Ketogenic Diet for Diabetes Management: Insights from Dr. Finny

The Journey to Ketogenic Diet Research

Dr. Finny's journey into ketogenic diet research began during his medical school years. As a way to maintain his sanity during the intense study periods, he would go on long bike rides in the mountains of the Bay Area, California. These experiences taught him the importance of carbohydrate intake for endurance sports, as he quickly learned that not consuming carbs within the first hour of a ride could lead to "hitting the wall" and feeling terrible on the way home.

However, his perspective on carbohydrates and endurance performance would be challenged in the years to come. During his residency in Vermont in the early 1970s, Dr. Finny engaged in discussions with top diabetologists who were also avid cross-country skiers. One of them shared an intriguing anecdote about a friend who had lost significant weight on the Atkins diet and was able to complete a 30-mile cross-country ski loop without eating, while the diabetologist had to stop and eat every hour.

Intrigued by this seemingly impossible feat, Dr. Finny and his colleagues decided to investigate further. This curiosity led to a research project studying untrained obese patients on a very low-calorie ketogenic diet in a metabolic ward over six weeks.

Early Research Findings

The results of this initial study were surprising:

• After one week, as expected, the patients' performance decreased.
• However, after six weeks, despite significant weight loss, the patients could walk longer on an uphill treadmill while wearing a backpack containing the weight they had lost.
• Remarkably, this improved performance occurred without any training during the study period.

Encouraged by these findings, Dr. Finny continued his research, taking courses at MIT and conducting a study with highly trained bike racers. In this four-week study, the athletes were fed enough fat to maintain their weight. The results were equally surprising:

• After four weeks on a ketogenic diet, the athletes maintained their high-performance statistics in terms of peak power and endurance time to exhaustion.
• They were able to perform the same amount of work while deriving less than 10% of their energy from body carbohydrate reserves.
• Instead, they were running on about 90% fat for energy.

These findings were groundbreaking and challenged the prevailing wisdom about the necessity of carbohydrates for high-level athletic performance.

Setbacks and Resurgence

Despite the promising results, the field of ketogenic diet research faced significant setbacks. Concerns about ketogenic diets and sudden death arose, partly due to a disastrous diet called the liquid protein diet that was popular at the time. This negative perception pushed ketogenic diet research into a very unfavorable position, causing Dr. Finny to shift his focus to other areas.

It wasn't until 2003 when Dr. Finny met Jeff Volek that his interest in ketogenic diet research was rekindled. Volek had read Dr. Finny's papers and encouraged him to return to this field of study. Together, they shifted their focus to addressing the long-term safety concerns surrounding ketogenic diets.

Since their first joint publication in 2006, Dr. Finny and Volek have published approximately 18 papers, primarily focusing on the safety aspects of ketogenic diets. Once they had established a solid foundation of safety data, they felt confident in offering ketogenic diets as a science-based program for managing various health conditions, including type 2 diabetes.

The Verta Study: Ketogenic Diet for Type 2 Diabetes

The meeting with Sami Inkinen, a world championship athlete and successful tech entrepreneur, marked a turning point in Dr. Finny's research. Inkinen, despite being a highly trained endurance athlete, had developed pre-diabetes while consuming a diet consisting of 60% or more calories from carbohydrates, many of which were highly processed.

This encounter led to the creation of Verta and the initiation of a groundbreaking study with Dr. Sarah Hallberg in Lafayette, Indiana. The study involved 260 people with type 2 diabetes and aimed to investigate the effects of a ketogenic diet on diabetes management.

Study Design and Participants

The study included participants with the following characteristics:

• Average duration since diabetes diagnosis: over 8 years
• Participants were generally overweight or obese
• The study also included a cohort of about 130 people with pre-diabetes

Participants were allowed to choose between two intervention methods:

1. In-person meetings at Dr. Hallberg's clinic

   • 26 meetings over the course of one year
   • Combination of group-based and one-on-one sessions for individualization
   • Telephone access to Dr. Hallberg and coaches for medication adjustments

2. App-based intervention

   • All instruction and interaction provided through a cell phone app
   • Participants only came in for research visits three times during the first year

Interestingly, Dr. Finny initially believed that the in-person intervention would be more effective. However, the results proved otherwise.

Study Results

The outcomes of the Verta study were remarkable:

1. Hemoglobin A1c Reduction:

   • Starting average: 7.6%
   • After one year: 6.2%
   • This significant reduction was achieved while simultaneously reducing medication use

2. Medication Changes:

   • More than half of the participants' medications were removed
   • For the 90 patients on insulin:
     • 50% completely discontinued insulin use
     • 42% reduced their insulin dose
   • Sulfonylureas and insulin, the two most dangerous medications in terms of causing hypoglycemia, were discontinued in many cases
   • Most other medications, except metformin, were reduced

3. Comparison of Intervention Methods:

   • No significant differences were found between the in-person and app-based groups
   • Surprisingly, the app-based group showed slightly better results on average

These findings challenge the conventional wisdom in diabetes management, which typically associates better glycemic control with increased medication use. The study demonstrated that it's possible to achieve significant improvements in blood sugar control while simultaneously reducing medication dependency.

Implications and Future Directions

The results of the Verta study have far-reaching implications for the management of type 2 diabetes:

1. Rethinking Diabetes Management: The study challenges the traditional approach to diabetes care, which often relies heavily on medication. It suggests that dietary interventions, specifically a well-formulated ketogenic diet, can play a crucial role in improving glycemic control and reducing medication dependency.

2. Potential for Diabetes Reversal: While Dr. Finny is careful not to use terms like "cure" or "remission," he promotes the concept of "reversal" in diabetes management. This term acknowledges that while the underlying predisposition to diabetes may still exist, its clinical manifestations can be effectively managed through ongoing dietary intervention.

3. Individualized Approach: The study highlights the importance of individualizing carbohydrate restriction. While the ketogenic diet was effective for the study participants, Dr. Finny emphasizes that carb tolerance can vary from person to person. This suggests the need for personalized approaches in diabetes management.

4. Long-term Commitment: The concept of reversal, as opposed to cure or remission, underscores the need for ongoing adherence to the dietary intervention. Patients must understand that maintaining their improved health status requires continued effort and commitment.

5. Potential for Telemedicine: The success of the app-based intervention group suggests that effective diabetes management through ketogenic diets can be achieved remotely. This has significant implications for increasing access to care, especially in areas with limited healthcare resources.

6. Challenging Nutritional Dogma: The study's results challenge long-held beliefs about the necessity of carbohydrates in the diet, especially for those with metabolic disorders like type 2 diabetes. It opens up new avenues for nutritional research and intervention in metabolic health.

7. Potential Applications in Other Areas: While this study focused on type 2 diabetes, the principles of carbohydrate restriction and ketogenic diets may have applications in other areas of health and disease management. Further research could explore the potential benefits in other metabolic disorders, neurological conditions, or even certain cancers.

8. Need for Long-term Studies: While the one-year results are promising, longer-term studies will be crucial to establish the safety and efficacy of ketogenic diets for diabetes management over extended periods.

9. Education and Training: The success of the ketogenic diet intervention highlights the need for better education and training for healthcare providers in nutritional approaches to disease management. This may require updates to medical school curricula and continuing education programs.

10. Policy Implications: If further research continues to support these findings, it could lead to changes in clinical practice guidelines for diabetes management and potentially influence health policy and insurance coverage for dietary interventions.

Conclusion

Dr. Finny's research journey from his early experiences with endurance sports to groundbreaking studies on ketogenic diets for diabetes management represents a significant contribution to our understanding of nutrition and metabolic health. The Verta study, in particular, challenges conventional wisdom about diabetes management and opens up new possibilities for dietary interventions in chronic disease.

By demonstrating that a well-formulated ketogenic diet can lead to significant improvements in glycemic control while reducing medication use, this research paves the way for a more nuanced and personalized approach to diabetes care. It emphasizes the power of nutrition as a primary intervention, rather than relying solely on pharmaceutical approaches.

However, it's important to note that while these results are promising, they also underscore the need for ongoing research, particularly in terms of long-term effects and individualized approaches. The concept of diabetes "reversal" through dietary intervention is a powerful one, but it requires a commitment to sustained lifestyle changes.

As we move forward, the insights gained from Dr. Finny's work may well reshape our approach to not just diabetes, but to metabolic health as a whole. It serves as a reminder of the importance of challenging established beliefs in medicine and the potential for dietary interventions to play a central role in managing chronic diseases.

Ultimately, this research opens up new avenues for patient care, potentially offering hope to millions of people struggling with type 2 diabetes and related metabolic disorders. As we continue to explore and refine these approaches, we may be on the cusp of a paradigm shift in how we understand and treat metabolic diseases.

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