Over the years, Bottom Line has highlighted emerging research on the benefits of the ketogenic diet for conditions as wide ranging as obesity, epilepsy, Alzheimer’s and heart disease. But there are challenges to this very low carbohydrate/high fat diet—being able to stick with it and getting the needed long-term medical supervision while following a dietary pattern outside the current mainstream. For it to be safe and effective, it’s just not as simple as replacing your bagels with bacon and your potatoes with avocados. Now one California health tech company is using telemedicine to make the ketogenic diet more accessible and effective for the millions of people battling our largest health epidemic, diabetes.

Background: The ketogenic or “keto” diet transforms your body from being a sugar-burning machine to a fat-burning one by flipping the standard American diet on its head. Most Americans eat between 200 grams (g) and 350 g of carbs a day, about half of daily calories. A typical keto diets cut carbs to between 20 g and 50 g a day, just 5% to 10% of daily calories. Remaining calories come from fat (70% to 80%) and protein (10% to 20%).

Examples of what’s emphasized with a ketogenic diet: Eggs, some full-fat dairy, meat and fish, olive oil, nuts and nonstarchy vegetables. Examples of what’s forbidden or strictly limited: Grains, sugar, starchy vegetables and most fruits. Berries, lemons and limes get the green light because they have less sugar than other fruits.

How it works: When your carb intake is this low, your body burns fatty acids and ketones—a form of energy for your body made in the liver when carbohydrates aren’t provided. Within about a week on a well-formulated ketogenic diet, your body enters a new metabolic state called nutritional ketosis where this occurs.

Studies show that the diet can improve type 2 diabetes by reducing blood sugar, in turn reducing the need for diabetes medications and triggering significant weight loss.

As your body adjusts to nutritional ketosis, you may feel tired and dizzy and have other flulike symptoms, but these generally go away with adequate salt consumption.

Important: Nutritional ketosis and diabetic ketoacidosis (DKA) are not the same thing. DKA only occurs in diabetes when insulin cannot be produced, mostly with type 1 diabetes. It’s an emergency condition in which ketones are produced at a dangerous rate, much higher than what occurs during nutritional ketosis.


For patients with diabetes, following a keto diet should be done only under the watchful eye of a doctor, especially if you take insulin, other diabetes medicine or drugs for high blood pressure. Your blood sugar and weight could drop quickly, so to avoid side effects like low blood sugar (hypoglycemia) or low blood pressure, you’ll need to work with your doctor on reducing your medication doses—that’s a lot of interaction.

To make monitoring easier and in turn make the diet more available, San Francisco-based Virta Health has developed a way to deliver it through telemedicine and is making a bold claim—the diet plus intensive medical support via the Internet can reverse type 2 diabetes.

Virta patients are paired with a remote health coach and a doctor who formulates a personalized ketogenic diet and provides monitoring. Through a smartphone or computer app, patients upload health data including their weight (through a cellphone-enabled scale), blood sugar, blood ketones, blood pressure (if they have hypertension) and ratings of mood, energy, hunger and cravings. How often this data is uploaded varies from patient to patient, said James McCarter, MD, PhD, the company’s head of research. Tracking of biomarkers begins as part of a daily routine and can become less frequent after several months as patients transition from the diabetes reversal phase to long-term success.

With conventional in-person care, a doctor knows about conditions and symptoms only when a patient contacts him/her or when there’s an appointment. Virta doctors can see your health data as soon as it’s uploaded and are able to reach out as soon as they see trends develop, Dr. McCarter said. This means, for example, that medication can be adjusted at intervals as short as one day.

Patients can consult their Virta doctors whenever they want to. But most day-to-day interactions are with the health coach, most of whom are trained as dietitians, nurses or in other allied health professions.

Coaches work with patients to personalize diet recommendations for their specific life circumstances and dietary needs. Planning and support are critical factors in success, Dr. McCarter said. Because the system can be personalized, it works for people in diverse situations, from night-shift workers with access to only cafeteria food to long-haul truckers eating at truck stops to stay-at-home parents and grandparents cooking for a large family.

Patients also have access to online resources like keto-friendly recipes and a patient community for more support.

Reaching the goals of reducing blood sugar, weight and blood pressure through nutritional ketosis and reducing doses or completely eliminating medications often happens in the first two months. Virta’s founders conducted clinical trials on the keto diet for diabetes before starting the company in 2015, and now more than two dozen studies support various aspects of Virta’s nutritional recommendations, said Dr. McCarter.

Virta and Indiana University Health are in the process of conducting a five-year controlled trial that compares outcomes of Virta treatment versus that of typical diabetes care. Results from the first year were published in the journals Diabetes Therapy and Cardiovascular Diabetology this year.

Researchers recruited 349 people with long-term type 2 diabetes and obesity. Of those, 262 volunteered to be in the Virta treatment group and 87 chose to stay with their usual diabetes care and saw their regular doctors and diabetes educators.

First year findings: Participants in the Virta group saw some big improvements…

  • On average, A1C (average blood sugar measured over two to three months) dropped from 7.6% to 6.3%, out of the diabetes and into “prediabetes” range.
  • The group lost 12% of body weight on average and lessened their need for diabetes medications.
  • 94% of those on insulin were able to reduce or stop its use, and sulfonylurea drugs were eliminated in all patients.

The people in the usual care group saw none of these improvements.

Most heart-health indicators among the Virta group got better, too. For instance, blood pressure and triglycerides went down and HDL (“good”) cholesterol went up.

Most of the people in the Virta group stuck with the program, and 83% were still enrolled in the study at the end of the first year.


A ketogenic diet, whether monitored and managed in person with a doctor and nutritional expert or remotely with a program like Virta’s, may reverse diabetes, but it’s not a cure. If a patient returns to a typical high-carb diet, blood sugar goes up and, chances are, weight rises again. For many people it’s necessary to stay on a ketogenic diet to control diabetes, though some people can tolerate a diet with a slightly higher amount of carbs, Dr. McCarter said.

The individualized and varied whole food diet that Virta patients consume provides more than adequate vitamins and fiber for health. Because sodium and fluid retention is also reversed on a ketogenic diet, obtaining adequate dietary salt, often through broth or bouillon is helpful to avoid side effects of volume depletion. Many patients take a magnesium supplement to counter the magnesium deficiency typical after years of eating the standard American diet, Dr. McCarter explained.

Virta’s specific program of advice and monitoring costs $500 for the starting fee plus $370 per month for the first year and $199/month after the first year. Most insurers including Medicare and Medicaid don’t yet pay for it. An employer-sponsored health plan might cover it. Virta offers a payment assistance program that reduces costs for lower income individuals.

To learn more about the ketogenic diet for other health conditions, read “Metabolic Syndrome Reversed with Ketogenic Diet,” “The Groundbreaking Alzheimer’s Prevention Diet” and “Starve Cancer to Death with the Ketogenic Diet.”

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