#162 - Sarah Hallberg, D.O., M.S.: Challenging the status quo of treating metabolic disease, and a personal journey through a grim cancer diagnosis
Dr. Sarah Hallberg discusses carbohydrate restriction's efficacy for type 2 diabetes and obesity, challenging dietary fat beliefs, and highlighting palmitoleic acid as an early metabolic disease predictor. She also shares her personal journey with stage four lung cancer, emphasizing living fully, honest family communication, and the critical need for self-advocacy and health equity in cancer care.
Deep Dive Analysis
15 Topic Outline
Introduction to Sarah Hallberg and Type 2 Diabetes
Dietary Fat, Carbohydrates, and Plasma Fatty Acid Distribution
Sarah's Journey to Carbohydrate Restriction for Diabetes
Institutional Acceptance and Early Clinical Trials
Prevalence and Early Indicators of Prediabetes and Metabolic Syndrome
Challenging the 'You Are What You Eat' Dogma in Fat Metabolism
Palmitoleic Acid (POA) as a Key Biomarker for Metabolic Health
Individualized Carbohydrate Tolerance and Metabolic Management
Sarah's Lung Cancer Diagnosis and Emergency Brain Surgery
Coping with Grief and Denial After a Terminal Diagnosis
Understanding Non-Smoking Lung Cancer and its Demographics
Pursuing Aggressive Treatment and Battling Cancer Mutations
Life-Threatening Chemotherapy Complications and Recovery
Challenges and Delays in Cancer Recurrence Treatment
Reflections on Living with Chronic Cancer and Advocacy
8 Key Concepts
De Novo Lipogenesis
This is the process where the liver synthesizes fat from non-fat precursors, primarily carbohydrates. It contributes significantly to elevated triglycerides and VLDL, and its acceleration is correlated with insulin resistance and adiposity.
Palmitoleic Acid (POA) / C16-1
A monounsaturated fatty acid with 16 carbons and one double bond, produced from palmitic acid (C16-0) by the SCD1 enzyme. Elevated POA levels serve as an important early biomarker for insulin resistance and carbohydrate intolerance, even before blood sugar rises.
Sterol-CoA Desaturase (SCD1)
Also known as Delta-9 desaturase, this enzyme converts saturated fatty acids into monounsaturated fatty acids, such as palmitic acid into palmitoleic acid. Increased SCD1 activity is an independent marker of triglyceridemia and abdominal adiposity, indicating increased fat synthesis and export from the liver.
Metabolic Syndrome
A cluster of five conditions (elevated blood pressure, high fasting glucose, high triglycerides, low HDL cholesterol, and truncal obesity) that collectively increase the risk of heart disease, stroke, and type 2 diabetes. Studies indicate that 88% of adult Americans do not meet the criteria for optimal metabolic health.
Carbohydrate Tolerance
Refers to an individual's capacity to consume carbohydrates without triggering adverse metabolic responses, such as increased de novo lipogenesis and elevated palmitoleic acid. This tolerance varies significantly among individuals and can change over time, influencing personalized dietary recommendations.
EGFR-Driven Lung Cancer
A specific type of non-small cell lung cancer, often found in non-smokers, characterized by mutations in the epidermal growth factor receptor (EGFR) gene. These cancers can be targeted by specific tyrosine kinase inhibitor (TKI) therapies, but often develop resistance over time.
Tyrosine Kinase Inhibitors (TKIs)
A class of targeted cancer drugs that block the activity of specific tyrosine kinase enzymes, which are involved in cell growth and division. TKIs are highly effective for cancers with certain mutations, like EGFR-driven lung cancer, but typically lead to temporary remission as cancer cells eventually develop resistance.
Atypical Hemolytic Uremic Syndrome (aHUS)
A rare and severe medical complication, in Sarah's case triggered by chemotherapy (gemcitabine), characterized by multi-organ failure affecting kidneys, liver, and respiratory system. It has a high mortality rate and often leads to permanent dialysis, with treatment involving specialized medications like plasmapheresis.
7 Questions Answered
It challenges the 'you are what you eat' dogma, showing that dietary saturated fat intake does not directly correlate with serum saturated fat levels, especially in the context of carbohydrate restriction, and highlights internal fat synthesis as a key factor.
Over 50% of adult Americans have diabetes or pre-diabetes, and a staggering 88% are not in optimal metabolic health, based on NHANES data and metabolic syndrome criteria.
Palmitoleic acid is a monounsaturated fatty acid produced by the SCD1 enzyme, and its elevated levels are an early predictor of insulin resistance, triglyceridemia, and future diabetes, even before blood sugar levels rise.
Yes, type 2 diabetes can often be reversed with very low carbohydrate diets, and many patients can gradually reintroduce some carbohydrates if they have sufficient functioning beta cells, though individual carbohydrate tolerance varies.
The median survival for stage four lung cancer can be 12 months or less, and non-smoking lung cancer, often adenocarcinoma with specific mutations like EGFR, is growing at alarming rates, frequently affecting healthy, thin young women.
Tyrosine kinase inhibitors (TKIs) can effectively shrink or eliminate tumors in EGFR-driven lung cancer by blocking specific enzymes, but they are not a cure, as the cancer typically develops resistance and recurs over time.
Even privileged patients face significant delays in accessing appropriate care for cancer recurrence, high out-of-pocket costs, and a healthcare system that often 'gives up' on patients once their cancer returns, highlighting issues of health equity.
16 Actionable Insights
1. Optimize Sleep, Exercise, Nutrition
Prioritize optimizing the “sleep, exercise, nutrition trifecta” and managing cortisol, as getting these right can significantly reduce the risk of heart disease, cancer, and Alzheimer’s disease.
2. Consider Therapeutic Carb Restriction
For individuals with type 2 diabetes or metabolic syndrome, a therapeutic carbohydrate-restricted diet (e.g., less than 50 grams/day) can significantly decrease triglycerides, improve glycemic control, and in many cases, reverse type 2 diabetes.
3. Monitor Palmitoleic Acid (POA) Levels
Consider monitoring palmitoleic acid (POA) levels as a biomarker, as elevated POA can indicate that an individual has consumed carbohydrates above their personal tolerance, even with normal blood sugar, serving as an early warning sign of metabolic trouble.
4. Be Hypervigilant About Blood Sugar
Physicians and patients should not ignore any elevation in blood sugar, even in the pre-diabetic range, as it indicates a long-standing underlying problem that requires immediate attention.
5. Understand Individual Carb Tolerance
Determine your individual carbohydrate tolerance, as this is key to personalized nutrition and health management, rather than relying solely on population-level data.
6. Utilize Continuous Glucose Monitoring
Consider using continuous glucose monitoring (CGM) even if not diabetic, to maintain a high standard of average glucose and manage glucose excursions, as an early detection tool for metabolic health.
7. Reduce Insulin Dependency
Understand that insulin is not benign; aim to reduce insulin requirements as much as possible, as a lower daily dose to achieve normal glycemia represents a significant improvement in health outcomes.
8. Reframe Obesity as a Disease
Understand that obesity is a disease process that often begins before significant weight gain and is not the patient’s fault, requiring providers to approach and treat these patients without bias.
9. Address Provider Bias in Obesity Care
Healthcare providers should self-reflect on and address any biases they hold against patients struggling with weight, recognizing that obesity is a complex disease process and not the patient’s fault.
10. Transform Anger into Action
When experiencing anger or frustration from life’s challenges, channel that emotion into productive action and advocacy rather than allowing it to consume you.
11. Choose to Live Fully
When faced with profound adversity or a terminal diagnosis, choose to actively live and make the most of your time, as this approach can positively impact your family and your own well-being.
12. Be Honest with Children
When dealing with a serious illness, commit to always telling children the truth about the situation, as constant uncertainty can be more detrimental than knowing the facts.
13. Become an Expert Patient Advocate
Develop strong self-advocacy skills in healthcare, especially when facing complex diagnoses like cancer, as the system may not always provide optimal support without persistent pushing.
14. Educate Stakeholders on New Approaches
When introducing an unconventional treatment or approach, proactively educate all relevant departments and stakeholders with evidence-based presentations to address potential resistance and gain buy-in.
15. Offer Carb Restriction Option
Physicians should provide all patients with metabolic disease the option of trying a carbohydrate-restricted diet, as it is based on evidence and can lead to significant improvements.
16. Acknowledge Personal Reality
Be realistic and honest about your emotional state and challenges, especially when facing severe illness, rather than pretending everything is “great” or adopting a “superwoman” facade.
8 Key Quotes
88% of adult Americans are not in optimal metabolic health.
Sarah Hallberg
By the time you get to prediabetes, there's some really serious things going on here. Their vision is being impacted. Their nerves are being impacted. You know, these are things we can't just say, oh, they haven't, they haven't gotten bad enough to bother with because they're not at the criteria for type 2 diabetes yet.
Sarah Hallberg
Obesity is not the cause of metabolic illness, but the result of it.
Peter Attia
The mandatory discussion that needs to occur is, I'm going to give this medication, this insulin that you're going to inject to you. And I'm going to do that because your blood sugars are so high that they could acutely kill you, put you into the hospital, put you at risk of all these complications. But I just want you to know, you're more likely to die on insulin. That's what we need to tell people.
Sarah Hallberg
Your kids are going to be better if you choose to live.
Sarah Hallberg
I don't care about anything outside of the walls of this house. And I would take a selfish approach in some ways, I think. And you've done this very selfless thing, which is continuing to sort of prioritize everything else as well. How do you do that?
Peter Attia
Bad things happen to good people. Like I said, there's been a pivot in every part of my career based on anger. And I certainly am angry about this. But what do you do with it? That's what's going to be the important question in life.
Sarah Hallberg
I just want to be a normal person.
Sarah Hallberg
1 Protocols
Sarah Hallberg's Aggressive Cancer Treatment Strategy (post-TKI resistance)
Sarah Hallberg- Continue the tyrosine kinase inhibitor (TKI) (e.g., Osimertinib) without interruption.
- Undergo regular cycles of chemotherapy (e.g., Cisplatin) to reduce tumor burden.
- Immediately after chemo, initiate anti-estrogen therapy, including medications like Lupron, Fulvestrant, and Pablacyclib, to target specific secondary mutations.
- Following anti-estrogen therapy, cycle through different single-agent, very low-dose chemotherapies (e.g., Gemcitabine, Taxols) to prevent new mutations and resistance.
- Proactively battle potential mutations by constantly changing treatments, rather than waiting for cancer to return or develop resistance.