Introducing Dr. Mariela Glandt
Dr. Eric Westman: It is my great pleasure to have Dr. Mariela Glandt.
Where are you speaking to me from?
Dr. Mariela Glant: I am in Madrid.
Dr. Eric Westman: Your home is also in Israel.
Dr. Mariela Glandt: Yes, Israel. I am back and forth to the US monthly.
Dr. Mariela Glandt’s background, tertiary education and qualification
Dr. Eric Westman: I am interviewing people who are traditionally medically trained, people who at some point in their time flipped or became open to the idea that diet might be important. It is an ironic way to start. Tell everyone who you are. Your pedigree – the schools you went to – is impeccable. And then how you turned into more of a lifestyle doctor for diabetes. This is a great story.
Dr. Mariela Glandt: I have been an endocrinologist for 20-plus years already. I have been treating patients with diabetes. I went to Penn (University of Pennsylvania) undergrad, and then I went to the University of Texas in Houston for medical school. Then I went to Harvard and Beth Israel for residency, and then I went to Columbia in New York for fellowship. Then I worked in the Bronx and the Upper East Side for a while, in Mount Sinai, and had a private practice in the Upper East Side and in the Deep Bronx. So, that gave me two really big contrasts. I was a very traditional endocrinologist. Then I went to work also in Israel, where I started. I married in Israel and ended up in Israel. I was the head of clinical trials for Hadassah. We were managing 23 different clinical trials with Victoza and all sorts of Pharma back then. I was giving lectures for Novo Nordisk and I was a regular old doctor and considered successful. My A1c was pretty normal and I did a good job with lots of meds. And then I ran into you.
Dr. Eric Westman: Let us spend one moment on your background.
The fellowship you did was in endocrinology, and this would give you a deep understanding of diabetes and thyroid problems, and adrenal problems. For those who do not know internal medicine, I am just an internal medicine specialist. My specialty was in clinical trials and general internal medicine, not endocrinology. You had much more training than I did in understanding the drug treatment of these things. Even getting into the clinical trials, I did that in the smoking cessation world, and it is a great job. You manage clinical trials and they send you around to give talks. I remember going to Texas and back one day, giving a talk on this new drug for smoking cessation and it takes a lot of time. It is hard work for the doctor, yet gratifying. You could have been happy doing that forever. So many doctors do.
Dr. Mariela Glandt: You do not know anything else. You think that this is the way. That is when I look at my peers today and I see myself back then. They really do not know that it can be so different and that they could be treating patients for real rather than giving them more and more drugs.
Dr. Eric Westman: So you think the lack of exposure to that in training is a bit, I am just inferring, that it is a huge deficit.
Dr. Mariela Glandt: I still want to think that doctors want to do the best for their patients. I really do believe they do, and I just think that every conference you go to is sponsored 100% by Pharma. You are never exposed to anything really deep when it comes to lifestyle. Lifestyle is thrown around like a word that people spend about two seconds on. Doctors spend very little time talking about it.
Dr. Eric Westman: None of my patients were able to change their lifestyle. I did not tell them what to do, but I told them to change their lifestyle. So that failure of having something that works apparently is not the doctor’s fault or responsibility.
Dr. Mariela Glandt: Exactly. The doctor does not know what to say. The advice that they normally give of eating less and moving more doesn’t work, and the doctor knows it. So they do not spend a lot of time on it so it is like it feeds on itself. I think if they had been exposed to it and had learned about it, then, what an amazing tool we have right in our hands.
Reading and a change in trajectory
Dr. Eric Westman: Absolutely. I helped influence your trajectory?
Dr. Mariela Glandt: Absolutely. You were very much at the beginning of my journey. You should definitely take credit for all the people that are benefiting now.
Dr. Eric Westman: I am passing along a baton in the great relay race. Thank you.
Dr. Mariela Glandt: I think we are still running together. I started reading, very early on, your trials and the books you wrote back then with Dr. Stephen Phinney and all these pioneers. When I ran into this I couldn’t sleep. I was in shock. I was like, what is going on? I had been practicing medicine for quite a long time, giving insulin, the whole lot like any doctor, and had no idea about this movement. It is not true that I did not have any idea because I had a friend, Jessica Apple, who was always talking about low carb, but you do not understand what that means. you are like, yes, of course, low carb. You should eat less sugar, it makes sense. The low-carb movement is so much more than that, and so much depth to it. So many things you need to understand because once you take away the carbs, then you have to add the fat, and what does that mean? What are the implications of that? It all gets confusing. It is not just about lowering the sugar. I had heard about it, but it was not until I ran into you and the real pioneers that I said, okay, I am doing something wrong. This got me into a whole year of reading and reading and understanding before I started implementing it in patients.
Implementing Keto to the patients
Dr. Eric Westman: How did you start implementing it with your patients?
Dr. Mariela Glandt: The story is actually funny. I had a patient that I presented at a conference once, his name is Hector. Hector had a cardiovascular history. He had an MI (heart attack), he had an infarction in the past. He was on insulin and GLP-1 and SGLT2 drugs, and the insulin was three times a day, short-acting plus long-acting, and metformin, the whole lot. He was well-controlled. He was 61 years of age. He calls me desperately saying my son was just diagnosed with type 2 diabetes, his A1C is 10, can you please see him instead of me because we have an appointment next week? I said that would be okay.
I sat with him and the son and I said, I know this is not what you expect from me, but I am going to tell you something different. I am going to give you meat and salad, and that is your medication. They left in complete shock. I put it very simply because he’s Argentinian, so it was convenient for me because he had a connection with the meat. What happened was that the next day, his wife barges into my office and she’s like, you are trying to kill my son. And I said, no, Sylvia, please listen to me. I think we have something here that can save your son from having diabetes. He does not have to live with it. He does not have to be like Hector. This was the beginning of a journey, and he did amazing. I was really lucky that my first patient did what I said and had such powerful results. He actually wrote about it. It was published in the newspaper in Israel because even his wife got pregnant after years of IVF. All these beautiful things happened as a result because they did it together. It was so reaffirming. I was lucky to have that first patient. That is how it started.
Dr. Eric Westman: Two of my patients did it without me. They lost a lot of weight and I asked them how they lost weight. It was not diabetes that got me into it. Back then it was very unusual, this is 25 years ago, to have one of my patients spontaneously lose over 50 pounds. It was a rare event. Now with the blood sugar measurement, did you incorporate the CGM, the continuous glucose monitor?
Dr. Mariela Glandt: I did not back then. It was already nine years ago, so it was not so common. We used it, but we started incorporating it later, so I was not using it yet.
Dr. Eric Westman: It would have been easier to reassure the mother that everything’s getting better if they had the daily view that the blood sugars are getting better every 10 minutes or five minutes.
Dr. Mariela Glandt: It is great feedback. It really helps to give that.
Dr. Eric Westman: I am reminded of the way I got into the management of diabetes. One of my friends, a doctor friend down the hall, had a patient whose A1c was 12 or 13. The blood sugars were 300-ish, that is milligrams per deciliter, three times normal. There was some miscommunication by my friend, who said, follow this list of foods. He basically got the list from my file cabinet and told the patient, go see Dr. Westman. It took three months for him to get into my office. My friend thought he would be able to get in next week. So without any insulin, without any monitor, he just stopped eating carbs, went to meat and veg, a little bit of vegetable, and his A1c went from 13 to 5.5 in three months. We violated so many guidelines – not on purpose, but it was that sort of mistake that got me thinking, you do not need to be monitoring so carefully as long as people are not eating carbs.
The implementation of this can be like in an underserved population where they do not have CGMs but they have access to food. My patient who used McDonald’s as the vehicle to get the meat is a great story because it does not have to be super clean expensive food.
Dr. Meriela Glandt: I just want to throw in there that you also influenced me there because I am now working with very underserved communities and McDonald’s is sometimes part of it, and that is what it is. But you work with it.
Dr. Eric Westman: It is a ‘compared to what’ situation. Would you rather, like in my area, have easier access to weight loss surgery because our insurance payment system is set up to pay for it, rather than allow someone to passively go to McDonald’s and just eat the meat?
Then medicines are brought with side effects and are expensive, so it is always ‘compared to what.’ Is McDonald’s the ideal place to get the food? Maybe not, but it certainly gets you to be able to reverse diabetes.
So, after patient zero, what happened to the father? I am very curious.
The first conference in Israel
Dr. Mariela Glandt: The father also adopted it and they started making recipes and they were very creative and were one of the leaders in Israel. It is a movement by the people. They hadn’t been influenced at the beginning of the movement and it has grown. We were so lucky to have you come to Israel and partake in the conference.
Dr. Eric Westman: Let us talk a little bit about that because that was in November of 2019. You invited a host of people. What got you interested in doing that?
How Dr. Mariela Glandt got interested
Dr. Mariela Glandt: I went to Low Carb USA in Boca a year before, and then I went to Denver, and I was like, this is so exciting, so thrilling, I have got to bring this to Israel. I called Gary Taubes. I said, Gary, I would like to do a conference in Israel, and he was great, let me help you. He sent out an email to you and others, and the next thing, I had 10 confirmations of people that were coming. I went home and I said to my husband, how are we going to pay for this?
Dr. Eric Westman: We did not all want to come and pay our own way. An expectation is that if we are invited to a meeting, at least the room and board would be covered.
Dr. Mariela Glandt: You guys were so generous. I find that in the low-carb period, the doctors do not get paid for their lectures, but the least you can do is pay for room and board.
This is how it started and I got together with somebody who was a believer in this. He is a very structured guy and he is a CFO of a big company and knows how to do things like this. We came together and we formed an NGO called Metabolix. We did not have anything to give people a tax break because it takes a year to get that. We started asking people if they would contribute to having a conference in Israel. I was lucky, the whole thing was paid for essentially by my patients. $150,000 came together, and so much generosity came from all sides. It was moving because one of my patients said, I will do the conference for you, it is going to be super easy because we know how to do this, and then I was like, no you do not understand, no Pharma here, this is not a normal conference. He was like, we will put it together with SK. I am like, no, you can’t. So she is like, what do you mean you are going to do a conference without Pharma? I was like, I am going to do a conference without Pharma,’ and that was insane. But we did it and it was so much fun.
Dr. Eric Westman: Most people do not understand how difficult and time-consuming it is, and how much money it costs to put on a conference like that. Thank you so much for doing that, I know it seems like yesterday.
Dr. Mariela Glandt: We had two more since and they were also fantastic. One was on Zoom. The last one was not but the point is that I think these conferences reinvigorate people.
Dr. Eric Westman: Do you think you will do some more conferences or are you burnt out?
Dr. Mariela Glandt: I do not think they will be happening in Israel, unfortunately. The situation is a giant disaster in every way, shape, and form. I do not see that happening right now.
Dr. Eric Westman: How about Madrid?
Dr. Mariela Glandt: We can do Madrid, but like I said, I am flying a lot to the United States so perhaps we will figure something out. Madrid also needs help.
How this knowledge is being shared with people and patients
Dr. Eric Westman: I am catching up on what you are currently doing. How are you organizing this knowledge and disseminating it to people?
Dr. Mariela Glandt: In the clinic – we have worked with around 3,500 patients on the ketogenic diet. Naturally, it grew when patients suggested making it more accessible, using technology and such. This led to a new initiative called Owna Health. Owna Health is a virtual platform that offers a service where we assist primary care doctors, who are often overwhelmed. They refer patients to us, we manage them through the app with daily communication, and then return the patients to better health.
Dr. Eric Westman: Reduced medication and all. I do not think any doctors are upset with me, except perhaps if LDL levels spike significantly.
Initially, were those thousands of people mainly diabetes patients?
Dr. Mariela Glandt: Yes, the majority had diabetes, but it was a specialty endocrinology clinic, so we had all sorts. We recently published our data a couple of months ago in January. We had to narrow it down to 344 patients, excluding weight loss and selecting specific time points for a six-month trial. It is not like a primary care clinic where patients are seen frequently, but the data is consistent with what we observe in the real world.
Dr. Eric Westman: Where was that published?
Dr. Mariela Glandt: It was in the Journal of Metabolic Health.
One interesting point from the paper is that, on average, we treated patients with 12 years of diabetes—some even with 35 years.
Dr. Eric Westman: It seems the duration doesn’t significantly affect outcomes.
Dr. Mariela Glandt: We can make a significant difference, though “reversal” is a tricky word, especially for those with 35 years of diabetes. Still, we can change the trajectory without a doubt. It is a matter of choosing to get healthier or older.
Statistics on how many patients stopped using insulin
Dr. Eric Westman: What about the classic statistic on how many stopped using insulin?
Dr. Mariela Glandt: 96% of patients improved, and I believe around 79% were able to stop insulin. The remainder reduced their insulin dosage substantially – from over 50 units to about 16. The decrease was quite significant. I did not prepare with these numbers, they are off the top of my head. I can send you the detailed version.
How to manage reducing medication
Dr. Eric Westman: This was a six-month follow-up, and in my experience, it may take longer, but nearly everyone can eventually stop insulin. It depends on factors like insulin resistance and obesity. It is important to manage expectations; diabetes might not reverse immediately, but we can certainly change its course quickly.
Sounds like you monitor closely. How do you manage reducing medication?
Dr. Mariela Glandt: I am often awake at night thinking about those who do not reduce insulin quickly enough. We manage it aggressively at first, usually cutting basal insulin by about 50%. I usually stop short-acting, but it depends on where they are starting. If they are A1c 7 versus A1c 11m I will have a different approach. I may not do that on the first day.
Dr. Eric Westman: If you have not watched us talk about diabetes reversal and deprescribing before, on the first day you change the carbs, you have to cut the medicine back. Otherwise, the blood sugar will go way too low.
I remember talking to a diabetes educator who got upset with me because she said, you have to give them carbohydrates or they will have a blood sugar that goes too low. And she thought she was saving lives because the endocrinologists put them all on medicines that cause hypos. Finally, I figured out, as we were chatting, well, no, you do not understand. I take them off the medicine that gives them hypoglycemia. I do not have to feed them carbs. Even then, she did not understand. You want a doctor or a practitioner who handles the medicine and the food at the same time.
Dr. Mariela Glandt: It does not exist that much. It is rare to find a doctor who enjoys talking about food because it is not part of our training whatsoever.
Dr. Eric Westman: Sometimes doctors do not talk about food and nutrition as we did not get exposure or training in it. Did you get any training in nutrition?
Dr. Mariela Glandt: None, zero.
Dr. Eric Westman: I was a history major in college, so at least I read back. What did they do a hundred years ago? When I got the book that said doctors basically cut the carbs out to treat diabetes a hundred years ago, I thought that was interesting.
Dr. Mariela Glandt: That is amazing. You are the one who found that piece of how people were being treated in the 1920s. That piece of paper is so incredible.
Dr. Eric Westman: That was brought to me by one of my patients who was a bookstore owner in a small North Carolina town. I was at the VA (Veterans Affairs) Medical Center at the time. She was one of my only female patients because at that time it was all men. This is 1990. It was all the veterans. And she brought in this little book and in there the treatment of diabetes in 1923 was basically what I was studying. Everyone thought it was so crazy and radical in the year 2000, yet it was common practice then.
It is as if the medical world doesn’t value anything other than randomized trials. And that means pharma is going to be riding high because they are the only ones, pretty much, that can afford randomized control trials. The Virta Health study, which was a controlled study, was not randomized, but it showed the reversal of diabetes. I have to imagine the real-world results and the results of the clinical practitioner will be superior to the Virta Health study because they have certain parameters they have to follow. And we can get to know people and talk to their moms or spouses and twist some arms here and there.
Dr. Mariela Glandt: Sometimes trials are better than real life. Usually, it is the other way around. We are doing a trial right now in West Virginia with patients on the CGM with diabetes and on insulin. We are using the platform, the remote monitoring, with the coach and a doctor Dr. Mark Cucuzzella and Amy Berger and it is great. This is just starting, but it is exciting to see.
Insulin and SGLT2
Dr. Eric Westman: I sidled up to writing a book with Amy Berger because she’s a professional writer. It was an award-winning book, End Your Carb Confusion. I am really happy to hear that you are working with her and then Dr. Mark Cucuzzella, who is in West Virginia now in the VA system there. He did a study earlier on handing out CGMs (continuous glucose monitors) to people, and people just started reducing their carbs, doing it with insulin, and it just means you need to watch and be more vigilant about the blood sugars and the medicines.
Dr. Mariela Glandt: Two medicines keep me up at night: SGLT2s and insulin.
Dr. Eric Westman: Insulin makes everyone realize it lowers blood sugar. If your blood sugar is under 100 mg/dL (5.6 mmol/L), do not take the insulin. What about the SGLT2 inhibitors? Tell me about that because I am not the only one who rants about this.
Dr. Mariela Glandt: Once you’ve seen a person going into DKA from this – the SGLT2 drugs – they artificially lower insulin. You urinate the glucose out and then your insulin goes down. It is backward. You can overdo it when you combine it with a diet. The issue is that some people I have seen come to me after they have the DKA. But I did have some cases at the very beginning.
As a clinician, you can’t breathe from the stress of someone in DKA that was caused by a medication. It is a very severe condition. And having uncontrolled fat being released from your fat cells sounds very much like a good thing. But it is not, because too many ketones and ketoacidosis, which is what all doctors fear. But sometimes those drugs are still a great tool. It is the art of medicine. Sometimes you do need SGLT2s because you have got to get those really high insulin levels to come down. And this is a way of doing it. But you have to be very, very careful.
Dr. Eric Westman: I remember 15 years ago, I went to a local drug company and said, look what I found. This low-carb diet. They looked and they said, but the LDL went up 5%. We can’t do it. We can’t look at it. That is a deal breaker with the FDA. Like, “Well, then what are you working on?” And they said, “We have this great drug that leaks glucose into the urine so people can just eat whatever they want and they just pee out the glucose and it fixes diabetes.” And I am thinking to myself, “This is not a good idea. You do not want to mess with this.”
And what else leaks glucose into the urine? The SGLT2 inhibitors are very popular among heart failure doctors and diabetes doctors. But the consequences and the side effects of these drugs can be quite disastrous. I had never seen ketoacidosis in a keto clinic until one of my patients went on these SGLT2 inhibitors. From the paradigm of “medicines come first,” a case study published of the keto diet causing ketoacidosis in someone on an SGLT2 inhibitor. They both contributed, but it blamed the diet because drugs come first.
Another interesting thing, the initial Virta approach, I do not know what they are doing today, is that they, at least, are monitoring people and then they had a paper on predicting who would come off those medicines first. So, even then, as a corporation, they did not say, do not use SGLT2 inhibitors, they are saying, we’ve got to be careful about these and taper people. But in their first paper that they published, the Virta Health study, they showed the ketone levels of the individuals in the study, and in the little figure, it said, these people were on SGLT2 inhibitors and they had higher blood ketone levels even in that study. It was not a huge study, just a couple hundred people.
If you are watching this, and you are on Jardiance or Farxiga you need to be careful of these drugs. I do not prescribe Farxiga. I did not know what Fournier’s Gangrene was growing up in the ’80s and ’90s in clinical practice. We never saw anybody with this. This is a genital infection that may be life-threatening.
I’ll say one-on-one in the clinic, it can cause ketoacidosis, and people kind of gloss over. No one knows what it means. And then I’ll say, it could give you a genital infection. You could die from it. Other people say, Dr. Westman, you are overreacting to this. No, it is so common.
Dr. Mariela Glandt: You know what is ironic about it? It actually raises LDL.
I discussed this drug with Steve Phinney, and he called it “stealth keto.” It does exactly what we do in keto, but only a small amount. Keto will lower everything much more powerfully. It is a much more powerful tool. But, like keto, it will increase your LDL because it improves the quality of your LDL. But no one talks about it.
Dr. Eric Westman: Keto doesn’t give you the glucosuria, the glucose in the urine.
Dr. Meriela Glandt: It is just ironic that nobody talks about the fact that this drug raises LDL. I think that is crazy because, you know, it is such a great parallel to keto that keto’s ten times more powerful. Why wouldn’t you use keto?
Dr. Eric Westman: Because perhaps one can’t make money from it.
The other interesting thing about the medicine is that the reduction of heart failure events is being turned around, and they are thinking that maybe this reduction in heart failure is actually from the ketosis that the drugs cause, getting to that idea of stealth keto, meaning the drug is giving you the benefit of a keto diet. Now there is a funded study of using a keto diet with and without supplementation, I think, for heart failure. So it took a drug and a side effect of the drug to get the powers that be to do a study. It is still minor. It is Steve Phinney and Jeff Volek who are the PIs (principal investigators) of that study. It is not like the pharma scientists are suddenly studying keto diets.
Dr. Mariela Glandt: Let us not get excited yet.
Dr. Eric Westman: I scratched my head to think why do basic scientists not study the keto approach? Not to implement it, but to see what happens, see what the changes are, because so many things change favorably. You can probably figure out a new drug, mechanistically, based on the effect of a keto diet.
Dr. Mariela Glandt: I do think it is happening. The conclusion is always related to a drug. For example, you see that beta-hydroxybutyrate (a ketone) decreases reactive oxygen species and this leads to an improvement in insulin resistance. So instead of saying, isn’t this great, let us create our own ketones, the answer is, let’s find drugs that let us do this. The scientists are there. More studies need to be done and hopefully new opportunities for molecules, etc. I do think that it is a movement and in curiosity because if you look at the publications over the last 25 years, there is a huge surge in basic science when it comes to the ketogenic diet.
Dr. Eric Westman: Also in the mental health area. The wealthy family of someone who was transformed by a keto diet started a foundation. As Chris Palmer says, mental illness is just a metabolic disease of the brain. And that is a funny thing for us. We are internal medicine specialists, and it kind of ends here. When you get to the brain, suddenly you are a neurologist or a psychiatrist. But it is all connected.
Dr. Mariela Glandt: That is also what keeps this field interesting. We keep learning about new things.
Where to find Dr. Mariela Glandt
Dr. Eric Westman: In wrapping up, how do people find you and what is your latest information and your clinical programs?
Dr. Mariela Glandt: One way is to go to Owna, owna.health and you could leave a message there. The website is a little bit of a temporary website, but definitely a way to get in touch with us easily in the United States. We are very active in the Bronx (in New York) in the United States, which is where we are doing our big pilot. They are seeing some amazing changes. We are also treating all sorts of patients everywhere. So come to owna.health and send us a message.
Dr. Eric Westman: It has been a pleasure to talk to you and all the best as we go forward learning.
Watch the video here.