The Case for a Low-Carb, High-Fat Diet

Guest: Dr. Sarah Hallberg

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Dr. Diulus: Hello, everyone. I am so happy to introduce a good friend of mine,

Dr. Sarah Hallberg. She is a board-certified obesity medicine physician, a
certified lipidologist, and an exercise physiologist who teaches people to be
healthy through low-carb living. She gave an amazing TED talk a couple of
years ago about type 2 diabetes and reversing it. So, I’m really excited to have
her here today. And we’re going to dig into a lot of cool science around fats
and low carbs.
So, welcome, Sarah.
Dr. Hallberg: Thank you. Thanks for having me, Carrie.
Dr. Diulus: It’s a pleasure. So, Sarah, everybody that we’ve done this with has
had a story with how they ended up doing this work. So why don’t we start by
how did you get here today?
Dr. Hallberg: Well, my previous life, which means—I hate to say it—but more
than 20 years ago, I got my Master’s Degree in Exercise Physiology. And
during grad school I used to do obesity counseling and then decided to go
back to med school and became an internal medicine physician but always
still loved preventative medicine and my exercise and obesity background. So I
used to incorporate it into my primary care practice all the time.
And then when Indiana University Health wanted to start an obesity clinic,
they knew that that was an interest of mine so they asked if I wanted to do it.

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And I said yes. And in that process I went back to get my second board
certification in obesity medicine. And discovered low carb.
So when our clinic started, we started exclusively as a carbohydrate-restricted
clinic. And of course, our primary focus was helping people lose weight. But
really quickly, we found weight loss was a small part of what was going on.
What was really happening is that people’s metabolic disease was getting
better. Their diabetes was just going away. And I could not understand how
this was not just done everywhere. I spent all this time in primary care.
Helped people manage their diabetes.
Dr. Diulus: Right.
Dr. Hallberg: But never saw it go away. And suddenly, that was what was
happening with everyone. So it motivated me. I mean, seeing these people’s
lives improve, seeing their disease go away, seeing them off of medication is
incredibly inspiring.
So I jumped into research and went back and got a third board certification in
lipidology because this all really ties in together. Metabolic disease is not just
obesity. It’s not just diabetes. It’s all kinds of things including hypertension
and including cholesterol and lipid management.
Dr. Diulus: Fantastic. So why don’t we jump right in to some of the science of
it all and let’s talk about proteins and carbohydrates and fats, and their effect
on glucose and insulin level. So what does each of these do to our glucose and
insulin level and why are they important?
Dr. Hallberg: Well, it’s really important to first remember that there are only
three macronutrients in food, right? So everything we eat is a carbohydrate, a
protein, or a fat. And so the problem with manipulating one of these
macronutrients, like in the low fat era, is that it absolutely will have an impact
on the other two. Since there’s only three, you can’t change one without
having some influence on the other two.
And so the problem is, these macronutrients have a totally different impact on
insulin levels. So carbohydrates make our insulin levels spike really fast. And
proteins cause insulin to go up but not as much as carbohydrates. And,
really, the response with fat is flat. So when people consume fat, their insulin
levels stay low.
Well, that makes sense very clearly with diabetes because the root of the
problem is insulin resistance, which leads to elevated insulin levels.

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Dr. Diulus: So, over 50% of our population at this point—and you know these
numbers better than I do—are either prediabetic or diabetic and it just
continues to go up. And we’re talking about predominantly type 2 diabetes.
There’s a small number of type 1. There are a few other subtypes of diabetes,
but predominantly type 2, which at the root of it is insulin resistance.
Dr. Hallberg: Right.
Dr. Diulus: And so can you explain what insulin resistance is and how it
manifests as type 2 diabetes?
Dr. Hallberg: Yeah. Here’s how I like to explain insulin resistant to our
patients. So what I usually do is I say, “Okay, let’s think about it this way,
let’s think about sugaring your blood.” So presuming somebody has a normal
blood sugar, how much sugar is actually—
Dr. Diulus: Okay. So what is the normal blood sugar? Let’s—
Dr. Hallberg: Normal blood sugar would be under 100, fasting. It’s a great
question. So let’s presume you got one of those. So your blood sugar is under
100. The question then is how much sugar actually is that in your blood? Like
give that to me in something I can understand. And it’s pretty interesting and
it surprises pretty much everyone. Because if you actually do the math on
this, it really turns out to be about 5 grams of sugar in the circulation system
at any one time. And 5 grams is a teaspoon. So it’s only one teaspoon of sugar
in your circulation at any given time.
All right, so what happens after we eat? If we bring more sugar into the
system, how are we going to deal with it? Well, one of insulin’s jobs is
essentially to open doors to the cells. So the sugar can get out of the
circulation as more of it is coming in and go into cells that are surrounding
the vessels. Because if all the sugar from our diet just dumped into our blood
vessel at once, I mean, honestly, we would all die of a diabetic coma after we
ate. And, clearly, that does not happen.
Dr. Diulus: Right.
Dr. Hallberg: So as we begin to eat, our insulin levels rise. Insulin
essentially—again, I like to describe it as the key, the key that opens the doors
to the cells so that sugar can pass into them.
Well, if you are resistant to insulin, what it really is, is that the key does not fit
the lock. Our body’s smart, right? And we know that we’re not going to just go
into the diabetic coma. And so our blood sugars aren’t going to just rise and
rise and rise. So what happens is our body’s backup plan, if you will, is that it
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makes more keys. It just keeps kicking out keys and our insulin levels go up,
and they go up, and they go up. And that’s going to work. We’ll get something
to fit in the lock. And the blood sugars can stay normal for years and years.
Dr. Diulus: Right.
Dr. Hallberg: But eventually this system backfires. Because when someone’s
diagnosed with type 2 diabetes, on average, half of the cells that produce that
insulin are essentially done, dead from being overworked for so long. And so
that’s when our blood sugar starts to rise. And that’s, boom, type 2 diabetes.
So in order to keep taxing this system so much and preserve those cells that
make the insulin, we’ve got to stop throwing so much sugar or glucose into the
system.
Dr. Diulus: Got it. And so, what foods are there that increase blood sugar?
Dr. Hallberg: So, carbohydrates increase blood sugar, right? I mean everyone
acknowledges that. Even the American Diabetes Association, in their dietary
guidelines, acknowledges that carbohydrates are going to determine what
happens to the glucose. And then they go on to say that actually
carbohydrates are going to determine how much insulin you need.
Well, I don’t want to take insulin.
Dr. Diulus: Right.
Dr. Hallberg: So let’s just go back to the problem, right? The root cause of it
and say, “Then I’m not going to eat the carbohydrates.” And that doesn’t mean
the patients literally eat ‘zero’ carbohydrates. I mean, it’s basically impossible
to do that. Even if you’re eating strictly meat, you’re going to get very slight
amounts of carbohydrates. But nobody wants to eat just meat, okay? That’s
definitely not what we teach patients.
So we have low carbohydrates, very important, not zero. And carbohydrates
are found—it’s amazing…They sneak into almost everything. So in the first
week in our clinic, we teach people about food. We send them out to look up
nutrition information. And 100% of the time, the first feedback we get from
patients when they return is, “I can’t believe how many carbs are in
everything.”
Dr. Diulus: Right.
Dr. Hallberg: They sneak them in everything. But carbohydrates are also
some of our basic foods, too. Fruits are carbohydrates. Vegetables are
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carbohydrates. So they’re found all over the place.
Dr. Diulus: So, talking about vegetables and fruits, do you limit them the
amount of vegetables and fruits that your patients have when you’re trying to
reverse their type 2 diabetes?
Dr. Hallberg: We definitely limit fruits. So especially in someone who’s
battling diabetes, the fruits generally make this much worse. I mean, I always
tell people the exception is maybe a very small amount of berry fruit. But I
always tell people, “Treat it as the garnish.”
Dr. Diulus: Right.
Dr. Hallberg: Don’t treat it as the main deal. So fruit’s definitely limited.
Vegetables, we always encourage only non-starchy vegetables. And if people
are eating non-starchy vegetables with fat, it’s actually pretty difficult to
overdo the vegetables. Our rule is this: never eat a vegetable without fat. So it
should be cooked in fat. It should be dipped in fat. And that’s the proper way
to eat a vegetable.
And the fun thing about telling people that rule—because, first, they always
go, “What?” And then they come back in a couple of weeks and they say, “You
know, I really didn’t think I liked broccoli. But when I put cheese and butter
on it, lo and behold, broccoli is actually pretty good.” Or whatever the case
might be. But you really wind up increasing people’s vegetable intake, which
is fabulous.
Dr. Diulus: So a lot of people out there who have lived through the low fat
dogma, if you will, of the past what, 60 years, just had a heart attack when
you say, “Don’t eat a vegetable without fat,” right? And certainly, this is not
the recommendation of the American Diabetes Association. And yet, you’re
saying that in your clinic, you’re reversing type 2 diabetes with these
recommendations.
So let’s talk a little bit about why you’re finding conventional treatments for
diabetes to be so harmful? And why does the ADA tell patients to eat whole
grains and eat a certain amount of carbohydrates per day?
Dr. Hallberg: Well, I mean, the long and the short of it is it’s hard to change
exactly what you just said. It’s hard to change dogma. I mean, it’s going to
take somebody right admitting that they were wrong. And that’s a stretch for a
major organization.
And so, really, the problem with the way we’ve been treating really comes
down to this phobia of fat, right? I mean, the Diabetes Association
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acknowledges carbohydrates are going to determine what happens to blood
sugar and the need for insulin. Okay, great, we can all agree on that. But
getting people to restrict carbohydrates, right, without increasing fat just can’t
happen, right? I mean, what are people supposed to eat, right? And so the
idea of people who say, “Well, I tried that. I tried restricting my carbohydrates,
I didn’t feel good.” Well, did you try to increase your fats, right? And so that’s
kind of the key. But it’s also the barrier because people have been phobic of it.
I mean, we have really programmed our entire society to feel like fat is the big
enemy.
But if we go back to that basic physiology of insulin, right? And we remember,
okay, carbohydrates cause our insulin to go up; and proteins, it goes up but
not as much; and fat, it’s flat. Wait a minute, fat’s not the enemy. Especially
when it comes to any metabolic disease, fat is our best friend. It is going to
keep insulin levels low when it’s really driving our big epidemics of diabetes
and obesity.
So fat, fat on your vegetables, right? Fat all the time. Our patients eat mostly
fat. When we look at the breakdown of the three macronutrients, I recommend
to patients to get at least, at least 50% fat.
Dr. Diulus: So you’re, again, an obesity specialist. You treat diabetes and
you’re recommending at least 50% fat.
Dr. Hallberg: Yeah. Actually, I’m also a lipidologist, right? So I’m treating
cholesterol with fat.
Dr. Diulus: Right. Which, again, like goes against everything that we learned
in medical school.
Dr. Hallberg: Right, right. But again, we go back to some of the basic
physiology. And that’s what I love about teaching my patients. Because the
funny thing is, my patients get it.
Dr. Diulus: Right.
Dr. Hallberg: You explain it to them. And they’re like, “Oh yeah, that makes
sense. Okay, great.” And then we learn the practical parts of it. But so why
that can’t extend to everyone, right? Okay, it makes sense, yes. Then, let’s do
it.
Dr. Diulus: Got it. So some of the things that we hear as pushback against
this, not looking at the outcomes but looking at the philosophy of it, if you
will, is that, well, type 2 diabetics have a lot of fat stored in their muscles and
that they can’t access that. And if they’re eating more fat, then they’re actually
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not going to be metabolizing fat that’s in their muscles and they’re just going
to lose muscle as a result of this.
So are you guys doing body composition testing on your patients as they’re
losing weight using these principles?
Dr. Hallberg: Absolutely, yes. So we do body composition on everybody in our
clinic at baseline. And then we do it every two to three months because, you’re
right, it’s important that patients lose. But it’s important that they’re losing
the right thing, right?
If we bring a patient in and they lose 100 pounds and 75 pounds of that was
muscle, I didn’t help them any. So it’s incredibly important as a physician
taking appropriate care of the patients that we can assure that when they’re
losing, they’re losing from the right place.
But going back to that whole fat in the muscle thing, that’s probably the root
cause of insulin resistance, and fatty acids…And the big core problem here is
not necessarily that fatty acids in the blood are a good thing. But how did they
get there, right?
Because let’s face it. You eat fat. It becomes fat in your blood. And that seems
to make a lot of sense, right? But it’s actually not what happens. And the
interesting thing is carbohydrate overconsumption not only increases the fat
in our blood, but—and this is something a lot of people don’t know—it
increases the saturated fat in the blood. So we make saturated fat when we
overconsume carbohydrates.
And it’s these things that kind of, again, it flies in the face of what seems to
make sense. “The saturated fat in our blood is coming from our saturated fat
that we’re eating.” Well, actually, that’s not what the science says. So just
because it seems to be true doesn’t make it true. We have to go back with
what are our studies showing us? What is the science saying?
Dr. Diulus: …so is the cholesterol in eggs making our cholesterol go up?
Dr. Hallberg: No.
Dr. Diulus: And do we care what our total cholesterol is?
Dr. Hallberg: No.
Dr. Diulus: Okay.
Dr. Hallberg: Total cholesterol and LDL-C, I tell patients, that’s about as

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helpful to me as what your hair color is as far as your risk goes. So that’s not
going to impact my treatment decisions, neither is total cholesterol or LDL-C.
What really matter are other biomarkers. And we’re finally starting to get a call
in the lipid community for a change on this. I’m so pleased to see it.
In the last month alone, there were two big papers that came out about this
that said, Stop—again, going back to this dogma, right? But why is an LDL-C
good? That’s what we’ve always measured. Well, just because we’ve always
measured it, doesn’t mean it’s the biomarker that tracks with risk. And so
what we want to see is their particle number, what’s called apoB or LDL-P.
Dr. Diulus: So just for our listeners, LDL-C is the typical LDL that we see on a
traditional cholesterol panel, and that’s a calculated value.
Dr. Hallberg: It’s not even real. It’s calculated.
Dr. Diulus: Got it. And so what are the problems with using that as a marker?
Dr. Hallberg: So what happens if we use LDL-C as a marker is we get hidden
risks. So that’s what I talk to my patients about all the time. So our patients
will come in, right, and they have type 2 diabetes and their LDL-C, that typical
LDL number we see…
Dr. Diulus: Right.
Dr. Hallberg: …oftentimes is at goal, right? So it’s 70, say, because that would
be considered goal by everybody. So their LDL-C is 70, fantastic. But what we
find because of the diabetes is that LDL cholesterol is being carried in way too
many particles. So in other words, the LDL-C tells us essentially about the
cargo. Like what’s in the trunk, right? So an LDL-C of 70 means, okay, that’s
how much cholesterol is being carried in all of the particles, the lipoprotein
particles, in a deciliter of blood.
But the total cargo is not what’s important for risk. It’s actually the vehicle
that the cargo is being carried in. So 70 can be carried in a bunch, many,
many little VW bugs, right? All these VW bugs can carry a cargo of 70. Or you
can have a couple of buses, right?
Dr. Diulus: Right.
Dr. Hallberg: Now the 70 can be same, but the risk is very different. Because
when we have a lot of small lipoprotein particles or our LDL-P is high, that’s a
high-risk situation. If we’re carrying the exact same amount of cargo in a
couple more buses, so the LDL-P or particle number is low, hey, we’re good.
The problem is the mark of diabetes almost always is the VW Bug.
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So diabetes means that the LDL cholesterol is being carried in these small and
plentiful vehicles. And so we’ll see that patient come in with that LDL-C of 70
but their LDL-P is through the roof. They have hidden risk.
Dr. Diulus: And with small particle size. So you look at both the particle size
and the total particle number, correct?
Dr. Hallberg: The total particle number. Correct.
Dr. Diulus: Got it. And so what is this test called? How do you get your doctor
to order this test? And what do you tell the person if their doctor says, “I don’t
know what that test is. All I know is just to order the cholesterol.” Like how
prevalent is this test? Like this is a big thing.
Dr. Hallberg: Okay. It’s becoming much more prevalent. And I am working
hard to teach other doctors that this is the appropriate test to order. Like that
this is my hill to die on right now. Because, again, we’re just not controlling
our patients’ risk well. But this test is called two things. You can order two
different tests and get an appropriate assessment.
Something called an NMR, that’s the easiest way to remember it, or more
commonly often seen as something called an apoB. and so what we’re looking
at in those is being able to determine how many particles again are carrying
our LDL cholesterol. So if your physician says, “I don’t know.” I mean,
honestly, if you’re someone who’s insulin resistant—okay, like we know that’s
anyone with type 2 diabetes. We know that’s anyone with pre-diabetes.
Of course, it extends beyond those two categories. And if we really look at the
pie chart of our country right now and we talk about adults, it’s probably over
75% of adults are insulin resistant. And so if you’re one of those people, you
cannot appropriately assess your risk with a standard cholesterol panel. You
need to actually be looking at the particle number or the apoB number.
So let me just, really quick, go back and say, “Well what is the apoB?”
Because we talked about the LDL-P, what’s the difference? apoB, LDL-P. Well,
each of those lipoprotein particles, right—we’re worried about the number of
particles—each one of those has wrapped around it something called apoB.
It’s the protein.
So when we talk about lipoprotein, lipo is the lipids; protein —well, the lipids
are the cholesterol and the triglycerides and phospholipids. And the protein,
one of them, is an apoB. So any potentially problematic lipoprotein particle
has an apoB and only one wrapped around it. So measuring the apoB is
essentially another way of looking at how many problematic lipoprotein
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particles are there or how much is the LDL-P.
Dr. Diulus: And if you find out that your lipoprotein particle number is high
or your apoB is high and it’s small particle sized, from a dietary standpoint,
it’s a little bit scary to think about going on a higher-fat, low-carbohydrate
diet. So what are you seeing, clinically, happen to people’s lipid profiles when
they make the shift?
Dr. Hallberg: So here’s the thing, cholesterol medication statins, right? They
do a wonderful job of lowering LDL-C. And for many patients, they are going to
need to have a statin on board to appropriately manage their risk. The
problem with just taking that view of it is kind of like looking through, okay,
I’m not looking at anything else, I’m just looking at this one thing, everything
else doesn’t matter.
Dr. Diulus: Right.
Dr. Hallberg: If we take that kind of a view of the situation, we miss the fact
that the statin medications don’t do as good of a job of changing the vehicle.
Dr. Diulus: Right.
Dr. Hallberg: Right? So they are lowering the cargo but they’re not doing as
good of a job of changing the vehicle. And the interesting thing is, when we
go—
Dr. Diulus: So they are not shifting from the small particle to the big
particles?
Dr. Hallberg: To the big ones, right. And what we know and what we have
seen in study after study—it’s not just one, it’s not just two, it’s multiple
studies—have shown us that a low-carb, high-fat diet can actually switch us
from these small VW particles into the big buses, right? And by changing the
vehicle what happens very often is that the total number of these particles
won’t actually drop. People always presume, “Oh my goodness, if I eat fat, my
cholesterol is surely going to go up.” And really, that does not happen most of
the time.
Now, again, occasionally I’ll say someone will have their cholesterol go up but
that is the minority of the patients. And so, therefore, statins still play a role
in here for some people.
Dr. Diulus: So there are also some studies on people who have epilepsy
who’ve been put on ketogenic diets. And initially, some of them, they saw a
spike in their LDL particles, their LDL-C, and an increase in their total
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cholesterol. But then interestingly, at two years and three years on these
people who had to be on this diet to control their seizures, their lipid profile is
normalized.
Dr. Hallberg: Well, we see that all the time in our clinic. And so one of the
things is when people restrict fat, even if it’s for epilepsy, even if they weren’t
overweight to begin with, people do generally lose some weight, okay? Whether
they mean to or not, it just happens. And where is our body’s biggest
cholesterol stores? I mean, our body’s biggest cholesterol stores are in our fat
cells. And so when we’re losing fat, what we’re doing is we’re mobilizing it,
right? And so we’re mobilizing these cholesterol stores.
Dr. Diulus: Whenever we lose fat.
Dr. Hallberg: Right, right.
Dr. Diulus: And however we lose it, right.
Dr. Hallberg: Exactly. So for some people, that causes their cholesterol to
temporarily rise. And when their weight plateaus, again, we see it get better.
Dr. Diulus: Which is in anorexics, we can actually see people who have
elevated—even though they’re taking in limited amounts of food but they’re
rapidly losing weight. We can see those elevated things.
Dr. Hallberg: Absolutely.
Dr. Diulus: Which, again, is counter to what we’re thinking. So when we’re
looking at all of these things and statins, do you feel that statins are being
overprescribed? Or what are the rules for statins?
Dr. Hallberg: Yeah. So there are definitely rules for statins. Do I think they’re
being overprescribed? Absolutely. But let me kind of clarify that remark, right?
I mean, the fact of the matter is that the reason that we’re overprescribing
statins is we’re not treating people’s problems the more natural, if you will,
way. So according to all guidelines, for example, anyone who has type 2
diabetes should be on statin medication if they’re over the age of 40, right?
That’s an awful lot of people.
Dr. Diulus: And let’s just stop there, because isn’t there an association with
statins and increase in the risk of type 2 diabetes?
Dr. Hallberg: Right. So what’s my favorite way to pull someone off of statin if
they’ve been put on it because, “Hey you have to because you have diabetes.”

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Dr. Diulus: Right.
Dr. Hallberg: My favorite way to pull someone off of statin is for them not to
have diabetes anymore, right?
Dr. Diulus: There you go.
Dr. Hallberg: I mean, that’s it. So they’re overprescribed because we’re not
treating things the appropriate way. And yes, I mean statin medications have
been shown to increase diabetes risk by 46%. So we have to take these things
seriously. And I think my frustration with statins is this, people go into their
doctor. Their doctor looks at their chart and says, “Oh your cholesterol,” and
they’re going by the LDL-C, “Your cholesterol is high, you must be on a
statin,” right?
And the conversation isn’t really happening. I mean we just knee-jerk do this.
And we say, “Well, I’ll give you six months to bring your cholesterol down on
your own.” And then the patient left going, “Well, how do I do that? I better not
eat cholesterol, right, or I better restrict my fat to do that.” And that’s not the
answer, almost ever. And so what we do is we just feed this vicious cycle of
needing more and more and more medication.
Dr. Diulus: Yeah. And it’s an issue. I mean, statins are not benign drugs. I see
it all the time in my clinics because people were referred to me for pain. And
it’s not uncommon that statins cause muscular type pain. And it’s assumed
that it’s coming from their spine.
And then I’d get an MRI and there’s not a whole lot of compression of nerve
roots. And I take people off of their statins. I mean, I have to say, when I was
firs doing that, here I am an orthopedic surgeon saying, “Alright, I know your
cardiologist put you on a statin but I think it’s causing your pain, why don’t
we try a statin holiday for just a week or two.”
And that’s part of—I was already doing a lot of nutrition stuff with my patients
already but it was that fear. And I think this is one of the things that is the big
barrier for people like, “Gosh, if I take this person off of statin, are they’re
going to like a week later have a heart attack and I’m going to get sued?” And
that just doesn’t happen.
Dr. Hallberg: No. I mean so what you were doing right is going against the
grain and getting good outcomes, right? And that’s just it.
Dr. Diulus: And the pain goes away very quickly…
Dr. Hallberg: Very quickly.
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Dr. Diulus: …when people stop the statins.
Dr. Hallberg: Very quickly, right. So I mean I’m not saying they’re not
appropriate for some patients. But I am saying that we’re putting too many
people on them for reasons that we can control otherwise.
Dr. Diulus: So when you see somebody in your clinic who’s type 2 diabetics
and obese, how quickly do you see their diabetes improve?
Dr. Hallberg: Oh, days. It is not unusual for us to get patients off 100 units of
insulin in a couple weeks.
Dr. Diulus: Wow.
Dr. Hallberg: That is a pretty par for the course day for us because it’s
amazing. Again, going back to that what causes blood sugar to go up?
Carbohydrates. When you begin to restrict the carbohydrates and you
increase the fat, it doesn’t take your body months for that. That happens right
away. And so it’s fantastic and this is joyous for patients obviously, right?
Dr. Diulus: Right.
Dr. Hallberg: And then it feeds on itself, right?
Dr. Diulus: Yeah, because insulin is expensive.
Dr. Hallberg: Oh my gosh, I’m motivated. And I’m saving myself money. The
real sad fact of the matter is a lot of patients come into our clinic and their
goal isn’t necessarily health, I mean because they can’t even see that far in the
distance. Their goal is I can’t pay for the medication anymore. I can’t afford it,
right? And so to be able to pull somebody off somebody’s expensive medication
is as joyful on many levels.
Dr. Diulus: So you guys have some data on 70-day outcomes on patients. You
want to talk a little bit about the data you’ve published?
Dr. Hallberg: Sure, sure. So we’re in the middle of what’s going to be the
largest and the longest trial looking at type 2 diabetes and low-carbohydrate,
high-fat nutrition intervention as a treatment for this, right? And so what we
have is we have 500 patients who have type 2 diabetes or pre-diabetes. And
100 of these patients are being treated with our typical ADA approach. And
then 400 of them are being treated with a low-carb, high-fat approach with the
goal of getting patients into a nutritional ketosis. And the results are pretty
remarkable.

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Dr. Diulus: Let’s talk about that just for a second. What do you mean by
nutritional ketosis? I think we should define that.
Dr. Hallberg: Absolutely. So nutritional ketosis means that you’re restricting
carbohydrates enough and increasing fat that you have elevated levels of
ketones in your blood. The one that we’re looking for specifically is the ketone
called beta-hydroxybutyrate.
So if we prick your finger, right, and we check your blood just like you would
be checking your blood for your blood sugar. And we happen to see that you
have elevated levels of beta-hydroxybutyrate, which is the ketone, that is proof
positive that you’re using fat for energy, right? And so as these levels go up,
because we’re restricting carbs and increasing fat, which is what caused these
levels to go up, it’s because we’re utilizing more fat for energy.
So going into nutritional ketosis is really essentially, if you restrict your carbs
enough over a period of five to seven days, what happens is that you literally
switch your metabolism. So we start out with a carbohydrate-based
metabolism, meaning that we are getting most all of our energy from
carbohydrates. But if we’re restricting them, our body can’t go without energy.
So it switches over to getting energy from fat, both the fat that we eat and the
fat that we have stored, which of course is a wonderful thing for anyone who’s
trying to lose weight.
And so the goal of our study is to get patients in to the state of nutritional
ketosis because then they’re burning fat. And it’s been shown to be very
helpful in blood sugar control. And I shouldn’t say control, I just caught
myself saying it—not control, making it normal resolving the diabetes. And
this is exactly what our study results have panned out to show.
Dr. Diulus: Fantastic. And you’re seeing them very, very quickly. And looking
at some healthcare dollar costs, in that people are coming off of significantly
expensive medications.

Dr. Hallberg: Significantly expensive medications. So it doesn’t—again, so

when we presented some of our early data at the National Lipid Association
this spring. And this is 70-day data. And for anyone who has diabetes and
regularly follows their A1c, you know that 70 days doesn’t even cover a whole
A1c cycle, if you will, because an A1c is what’s been happening the past three
months.
Dr. Diulus: Right.
Dr. Hallberg: So 70 days should be elevated, right? If we’re looking at 70 days,
© Fat Summit 2. All rights reserved. 14
it’s not a whole cycle. We should still have some of the blood sugars from
earlier on. But in 70 days alone, we are seeing dramatic drops in A1c, 0.9.
Which a 0.9 drop in an A1c is impressive, but this is a drop while we are
removing medicine.
Dr. Diulus: Wow.
Dr. Hallberg: Not adding more.
Dr. Diulus: So are you seeing people who struggle with—one of the things that
docs get a little bit concerned about is, okay, you put somebody who’s on one
of the sulfonylureas on a low-carbohydrate diet, are you seeing patients who
are getting into trouble with hypoglycemia?
And how are they knowing when to go off of these medicines or their insulin
where they don’t necessarily—as a type 1, I adjust my insulin based on what I
eat and what my blood sugars are literally like every minute of every day, 365.
But for somebody, a lot of my type 2 patients are like, “I don’t know, they told
me to take 40 to 60 units of Lantus in the morning and 70 units in the
evening. And I take 30 units of Humalog every meal,” which these numbers
are just like really high. But this is what people are on.
Dr. Hallberg: Oh, yes.
Dr. Diulus: Yeah. And they never adjust it. They just give themselves that
same dose every day. So when you’re getting them off of these higher-
carbohydrate diets, is it tricky to transition people off without having them get
into trouble with hypoglycemia?
Dr. Hallberg: You have to know what you’re doing, right? I mean, this is key.
And I mean, this is my area of expertise is I’ll look at someone’s lab, we’ll talk
about their blood sugars. And the day they start making dietary changes, I’ve
already adjusted their medications, like we preemptively do it.
So this is a big warning for everyone who has diabetes if they’re on insulin or
sulfonylureas. I mean it’s really important that you’re followed by a physician.
A physician who knows what they’re doing in removing people from medicine.
And actually that sounds like, okay, any physician could do that, right? I
mean any physician could take away medicine. But in medical school you
learn one thing, you learn how to put people on medicine.
Dr. Diulus: Right.
Dr. Hallberg: Nobody ever teach you how to take people off of it. So actually
it’s something that you have to know something about. So I mean we have a
© Fat Summit 2. All rights reserved. 15
great track record. I mean, in our study, we’ve had no complications. And in
our clinical practice the same thing. But that’s because we are on top of it. We
are very, very vigilant about it. You have to be.
Dr. Diulus: Well, and that’s one of the things that’s surprising to me, is how
many type 2s who are on insulin? When I see them in my office I’ll say, “Well,
pull out your meter, let me see what your readings have been.” And they’re
like, “I don’t have my meter with me.” And I’m like, “You just got out of the
car. And you’re on insulin and you don’t have your meter with you.” And it’s
surprising how many people, as they’re coming down, feel low with a blood
sugar of a 120.
Dr. Hallberg: Oh, absolutely.
Dr. Diulus: So can you talk a little bit about that. Because I’m sure there’s a
lot of type 2 folks who are out there who are listening to this and who may be
wanting—maybe they don’t have support of their doctor, which is a little bit
tricky. And how do you respond when somebody’s blood sugar when they feel
low and they’re in the 120s versus if they feel low and they’re say, 80 or 50?
Dr. Hallberg: Right. So it’s really common. That happens in our practice all
the time. So someone’s been used to running 250 all the time.
Dr. Diulus: Right.
Dr. Hallberg: Right? To their body, I mean 120 is like half that, more than
half that drop. So I mean, of course, they’re going to feel low. So those people
we want to decrease slowly, right. We want them to be in the normal range.
But what they’re experiencing is called relative hypoglycemia.
So they’re not really hypoglycemic. Their blood sugars are normal or even a
little bit elevated. But their body is just not used to that and so they’re feeling
those effects of being hypoglycemic. That will go away. And people wil l feel so
much better at 120 than they did at 250. And then they’ll feel even better yet
when their blood sugars are under 100. But you can’t just drop them
overnight.
Dr. Diulus: Right, right. So talking about nutritional ketosis, how do we define
when we’re in ketosis? And do you see that there are people who struggle to
get into ketosis?
Dr. Hallberg: Yeah. And everybody is a little bit different, right? I mean we
always have to say that about every patient and, honestly, only because it’s so
true.

© Fat Summit 2. All rights reserved. 16

Dr. Diulus: Right.
Dr. Hallberg: And so the generally accepted, where are if you’re on nutritional
ketosis is a beta-hydroxybutyrate, that ketone level above 0.5 millimolar. And
then for nutritional ketosis that, we say patients go up to about 3. We almost
never see anybody go above 3. So it’s 0.5 to 3.0.
Dr. Diulus: In a type 2 diabetic.
Dr. Hallberg: In a type 2 diabetic, right. Now, do we have some patients who
never get to 0.5, right. I mean the best they could ever do is 0.3. Does that
mean that they’ve somehow failed this? And the answer to that is no. The
ketones are a marker that helps us, right? It’s not the end-all be-all marker.
What is the end-all be-all marker? How do you feel? Are you accomplishing
your goals? Are you losing weight? Are your blood sugars normal? Well, you’ve
rocked it then.
And in fact, as far as checking ketone levels go, other than research, I almost
never have anyone check their ketone levels. I just ask them the important
questions, what’s really important. Are you feeling good? Are you losing
weight? Are your blood sugars becoming normal? Are we getting you off
medications? And if the answer to all those questions is yes, fine, you’re good.
On occasion, we’ll still need to check ketones in someone who we’re
troubleshooting, really. We’re troubleshooting.
Dr. Diulus: So one of the interesting things that’s come up over the Fat
Summit in talking with the different experts and, specifically, some issues that
women have had with this. And I don’t know if you’re seeing this in your
clinics as much as I am seeing, sort of middle-aged women with their
perimenopausal or postmenopausal, and they’re doing the ketogenic diets.
And they’re doing it when you take somebody who’s hardcore low-fat calorie-
counting and they’re doing it to the T. And their blood sugar, their fasting
blood sugars in the mornings tend to stay high even though they’re actually
not—their A1c may be 5.5. But they’re seeing these 110s, 106s as their fasting
blood sugars and they’re not losing weight to the extent that they’re wanting.
Are you seeing that there are sort of cortisol levels that are going up in some
people related to ketosis? Or are there different issues with women?
Dr. Hallberg: We don’t see it in women, per se.
Dr. Diulus: Okay.
Dr. Hallberg: I mean there can be with other people. The fasting blood sugar
is a bad marker.
© Fat Summit 2. All rights reserved. 17
Dr. Diulus: Okay. Let’s talk about that.
Dr. Hallberg: Fasting blood sugar is a bad marker. And I draw this little graph
out for my patients and I’ll talk about, okay, someone who’s eating carbs, we
have these spikes—these peaks and these troughs all day long with their
blood sugar.
And what we see in someone who’s following a proper low-carb, high-fat diet is
that instead of these peaks and troughs, what we see is that we see this start
a little bit higher on one end of the graph and then a slow like decline through
the day. And so unlike when someone’s eating carbohydrates with the peaks
and troughs—the trough is the fasting in the morning, right? It’s the lowest.
But in people who are on a low-carb, high-fat diet, the fasting often is the
highest blood sugar the whole day.
Dr. Diulus: Okay.
Dr. Hallberg: And that’s two reasons for that, right? Two reasons for that.
Number one is that if they’re doing it properly, their insulin levels are low. And
so overnight, insulin generally shuts off what is called gluconeogenesis. So
their liver makes insulin overnight. That’s how we all fast successfully when
we sleep. We’re fasting for eight hours overnight.
But our blood sugar doesn’t go to sugar because our liver is constantly
making some. Elevated insulin levels shut off that production. So if someone’s
insulin level is low because they’re doing low-carb, high-fat properly, we could
still have that churn of the glucose overnight. And then we have a cortisol
surge. Everybody’s cortisol surge is in the morning, right?
Dr. Diulus: Right.

Dr. Hallberg: And so that probably is creating some of it. To be perfectly

honest with you, this has not been well studied. So a lot of this is speculative,
right? And it needs to be well studied. But because one of the other interesting
observations is that if people can get their ketones high enough, this is what
we see. So we’re not talking above 0.5. We’re maybe talking 2. If people’s
ketones are running 2 then even their fastings are low.
Dr. Diulus: Got it.
Dr. Hallberg: I am going to stress that this is an observation that I see.
Dr. Diulus: Right.

© Fat Summit 2. All rights reserved. 18

Dr. Hallberg: This is not from a study, anything like that. This is a question,
an observation in someone who does this all the time with patients, and
something that we really need to focus on studying.
Dr. Diulus: So the shift, from this a little bit, back to what specifically to eat.
So if we’re talking about fat with our vegetables and fat, what kind of fats are
we talking about? Are we talking about seed oils and vegetable oils? Are we
talking about saturated fat? What are your thoughts on the different fats and
where should we be going?
Dr. Hallberg: We’re talking about any naturally occurring fat. I mean that’s it.
If the fat is naturally occurring, then you’re golden, right? So like what is an
example of a naturally occurring fat? Olive oil. How do you get olive oil? You
squeeze an olive.
Dr. Diulus: Right.
Dr. Hallberg: That’s natural. That’s very natural, right? That works, right?
Some of the nut oils, right? They can be good. Avocado oil, these are coming
from natural sources, right? Vegetable oil, I discourage patients from using
vegetable oil. It’s very highly refined, right? If you actually watch a video on
how they make these vegetable oils, there’s nothing natural about it.
So it’s a very easy rule. Naturally occurring, you got it. Because our trans fats,
these processed trans fats, you’re not going to get in a proper low-carb, high-
fat diet anyway because they’re only found in processed foods, which we’re not
going to be eating anyway. But a naturally occurring fat, let me stress, is also
a saturated fat, right? I mean, heavy whipping cream, by itself or made in the
butter, is a saturated fat and is an unbelievably wonderful source of fat on a
proper low-carb, high-fat diet, same thing as fat from meats.
And people always think like, “Okay, well the fat from meat is all saturated fat
or fat from any of these sources is just saturated fat.” But if you actually look
at it, like take a piece of meat, yeah, there’s saturated fat in it too and there’s
monounsaturated fat and there’s polyunsaturated fat, right? We confuse these
things and simplify it too much. But the easy way is just to say if it’s a
naturally occurring fat, eat it.
Dr. Diulus: And so what are the problems that happen with eating these
unnaturally occurring fats. Because we’ve all been—the corn oil and the
safflower oil and the sunflower oil and all those things that were the healthy
oils that were in the grocery store.
Dr. Hallberg: Right.
© Fat Summit 2. All rights reserved. 19
Dr. Diulus: What are the issues?
Dr. Hallberg: Yeah. Inflammation, I think, is the root cause in women. What
we’ve seen in some studies is that some of these refined vegetable oils are
associated with higher risks of cancer. I mean, eating vegetable oil is going to
probably bring down your LDL cholesterol, right.
But if you die from something else, you don’t really care what you’re LDL
cholesterol was, right? I mean, we have to look at the total mortality from
these things. That’s what really matters. And so bringing down your LDL
cholesterol, doing something that may otherwise be bad for you just because,
again chasing, this number is not a really smart way to do it.
So I like talk to our patients. I mean one of our big lectures that we have in
our clinic is, okay, I understand fat right. By the time our patients come into
the fat lecture I call it, right? They get it. They understand the physio logy.
They are all over that. And then what we say is, “Okay, so what does that
mean for lunch,” right?
Dr. Diulus: Right. That’s what I was just going to ask. Like what is a typical
day like?
Dr. Hallberg: Right. So how do you eat 70% fat, right? Someone will go, “All
right, I’m trying to eat 70% fat.” And all they see is that they have to lick
butter for that. Like the only way is if I just sit and chew butter all day. And I
always go through this whole example, right?
So if you take 6-ounce rib eye for example, right? That’s a pretty good amount
of steak. All right, take a 6-ounce rib eye and you take a cup of broccoli. And
then because you’re working on fat, right, you know the rule. You never eat a
vegetable without fat. You put two tablespoons of butter on the fat. And so
then people look at that—
Dr. Diulus: On the vegetable.
Dr. Hallberg: Excuse me, did I say butter on the fat? See, I’m very fat—I’m
thinking of fat all the time. You put two tablespoons of butter on your broccoli
because broccoli is better with butter. Trust me.
Dr. Diulus: I’m taken.
Dr. Hallberg: Yeah. You think of this and you say, “Okay, well that’s a very
heavy protein meal,” right? I mean there’s no way I’m going to get the fat I
need because I’ve got this big meat, right? Okay, yes there’s a lot of protein in
that. But if you actually did the math on it, what it winds up being for that
© Fat Summit 2. All rights reserved. 20
meal there is 42 grams of protein, 60 grams of fat. But then if you’re thinking
about the percentage and you say, “Well, my fat’s still not high enough.”
You’ve got to remember, when we’re talking about the percentage, we’re
talking about calories.
Dr. Diulus: Right.
Dr. Hallberg: So we’re multiplying the proteins by 4 and the fats by 9. And lo
and behold, that is a wonderful meal, right? And I’m just going to point out
that, that meal has meat in it, right? And so meat can be something that you
can enjoy. But one of the other things is people—and I kind of said this at the
beginning too and I think it’s worthy of repeating, is that people perceive a
low-carb, high-fat diet as meat centric, right? “Oh well, I just got to eat all this
meat all the time.”
And I will tell you I’m not a big meat eater myself, personally. And I’ve been in
nutritional ketosis for years now. I enjoy meat. But there are plenty of days—
and days can go by where I don’t even eat any. We have tons of vegetarians in
our program.
Dr. Diulus: Okay. So what does that look like? Without meat, what does your
day look like?
Dr. Hallberg: What does my day look like? So honestly, if I’m working, my day
almost always starts out with low-carb mousse, okay, which I might actually
have at the beginning of the day and at the end of the day. So I make mousse
out of Mascarpone cheese and heavy whipping cream and with like some
vanilla extract and just a splash of a sweetener in it.
Dr. Diulus: And what sweeteners do you allow?

Dr. Hallberg: So xylitol is the one that we often encourage. Sometimes our
patients will use just a squirt of stevia for example. It doesn’t take much. My
taste has changed.
Dr. Diulus: Yeah.
Dr. Hallberg: So I don’t need a lot of sweetness in this mousse.
Dr. Diulus: I make a mousse with an avocado instead of this, since I can’t do
dairy. I use the avocado and it—
Dr. Hallberg: Yeah. You can make it with an avocado. Absolutely. Right. So I
make that mousse and I whip it up like I put it in the mixer and I whip it. And
so with a container of Mascarpone and a couple cups of heavy whipping
© Fat Summit 2. All rights reserved. 21
cream, that lasts me for breakfast for the entire week.
Dr. Diulus: Got it.
Dr. Hallberg: I just have a little bit of it in the morning. It’s a great way to kick
start. I mean it’s essentially just fat. And it gives me like a super energy and
then I am not hungry. Sometimes I eat lunch. Sometimes I don’t. It depends
on how busy I’ve gotten that day. But I don’t need to eat lunch because I’m
starving. Because that fat breakfast will satisfy me for a long time.
But if I eat lunch, it’s always a salad, essentially. I eat some sort of a salad for
lunch. And again, remembering the rule, never eat a vegetable without fat, I
put olive oil on my salad. And I encourage patients that if they like ranch
dressing or blue cheese, use it. But additionally add olive oil to it, because
we’re really trying to go fat heavy. So salads can be, believe it or not, can hit
that over 50% mark really easily if you’re dressing it properly.
Dr. Diulus: Right.
Dr. Hallberg: And then for dinner, it depends. Sometimes we just have veggies
with fat. I mean that’s not an uncommon thing in our house. I eat a lot of
hemp too.
Dr. Diulus: Okay.
Dr. Hallberg: Hemp seeds. So we may have veggies and hemp rice. That’s a
pretty typical dinner for us. You can make rice out of shelled hemp seeds. It
tastes just like regular rice.
Dr. Diulus: Really?
Dr. Hallberg: Yeah. It takes just like regular rice. So the shelled hemp seeds,
we cook up with a little maybe chicken stock or white wine or something and
serve them with veggies. I mean that is not an uncommon thing. And then
sometimes we’ll have meat. Our family’s favorite meat is lamb. We eat a lot of
lamb.
Dr. Diulus: Yeah. Lamb is my favorite meat.
Dr. Hallberg: Yeah. But it’s not an everyday thing either.
Dr. Diulus: Got it. So the hemp seeds, I’ve never done that. I’m going to have
to do that. I make rice with cauliflower.

Dr. Hallberg: You know what, I have an entire lecture on hemp, like a set. I
would tell every patient, when they come in, “Okay, there’s a lot of new foods
© Fat Summit 2. All rights reserved. 22
here for you to try but there’s only one food I absolutely want everybody to try.
Everybody has to try hemp,” right? So hemp is like this brilliant food. You can
have toasted hemp seeds and you put them on your salad. It increases the fat.
It’s got what’s considered the ideal ratio of omega-6 to omega-3s. They’re
unbelievably universally appealing. They’ve got this great nutty flavor to it.
And then the ones that are shelled that are crunchy, again, I make rice out off.
I make hemp cereal. I like to eat hemp on everything.
Dr. Diulus: There you go. So to change away from that just a little bit, one
sort of final question here, what about bariatric surgery?
Dr. Hallberg: Bariatric surgery has a place. It has a place in our society. It
just doesn’t have a first place in our society, in my mind, right. So we resort to
it without helping people appropriately, right? I mean, so many patients would
go straight to surgery because they have this feeling of hopelessness, right?
“Nobody’s helping me. It’s the only that I can get better,” right?
And then that’s just not true. So the fact is we acknowledge that bariatric
surgery can reverse diabetes. But again, what we see in our clinic is that so
can appropriate nutrition intervention. It’s just that the appropriate nutrition
intervention is different than what we’ve been telling patients for decades.
So it’s got a role. It just needs to be a lower role. It needs to be more of a last
resort. And I’m very concerned that now that it’s being pushed in the
treatment guidelines, that what we’re going to do is have a knee-jerk reaction
just like we have to everything else and send everybody for surgery. And you
know what, not only are we going to have complications from that, we flatly
are going to go broke. We can’t afford it. We cannot afford it. We have to start
getting smart.
Dr. Diulus: Fantastic. Well, thank you so much for all of this. Is there—
Dr. Hallberg: Absolutely.
Dr. Diulus: If people are interested in hearing more from you or working with
you, how should they contact you? Where are you available?
Dr. Hallberg: Well, actually, I’m only seeing patients in the clinic at IU. I wish
I did telemedicine or something. We’re just not set up for that at Indiana
University right now. So I have a clinic here in La Fayette, Indiana.
Dr. Diulus: And do you see out-of-town patients?
Dr. Hallberg: I do. We do see a lot of out-of-town patients.

© Fat Summit 2. All rights reserved. 23

Dr. Diulus: Fantastic. Well, is there anything else that we didn’t talk about
today that you would like the audience to know about fats and low-
carbohydrate diets?
Dr. Hallberg: Eat it. Eat fats, right. And low-carbohydrate diets, again, are
just an incredibly important tool in our armamentarium to help patients. And
there are tools that need to be promoted from the bottom of the rankings up to
our first line for these metabolic diseases, because patients get better.
Dr. Diulus: Yeah. So one last question that I have to ask is, can people overdo
it on the fat, where they eat so much fat that they’re really not losing weight or
not reversing their diabetes?
Dr. Hallberg: Yeah.
Dr. Diulus: Save the tricky question for last, right? Yeah.
Dr. Hallberg: No, no. I just have so many funny stories to go along with that
question. I’m in my mind trying to come up with my favorite funny story. So, I
had a guy once, I’ll tell you, you can overdo that, right? If you’re overdoing fat
though, what you’re doing is your breaking the cardinal rule of mine. The
cardinal rule is eat when you’re hungry, don’t eat when you’re not. So I had a
guy once come in who said, “I don’t understand, it’s not working, I’m not
losing any weight.”
So of course we go back to the first question, which is what are you eating
then tell me about your diet, right? He’s like, “Oh, I really like that fudge. I
make it every other day.” I was like, “You make it every other day?” So we sat
down and did the calories. I’m like, “That’s 4,000 calories a day of fudge you’re
eating.” He’s like, “But it’s good.”

Dr. Diulus: A low-carb fudge.

Dr. Hallberg: I eat low-carb fudge. I’m like, “You’re eating when you’re not
hungry.” You do not need that much fudge, right? So it’s just getting people in
that groove, right, of eat when you’re hungry, don’t eat when you’re not, which
sounds simple, but is actually very difficult and something that we have to
help patients through.
Dr. Diulus: Right. Well, thank you so much for this. This has been fantastic. I
really appreciate you coming. And I want to thank Dr. Hyman for making this
opportunity available to us.
Dr. Hallberg: Yes, same here. Thank you, Dr. Hyman. And thank you, Carrie,
so much for this opportunity.
© Fat Summit 2. All rights reserved. 24
Dr. Diulus: Thank you. So thanks, Dr. Sarah Hallberg, for everything that you
do and getting out there and changing the world.

© Fat Summit 2. All rights reserved. 25