How would someone go about finding out that they have type 2 diabetes or are on their way to getting it?
You have to understand that diabetes is defined by high blood sugar – blood glucose, to be more specific. It’s an elevated blood sugar all day long. It’s often picked up on an annual physical. Sometimes you get sick and it’s figured out because you didn’t realize that urinating a lot, being hungry, losing weight, and not feeling well might be diabetes. But that’s less common. Most commonly, a doctor will tell you that you have pre-diabetes if your blood sugar was too high on a blood test. It’s all defined by blood glucose.
Another test that can be done is called a hemoglobin A1C or just “A1C” for short. That’s just the three-month average of the blood sugars. They figured out a way to look at the sugar attached to red blood cells and it stays, because it’s sticky. So, if your hemoglobin A1C is elevated, your doctor might tell you that you have pre-diabetes.
Pre-diabetes, in most cases, will be around for years before full-blown diabetes. It’s all defined by the level of blood sugar that you have. Diabetes mellitus is a high blood sugar. (Diabetes insipidus is a different condition that is very rare and totally separate from type 2 diabetes.)
Different countries around the world have different thresholds in order to be diagnosed with either pre-diabetes or diabetes. Are you able to give us those numbers for the U.S.?
In the U.S. measurements, a doctor will start suggesting pre-diabetes for a hemoglobin A1C of 5.5 or 6.0. Each guideline has a bit of a different number and it changes, so the main thing is that if it’s too high, you want to get it down. You want to lower it because pre-diabetes commonly leads to diabetes and then diabetes can lead to all sorts of complications that you don’t want to have, like blindness, heart disease, neuropathy (numbness and tingling in your toes), and kidney failure. You don’t want to go down the path of having full-blown diabetes. Even with medical treatment today, it doesn’t prevent those things from happening totally.
So, pre-diabetes you were saying is around 5.5 to 6.0. I would imagine anything over 6.0 means that you would already have type 2 diabetes, is that correct?
You can use those as rough numbers, yes.
In your opinion, where does it all begin? What is the root cause of type 2 diabetes?
It’s complicated. Depending on the individual’s metabolism, you can either handle carbohydrates or you can’t. We call that carbohydrate intolerance. It might even be in the family – one of your parents had it and the other maybe didn’t, so that can be quite confusing.
In a keto, low-carb world where you’ve reached your optimal weight and metabolism, there is no diabetes, which leads me to the fundamental conclusion that it’s carbohydrates that cause diabetes. Carbohydrates are sugars and starches, and they get digested to glucose, which you absorb as glucose, so it makes sense that if you ate something that had glucose in it, your blood glucose would go up. It really mystifies me why the medical community is so entrenched into not believing this. To my patients who are instructed in this, it’s obvious! They say, “Well, why would I want to have an apple when it raises my blood glucose and my blood glucose is already elevated?” Right! That’s exactly right!
There are individual differences, but most often diabetes is accompanied by obesity, and obesity causes something called insulin resistance, which is from carbohydrate intolerance. But, diabetes is not always paired with obesity, which complicates it a little further. The good news about a low-carb diet or any effective weight loss program is that you fix the weight and you fix the insulin resistance, and you fix the diabetes all in one fell swoop. So, I’m a big fan of lifestyle approaches, including keto, to address diabetes and obesity if they’re together, because it handles all of it in one fell swoop, so all of it gets better.
It’s my understanding that type 2 diabetes is a progressive illness, is that correct?
No! No, it doesn’t have to be!
This is one of the reasons why the medical community is mystified and doesn’t understand what we do. Yes, in their experience it’s always progressive, because people don’t change what they do. The doctor rarely advises you to make radical changes in your diet to fix the diabetes. Maybe they’ve never even seen it happen! There’s a whole clinical experience and clinical world—my world of using low-carb keto diets—where we’ve seen diabetes reversal, meaning it’s not progressive.
But you do have to change what you’re doing. If you don’t want diabetes, then consider these other options. What’s amazing is that it’s not that difficult. It’s just getting the right information. Again, my fellow doctors, even in my own Duke University community, have never seen it, so they don’t think it can happen. And they think what I do is so extreme. No, actually it’s not. They don’t really understand the world we’re in where we do see diabetes reversal and where diabetes is not necessarily progressive if you make changes.
You have been treating people for type 2 diabetes and obesity for 12 or 13 years now?
Yes, but the research studies go back 20 years now. It’s hard for me to believe when I first got involved because of a patient of mine who followed this approach. I was curious and after about eight years of research, we opened our own clinic at Duke.
We’ve been seeing this happen and I’ve treated people with lots of different medical issues as well. There’s a medical monitoring piece to all of this that’s really important. If you have diabetes and you’re on medications, they need to be reduced almost immediately in most cases. So I highly recommend that you see a doctor or a health practitioner who understands how to take you off medicines. It’s called ‘deprescribing’.
The first world conference on deprescribing just happened this last weekend in Vancouver (it was a virtual conference). A lot of doctors don’t know about it. They’ll just assume you’re always going to have diabetes. You might even have heard that, and it breaks my heart that people don’t know that there’s another way to do it. It sometimes agitates me that other doctors are just perpetuating the failure that people feel. We actually can make it simple and make it work for just about everyone.
Then there’s the question, “Well, why would doctors not know about it?” Well, they get educated by companies that sell drugs, so that’s really what we’ve been taught to do in the medical world – to treat diabetes with drugs.
If you’re diagnosed or told you have high blood glucose and pre-diabetes, you may be offered to just take medicine. No, that’s not the answer! This is the “managing” approach rather than fixing it. Drugs are being advertised on TV with jingles, harkening back to songs from when I was a child. They rewrite the words and they want to make you manage your diet. But, no, you don’t want to “manage” diabetes, you want to fix it. You want to reverse it. (The language is interesting – the Federal Trade Commission in the U.S. gets a little bent out of shape if you say ‘cure’ diabetes, so we say ‘reverse’ and ‘fix’, because there are a lot of people who claim they can cure diabetes and they can’t. They’re just trying to sell you another substance.)
More and more, people come in and they’re telling their friends and neighbors, and once doctors understand what I do, they start sending me their patients. That’s why there’s such a long waiting list at my clinic door, unfortunately.
Can you give us an example of a typical medication people are on? How quickly can someone be weaned off their medication?
Let me start with the minimal medication. If you’ve been diagnosed with pre-diabetes, you might be on a medicine called metformin or another oral agent, just one pill. Those go away immediately. If you change the diet, you don’t need to take those pills. They’re very weak. They’re treating the food, and changing the food is much more powerful than those medications. So if you have just a mild pre-diabetes, you’ve only been put on one medicine, that’s simple. It’s gone on the first day. Don’t just take the medicine if the doctor’s offering it. Change your lifestyle! You won’t even need the medicine.
Worst case, you’ve been going down this path of medication treatment management of diabetes and now you’ve gained weight. A lot of these medicines cause weight gain, especially insulin. I’ve had people on four shots of insulin a day, with these new other shots that are once a week, and pills. If the blood sugar is in the normal range, I need to reduce the insulin immediately or the blood sugar will go too low. I’m not talking about 1–2% – it’s a 50% reduction in insulin on the first day! This is called de-prescribing, and I explain to people what’s going to happen. They have to check their blood sugars before taking insulin, because the blood sugar might go too low even on the first day. You have to understand that the medicines are adjusted to the carbs that people eat. The more carbs you eat, the more medicine you need. If you eat fewer carbs, then you need less medicine. We help people reduce that.
Some exciting programs, which I am keen to learn myself, because they’ve now become available inexpensively, include a continuous glucose monitor (CGM) for the first week or two, so that people can see their blood sugar every five minutes. It takes away the fear, the worry, the concern. Often I’m the new doctor that they’ve met for the first time and I’m going against what their doctors that they’ve known for maybe 20 years have said. I work really hard to show exactly what’s going to happen to make sure people are measuring their blood glucose, because when you’re measuring, you’re really in charge of managing the medicine as well.
My record is taking someone off 180 units of insulin in two days! Looking back, this individual was drinking sugar-sweetened beverages, a liter or two per day, so the insulin was treating the sugary drinks. When he stopped consuming the sugary drinks, he stopped the insulin and the proof was in the blood sugar. The amount of sugar that we eat and drink is massive when you compare it to the blood sugar level. When you look at the blood sugar level, you get a number of 100 mg/dl. This is in milligrams. When you eat an apple it’s 20,000 milligrams! (It’s 20 grams of sugar, but 1 gram is 1000 milligrams!) We’ve been accustomed to this, to see it as nothing, but these are big deals to a blood sugar system that only has milligrams of sugar. You need to be really careful if you have diabetes to not have grams, let alone hundreds of grams, over the course of the day. I try to explain the biology of it and to the level that someone wants to know, but measuring the blood glucose will help people get off the medication, often on the first day or two.
I’ve had people who are in a program where they’ve had to lose 200 pounds, they have diabetes as well, and they might still be on insulin a year later. So, the ultimate fix for diabetes is losing weight if weight is the contributing cause to the diabetes. What’s great about a keto low-carb diet is that as you cut the carbs out immediately, the blood sugar goes down and you also lose weight if that’s partly the cause of the diabetes for you. It’s a really unbelievable approach, because it really fixes the short-term blood sugar rise and the long-term obesity contribution to diabetes.
I want to make it clear to people who are watching, the importance of being monitored by your doctor before trying to implement this diet on your own. A lot of this medication that you’re speaking about can be very dangerous if you embark on this sort of program and you keep the same strength or the same dosage of medicine. Do you want to touch on that before we start moving on to some questions?
Right. To clarify, I think this is healthy eating for anyone if you’re not taking medication. If you are taking medications, especially diabetes and high blood pressure medicines, they can become too strong very quickly.
Do not do this on your own if you have those diseases and you’re on medications. Otherwise, I think this is just healthy eating.
If someone wanted to learn your method, how would they go about it?
There are a lot of ways to lose weight and to fix these problems. My method is based on lots of teaching I learned from different doctors who had done this for years and then we published our results in medical journals over the last 20 years. We’ve taught lots of different doctors to do this in their clinics.
Currently of course our Adapt Your Life Academy is a great way to learn more about how to do keto very simply, as is my book, End Your Carb Confusion. And people can get inexpensive resources from my own website, Eric Westman MD. Again, do it with medical supervision if you have these kinds of medical issues.
Martin asks: “I have been a type 2 diabetic for over three years and I’ve always been told to eat between 45 and 60 grams of carbs per meal. Why is this?”
A good question! The recommendations to eat carbs developed over a slippery slope of, “Now that we have medicines for diabetes, let’s let people eat like ‘normal’ people” (meaning, bread and all those carbs). First of all, that’s not necessarily normal. And, normal doesn’t mean optimal. What happened, if you look back in the 1900’s when insulin was developed and then these other pills and products, is that the medical world kind of lost its brain in terms of the carbohydrate contribution to diabetes. So, in order to make it so that you don’t have low blood sugars on medicines you’re taught to eat carbs. Let me say that again: you’re taught to eat carbs so that you don’t have low blood sugars when you’re on the medicines that you don’t need in the first place!
It’s as if the researchers in diabetes got derailed by the worry about cholesterol in the blood and it’s a difficult story to tell briefly, Gary Taubes’s book, Good Calories, Bad Calories, was quite influential for me. Pioneering work to tell the story of how this all got messed up. You’re basically taught to eat carbs so that you won’t have low blood sugar from the medicine that you need to treat the diabetes that’s from the carbs in the first place.
Lucy asks: “Folks with type 2 diabetes are at greater risk of cardiovascular disease. If I eat more meat and fat, won’t my risk profile for cardiovascular disease go up?”
No. That was the surprising result of our research 20 years ago and it’s been replicated over and over and over. It’s not the fat in the food that causes fat in the arteries, which is what we were all taught. (I know – I was taught that, too!). It turns out that there’s something called metabolic syndrome. If you look, it’s the carbohydrates and sugars that cause metabolic syndrome, not the fats in the blood. I have no problem using this in someone with heart disease or pretty much any medical issue with monitoring.
Nina Teicholz’s book, The Big Fat Surprise, and Gary Taubes’s book, Good Calories, Bad Calories, will tell you the story of how this all got messed up. Scientists and medical doctors got distracted by the worry about cholesterol in the blood. That’s still probably the most significant medical barrier for doctors to understand this and to use it. (Learn more about cholesterol in our online course, End Your Cholesterol Confusion.)
Arlene says: “I’ve been following Dr. Westman’s method for over three years. I’ve lost over 80 pounds, I’m no longer on medication, and my blood pressure has normalized. Thank you so much for showing me that this can be done.”
Check out the full video here.