LADA: Unveiling Autoimmunity In Type 2 Diabetes

Terry Wahls, MD

Hey, thank you for having me.

William Hsu, MD

Dr. Wahls, you’re well known to our audience here and to our listeners, and you have done decades of work in your fight against autoimmune conditions. Tell us a little bit about your journey.

Terry Wahls, MD

Yes. I’m an interim medicine doctor, and in 2000, I developed a weakness in my left leg. I ultimately get worked up by my neurologist, and we make the diagnosis of relapsing-remitting multiple sclerosis. I see the best people. I do my research, find the best MSA in the country, and take the newest drugs. But three years later, I’m in a tilt-recline wheelchair, and I’m only 48. That’s when I go back to PubMed and start reading the basic science. I began tinkering and experimenting with myself, and I will ultimately create a diet and lifestyle program that gets me out of the wheelchair. At my worst, I was unable to sit up. I had severe trigeminal neuralgia and severe brain fog, and I thought I was destined to become bedridden by mental illness, demented by mental illness, and probably die with intractable trigeminal neuralgia. 

Fortunately, I redesigned my diet into the paleo diet. I was using targeted supplements. I was using electrical stimulation of muscles. One year later, I’m out of the wheelchair. My pain is controlled. My fatigue is gone. I’m able to do an 18.5-mile bike ride with my family. This radically transforms how I think about disease and health. It will transform the way I practice medicine, my chief of medicine, and my chief of staff at the V.A. encouraged me to shift my research program and begin studying my program, diet, and lifestyle in the setting of multiple sclerosis. That’s what I’ve been doing, basically, since 2010.

William Hsu, MD

This is such an amazing story. Not only do you have the science to back it up, but you also have your testimonial. This is so powerful, Dr. Wahls. I think a lot of our listeners today are wondering, Why are we talking about autoimmune disease in the setting of type 2 diabetes? I wanted to paint a picture for our listeners. We know about 38 million people now in the US who struggle with and live with type 2 diabetes. I mean, the very title of this summit is to reverse that type 2 diabetes. But most people are not even thinking about reversing. 

Out of this, 38 million people are estimated to be about 10 to 15% of the population. When you look for antibodies, there are positive antibodies against the islet, insulin, or, almost reminiscent of type 1 diabetes, except that the presentation is not as abrupt onset. They don’t often present with ketoacidosis.  So there is this subsegment of the population with type 2 and a lot of the physicians actually wouldn’t know that they have autoimmunity, but in fact, they do.

Terry Wahls, MD

Correct. I guess that if we aggressively go, look, it’s going to be a lot more than that. 10 to 15%. I think our environment has radically changed over the last 100 years. We’ve changed our diet, our lifestyle, the foods we’re eating, and our toxin exposures such that autoimmune processes are increasing, and we have about 20 million people with heart disease. About 20 million—25 million—have cancer. You just gave us the quote on the folks with type 2 diabetes. We have, I believe, another 50 million that have autoantibodies. We don’t necessarily have an overt autoimmune diagnosis, but we’re developing antibodies against our tissues. If we don’t get to the root cause, we will develop Hashimoto’s thyroid disease, multiple sclerosis, and, as you said, autoimmune-associated diabetes. We will also develop psoriasis, which is happening in. 

The other thing that is happening is that if you get your first diagnosis, people come to see me; they have multiple sclerosis, and then I begin talking with them, and we investigate what other autoantibodies they have, and nearly all of them have other autoantibodies; they’re attacking other parts of their body as well. Now, fortunately, I have begun helping them, addressing these root causes so we can turn off these autoantibodies, prevent the development of other autoimmune diagnoses, and often markedly regress the problems with their autoimmune problem that they came to see before.

William Hsu, MD

This is so important, as you just mentioned, that when somebody presents initially with one autoimmune condition, the likelihood is that if you look hard enough and if you track it longitudinally over time, you get to find a cycle.

Terry Wahls, MD

Absolutely and we can look at what the time is from when the autoantibodies show up to the diagnosis of the next autoimmune disease. It’s 3 to 5 years. I will have evidence of autoantibodies before I develop rheumatoid arthritis. I’ll have evidence of autoantibodies before I develop Hashimoto’s thyroid disease. I’ll have evidence of autoantibodies before I develop lupus again 3–5 years from now, which is why those 50 million people in America who have these autoantibodies are on track to develop another autoimmune disease.

William Hsu, MD

This knowledge is very empowering. To know how to look for it, to know how to prevent it, and once they have it, how do we reverse it? Let’s talk a little bit about that. You started by mentioning that the conditions are increasing. These are immunities, and you begin to attribute them to a few causes. Can we just land there for a few minutes? What are the causes? Why are we seeing this global surge in autoimmune autoimmunity?

Terry Wahls, MD

I’m going to speak in the sense of multiple sclerosis because I know that so intimately. Well, the conventional neurology doctor will say, Well, you have genes that put you at risk, then you have an infection, and then most people get that infection cleared. Don’t go on to get MS. But some will, and we don’t know what the environmental factors are. We’ll just give you the details. We won’t talk about the environmental factors. 

Okay, so my approach is all, so what’s the list of environmental factors that have been implicated? We know how far you are from the equator and how much ultraviolet light you get. Your vitamin D level and your sunlight exposure, we know your physical activity level. If you’re not physically active, your risk is much higher. We know early life stress and adverse childhood experiences are increased in people who have autoimmunity. We know that loneliness and being isolated increase the risk.

William Hsu, MD

Now you just open up a whole can of worms there. 

Terry Wahls, MD

I have this radical, diverse, radical idea about backgrounds backward. My wheelchair gets more and more, every year, relentlessly worse. I said, Okay, what I’m going to do is chase all those health-promoting behaviors. I’m going to get back to my daily meditation. I was exercising, and I saw a PT regularly, so I could do 10 minutes of exercise. I was still going to church daily, but weekly. I’d been doing the paleo diet for five years. Okay, how long is it going to take for that to make a difference? I didn’t know, and I was using supplements to target my mitochondria. 

I concluded that mitochondrial dysfunction was a big driver of disability. When I redesigned my paleo diet based on the long list of mitochondrial-focused supplements, that’s when the magic helped. That’s when, in a stunningly rapid sequence, my mental clarity improved, my energy improved, and my physical therapist said, Wow, you’re getting stronger. We’re going to advance your exercise. You can do 10 minutes twice a day, and then 15 minutes twice a day. 

For everyone who is listening, what I want you to do is, step by step, begin to examine what we call modifiable lifestyle factors. This radical notion of eating non-starchy vegetables and eating sufficient protein. I’m very fond of olive oil and have lots of olive oil. It’s great for you. That’s a great start. We can have a debate about the benefits of doing food sensitivity testing to see if you have an immune response to gluten, dairy, or eggs, which are the three foods that I have a severe reaction to, and that’s where I have people start. Take Ellis’s gluten-free dairy out for a while and then see what happens if you reintroduce them. Often, people take it up and take gluten and dairy out. I tried to get them to take it out for three months. But in my clinic at the VA, they say, Okay, let’s go for at least two weeks. They took about two weeks and discovered that when they reintroduced that food, the migraines came back.

William Hsu, MD

Their symptoms come back.

Terry Wahls, MD

Their headaches and joint pain came back, and their psoriasis rash became much worse. That was super helpful. Teaching them to pay attention to their diet and lifestyle choices and what was happening to their symptoms.

William Hsu, MD

Would you say that nutrition is probably one of the key factors here?

Terry Wahls, MD

I think 

William Hsu, MD

Modifiable risk factors.

Terry Wahls, MD

I think diet and exercise are the two foundations that I want all of my followers to embrace. While I’m very, very fond of the paleo diet, I’ll ask the patients, What could you and your family do? Is a Paleo diet realistic? What are the foods that you could add? What are the foods that you would reduce or eliminate to make this choice as a family? If that means that a Mediterranean diet speaks more to you, that’s fine. Do that. If just doing the dietary guidelines for Americans speaks to you, that’s fine. Do that.

William Hsu, MD

All these are better than that.

Terry Wahls, MD

They’re all better than America.

William Hsu, MD

They’re all better than the Standard American Diet.  Which is.

Terry Wahls, MD

We tend to do this as a family, which will not work. What will be a huge struggle is to say, Okay, Terry, you eat your crazy diet.

William Hsu, MD

Yes.

Terry Wahls, MD

We’re going to keep having pizza and beer every Friday night, and we’re not going to change our diet. That’s a huge struggle. The family should agree. What are we going to add? What are we going to reduce and make changes that the whole family can embrace?

William Hsu, MD

That’s for sure. Well, let’s turn our attention to the exercise part because you mentioned diet and exercise. What should our listeners be paying attention to when it comes to exercise?

Terry Wahls, MD

Well, simple things get up and move a little bit every hour. I have to wear an Oura Ring, and I’ll get on alert. Okay, you’ve been sitting around too long. I stand up and do some deep events, or I go to the bathroom, go to the kitchen, have some water, and moving every hour is very helpful. I also do strength training and aerobics, but it’s a great start for everyone to wear a wearable device that can keep track of your minutes of sedentary sitting time, minutes of low-intensity activity, minutes of moderate intensity, and minutes of high intensity. You don’t necessarily need that much moderate or high intensity if you’re just moving out. Some of my colleagues have gotten these wonderful walking treadmills where you walk about one mile an hour, so you’re still getting maybe 6 to 8 miles of one in a day.

William Hsu, MD

Okay.

Terry Wahls, MD

Low intensity, which is wonderful for their health. Or you can do the moderate-intensity activity, but you just start tracking how many minutes of sedentary time, low activity, moderate activity, and high intensity you spend, and gradually make changes.

William Hsu, MD

The word we’re hearing about here is tracking, because without tracking, you don’t know how much you can improve. Having that data point, this is.

Terry Wahls, MD

Huge.

William Hsu, MD

Yes. I mean, we have so many devices that do that now.

Terry Wahls, MD

It can be very easy. When I first started doing this, I just had to get a step counter, and I said, Just write down how many steps you take every day.

William Hsu, MD

Yes, a few dollars. Yes.

Terry Wahls, MD

That was very easy for them.

William Hsu, MD

It’s interesting. Now, all these things that you talked about are good for people with autoimmune conditions, but they are also extremely helpful for people living with type 2 diabetes. I mean, there’s no conflict there, in terms of, I have surgery and then also the exercise component.

Terry Wahls, MD

Correct. Then, a third thing that we can do, again, that does not cost a lot, is have a gratitude practice. 

William Hsu, MD

Well, tell us more about that.

Terry Wahls, MD

I see that this is a lovely thing you can do before your meals with your family: be thankful for one thing, one thing in the day, and it could be that today I did a short walk around the block with my dog and my daughter. It was a beautiful day. That’ll be my gratitude. This doesn’t cost you anything. However having that expression of gratitude can lower inflammation, producing cytokines.

William Hsu, MD

Lowers distress and promotes some of the happy hormones that correct your body. That’s amazing there. So we talked about nutrition and exercise. Now, you wrote a whole book extensively about this; I believe it’s called The Wahls’ Protocol.

Terry Wahls, MD

Yes. I wrote that about my story of your profound disability and how you reversed it. Then I gave people step-by-step instructions on what they could do to grow their motivation to make the change. Some suggestions on how to transition from their current eating to progressively more healthy eating. Some strategies to think about are movement, stress reduction, toxins, hormones, etc.

William Hsu, MD

Yes, it’s interesting. This is certainly unplanned, but I’m going to throw it out there. I know that, for example, Professor Valter Longo has, at least in animal studies, shown that by fasting, he saw changes in the neurons of animals with multiple sclerosis. What is yours?

Terry Wahls, MD

Yes. I love fasting. I think fasting is a phenomenal strategy. Intermittent fasting, caloric fasting with a 24-hour fast or a 36-hour fast, or Dr. Longo’s version, which is reducing calories for 3 to 5 days. All of these things will stimulate more nerve growth factors in my brain and more stem cells that will be released in my bloodstream, which will help repair whatever needs repairing in my body and will again support better myelin repair in my brain. I love that I did five to seven days of intermittent calorie restriction for about two years. Then I went to eat every other day for another two years. Then my primary care person said to me, You’re losing too much weight. You got it. You have to be eating a little bit more. I’m eating a little bit more these days.

William Hsu, MD

In my conversation with Valter, he did mention that while fasting is an important component, the refeeding is as important in the process as magic. It’s almost like when you exercise, it’s not simply enough to tear apart those muscles, the strain, the muscles, but to allow the muscles to heal and then fast.  Their stress on the body and that refeeding phase, where you eat the food to regrow those parts of the cells that were cleaned up during this prolonged fasting, are so important. I think a lot of people miss the point. Just fast, as long as possible. That’s not the issue; the issue is the repeated cycles of fasting and then feeding.

Terry Wahls, MD

I think that the way to think about it is the yin and yang of life. That’s. No, it’s the growth and repair phases. I’m a former athlete, sometimes highly competitive. It’s not surprising that perhaps I get a little too gung ho on the fasting part and do not pay quite enough attention to the re-feeding part.

William Hsu, MD

Well, this is where I think modern-day science is adding followers to the whole discussions around nutrition, because for a long time, we talked about food as being the key, but the times when you don’t eat food, that is, the fasting phase, can be as powerful as the nutrition themselves, but they have to be done in a coordinated way. Much as I said, fasting is a stress to the body, and the body has a response, but also the re-feeding phase, where now you’re giving the body, you’re replenishing the body with nutrients. That’s going to build up the tissue, and to regenerate and rejuvenate these tissues and cells is critically important.

Terry Wahls, MD

It is wonderful.

William Hsu, MD

Yes. Dr. Wahls, how do you think the field is going? This whole autoimmune condition, including this auto-immune type 2? What is the whole feel? You’ve been doing many talks and you continue.

Terry Wahls, MD

Yes, well, I’m excited to see that there’s more and more acceptance that nutrition matters. When I first started studying this in 2010, this was a radical idea. When I was condemned and banned, you would want to just take the empties now; there’s much more. Embracing a diet does matter. That influences the microbiome, and the immune system, exercise matters, stress reduction matters, and loneliness matters. There’s more appetite from funding agencies to fund wellness studies, diet studies, and lifestyle studies. Now instead of just writing grants for a diet, we’re writing grants for diet plus exercise because I think we need to do everything together if we’re going to create health because we are just mice, which is super interesting for mechanistic studies. But if you want to know, does that work for type 2 diabetes? Does it work for multiple sclerosis? You have to study people. There’s a lot more interest in people doing lifestyle medicine in people.

William Hsu, MD

But that’s so well said. Dr. Wahls, if people want to find out more about what you’re doing or read more about the Wahls’ protocol, where can they find it?

Terry Wahls, MD

Well, the best thing to do is to come to our Instagram. Dr. Terry Wahls. DRTERRYWAHLS and go to my website, her wall, TerryWahls.com, and go pick up the Wahls’ Protocol wherever books are sold.

William Hsu, MD

That’s fantastic. Maybe one moment of encouragement for those of our listeners who are struggling, and they may find out that they have autoimmune conditions or even not so well. What encouragement can you offer?

Terry Wahls, MD

If I can come back from a profound disability to the point where I can hike, bike, and now jog, there is hope for you. Do not despair. Just begin improving your health behaviors, one step at a time.

William Hsu, MD

Dr. Terry Wahls, thank you very much for spending time with us today.

Terry Wahls, MD

Thank you.