Memorandum

Virta Health launches to reverse T2D in 100 million people by 2025; combines nutritional ketosis and technology; 1% A1c reduction at 10 weeks; impressive investors include Venrock, Redmile – March 8, 2017

Executive Highlights

  • Virta Health launched yesterday with the very bold mission of reversing type 2 diabetes in 100 million people by 2025. The Virta model relies on nutritional ketosis driven by carbohydrate restriction – less than 30 grams of carbs per day, paired with diet high in fat and moderate in protein. Virta calls itself an “online specialty medical clinic” because participants get access to a health coach and physician, online peer support, and ongoing information and feedback on their health.
  • Along with the debut, Virta published its first major study. 10 weeks on the program produced a 1% mean A1c reduction from a 7.6% baseline. Participants lost 7% of their body weight, and 56% of those with type 2 diabetes at baseline went into remission (A1c <6.5%). An impressive 87% of those using insulin either decreased their dose or eliminated their use of insulin altogether. Similar medication reduces were seen for orals.
  • Virta is currently available to people with type 2 diabetes and prediabetes as a covered benefit through some self-insured employers/health plans (none specified), and to individuals able to pay out of pocket (~$400/month for the first year). Patient consultations are free, and physicians can refer patients directly to Virta.
  • The “full-stack healthcare company” will be led by Sami Inkinen (CEO; former President of Trulia) and two very well known ketogenic diet and metabolism researchers: UC Davis’ Dr. Stephen Phinney (Chief Medical Officer) and Ohio State University’s Dr. Jeff Volek (Chief Science Officer). The team is 54 people and the advisory board is impressive.
  • Notably, Virta is backed by $37 million in funding from well-known technology and healthcare investors, including Venrock, Allen & Company, Obvious Ventures, Redmile Group, and Scifi VC.

Impressive startup Virta Health launched yesterday with the bold mission of reversing type 2 diabetes in 100 million people by 2025. The unique approach uses nutritional ketosis (very low-carb, high-fat ketogenic diet) coupled with digital health coaching, behavioral support, biometric feedback, and online peer support – read the press release here (Dr. Bob Ratner is quoted) and see the company’s website here. Read on for our top highlights from this announcement, followed by our questions.

1. Virta’s launch was timed with 10-week results from its first study published in JMIR Diabetes. The program produced a mean 1% reduction in A1c (baseline 7.6%) in 262 people with type 2 diabetes in a non-randomized trial. 56% of those with type 2 diabetes at baseline went into remission (A1c <6.5%), and 97% of that group did so without an increase in the number or dosage of medication. Average body weight loss was a strong 7%. An impressive 87% of those using insulin either decreased their dose or eliminated their use of insulin altogether. Study retention was strong at 91%, and the patient testimonials are encouraging. In preliminary six-month data on the company’s website, average weight loss has increased to 12%.

2. Virta is currently available to people with type 2 diabetes and prediabetes as a covered benefit through some self-insured employers/health plans (none specified), and to individuals able to pay out of pocket. The cash-pay cost is roughly $400 per month for the first year – quite pricey for the average person– though presumably some of this would be offset by medication reductions. Patients can apply directly to receive a free consultation. Physicians can also refer patients directly to Virta. In these early days, we assume payer coverage is limited, but will expand with these early outcomes and further commitment to publishing data.

3. Virta Health was co-founded by Sami Inkinen (CEO; former President of Trulia) and two very well known ketogenic diet and metabolism researchers: UC Davis’ Dr. Stephen Phinney (Chief Medical Officer) and Ohio State University’s Dr. Jeff Volek (Chief Science Officer). Highly regarded Dr. Peter Attia is also on Virta’s healthcare industry advisory board and shared an enthusiastic post on these results: “Is Type 2 Diabetes Reversible at Scale?” His best quote: “Clearly we need to look at the long-term success, and see many more patients succeed safely, but this is more promising than anything I have ever seen.”

4. Impressively, the company is backed by $37 million in funding from notable technology and healthcare investors, including Venrock, Allen & Company, Obvious Ventures (started by Twitter co-founder Evan Williams), Redmile Group, and Scifi VC (started by PayPal founder Max Levchin).

5. Virta’s highly ambitious goal is to reverse type 2 diabetes in 100 million people by 2025. This would be moonshot-level impressive and require achieving some enormous scale in the next eight years. Since only half of those with diabetes globally are diagnosed (~200 million), this means Virta must reach roughly 50% of the entire global diagnosed population – a tall order. Obviously, even treating hundreds of thousands or millions of patients with Virta’s model rests on longer-term and sustained outcomes; scalable technology and coaching efficiency; and an attractive cost-saving business model for payers, health systems, and countries.

6. A promising aspect of Virta’s program is the potential for cost savings. Unlike therapeutic approaches of comparable efficacy, Virta involves no additional medication in the vast majority of patients. Given the high price of newer diabetes drugs, especially insulin, perhaps the program can pay for itself short-term.

7. The extremely low-carb (<30 g/day), high-fat ketogenic diet at the cornerstone of Virta’s program stands in contrast to the ADA’s historic dietary approach, where the recommended diet is usually moderate in carbs (~40% of total calories) and low in fat. The ADA has somewhat relaxed its stance on dietary fat in recent years (“individualized” approach, per its 2014 recommendations), but the organization has not been a staunch advocate for low-carb, high-fat approaches in the past– despite their proven value for improving glycemia, insulin dosing safety, weight, diabetes hassle, and more (read Adam’s diaTribe columns here, see Virta’s citations here, and a 2015 review article here). We can’t wait to see longer-term data.

Detailed Highlights

1. Virta’s Debut Study: Trifecta of Benefits including 1% A1c Reduction, 7% Weight Loss, Medication Reductions in Most Users

Virta Health’s debut comes on the heels of publication of its first major study (JMIR Diabetes), offering evidence that nutritional ketosis coupled with on-site or remote education/coaching produces a trifecta of benefits: A1c improvements (-1% from a 7.6% baseline), 7% body weight loss, and substantial reductions in diabetes medications (especially in insulin, SU, SGLT-2, and TZD users). The non-randomized study involved 262 people with type 2 diabetes (mean BMI of 41 kg/m2 and mean age of 54 years) medicated with at least one anti-hyperglycemic drug (30% on insulin). Ten weeks of Virta’s program reduced mean A1c across all participants by 1% (p<0.001), bringing 56% of those with type 2 diabetes at baseline into remission with an A1c <6.5%. Of the individuals who achieved diabetes remission, 97% did so without an increase in the number or dosage of their medications. The study is open access and definitely worth a read; we dig into some of the outcomes below.

  • Medication reductions were strong regardless of the baseline drugs used. Notably, 51% of insulin users reduced their dose by the end of 10 weeks, while 36% completely eliminated insulin. A full 90% of sulfonylurea users, 86% of SGLT-2 users, and 57% of DPP-4 users eliminated their respective drugs. The chart below shows very encouraging medication reductions in pretty much every category, an encouraging sign for cost-effectiveness.

  • The Virta program produced an average of 7% body weight loss, with weight changes ranging from 0% to over 16% of body weight. 75% of individuals who completed the 10-week study lost 5% or more of their initial body weight. (In preliminary six-month data posted on the company’s website, average weight loss has increased to 12%! This will be published at some point in the future, perhaps at ADA 2017.)

  • Meanwhile, baseline hunger (on a scale from never hungry [1] to always hungry [4]) remained at a solid 1.6 on average, confirming that willpower-driven caloric restriction was not a facet of Virta’s ketogenic dietary recommendation – an early positive sign for sustainability.
  • There were no cases of diabetic ketoacidosis (i.e., hyperglycemia concurrent with serum ketone level >6 mmol/l), a common concern for critics of the ketogenic diet in diabetes. Daily ketone levels (BOHB) averaged over 10 weeks of the program was 0.6 mmol/l, indicative of a modest state of nutritional ketosis in most of the subjects. The highest value of ketosis was similar to levels observed during fasting.
    • No episodes of severe hypoglycemia were observed over the course of this 10-week study – as expected, given the tight supervision and Virta’s focus on safe ketosis. This is another beneficial beyond-A1c outcome for Virta’s program, along with weight loss and reduction/elimination of diabetes medications.
  • Virta’s intervention involves a ketogenic diet complemented by digital health coaching, behavioral support, biometric feedback, and online peer support. Virta refers to this medication- and surgery-free suite of interventions as “technology-enabled medical service.” At its core, the program involves educational content on the pathophysiology of diabetes, the principles of nutritional ketosis (typically requiring dietary carbohydrates to be restricted to <30 g/day), how to utilize ketone levels as a form of biofeedback (participants were encouraged to obtain BOHB [beta hydroxybutyrate] readings ≥0.5 mmol/L), and a discussion of behavior change techniques, all of which is deliverable in the form of either weekly on-site 90 minute group classes or web-based recorded content. To supplement this content, subjects received individualized nutritional recommendations to help maintain ketosis while also achieving satiety, weekly physician care, and access to a personal health coach available for advice and problem solving via text. Virta participants also had access to an online community of fellow participants, taking a page out of Omada Health’s book. Subjects monitored and reported glucose levels online to the care team 1-3 times per day and were prescribed medication changes on the basis of this. Presumably the glucose reporting could be automated with a Bluetooth-enabled meter.
  • The study had a 91% participant retention rate, an encouraging figure for what is typically viewed as a “hard to stick to” diet. The coaching and support presumably helped. (We also think low-carb diets receive an unfair level of criticism for being difficult to stick to.) This hopefully bodes well for the ease of adhering to the Virta program, and dispels potential concerns regarding the willpower needed to stick to a strict ketogenic diet (a point that was also underscored by the low reported rates of hunger).
    • Post hoc analysis revealed that the delivery method for Virta’s educational content (on-site vs. online) had no impact on the participants’ health outcomes, a promising sign that the program can scale virtually. In the study, the on-site vs. online intervention modalities were assigned according to participant preference.
  • The trial will continue for a duration of at least two years, with one-year data possibly coming at ADA 2017. From an efficacy perspective, it will be crucial for Virta to establish that the outcomes from the first 10 weeks of the trial are durable over time – this is the most obvious and biggest criticism the company will face in these early days. Dr. Peter Attia, a prominent figure on Virta’s healthcare industry advisory board, hinted at these forthcoming one year data in an enthusiastic blog post, noting that it “looks very impressive.” As noted above, preliminary six-month data mentioned on the company’s website says average body weight loss has increased to 12%.
    • Shared CEO Sami Inkinen in a conversation with us: “I can’t wait to share our official one- year data publicly. I know people are already asking about “sustainability.” Unfortunately the peer-review and analysis process is time consuming, although many of our patients are already 1.5 years into the trial and almost everyone is past one year. We already submitted a one-year results abstract to ADA. That’s probably the first time we’ll make the data public.”
  • We highly recommend watching the video testimonials of study participants. On Virta’s website, see testimonials from Wilma, Jerry, Robin, Tim, and nearly a dozen other people with diabetes and several doctors, including Dr. Mark Savant from here in San Francisco and Dr. Denise Bilbau, an internist in Portland, Oregon who works with Kaiser. These interviews with doctors are nearly as interesting as the ones with patients and we recommend them to understand more views about Virta.
    • Elaine: After 12 years living with type 2 diabetes, Elaine reduced her A1c from 10.5% to 5.5% and has lost nearly 60 pounds. Her testimonial particularly emphasizes the value of Virta’s health coaching system, underscoring her relationship with her online health coach. “Before the Virta program, I felt terrible every day,” she notes, “I am no longer taking a medicine cabinet full of drugs every day.”
    • Jerry: After 10 years of living with type 2 diabetes, plus a long family history, Jerry, has reduced his A1c from 8.9% to 6.4% after three months of the program and has lost over 50 pounds. His testimonial emphasizes how the Virta program helped him reduce his medication regimen from four drugs to one. Notably, after many years of concerns over high blood pressure, his blood pressure is now “better than normal.” He notes that Virta gave him the “kick” he needed to change his lifestyle and behavior for the better.

2. the Virta Program Is Currently Available Through Some Self-Insured Employers and Out-of-Pocket to Patients at ~$400/month for the first year

The Virta program is now available through self-insured employers, payers, health systems, and people with type 2 diabetes able to pay out of pocket (~$400 per month for the first year). Patients can apply directly to receive a free consultation with the Virta care team, and physicians can consult with the care team to discuss patient referrals. It is not clear which payers or employers are covering Virta now (we assume only a few), but the company told us most come through employer-sponsored health plans (none specified). Notably, some employers are even offering Virta to people with prediabetes – great to hear. Monthly and yearly payment options exist for those paying out of pocket, and Virta also offers a patient assistance program based on the ability to pay. We wonder how widely Virta will be covered among traditional insurers and how quickly.

  • While the $400 per month sounds expensive, the concomitant medication reductions could make it cost neutral or even cost-saving short-term. We wonder if cost-effectiveness data will be published in tandem with the upcoming one-year data.   

3. The Impressive Virta Health Team

Virta Health was co-founded by Sami Inkinen (CEO; former President of Trulia) and two very well known ketogenic diet and metabolism researchers: UC Davis’ Dr. Stephen Phinney (Chief Medical Officer) and Ohio State University’s Dr. Jeff Volek (Chief Science Officer). Both Drs. Phinney and Volek have had impressive careers in academia. Dr. Phinney has an MD from Stanford, a PhD in Nutritional Biochemistry from MIT, and did his fellowship at Harvard. Dr. Volek has published over 300 peer-reviewed papers and received his PhD from Penn State (some of his lectures on YouTube, like this one, have over 100,000 views – wow!). Mr. Inkinen, a very big-deal guy, co-founded Trulia, helped oversee its multi-billion sale (for $3.5 billion – see compelling NYT story here) and is an alum of McKinsey, Nokia, and Microsoft. The Virta Health team is already 54 employees, ranging from clinical experts to design and engineering. It is a highly compelling group – we recently visited the offices and were extremely impressed by the focus and drive of this entrepreneur and the entire team that we met in their downtown San Francisco offices.

  • Highly regarded Dr. Peter Attia is on Virta’s healthcare industry advisory board and shared an enthusiastic post on these results: “Is Type 2 Diabetes Reversible at Scale?” His best quote: “Clearly we need to look at the long-term success, and see many more patients succeed safely, but this is more promising than anything I have ever seen.” Dr. Attia formerly served as President of the Nutrition Science Initiative (founded with Gary Taubes to bring more rigorous science to nutrition) and now runs a concierge medical practice focused on longevity. He is extremely impressive and seeing his enthusiasm gives us serious confidence in Virta – he is unbelievably data-driven and not one to dole out praise lightly.
  • Virta’s experienced scientific advisory board includes UCSF’s Dr. Ronald Krauss, a pioneer in lipidology (400+ publications on lipoproteins and coronary artery disease); Harvard Medical School’s Dr. Bruce Bistrian, a former President of the American Society for Clinical Nutrition (500+ publications); and UCSF’s Dr. Frederick Hecht, Research Director of the Osher Center for Integrative Medicine (200+ publications).

4. Virta’s InvestorS: Experienced in Technology and Healthcare

Impressively, Virta is backed by $37 million in funding from notable technology and healthcare investors, including Venrock, Allen & Company, Obvious Ventures, Redmile Group, and Scifi VC. This investor group’s technology experience is impressive – see Venrock’s portfolio here (includes Apple and Intel, among many others); Allen & Company here (includes Zagat, Pandora, Flatiron Health, among others); Obvious Ventures here (started by Twitter co-founder and former CEO Evan Williams); Redmile Group here (an investor in Xeris and One Medical, among others); and Scifi VC here (started by former Payal founder Max Levchin). We see this group as a vote of confidence in Virta’s business model and go-to market strategy. However, the technology experience in this investor group is definitely deeper than the healthcare experience.

5. Virta’s Ambitious Goal: Reverse Type 2 Diabetes in 100 million People by 2025!

The press release announcing Virta’s debut highlights the company’s highly ambitious goal: reverse type 2 diabetes in 100 million people by 2025. This would be moonshot-level impressive and require achieving some enormous scale in the next eight years. Assuming only half of those with diabetes globally are diagnosed (~200 million), this means Virta must reach roughly 50% of the global diagnosed population in eight years. Obviously, even treating hundreds of thousands or millions of patients rests on longer-term and sustained outcomes, highly scalable technology and coaching efficiency, and an attractive business model for payers, health systems, and countries. Treating hundreds of thousands is itself a real accomplishment at a population level; it was very interesting to us and perhaps the only major misstep we saw to set a goal of such awesome proportions before proving diabetes reversal in even a thousand patients. Still – a goal is a goal and the company can certainly create the goal that it likes!

  • We pressed CEO Sami Inkinen on this goal, and he shared the following: “The human genome project was a 15-year funded project. At ~7 years, 1% (of the 100%) human genetic code had been sequenced. Most people thought the project will never complete in time. But thanks to technology (which mostly scales with exponentially), the entire 99% was sequenced and solved in the following seven years. That’s an imperfect analogy, but it’s likely what’s going to happen with Virta: our progress towards 100 million people helped will be exponential, both in our ability to access people living with type 2 diabetes and our ability to safely and successfully treat them. And as we scale, the cost of our treatment will also come down, allowing us to profitably help people in much lower-cost countries than in the US, such as Arab countries, Southeast Asia, etc. For 2017 and 2018, our focus is to keep scaling while further improving our outcomes. Equally important is to be able to roll-out Virta successfully with health plans and employers. That requires flawless operational execution. We have a lot of work ahead of us and as ambitious as it sounds like, we are on track to scale exponentially in the years ahead of us. But the path from thousands of patients to millions is definitely not linear!”
  • Virta has been thoughtful about marketing, de-emphasizing the focus on “low-carb,” “ketogenic,” and “diet,” and launching with the “bold mission to “reverse type 2 diabetes.” Carb restriction appears for the first time in the press release in the sixth paragraph. Instead, the company focuses on the technology aspects and the value-add: “an online specialty medical clinic that reverses type 2 diabetes safely and sustainably, without medications or surgery – shifting the focus from diabetes management to reversal.” While this is smart, we also think it’s important to think about what patients will want to do and be willing to do; long-term outcomes from our view also depend highly on patient willingness to forego carbs over the long term. Said one patient to us today: “The approach definitely works; I get to month three and four, and then I can’t go on!” We have also spoken to some HCPs who argue with “reverse,” pointing out for some, diabetes goes into “remission.” We can’t get too worried about the specifics, though it is true that long-term data is needed to prove that “reverse” is the right word.

6. Virta’s Cost Saving Potential?

A promising aspect of the Virta program (besides its early efficacy) is the potential for cost savings, especially those with longstanding diabetes. Unlike diabetes drug approaches of comparable efficacy, to date, in this small trial, Virta reduces medication load in the vast majority of patients. Public outrage over the price of drugs (insulin in particular) continues, and Virta could provide a possibly less costly avenue for individuals to achieve a lower A1c, weight loss, and better cardiometabolic health, though the pricing certainly is not, vs. costly drugs alone, inexpensive. We’re not sure if the pricing of $400 per person per month is consistent for direct-to-patient vs. self-insured employers/insurers. We also don’t know how low that price can go once Virta achieves more scale and experience – could it get to $50 per month? It’s unclear, but from Mr. Inkinen’s comments above, this seems to be part of the plan. The benefit of Virta’s virtual model is it could be quite scalable with technology, but reaching millions or tens of millions of patients is obviously a serious step function change. How many patients can Virta’s current clinical team manage? What is the company’s ultimate goal for coach/physician productivity? Assuming Virta can ultimately handle an ambitious 500-1,000 patients per team (we assume at least one coach paired with one physician), caring for 1 million patients would require 1,000-2,000 teams (2,000-4,000 employees).

7. Virta’s Ketogenic Diet: A Stark Contrast to Traditional Diabetes Dietary Recommendations

The extremely low-carb (<30 g/day), high-fat ketogenic diet at the cornerstone of Virta’s program stands in contrast to the ADA’s historic dietary recommendations, where the recommended diet is usually moderate in carbs (~40% of total calories) and low in fat. The ADA has somewhat relaxed its stance on dietary fat in recent years (“individualized” approach, per its 2014 recommendations), but historically, the organization has not staunchly advocated for low-carb, high-fat approaches – despite their proven value for improving glycemia, insulin dosing safety, weight, diabetes hassle, and more (see Virta’s citations here and read Adam’s diaTribe columns here).

  • Of course, it is important to note that Virta’s study did not directly compare its program head-to-head against the coaching + current dietary recommendations for people with diabetes. We suspect the low-carb approach would beat traditional diet advice + coaching, though the lack of a control group is the most obvious limitation right now. That said, startups rarely launch with this kind of clinical data, and given Virta’s team, we know there is a commitment to showing outcomes and proving value and sustainability. Longer-term data will be key for confirming these early results.
  • Read this 2015 Review in Nutrition (“Dietary carbohydrate restriction as the first approach in diabetes management: Critical review and evidence base”). The abstract makes some persuasive points: “The inability of current recommendations to control the epidemic of diabetes, the specific failure of the prevailing low-fat diets to improve obesity, cardiovascular risk, or general health and the persistent reports of some serious side effects of commonly prescribed diabetic medications, in combination with the continued success of low-carbohydrate diets in the treatment of diabetes and metabolic syndrome without significant side effects, point to the need for a reappraisal of dietary guidelines. The benefits of carbohydrate restriction in diabetes are immediate and well documented. Concerns about the efficacy and safety are long term and conjectural rather than data driven. Dietary carbohydrate restriction reliably reduces high blood glucose, does not require weight loss (although is still best for weight loss), and leads to the reduction or elimination of medication. It has never shown side effects comparable with those seen in many drugs...The insistence on long-term randomized controlled trials as the only kind of data that will be accepted is without precedent in science. The seriousness of diabetes requires that we evaluate all of the evidence that is available. The 12 points [in this article] are sufficiently compelling that we feel that the burden of proof rests with those who are opposed.”
  • Per the ADA’s 2014 Recommendations: “Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes (evidence grade: B); therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals (evidence grade: E).
  • In their valuable book, the Art and Science of Low Carbohydrate Living, ketogenic researchers Drs. Jeff Volek and Stephen Phinney (now on Virta’s team) argue that type 2 diabetes and obesity are conditions of carbohydrate intolerance and fat storage vs. utilization. From that lens, they argue, type 2 diabetes and obesity are best managed with carbohydrate restriction that drops insulin levels and glycemic load. Their arguments are persuasive.
  • Although the ketogenic diet is often perceived as very strict, 91% of participants in Virta’s 10-week results remained in the study. Participants remained in ketosis throughout the trial (on average, 0.6 mmol/l) indicating they actually stuck to the dietary intervention – this is a frequent limitation of food studies, where the prescribed food approach is not actually followed. Having this biofeedback is an asset for Virta, since they can prove the intervention was followed. We do not know how many people were screened for the trial or to what extent patients were sought who would want to eat low-carb.
  • “The food was great” was also a resounding piece of feedback from the trial participants featured in Virta’s video testimonials. These folks did not seem to be pre-selected for disliking carbs!
  • For the Virta program to scale sufficiently to reach its ambitious goal of reversing type 2 diabetes in 100 million people in the next eight years, we assume the ketogenic diet will need to be culturally appropriate and somewhat malleable – a for example, adding foods and ingredients that are affordable and accessible for a wide variety of people. We haven’t heard much on this front and would be curious to know what provisions Virta has in place, or is planning, to ensure that the dietary recommendations at the cornerstone of its program remain easy to adhere to. Will Virta ever provide the food directly to patients?

Close Concerns Questions

Q: As the study continues, will one-year and two-year data confirm these promising early results? How would results look if the same technology was deployed with “standard” low-fat diet advice? Will results be maintained

Q: Can Virta participants sustain the ketogenic diet (<30 grams of carbs per day) over a longer period of time? How would results vary with slightly higher levels of carb intake (e.g., 60 or 100 grams of carbs per day)? What degree of ketosis is the minimum effective dose for improving glycemia and metabolic health? How much individual variation is there?

Q: Are there plans to use this program as an effort toward diabetes prevention? Could this be deployed in type 1 diabetes? Will the study’s success in a type 2 population bode well for other populations?

Q: How did the outcomes compare between the majority of participants who had diabetes (i.e., A1c > 6.5%) at baseline versus the minority without diabetes but who were taking anti-diabetic medications?

Q: Who were the responders and non-responders in this study? Did the same cohort of participants experience the trifecta of A1c reduction, weight loss, and medication elimination, or did participants instead experienced mixed results in achieving a subset of these different outcomes?

Q: What will payers think of these data? How cost-effective and scalable is Virta’s approach – how many patients can one team (e.g., coach + physician) handle? How will Virta’s pricing and business model change over time? How much consumer demand will it see initially ($400 per month for the first year)?

-- by Abigail Dove, Brian Levine, Adam Brown, and Kelly Close