How the Next President Can Reverse Chronic Disease
The most effective solution, backed by the most evidence, is not yet being discussed
How can we reverse chronic disease in America? Whatever your views on Robert F. Kennedy, Jr., he deserves praise for being the first leader to stress the urgency of this problem. His “Make America Healthy Again” campaign is now part of the Trump platform, and a super-PAC has just been launched to fund these efforts. Still, there’s time for Kamala Harris to raise the sword on these killer diseases, as a column in The Guardian urged this week. It should be a winning issue for any candidate. According to one study, only 12% of adults are metabolically healthy, and the vast majority of our $4.5 trillion in healthcare spending each years goes to treat chronic conditions. Reversing these diseases could at least put a dent in our spiraling deficit while alleviating the suffering of untold millions of Americans. It’s a rare win-win for our country.
Still, our leaders need to get the solution right. Otherwise, they risk making changes that accomplish little while possibly even causing harm. We should never forget the cautionary tale of the low-fat diet, adopted in the 1970s with all best intentions yet precious little evidence to back this nation-wide intervention. Only decades later did experts reluctantly discover that reducing fat propelled people to eat more sugars and refined carbohydrates, which are now considered by many experts to be far greater drivers of chronic disease. We should heed this story, a contender for the greatest public-health blunder ever made, and not repeat the mistake of jumping blindly into unproven policies. Or—as seems more likely—not tinker around the edges of the problem without solving the root cause of chronic disease.
I’ve long focused on type 2 (T2) diabetes as the most important condition to address, because it’s one of the most devastating to experience, the most expensive to treat (>$1 billion/day nationally), and because we now have a sizeable body of rigorous evidence to show that it can be put into remission in a matter of weeks.1
The U.S. news media has barely reported on the fact that a ruinous disease affecting 13 million Americans can rapidly be reversed—a stunning omission. The silence on diabetes reversal is deafening. The American Diabetes Association (ADA) has all but buried the evidence on reversal. And while successive Presidents have talked about reducing the cost of insulin, they don’t appear to know that elimination of insulin for people with T2 is a reasonable—and preferable-- goal.
Currently, there are three “evidence-based” approaches for reversing type 2 diabetes (type 1 is not known to be reversible). These approaches are: 1. bariatric surgery, 2. a very low-calorie diet with most meals taken as patented, liquid formula shakes, and 3. a very low-carbohydrate diet.
When I say “evidence-based,” I mean an approach that is supported by multiple controlled clinical trials, i.e., the only kind of evidence that can reliably establish a cause-and-effect relationship and ensure that the benefits outweigh the harms. This is not my standard but that of every internationally recognized methodology for evaluating scientific studies. (These include AHRQ, GRADE, Cochrane, and one by the Institute of Medicine.)2 Nearly all of our public health institutions subscribe to one of these methodologies, at least in a pro forma way.
Explaining the three, evidence-based ways to reverse diabetes was best done by the late Dr. Sarah Hallberg. She was the principal investigator on a large 2-year trial using a ketogenic diet. Here is a 3:15-min dazzler of Sarah earning an ovation for her rapid summary of this topic, at a 2018 SwissRe conference in Zurich:
Hallberg later detailed the evidence for these approaches in a 2019 narrative review in Nutrients. Since then, the evidence for a low-carbohydrate approach has only grown stronger.
What’s remarkable is that diabetes can be reversed so quickly. In Hallberg’s trial, two-hundred and sixty-two subjects had been living with T2 diabetes for an average of 8.4 years when they enrolled, and nearly 56% effectively reversed their diabetes within just 10 weeks (i.e., their average blood sugar, or HbA1c, dropped below 6.5%) without increasing the number or dosage of their diabetes medications. This 50%+ number was sustained at year two, when the trial ended.
I’m focusing on a ketogenic diet for diabetes reversal over the two other options-- bariatric surgery or the very low-calorie, liquid formula diet—because only keto is a whole-foods solution. I believe this approach should be favored, for the obvious reason that it relies on real food and doesn’t involve patented formulas or expensive surgery.
Diets that many people think should work to accomplish this same goal—Mediterranean, low-fat, vegan, vegetarian, DASH (Dietary Alternative to Stop Hypertension)—may seem like compelling options but are simply not backed by the same rigorous, clinical trial evidence. People may have conquered their diabetes using these approaches, but the level of data needed to make a population-wide recommendation, aka policy, don’t exist. (For a clear, basic review of the evidence on all these diets, I suggest watching this lecture by Dr. Laura Saslow, part of a free course (with CME credits) on “Dietary Strategies for Reversing Type 2 Diabetes” hosted by the Cardiometabolic Health Congress that I co-organized.)
Other currently popular ideas such as eliminating seed oils, food dyes, toxins, or ultra-processed foods also aren’t backed by the kind of clinical trial evidence we need to advocate for them as public health interventions. Your health may improve greatly by avoiding these substances. Nixing these industrial products certainly seems like a good idea, but the evidence is lacking to make broad proclamations that these measures will reverse disease. We need to remain humble. As another cautionary tale, remember that 20 years ago, nearly every health expert told us that eggs caused heart disease. Now we (mostly) find that advice absurd.
Of course many people are skeptical of low-carbohydrate diets. The dietary approach suffers from longstanding stigma problems, going back half a century to when it was known as the “Atkins” diet. Doctors feared the cholesterol effects from eating more saturated fat, and they could not believe that weight loss, without counting calories, was possible.
Also, because keto has shown such promise in reversing a host of major chronic diseases, it obviously threatens big Food and big Pharma. There’s no doubt, too, that our longstanding public health institutions such as the American Heart Association and Centers for Disease Control cannot abide low-carb when they have for decades been recommending its exact opposite: low-fat.
Gone are the days when Dr. Robert Atkins was shouted down at meetings of the American Medical Association. Yet concerns around keto remain. Physicians still fear that the diet’s saturated fat content will increase a person’s risk for heart-disease by raising LDL-cholesterol. Yet Hallberg’s trial found at one year that of the 20 heart disease risk factors measured, fully 17 showed significant improvements while two remained unchanged.3 LDL-C was the outlier—the sole risk factor that worsened. (Overall, the 10-year atherosclerotic cardiovascular disease (ASCVD) risk score for these subjects decreased by − 11.9%.)
Even the notion that LDL cholesterol is a meaningful heart-disease risk factor for people on low-carbohydrate diets has now been challenged. A recent meta-analysis of 41 low-carb diet trials concluded that only lean people (BMI<25) see this type of cholesterol go up. Further, a recent study, in the Journal of the American College of Cardiology (JACC), found that these slim outliers, despite their increased LDL-C, had no significant plaque build-up after 4.7 years, compared to a matched control group. The JACC study suggests that elevated LDL cholesterol on low-carb is simply not meaningful in terms of observable heart disease.
The evidence is clear. For Americans with T2 diabetes (and pre-diabetes), our next President should immediately recommend the implementation, via any relevant authority, of a low-carbohydrate solution.
RFK, Jr.’s op-ed in yesterday’s Wall Street Journal contains a number of great ideas on how to attack chronic disease but does not discuss the carbohydrate problem.
Other recommendations for the next President—in this case Kamala Harris—come from an essay by the journalist Neil Barsky, in The Guardian. Number one, he writes: appoint a diabetes czar, who could oversee various measures, including confronting the $1bn-plus in sugar subsidies provided by U.S. taxpayers. Second: “defund, disqualify and otherwise delegitimize the American Diabetes Association,” which plays an outsized role in setting standards of diabetes care for clinicians yet has “become a virtual branch of big pharma and big food.” Third: get the National Institutes of Health (NIH) to fund research on low-carbohydrate diets. Despite the enormous suffering caused by diabetes and its burden on the health care system, the NIH has funded only a tiny handful of such trials, even though the existing evidence shows the diet to be effective not just for the prevention and reversal of diabetes but also for heart disease, fatty liver disease, kidney disease, cancer, hypertension, mental health disorders, and more.
Finally, writes Barsky, we should listen to the people who’ve actually reversed their diabetes. For all the doctors who believe a ketogenic diet is ‘too expensive,’ ‘too restrictive,’ or ‘too difficult,’ you can find stories of people triumphing against all odds. Such as Ajala Efem, a 47-year old Bronx woman, whom I recently profiled for an article in Medscape. Ajala lost nearly 30lbs and got off 15 medications after her healthcare provider prescribed a low-carb diet. The article also describes a woman in a homeless shelter who managed to lose 25lbs and recover from polycystic ovarian syndrome on the diet. People need to know that this is possible. If they are told by their physicians that a whole food, very-low-carb diet can safely reverse their disease and get them off medications, they will find a way to manage.
This following point is the most important: our public health institutions need to promote the evidence-based options for reversing the chronic diseases that have come to afflict so many of us. We deserve to be healthy again. Any President who can stand up to the food and pharma lobbies to make that happen would be a 21st century hero.
Attempts have been made to define “remission” vs. “reversal.” According to a 2019 ADA consensus report, remission is when the patient achieves normal average blood sugar (HbA1c <6.5%) for at least 3 months without any blood sugar-lowering medications such as insulin. Reversal is the same as remission but allows metformin still to be taken, since it’s often prescribed for uses other than controlling blood sugar. The term “cure” is not considered applicable to T2 diabetes, because reoccurrence is always possible if a person reverts to a former way of eating.
AHRQ is the Agency for Healthcare Research and Quality. GRADE stands for Grading of Recommendations Assessment, Development and Evaluation.
The two that remained unchanged were LDL-P and ApoB.
What a brilliant piece you have written and it's very timely given what Dr James Muecke has written this week.
Eye surgeon Dr James Muecke was the Australian of the Year in 2020 & has written a very insightful piece that will challenge what a lot of people believe about eating red meat.
Those of you who are vegan, vegetarian or work in the medical fields need to consider what James has written here, what his motivations (we know what they are) are.
He is very well respected & all he wants to do is make the population well again.
https://www.northweststar.com.au/story/8724002/the-benefits-of-red-meat-for-your-health-and-the-planet/
The metabolic health issue deserves bipartisan support. But I doubt the pharma companies that advertise in mainstream media will be happy with the threat. I hope the truth will continue to break through.