Dr. Eric Westman: I could bring in cardiologists locally, and I could bring in experts who have a popular Twitter following and are known in pop culture. But that’s not my style. I want you to hear from the experts who are in academia, who are making changes within universities, considering how you bring this new knowledge in with the old knowledge. There are so many questions about cholesterol, LDL, and heart disease – we were all taught that this way of eating was going to be bad. There are some people who just won’t ever shift to the new paradigm.
It’s my great pleasure to bring in the former Canadian Cardiovascular Society president. Dr. Blair O’Neill and I crossed paths in the scientific world, giving information at meetings. I recall we gave a conference together in Toronto, together at the Canadian annual meeting, and it was great. It was packed, the cardiologists were so ripe and so ready for this. There were these wide-eyed dietitians in the room, all shocked that we were talking about eating fat and how this would be good for the heart. I wanted to bring Blair up for you to meet. We’ll have Dr. O’Neill talk about his personal experience as a teacher in the Canadian health system and academic world, and then we’ll open it up for questions. From the northern climes in Canada, I want to introduce you to Blair O’Neill. How are you doing, Dr. O’Neill?
Dr. Blair O’Neill: Very well, thank you, Eric.
Dr. Eric Westman: Thank you so much for being on. I seem to remember you said you taught just about every interventional cardiologist in Canada.
Dr. Blair O’Neill: Not just interventional cardiologists. I earned this gray hair for a reason, being around so long. I have contacts across the country, many of whom I trained or hired in a division director position. When the current crew is looking for jobs, they’re always asking me, “Do you know so-and-so?” And I reply, “Yes, I actually taught them.”
Dr. Eric Westman: You’re talking to us from Edmonton, Alberta, Canada. I’m going to hand it over to you now.
Dr. Blair O’Neill: Thanks again for the invite, Eric. I think you’re doing a lot to clear up the confusion. I consider you so highly that a resource I would recommend is this book of yours and Amy Berger – End Your Carb Confusion. There are tons of resources on the internet about this. Some of it is accurate, but you’re inundated with information, and some of it is not very accurate. Kudos to you for trying to get people on the right path. Another interesting story about End Your Carb Confusion is, unbeknownst to each other, my wife and I actually each ordered a copy of it. If I hadn’t been smarter, I would have gotten you to sign a copy for Barb. We’re big fans. Eric has flattered me with a little description of my background, but I’d like to give you some more.
I am a very traditional cardiologist. I’m an interventional cardiologist – the guy who comes in at two o’clock in the morning when you’re having a heart attack. I’ve always prided myself on championing prevention and cardiac rehabilitation programs, in my various leadership roles. I come from the east coast of Canada originally; I was division Chief at Dalhousie in Halifax, Nova Scotia, and then was recruited to the University of Alberta in Edmonton to help open the Heart Institute there. Along the way, I was president of the Canadian Cardiovascular Society. I have a lot of background in health policy, patient safety, and quality. I think that has given me a lot of street credibility when my personal journey has brought me to keto.
What led me to keto?
In my personal practice, I’ve been a lifelong active person, runner, boot camper, you name it. I love that stuff. I love, in my 50s, to be able to beat the 30-year-olds at boot camp because you don’t get to be a cardiologist unless you’re ridiculously competitive. Over the years, I noticed that despite following all the guidelines, watching the fat, and having my high-fiber cereal with skim milk and a banana before my workout in the morning, I gradually put on weight. One day, a sister-in-law of mine took a picture of my brother and me, who is 11 years older, and the familial resemblance was around the midsection. As somebody who is in public, I want to make an example of what I’m trying to speak of. It was very depressing. I began to realize that what I’d been advising patients to do for many years wasn’t really working; it certainly hadn’t been working for me.
A colleague introduced me to this whole concept of keto. Most doctors don’t know a lot about nutrition. We’re not taught it in medical school. We’re not taught it in our residencies. So this is really a new field. What I knew about nutrition was from the dietitians that I had worked with and had no reason to doubt other than the advice they were giving me and the advice they were giving my patients, which wasn’t particularly working. I discovered keto, and it worked, as so many of you are finding out or have found out already. It works like a charm. You can’t unsee that.
For patients who are struggling with their weight, you want to help them. Keto worked for my patients, and I expanded my knowledge, attended the meetings, and crossed paths with experts in this area. I have been doing it since the early ’90s, and expanded my expertise. I read more about it and interacted with the experts, and have, I think, become one of those experts as well, who my colleagues come to. I would have colleagues in my group chasing me down the hall saying, “Blair, Blair, I’m following your diet.” I would say, “Well, it’s not actually my diet, but you look great!” That’s my personal experience and it has been good.
Collaborating with Eric has rekindled my interest in academic medicine. When you become an administrator; you leave it to others to write. But we’ve put together some articles that have made a difference. The ketogenic diet, this low-carb lifestyle, is becoming very, very mainstream. One paper we wrote is published in Atherosclerosis, which became the leading downloaded paper in 2019 and 2020, consecutively, showing the impact of ketogenic diets. Who’s interested in it? It’s a lot of mainstream people that are thinking about it, at least if nothing else. Then, in collaboration with Eric as our editor, we published another paper which has been highly cited, highly downloaded.
Keto is starting to make a difference in the world. I think that’s because of this epidemic of obesity, which we’ve seen. Now, 7 out of 10 adults are overweight or obese – obesity is a body mass index of over 30. Probably at least 4, and in some states 5 out of 10 Americans are actually categorized in that obese category. The chilling thing is that 4 out of 10 of our children now are overweight or frankly obese. We’re now seeing something we’d never seen before – type 2 diabetes, adult onset diabetes in our children. It’s a true epidemic. And, of course, we’re seeing that in our adult population. In the 1960s, we would have been lucky to see one to two percent of our adult population with type 2 adult-onset diabetes. Now you can’t go through a cardiology ward without virtually every patient, 70 percent of them at least, having type 2 diabetes with all the complications that go along with it.
We were not made to eat carbs
I thought what I’d mainly focus on here is to talk about the heart and blood vessel cardiovascular effects of obesity and overeating carbs. All of us have a spectrum of tolerance for carbs, but the reason that we become overweight with them is because we can’t eat carbs. Our body produces excess insulin which stores that, and we’re expecting that we’re gonna have a famine that never happens. So we’re always feasting and never having that famine. Over time, as I found out in my own life, even though I ran every day, I couldn’t outrun a bad diet. That “bad diet” was what was recommended and what is currently still recommended: a low-fat diet because of the concern that eating saturated fats leads to increasing LDL cholesterol, which clogs arteries.
That is a hypothesis that actually has never been shown. It’s really a hypothesis that was only derived at the end of the 1950s and became very popularized by a famous nutritionist at the time, Dr. Ancel Keys, and became mainstream in a very short period of time. All our food guidelines, which started in the early ’70s, have been based on this premise that fat leads to high cholesterol, which leads to heart disease. I’ve looked at the literature very carefully and there really is very poor evidence for that hypothesis. Prior to Ancel Keys, there was lots of evidence that it’s actually sugar in the diet that causes problems. Even in the late 1800s, it was well known. One of the most famous physicians in history, William Osler, who actually was a Canadian, developed internal medicine programs in the United States at Johns Hopkins University and wrote one of the first textbooks in Internal Medicine. If you read his textbooks from the time, it was clear: avoid bread, and starchy foods, and rather eat healthy meats if you want to live to a ripe old age. Somehow, that got lost in Europe. It was well known before the second world war but again lost, and we’re beginning to see a resurgence of what I would consider to be the true case, which is the carbohydrates that are poisoning us and causing us this long-term weight gain.
The development of insulin resistance
Essentially, the common mechanism is when you eat sugar – complex or simple sugars – insulin is produced. If you just constantly take in these sugars, your insulin level never goes down. Insulin is a growth hormone that leads to the expansion of your fat cells. We now know that cancers in women, one out of two of them, are related to overweight or obesity, likely related to prolonged insulin. Similarly, in men, about one out of two cancers are related to overweight and obesity, likely related to chronic insulin exposure.
Insulin is a very important hormone, obviously, but any hormone that you’re exposed to in excess for a prolonged period of time you tend to become resistant to, so you can become insulin resistant. Eventually you become so insulin resistant that you develop type 2 diabetes. In between that period of time that you developed diabetes, the insulin has very negative effects on your carbohydrate system. If you have nice physiologic levels of insulin that rise and fall, and rise and fall, with appropriate levels of fasting over the nighttime, insulin is actually a protective hormone. It’s anti-atherosclerotic. But chronic exposure to high doses of insulin makes it more pro-thrombotic, pro-atherosclerotic. Those white cells want to stick to your vessel wall, they want to penetrate your vessel wall, and they tend to make your LDL cholesterol abnormal and they oxidize it. Insulin at high levels actually becomes very counter-regulatory and very bad for the system; that leads to the cardiovascular diseases that we see are rampant now.
Hypertension is probably the main effect. We consider hypertension almost a normal process of aging since 80 to 85 percent of us will develop hypertension – at least on the standard American diet (SAD) we will. One of the things we find with the ketogenic diet is it’s very effective at reducing blood pressure. Something that can happen if you have chronic high blood pressure for a prolonged period of time, probably because it’s associated with this growth hormone insulin, is your blood vessels actually become very hardened. This whole concept that our grandparents talked about, hardening the arteries, is a real phenomena. Once you get to that stage, it’s very difficult to reverse it. Before that, when it’s all related to increased nervous supply to the blood vessels, it’s very reversible. And that’s one of the things that we find we can de-prescribe from our patients is their blood pressure medications because all of a sudden their blood pressure becomes very easy to control when they’re on a low-carb or ketogenic type of diet.
Heart failure and preserved ejection fraction
Another disease that’s becoming very prevalent in this day and age is heart failure with preserved ejection fraction. In the olden days, I would say most heart failure was caused by several heart attacks, and your heart function was very reduced. It’s understandable that you would develop heart failure because your heart just isn’t pumping hard enough. But today, the most common form of heart failure, again as we get on in years, is heart failure with preserved ejection fraction. So the ejection fraction is normal; the problem is the heart becomes stiff because it’s infiltrated with fibrotic tissue. Again, insulin is a pro-fibrotic factor that makes it difficult for the heart to stretch and accept the blood. If the heart can’t stretch and accept the blood, the pressure behind the heart is going to build up, that’s going to go to the lungs, and you’re going to feel short of breath when you do anything. So, again, we’re finding an epidemic, particularly in overweight obese individuals where you’d expect those insulin levels to be high for long, long periods of time. Early on, it can be perfectly reversible.
I’m sure you all know people who have an irregular heartbeat, have to take blood thinners to reduce their risk of stroke – it’s called atrial fibrillation. It can either occur intermittently or it can occur chronically. Again, that’s related to that same process of fibrosis – fibrotic tissue replacing the normal muscle tissues, this time in the atria rather than the pumping ventricle chamber of the heart. It’s enough for the electrical impulses to be dispersed to cause a short-circuiting and to lead to this atrial fibrillation.
I have an anecdotal patient story I’d like to share about this. This is an ex-special service, very fit, in his prime guy who is plagued with atrial fibrillation. He’d be in the emergency room two to three times a month to get electrically cardioverted and then go home. By the time he saw me, he said he was fired by his electrophysiologist. The electrophysiologist was trained, as most of us are, and just said lose weight, these episodes will get better. Of course, he tried all the methods and he went to a regular dietitian, and tried the low-fat, reduced-calorie count, and of course, nothing happened. One of the nurse practitioners in that clinic knew that in the same complex, there was this O’Neill guy who believed that he could help people with a ketogenic diet. So he came to me. We had a good heart-to-heart talk. He was willing to do anything. Basically, we just used Eric’s program, that famous Page 4. We got him to ditch the carbs, eat meat ad lib, and he lost weight. His measurements improved dramatically.
This guy, although he had been in special services, was short of breath going from the parking lot of his office building to the front door, so much so the commissioner there talked to his CEO and asked, “What’s wrong with this guy? He’s going to have a heart attack. He’s just walking to the door.” After losing 50 pounds on keto, with measurements much better, that winter, he actually went to one of our famous ski hills here and skied with his family, which was something he hadn’t been able to do for about 10 years. No more episodes of atrial fibrillation, no more episodes of going to the emergency room. The standard approach to these people is what’s called ablation, where you create an electrical fence around where these short circuits are occurring. There is at least one trial that shows that diet is about equally effective because there are a lot of recurrences after people undergo this electrical ablation procedure. So he was fortunate, he didn’t have it, but used the ketogenic diet and solved his situation. He’s just one; he’s very dramatic. I just remember that story when he came in and bragged to me about being able to ski with his family, something he hadn’t been able to do for a decade. It’s just an example of using real, natural food, to be prescribed to make people feel tremendously better rather than pills, which often don’t make you feel a lot better and have a whole raft of other side effects.
This stuff works. As a practitioner, it is tough to unsee when you experience a personal benefit as I have, but then when you have patient after patient who describe thinking more clearly, feeling better, coming off their medication. I haven’t even talked about diabetes; I’m not a diabetes expert, but I do take care of my share of diabetic patients, and we can get patients off their diabetic medication. In fact, probably the best trial evidence for getting patients off, for instance, is on a ketogenic diet.
We haven’t talked about the lipids, and I should really do that. I know Eric wants me to do it, and it is an area of controversy. Just to step back about the lipid story, personally, I was an investigator in many of the original statin trials – the TNT (treating the new targets) that showed that we should get that LDL cholesterol down to 2.0 mmol/L (~77 mg/dL). That was replicated in patients with coronary artery disease, not primary prevention. We noticed in that trial that there were some patients, and we called this residual risk, where treating the LDL cholesterol and even getting it below 100 mg/dL (~2.58 mmol/L), there were still significant patients at risk. Who were those patients? Well, this other thing, HDL cholesterol, the good cholesterol, if it was low, particularly when we divided patients into five levels of HDL, the two lowest levels really got minimal benefit from having their LDL cholesterol lowered. Not understanding what that really means, we looked for a molecule that’ll raise the HDL. I ended up being chair of the global international study looking at a molecule, which was going to be the next home run when combined with atorvastatin or Lipitor. Unfortunately, as all good clinical trials do, there’s data safety and monitoring, so I was on the endpoint committee. It basically showed that even though HDL went up 60-70 percent, the outcomes were poorer in that group. Obviously, we were raising HDL, but it wasn’t functional HDL; we didn’t know what the heck we were doing was the bottom line. Now that we understand this whole process more, what’s going on, those patients are all insulin resistant, they’re all carb intolerant. Not only is their HDL low, their triglycerides are often up.
When I’m screening patients in the cath lab, what do I look at? I look at their cholesterol profile, their lipid profile. I don’t even really pay much attention to their LDL; I’m looking at their triglycerides and HDL. One, oh yeah, triglycerides are abnormal, HDL low, even if they are on a statin, they have disease. I’m going to put them on a statin; it’s the best we have until we can prove that a simple diet alone will be effective. But I can tell you what I know will be more effective: what I think will be more effective is getting them on a ketogenic or low carbohydrate diet to fix those triglycerides and HDL. That’s the most effective therapy we have. No pills have worked. We know from trials and we know from personal experience that if we want to fix triglycerides, HDL, as well as a number of other factors that lead to heart disease, the ketogenic diet is the best way to go.
I was just about to talk about diabetes. The same trial done by the Virta Group from the west coast, although this trial was done in University of Indiana and randomized patients to a traditional approach, face to face with a dietitian, low-fat diet versus a Virta trial using a ketogenic diet, we’re able to measure the fact that these patients, yes, they were actually producing ketones in their blood, so they were being very compliant, very adherent to their diet. Again, they found that 50 of these patients were able to come off insulin if they were on it, 90 were able to either come off it or reduce their insulin level, and many of the other diabetic medications actually were reduced. The beauty of this diet is from a physician perspective, you can actually de-prescribe rather than prescribe, and that’s a tremendous advantage. I know many of my patients, when I talk to them heart to heart, would prefer not to take pills if they didn’t have to. I have to provide them with good evidence that, okay, not taking a pill is going to be advantageous and I’m not going to disadvantage you by not putting you on a prescription.
Do I use statins? Absolutely, if you’ve had a heart attack, then the evidence says use it. But I would also remind you that that evidence was gathered in a population that were eating lots of carbohydrates, as recommended by our dietary guidelines. We don’t really know if statins work as well in a low-carb population, but we have to go with the evidence, and as a cardiologist, that’s what I do. I really loathe using them in primary prevention. I would use all sorts of other strategies to avoid it, whether it’s calcium scores or intermediate intimal media thicknesses and ultrasounds of the neck. I think if you don’t have atherosclerosis, the number needed to treat a statin is very, very high. If you look at all the other metrics that we can measure like CRP levels, measures of inflammation, triglycerides, HDL, the one thing that goes up, and Eric has said, it’s unfortunate, the one thing that can go up in about a third of patients is the LDL, and everybody freaks out. But in primary prevention, I’m not as concerned, and I’ll use one of these other tests to try to reassure other practitioners that they’re not going to blow up because their LDL has gone up, and every other measure that we know is beneficial to patients in the long term is improved.
In diabetics or pre-diabetics, that’s the hemoglobin A1C that we just see so effectively treat it. It’s a sign of how the profession sometimes is misled by biomarkers when you talk about LDL. Hemoglobin A1C is one of those biomarkers we use to measure how good we are at controlling diabetes, but we’re not really thinking about the root cause. We can add insulin; you’re already insulin resistant, but we can add more insulin and control your hemoglobin A1C, but in another year, you weigh more, and we’ll have to use more insulin to reduce your hemoglobin A1C. Yet, if we treat you with diet, you weigh less, your hemoglobin A1C can go back to normal, often does, without medications. We know insulin and other insulin-producing substances like the sulfonylureas, glycoside, for example, actually increase your chances of a worse outcome, but they make your hemoglobin A1C better. So again, that’s an example of how we as a profession sometimes misinterpret a biomarker because we’re thinking of the wrong evidence and not thinking about, well, what’s the root cause of this? Can we fix the root cause of this? I think those of us who practice ketogenic medicine and low-carb lifestyles are trying to think about how we address the root causes of many of these diseases, whether it’s high blood pressure, whether it’s heart disease, whether it’s heart failure or atrial fibrillation or diabetes.
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