutely right. We have a global crisis. This isn't just an America problem. This is a global crisis. Virta's company mission is very

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clear: our goal is to reverse 100 million cases of type 2 diabetes by the year 2025, which means we're going to head out of the US at some point. We think that the remote care model is going to be the absolute number one part of this successful scalability of this. We're already incredibly rapidly scaling, but once again, the idea of being able to bring care to patients at their schedule, and support that can be around them even when they're not in the doctor's office, right? Where they're in their after work party, when they're at ... These are the things that are going to make this successful across cultures; and again, be able to keep the personalization piece in there.

Sarah Hallberg: If we don't have that personalization, you just ... It's so central. It's like the skeleton of it, but it can be applied, again, across cultures, and across ethnicities. That, I think, is going to be what is going to be the key to successful scalability around the globe.

Brian Mowll: I love it, I love it. So, we're getting close to wrapping up here. I want to ask you three questions I ask all of my guests in just a minute, but before I do that, I'd love for you to share maybe a little bit about how people can find out more about Virta, and then I know you have some studies that are being published, or getting ready to be published, or certainly that you're wrapping up now. So if you wouldn't mind sharing some of that as well, I'd love for people to be able to find more information.

Sarah Hallberg: Sure. Information, it can be VirtaHealth.com. If your employer is not one of the employers that we are contracted with to bring Virta Health to their employees at for free or low cost, talk to your HR department, encourage them to look us up. We'd be happy to come and talk to them about how we can successfully reverse type 2 diabetes as a team.

Sarah Hallberg: As far as additional studies going, yes, we just had a paper published on the patient reported sleep outcomes in our clinical trial. An area that hasn't really been looked at, but as we all know, sleep is critical for health. So, we're pretty excited about that. We're expecting our paper on liver disease to be publishing any day now, so keep an eye out for that, because again, liver disease, as you already mentioned, one of those things that can be reversed if caught early. We've got some remarkable results on how we were able to that, and improve, again, the non-alcoholic fatty liver disease in our participants.

Brian Mowll: Yeah, such a strong link between non-alcoholic fatty liver disease and type 2 diabetes, and pre-diabetes; and again, fits into this metabolic spectrum of problems. So, that's important work, and it's amazing with the same model of practice that you're seeing incredible results with sleep, liver health, pre-diabetes, type 2 diabetes, and who knows what else. This is really exciting, really exciting stuff.

Brian Mowll: So okay, so the first question is is there a thought or an idea, or maybe a favorite quote that you have that kind of best summarizes your work, or that you want to kind of leave people with today that characterizes what you're doing?

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Sarah Hallberg: Diabetes reversal is possible. It's the responsibility of every person and every provider to understand that, and be educated in it so that decision making can be had in a team, a team based effort. Patients and their providers discussing all the options, and keeping reversal as an option for anyone who chooses to go down that route.

Brian Mowll: Beautiful, love that. What a great vision. Next question is, I'm an avid reader, I love books, and I think books change people's lives. So I'm curious, is there a book for you that you read that you feel like changed your life, or perhaps changed the direction of the way you practice, or the things that you teach, or the way you think?

Sarah Hallberg: Yeah. So I think that of all the ones that I've read, it's actually one that I was a little late to the game reading, which was 'Man's Search for Meaning.' I think that I really like that book, and it hit home in that we all have a purpose here. It's how can you make the most of it?

Brian Mowll: Beautiful.

Sarah Hallberg: Mine is patient advocate. I ... That's what gets me up every day.

Brian Mowll: Yeah, yeah. Well, I know you really put yourself out there, and you take some arrows for a lot of other physicians, and other advocates who want to push this message to help as many people as possible. Because of your position, I think unfortunately, you probably have to get up and put some shields on every day. But, I know that you're [crosstalk 00:41:14] really appreciated for that. ... Exactly. Okay, last question, and this will sort of be a slam dunk right in your wheelhouse today. If someone came to you, a friend or a family member, maybe somebody personally close to you, and was just diagnosed with type 2 diabetes, and you just had a minute to share sort of your best advice for them, what would you tell them to do?

Sarah Hallberg: I would tell them carbohydrates are again, at the root cause of diabetes. They are what cause blood sugar and insulin to rise. So if you want to get physiology on your side and make reversal of the disease possible, you need to pull back on the carbohydrates. You need to start consuming the one macro nutrient that won't cause insulin and glucose to rise, and that's fat. In a nutshell.

Brian Mowll: Yup, that's exactly, [crosstalk 00:42:08] in a nutshell. ... Pun intended, I'm sure. Okay, excellent. Well Sarah, thank you so much for being here with us. Dr. Sarah Hallberg of VirtaHealth.com. Check her out, and there's some great blogs there, by the way. Sarah's written some, and a lot of the other people involved with Virta have written great articles over there. You can learn a lot. Videos, and all sorts of resources; and watch out for those studies. So Sarah, thanks for taking the time to do this. I'm glad we finally got it done. Everybody, go check out Dr. Sarah Hallberg. Thanks a lot for being here.

Sarah Hallberg: Thanks so much.

Sarah Hallberg, DO - Diabetes Summit 2019 (Completed 05/01/19) Transcript by Rev.com Page ! of ! 12 13

Brian Mowll: All right, guys, that was Dr. Sarah Hallberg from Virta Health. I hope you really enjoyed that, and hope you're excited about some of the research that Dr. Hallberg is doing to prove out this model of using a low carb ketogenic style diet to help control blood sugar and reverse pre and type 2 diabetes, and helping to take patients off of medication. That's really exciting. To me, that's what we do with our clients. It's great to have some data to back that model up. To learn more about Dr. Sarah Hallberg, go to VirtaHealth.com, or you can just go to YouTube, type her name in, and check out her TED talk.

Brian Mowll: All right, everybody, thanks for being part of the Diabetes Summit 2019. This is Dr. Brian Mowll, the Diabetes Coach. I'll be back soon with another expert interview.

Sarah Hallberg, DO - Diabetes Summit 2019 (Completed 05/01/19) Transcript by Rev.com Page ! of ! 13 13