Introduction to Dr. Tro Kalayjian
Dr. Eric Westman: It’s my pleasure to speak with Dr. Tro Kalayjian today. How are you doing?
Dr. Tro Kalayjian: Thanks for having me on. It’s been great working with you on this new position statement and just happy to be here.
Dr. Eric Westman: The Type 1 Diabetes position statement from the Society of Metabolic Health Practitioners just came out, and it’s creating ripples. Before we get to that, imagine you’re talking to a group of my patients who don’t know who you are, never heard of the Low Carb MD Podcast, never heard of Dr. Tro, and what you’ve done. Where did you get started, and how did we come to meet?
Dr. Tro’s background history
Dr. Tro Kalayjian: My name is Tro Kalayjian. I go by Dr. Tro on social media. I am a board-certified internal medicine doctor. I trained in the Yale-New Haven hospital system. I was a chief resident at Greenwich Hospital, in Internal Medicine.
After I found myself a 350-pound doctor, I was challenged by my wife to sort of understand obesity like I understood all of medicine. My wife, who knows how to manipulate me quite well, really played on my arrogance, my New York City arrogance, and she said, “You’re so smart. You got in the 90th percentile in your board exam, can you figure out obesity like you know the rest of medicine?”
That’s where my journey started over 10 years ago. I was 350 pounds. I went to the literature at that time, and lo and behold, I read all of your work. I subsequently read your textbook on obesity and all the studies you did yourself, Yancy, Gardner, at the time, the A to Z trial. I went through the systematic medical literature. I just wanted to know what would help me. When I turned to the medical literature, I took the approach that this was an antibiotic for pneumonia. I wanted to see, head-to-head, what was the best. I wanted to go with what was the best. As I looked into the interventional data, what I saw was every interventional trial showed one conclusion, but all the guidelines and observations had another conclusion.
So I went with what I thought would help me, which was the interventional data. I ended up doing a low-carb diet, really relying on Atkins, yourself, Yudkin, and Yancy, and the rest was history. I lost 150 pounds. I became a certified personal trainer, a certified health coach, and obesity medicine certified because I had a new lease on life.
My kids got to see me go from an old, tired, achy, 350-pound dad, who was barely around because he was overworked, to a healthy person who has a new lease on life. I couldn’t practice the same way. For several different reasons, I left traditional and academic medicine and pursued private practice.
I now have a nationwide telemedicine practice with myself, Dr. Laura Buchanan, and a PA. We have four health coaches, all of whom have lost weight. Our team has collectively lost 700 pounds. Our four health coaches are personal trainers, and we provide comprehensive, nationwide care with more of a focus on employers.
We go directly to employers. We tell them, “We have a track record. Here are our results in people who are overweight or have metabolic syndrome, and here’s how much money we save, from the prescriptions that are no longer needed.”
So our focus over the last two years has been adding a seventh, eighth, and ninth employer now. I started seven years ago with the Low Carb MD Podcast, on which you’ve been twice or three times, which we’ve been grateful for. We’ve had the pleasure of working together, I think, on three or four papers now. Your leadership and guidance have meant a lot to me, so I just have to say it: I thank you for everything you’ve done.
Dr. Eric Westman: I’m just passing along a baton in this relay race.
When you started, it’s fascinating, did you get nutrition training at all in practice or in medical school? What was your undergraduate degree?
Nutrition training and undergraduate degree
Dr. Tro Kalayjian: I had an undergraduate degree in health science, where nutrition was one of my courses. I went to an osteopathic medical school, which has more of an emphasis on both diet and manipulation, and exercise. There’s a bit more of an emphasis on that and anatomy as well.
I trained in an allopathic internal medicine residency program in the Yale system, so I’ve experienced all the different worlds. I look back, and it was basically vitamin deficiency, that was it. That was the extent of it. There was no medical nutrition therapy taught in any systematic way, and I had to learn that on my own.
It wasn’t even taught in obesity medicine education. Which is, as you know, being a prior president of the OMA, it’s basically soups and shakes and drugs. So it’s all self-taught.
Dr. Eric Westman: In internal medicine, even to this day, I’m in the internal medicine division that teaches at Duke, we basically teach medications and medication care, and I’ll joke with my patients as I have them write out what they eat over the course of a day, “Has any other doctor ever asked you what you eat over the course of the day?” Usually, they’re like, “No, they just say what kind of diet am I following,” and, “Just eat less and exercise more.”
When you got started with this, it was your family member who challenged you to learn about this, not your workplace, not doctors or patients. That’s great!
It was two of my patients that got me to learn about this as they lost weight in front of me. It’s great that you went to the literature looking for what was best. By that time, there were a dozen studies of low-carb diets, ours being one or two of them and they all beat out a low-fat diet.
Nobody knows what a Mediterranean diet is, so, with that, getting to internal medicine now, the treatment that both of us do with our patients, it’s pretty remarkable, isn’t it?
Internal medicine
Dr. Tro Kalayjian: I can tell you I went through training and 10 years as an attending, and it wasn’t until I emphasized nutrition and lifestyle that I saw any disease improve or reverse. I mean, full stop. I had never seen diabetes reverse, only saw it progress. Never saw hypertension reverse, only saw it progress. Never saw obesity reverse; I had only seen it progress.
Unfortunately, it’s the same with alcoholism and cancer, psychiatric illnesses, the list goes on and on. It’s disheartening being a doctor, wanting to go into a profession of actually healing, and then never doing it.
Dr. Eric Westman: Well, we were managing people with medicines. Isn’t that fun? No, it’s not fun.
A lot of doctor friends in my area just get used to that, of not fixing anything. I think there’s a lack of awareness among doctors that you can reverse diabetes, hypertension, all these other problems, obesity, of course, by lifestyle change. Is that your experience, that other doctors just don’t know about it?
Do other doctors know of lifestyle changes
Dr. Tro Kalayjian: I think not only do they not know, they’re apprehensive – like it’s as though something shifty is going on. I’m happy that they are skeptical, and that’s why I think you published what you published. That’s why I’ve always published.
We do case series of our results and case reports and retrospective analyses just to show people what we do so they can see it in the peer-reviewed literature and not have to trust me for it. That’s been a passion.
Dr. Eric Westman: Yet, there’s a failure of belief in the literature. Even some people are skeptical of the drug companies and their papers. To have the daily reversal of diseases that we have it’s pretty amazing to me that it’s been underappreciated.
I’m happy. And there is a pressure point for companies, companies that are self-insured in particular, because they can do things outside other insurance systems. Then they save the money if they spend less on it.
It occurred to me some time ago that health insurance doesn’t really care if we help out. That’s kind of odd, but they don’t mind just managing the diabetic and building more dialysis centers and all that. But a self-insured company, and the individuals themselves, should mind, right?
Tell me some pearls from the Low Carb MD Podcast. You’re talking to doctors, you’re talking to patients, you’re getting a lot of feedback there. What have you noticed changing from the podcast?
Low Carb MD Podcast
Dr. Tro Kalayjian: The podcast has run for over six years now, and we’re in our seventh year, with over 10 million downloads. I’ve had the opportunity to interview over 350 amazing people. About half of them are doctors; the other third are scientists or sort of advocates, and then a third are patients with remarkable stories or challenging stories or having difficulty.
It’s been fantastic to be able to network, meet people, and share some pearls like you do with this Adapt podcast. It’s been great to be able to sort of reach out and reach people. We have no commercials. We’ve never accepted any sponsors or commercial interests. It’s 100% funded by the listener. At least the listener can know that it’s not sponsored by an electrolyte company, a vitamin or supplement company, a green shake company, or anything like that. They’re getting unfiltered, uncompromised input. It’s been great. It’s been awesome.
Dr. Eric Westman: I have a vague memory of one of the first times we met at a meeting, and I, not being into the internet podcast world, was skeptical and thought, “Who is this Dr. Tro, putting himself on the podcast and Low Carb MD?” But I’m so, so impressed with what you’ve done, and I apologize for any early missteps or misunderstandings. I should have been supportive. But I was apprehensive about internet podcasts and all. It was only after watching Low Carb Diabetes.co.uk be online for a decade without harming people with diabetes, talking about low carb. That’s my concern. That we will teach someone who’s on way too much medicine and not teach them how to get off the medicine, the deprescribing, quickly.
It’s really helped that we, as practitioners, are all coalescing together in various places, one being the Society of Metabolic Health Practitioners. That’s the guideline that just came out, and thank you so much for putting together the Type 1 Diabetes consensus statement or guideline statement. It’s published in the Journal of Metabolic Health, and you can go to the journal’s website and look it up right there.
How did the Type 1 Diabetes consensus statement come about from the SMHP?
The coming about of the Type 1 Diabetes consensus statement
Dr. Tro Kalayjian: This was Adele Hite, whom we both know. This was her dream: to create a Metabolic Health Consortium and really start to make disease-specific guidelines. She and Sarah Hallberg, the late Dr. Hallberg, and the late Dr. Hite, both of them were doctors, and this was their dream.
When we came together and formed the Society of Metabolic Health Practitioners, which all of you listeners should go visit at thesmhp.org it became a platform for uniting metabolic health practitioners. Look them up, visit the site, and consider a donation. It’s a not-for-profit. What we do is educate doctors, and bring them together, and we also have a sister journal, the Journal of Metabolic Health. The idea is to unite the metabolic health movement and work on projects like what we just did, what Adele had envisioned, and what Dr. Sarah Hallberg had envisioned.
If you’re a health coach, personal trainer, or an average person who wants to be an accredited Metabolic Health Practitioner, you can go and become accredited, which is really cool. If you want to start helping people and gain some certification, the Society of Metabolic Health Practitioners makes that possible. You and I have been on the board now for a number of years along with so many others.
The Type 1 Diabetes consensus statement came together when we received a lot of interest around Type 1. This happened about a year ago at the Boca Conference. If you’re a listener, we had an amazing conference in Boca that everyone should go to. While advertising this type 1-focused conference, we received significant interest in collaborating and starting a project like this. Many amazing people came together, including yourself as a senior author.
Contributors included Dr. Laura Beunin, Ian Lake (a doctor with Type 1 from the UK), Evelyn Bordua Roy (a Canadian doctor), David Dikeman, who’s written a paper with you and has been on your podcast, Dr. Robert Cywes, Mark Cucuzzella, Matt Calkins, Beth McNally, and many others. After the conference, we worked collectively to identify the gaps and develop a consensus.
For the average listener who knows nothing about type 1, here’s what you need to know: type 1 diabetes is an autoimmune disease where the body attacks the pancreas. The pancreas’ beta cells, which produce insulin to regulate blood sugar, start to die off. There are some antibody tests that can help diagnose it, but often it presents like the flu. Many people end up in the hospital dehydrated, with blood sugar levels over 400 mg/dL (22.2 mmol/L), and then learn they have type 1 diabetes.
Now, unlike type 2 diabetes, which, thanks to the work of Dr. Yancy, your colleague at Duke, now has clear recommendations that a low-carb diet works and is effective. Type 1 has no specific dietary recommendations. The ADA acknowledges that low-carb works for type 2, but simultaneously suggests three other high-carb diets, making it confusing.
In type 1, there is no clear recommendation for any specific diet. As a result, endocrinologists, pediatricians, and dietitians often default to USDA guidelines, which are high in carbohydrates. What happened is these patients are forced into a higher carbohydrate diet by default. That’s one issue. The second issue is their health outcomes have been disastrous. People with type 1 diabetes die 20 years younger than the average person. If you’re in a third-world country or a country with less access to medicine than the United States or some European countries, you could die 40 years younger than you should.
The damage from high blood sugar is devastating. To the eyes, where you can experience blindness; to the kidneys, where you can experience renal failure; and to the nerves, where you can lose feeling in your limbs, possibly resulting in amputation. The rates of these complications are tenfold higher. It is truly terrible.
In the United States, where we should have the most amazing outcomes for these patients, with insulin pumps, closed-loop systems, and the availability of insulin, the average A1C is eight. This is almost three standard deviations out from normal. This is a huge problem because our current approach is producing disastrous results. An A1c of 8 means a patient with type 1 is going to die young. They’re going to experience blindness, not to mention the comorbidities associated with type 1 that often go unrecognized like anxiety, depression, and constant fear of blood sugar fluctuations. It is a truly terrible life.
To be told by a dietitian, when you want to go on a low-carb diet, that it’s an eating disorder or inappropriate because you have type 1, is a crime. That’s the passion with which this consensus statement came from.
Type 1 diabetes
Dr. Eric Westman: The science is so solid here. Diabetes, even type 1, is a problem of excessive blood sugar or glucose. So, you’d think it would make sense to lower the glucose and sugar in the foods. Especially in type 1. I learned this first through Dr. Bernstein, who wrote the book The Diabetes Solution. He’s been practicing out of his office on the Long Island Sound in Mamaroneck, New York. I visited him 20 years ago, and just a couple of years ago, I went back. He was still at the same desk in his same house.
Dr. Bernstein, who just turned 90, has type 1 diabetes himself. He wrote a book and developed a following, and some followers helped get his information onto Facebook and the internet. We surveyed the followers of Dr. Bernstein and published that paper. Belinda Lennerz and David Ludwig at Harvard got it into the journal Pediatrics. It was the most cited paper of the year.
I remember the rebuttal article to the survey of Facebook folks following low-carb diets with type 1 diabetes. Their A1cs were normal, and on average, they were using 25 units of insulin a day. The rebuttal argued that these weren’t “normal” people; they were “superhumans,” and mere mortals couldn’t achieve this while using medications.
Again, the powers that be in the pediatric world for type 1 are medication-focused. Yet, parents told me at the Boca meeting, this is Boca Raton, Florida, where the SMHP has a meeting once a year on the East Coast, and another on the West Coast in San Diego, that they go to their pediatrician with normal blood sugars and low hemoglobin A1cs, and the doctors suspect them of mistreatment.
The reasoning is that nobody has blood sugars that low. The doctors assume the patients are balancing hypers with hypos. But when the parents show the glucose monitors, the doctors freak out. I don’t get it, except that I remember 20 years ago, when I started with this, how long it took me to get used to the idea that some people have an elevation in cholesterol. Now we’re learning that it’s probably not as bad as everyone said it was going to be. I know it’s not as bad.
I remember treating someone with type 1, a young man, and I was worried because his LDL cholesterol went up. I wonder if that’s one of those guardrails that make pediatricians not consider low-carb diets. Of course, not everyone has that sort of cholesterol elevation. But hearing these parents say that they’re often told by doctors to stop what they’re doing because their blood sugars are “too good” is crazy.
Dr. Tro Kalayjian: I think you hit the nail on everything that matters. The position statement outlines all the literature to date that supports a low-carbohydrate approach in type 1. That doesn’t mean there aren’t questions remaining or that more research doesn’t need to be done.
But this group, which included patient advocates and patients with Type 1 diabetes, came together. Family medicine doctors deal with everybody, from pediatrics to OB, including internal medicine doctors. There were also doctors from other countries, including Canada and the UK, as well as researchers from South Africa and all the way to Montana.
Position statement
When we started this position statement, the goal was to get metabolic health-oriented doctors and a group together to figure out what we agreed on. The outcomes were unanimous. You were on those emails and in those meetings where we surveyed everyone. The consensus was that low-carb diets should not be withheld. Every single endocrinologist, pediatrician, and dietitian needs to offer it as an option in relation to the current status quo, which is largely unacceptable.
That doesn’t mean that issues may not arise, and it doesn’t mean that more studies don’t need to be done. However, there is no evidence to suggest that the current diet is the ideal diet. In the absence of such evidence, we should fall back on the best evidence available. The best evidence available suggests that a low-carbohydrate diet is absolutely feasible, safe, and has the best potential in the literature.
It could be that not everybody can do it, and that’s fine. Those people can eat the way they feel most comfortable, and their clinical teams, their medical teams, can continue using the current carb-counting approach if they want. In addition, they should be offered a low-carbohydrate approach.
It was hard to get 15 people to agree, but I think we agreed on most things. The statement is pretty strong, and hopefully, we can raise some money to do research. There is already research and head-to-head studies showing that low-carb diets improve the “time in range,” which refers to the amount of time blood sugar remains between 70 and 180. A normal range for blood sugar is 70 to 120. We have the evidence to say it will improve the time in range. It would be great to add to that body of literature with more studies so that we can definitively say it doesn’t cause hypoglycemia, there’s no evidence of that, and we’d like to firmly state that. We also want to be able to say it doesn’t increase the risk of DKA. Again, there’s no evidence for that, but we can tease these things out in the literature, hopefully.
Dr. Eric Westman: I did a paper with David Dikeman, one of the authors of the survey who helped with Dr. Bernstein. We basically did a power calculation, meaning we looked at how many people would need to be in a study to show that the low-carb diet has better A1c control than the standard American diet. There were around 50 people. That’s very similar to the study we did on type 2 diabetes, comparing low glycemic keto to low glycemic diets. You don’t need many people to show a benefit.
Children with Type 1 diabetes
If I could, with a magic wand, dream up and carry out a study, it would be randomizing people with type 1 diabetes to a low-carb diet or the recommended diet. You would look at insulin, time in range, hypos, and patient satisfaction. What I learned from parents is that they’re deathly scared that their children will have low blood sugars in the middle of the night. If you don’t have type 1 diabetes or don’t know anyone with it, you might not realize that if children have very low blood sugar at night, it can be lethal. At a minimum, it could be very harmful. Some of these parents are measuring their children’s blood sugars at night with glucometers, which now allow them to monitor without waking the child for a finger prick.
What I experienced was parents telling me they were relieved now that their children don’t have these nighttime hypos anymore. These hypos often happen because of all the carbs going in and the insulin being given, which was one of Dr. Bernstein’s teachings from a long time ago.
The parents really helped me understand. I kind of knew the complexities of the problem, but many people come into this not knowing what to do. They look to their doctor almost like they’re looking for religious advice. If the doctors aren’t saying that low-carb is okay, they won’t do it. They’re under the fear of this disease.
The Dikeman family wrote a course to teach parents how to do this. I watched the course, and at first, they were told the exact opposite. They were told that David could have pancakes and sugar all day long. It was actually David who came up with the idea: “Why don’t I just not eat sugar?” The blood sugars then stabilized dramatically.
The confusion from the medical world is apparent. As I looked over the consensus statement, it struck me that we don’t have a pediatrician on it. That didn’t hit me until recently, but it makes sense because the mainstream pediatric paradigm doesn’t include the low-carb diet, does it?
Dr. Tro Kalayjian: That was the paper we wrote together earlier, published in the Journal of Metabolic Health, criticizing their consensus statement. The AAP (American Academy of Pediatrics) has been under a lot of scrutiny lately. You may have seen them in the news for a number of comical hearings involving their executive and lead committees. They put out a consensus statement in late 2023 saying low-carb diets require 20 labs and an imaging study to be done safely. If you want to do bariatric surgery on 13-year-olds, go right ahead. That’s just me exaggerating, but it’s not far from the truth.
Dr. Eric Westman: For those unfamiliar, the AAP stands for the American Academy of Pediatrics.
Dr. Tro Kalayjian: Correct. When you look at the people who write the guidelines for low-carb diets, these are often individuals who have taken over $200,000 from pharma companies. These individuals really have no experience with metabolic health and have certainly never lectured on the topic. The authors of that consensus statement omitted several important studies and focused on some very obscure literature bodies.
The problem is exactly what you said: if you’re a patient out there right now, listening to this, and you have a family member with type 1 diabetes, they will likely be told to eat Oreos and dose insulin. What that means, just so everyone knows, isn’t that I’m trying to take anybody’s Oreos away. I’m not. But what happens is that these individuals live in fear. Their blood sugar spikes, so they have to take a lot of insulin. Then, they live in constant fear that their blood sugar is going to crash, especially at night.
The families are afraid. The parents are afraid that their child might die at night. They’re also afraid of the child getting very ill. It doesn’t feel good to go into hypoglycemic shock. There is a lot of stress around this because the doctors don’t know enough to offer better alternatives. They could simply say, “If you really want a cookie, try making it with almond flour and some sweetener.” It’s not hard to do. This is accessible, and people can manage it.
In fact, we have a great endocrinologist, Dr. Mariela Glandt, who has successfully implemented this approach for patients on SNAP benefits in the Bronx. This demonstrates that the low-carb approach is accessible and achievable for any socioeconomic group. It stabilizes blood sugars, and the quality of life appears to improve significantly. Every single patient with type 1 diabetes deserves to be offered this as a solution.
You’re absolutely right. Putting together all the studies in support of this approach was a monstrous learning experience for me. Getting these groups together, talking to them over Zoom, taking notes, drafting the paper, iterating on it over several months, and coming to a consensus was an enormous undertaking. We sent surveys to the entire team of doctors, advocates, and scientists, reviewed their feedback, and asked reviewers to critique it thoroughly. After they tore it apart, we revised it, conducted further surveys, and reached a consensus in an organized way. This is called the Delphi methodology, which is a standard for reaching consensus in medical literature.
This was a huge project that took countless hours. I’m grateful that you guided me through the entire process. The outpouring of support since its publication has been incredible.
If you’re listening to this and have a family member with type 1 diabetes, go to the Journal of Metabolic Health or the Society of Metabolic Health Practitioners (SMHP). Download the paper and share it with your family member. Tell them, “You have help now. You have a team of doctors and scientists who say your doctor should support you in this approach if you choose it.”
There’s another amazing group that I’m not a part of but feel compelled to mention because they’ve done fantastic work. On World Diabetes Day, IPTN in Canada, our sister group, put together an excellent “how-to” resource. This was led by Beth McNally, Franziska Spritzler, Andrew Koutnik, and Caroline Roberts. They did a phenomenal job. I hope we can include links to their resources so that people with type 1 diabetes have access to both the SMHP and Journal of Metabolic Health materials position statement and then this “how-to” for your dietitian and doctor, spelling out exactly how to help you do this diet, these are two amazing resources.
I’m the corresponding author, so you’ve been spared all the emails, but the emails! They’re so thankful. You know, “I’m a patient with type 1. I’ve lived with type 1 for so long. Thank you for doing this. My kids thank you. We needed this.” I can’t tell you how appreciated this has been by the type 1 community, which has been ignored.
Dr. Eric Westman: I hope that some young investigator in the academic world who wants to get started will see this and realize it’s kind of a slam dunk. One of my colleagues once said I was “shooting fish in a barrel” when I did my first study because I visited Dr. Atkins, learned what he did, and then published papers based on that. Shooting fish in a barrel means it’s not hard. It’s a slam dunk to beat out the other diets with a low-carb diet when treating any sort of diabetes, including type 1 diabetes.
Now you have the roadmap. You have the literature review from the Journal of Metabolic Health and then the actual research protocol and the IPN manual on how to reduce medications, that sort of thing. What’s kind of crazy is that the grassroots world is already doing this, right? And yet, to get the academics, the mainstream pediatricians, and the pediatric endocrinologists on board, you need to get those studies done through the system. I think that’s going to happen; it just takes so long for it to move forward.
I’m getting people talking to me about things we’ve been doing for 15 years, but they’re just now doing them in study form, thinking it’s something new. Take, for example, the fatty liver issue, where there are new drugs for fatty liver. No, low-carb fixes fatty liver. These are things we’ve already been able to address.
Funding
The thing that needs to happen is funding. Funding needs to become available for this. Yet, the catch-22 is that you don’t get funded unless you send in a grant requesting it. Sometimes an organization will send out an RFA (Request for Applications). Let’s say you’re watching this, and you’re in charge of an organization’s research portfolio, send out an RFA that says, “We need to study low-carb diets and type 1 diabetes.”
If you’re an individual, you can still do this without waiting. But you’ll want to approach it with someone who has experience in this area. Parents have created organizations, Facebook groups, and teaching classes to help out. I’ll put down as many of these resources as I can in the description below.
Dr. Tro Kalayjian: My hope is that we can bring more attention to the SMHP and all the grassroots organizations out there that want to embrace metabolic health. They need to know what we can do. We want to continue advocating, for those with food addiction, type 2 diabetes, hypertriglyceridemia, and others who are told not to try a low-carb diet. We want to do a lot of advocacy, but we need support. We’re not going to be able to do this alone, at least not at this level. There are so many other levels we need to reach.
As you said, the research needs to be done. The hope is that we can continue this sort of advocacy in the literature and, hopefully, in the research realm as well. I’m just excited. I’m happy for the type 1 community. I’m happy this project is out. I’m happy that you’ve offered to bring me on here to talk about it. I’m happy for every type 1 patient, or maybe even a severe type 2 patient whose diagnosis borders on type 1. Whatever the case, now you have a position statement in the medical literature.
When you go to your doctor and say, “I had a hospitalization due to hypoglycemia because of the high-carb, carb-counting insulin-dosing strategy you recommended. Why didn’t you offer me this?”, now it’s in the literature. I think we’ve evangelized a huge community to advocate for themselves with nutrition.
Stump the doctor question
Dr. Eric Westman: Thank you so much for your heavy lifting on this and pushing it forward. Before you go, I have a “stump the doctor” question for you.
A patient came to me. She had anemia for seven years and no one could figure out the cause. She went to hematologists, who said she wasn’t making iron. They gave her iron infusions, but she couldn’t absorb them. She went to GI doctors to ensure her GI tract was fine, and that there were no cancers, no bleeding, nothing of that sort. Then, she went on a carnivore diet. She tells me this story: in two weeks, it was fixed. Seven years of iron deficiency anemia and a carnivore diet fixed it. So what’s your diagnosis?
Dr. Tro Kalayjian: I know the answer. The first diagnosis I had, it’s celiac, right?
You know what the diagnosis is: a really crappy medical system.
Dr. Eric Westman: No, it was the best medical care you can get.
No, it was missed gluten enteropathy, or celiac. And remember, the garden-variety workups don’t always include a duodenal biopsy, right? The person should have gone up the tertiary care ladder a little bit, right, for the diagnosis.
But how could a carnivore diet fix gluten enteropathy?
Dr. Tro Kalayjian: It doesn’t have gluten! Of course, it’s an elimination diet, a gluten-free diet.
I would say, the one thing that, excuse me for being such a rough New York City doctor, but I’m sorry, that’s a failure at the highest level. I don’t know what institution this is, I’m not trying to knock them. But this is a failure of doctors to listen, think critically, and think differently.
I would feel a little better if she menstruated regularly, right? This is a huge miss.
Dr. Eric Westman: It’s just an example of a low-carb or carnivore diet – it’s a gluten-free diet, it’s a sugar-free diet. So, FODMAP, the diseases associated with that, and it’s an artificial-dye-free, preservative-free diet, depending on how you do it.
It’s really an elimination diet of so many possible offenders. You got it right off the bat. I didn’t have to give it to you, but then you’re a former chief resident, and me too, where we would come up with cases to try to stump other people.
A case for Dr. Westman
Dr. Tro Kalayjian: So, I got a case for you then before we leave, okay? And, if you read the paper I sent you that I published then you’ll get the answer.
I had a 30-year-old patient come to me with amazing weight loss with a low-carb diet but persistently elevated blood pressure.
And he still had some signs of insulin resistance, including stretch marks on his abdomen.
He showed me his weight loss during our first visit. He had a hospital’s documentation from his hospitalization due to a hypertensive emergency on three medications, and three blood pressure medications, which he shared with me.
During that hospitalization, he had a fairly robust workup and was told to go on a low-salt diet and lose weight. He was discharged with no answers. Followed up with a cardiologist with no answers. And followed up with his primary, who said, “Count your calories, keep up your weight loss, and stick to your medications for blood pressure management.”
In my office, now down 30 pounds, his blood pressure was 200 over 100.
On examination, his abdomen had purple markings. And he shared with me, he was so adamant, and he’s like, “Doc, can I share with you? I posted on all social media all the carnivore meals that I’ve had.”
And he showed me all his carnivore meals on his social media account. And there was an old picture of him. Despite being 30 pounds heavier two years prior, his jawline was much more clear, and his face was very round compared to that picture despite the weight loss.
What is your diagnosis, doctor?
Dr. Westman gets the correct answer
Dr. Eric Westman: You’re going down into the metabolic problems that we all learned in residency. Did he have elevated blood glucose?
Dr. Tro Kalayjian: He did have an elevated morning glucose.
Dr. Eric Westman: And did he have a buffalo hump?
Dr. Tro Kalayjian: He did have a bit of a fat pad on the back of his neck.
Dr. Eric Westman: I’d be very interested to do cortisol testing to see if this was Cushing’s.
Dr. Tro Kalayjian: His cortisol came back wildly elevated.
Dr. Eric Westman: Mildly elevated?
Dr. Tro Kalayjian: No, wildly.
Dr. Eric Westman: I would be very interested in his cortisol level. Does he have Cushing’s?
Dr. Tro Kalayjian: He absolutely has Cushing’s. His cortisol level was wildly elevated.
Dr. Eric Westman: This is a good point that if you’re complicated , you have medical issues, or things aren’t going as expected, see a doctor.
We’re giving mixed messages. Many times we’re saying don’t see the doctor, but no, see the doctor in this case.
So, was it primary or secondary, or was there an outcome that helped with the hypertension?
Dr. Tro Kalayjian: I’ll send you the paper.
Despite seeing a cardiologist and his primary (care doctor), several times, and a hospitalization the diagnosis was missed. It was made by a chance finding that his face was bigger in my office. Despite losing weight, he had a moon face. It was just because I had the time to look through his social media and compare his picture from when he was heavier, which had a straight face. It turned out that when we looked to see if his cortisol was high just because he was stressed out or if it was due to a problem, we gave him steroids to see if his cortisol would suppress, and it didn’t. The adrenal glands should stop making the stress hormones if you give them a bit of steroids, and it was high.
Then we found out that he had a brain tumor. We did a test to make sure that the tumor we found in his brain was producing the hormone that would make more stress hormones in him. He went and got the tumor removed through a procedure in his nose.
Now, he is off the three medications, and he is doing fantastic. He’s doing great.
You had the right diagnosis.
Dr. Eric Westman: The purple stretch marks on the abdomen are often kind of non-specific, even though we say that’s common with Cushing’s. I see a lot of people, I’m sure you do, who do have some stretch marks, and they don’t have Cushing’s.
Don’t worry. Not everyone is going to go home and look at their stretch marks. I think the telltale sign here, or what’s different from what I normally see, is that really high blood pressure.
Thinking back to renal alkalosis. That coarctation of the aorta. I think we always need to think about those.
Dr. Tro Kalayjian: Those were ruled out, thankfully, in the hospital, where they told him to reduce his salt and lose weight.
Dr. Eric Westman: The last one was the pheochromocytoma, right?
Dr. Tro Kalayjian: Correct.
Dr. Eric Westman: Up and down and even hot flashes, that sort of thing. What a great “stump the professor” case, although you gave me an easy one.
Dr. Tro Kalayjian: It was an easy one. I knew you’d get it.
Dr. Eric Westman: Have you done this on the Low Carb MD podcast, where you have cases?
The world is really interesting. There’s a Curbsiders podcast that young doctors listen to. My nephew, who is a young doctor and internist, actually heard Dr. Yancy, my colleague, on Curbsiders being interviewed.
Suddenly, my nephew was like, “Hey, Uncle Eric! Dr. Yancy’s on!” Then a minute later he said, “He mentioned your name!”
We have to get this information out. The powerful effects of nutrition and lifestyle, I’m afraid, just aren’t represented in our medical education, are they?
Dr. Tro Kalayjian: No, not now.
The beauty of this was this particular case. I love the Curbsiders, and Yancy is a hero of mine, along with yourself. But, it was the power of nutrition. The keto diet was able to mitigate the symptoms of Cushing’s. Some of the symptoms, his blood sugar was not elevated. He had lost weight. He couldn’t out-diet a brain tumor, but so many of the symptoms were actually masked. I thought the case was very interesting. I’ll send you the case report.
Dr. Eric Westman: A related Cushing’s story: a patient of mine, finally, because of the high blood glucose, resorted to low-carb shakes and low-carb eating in order to keep the blood glucose down while he was getting worked up. He had a pituitary adenoma, that brain tumor thing, that pretty much surgically fixes the problem for most people.
We practice the best medicine of our lives without medications, don’t we?
Dr. Tro Kalayjian: I know this is getting off on a tangent, but what a great case to exemplify the power of nutrition. Certainly, nutrition can’t cure brain cancer, which ultimately this patient needed. But it’s still so powerful.
It’s powerful in patients with Cushing’s. It’s powerful in patients with celiac, like your patient.
It’s powerful. My heart goes out to those type 1 patients out there who, unfortunately, for decades have been told to eat carbs, count carbs, and dose insulin.
As you and I work on boards together, we’re looking to expand the literature. I hope that can use the medical literature in a way where others can push the status quo and the convention to think differently. I don’t want to say weaponize the literature, but I’d like to continue to weaponize the literature a little bit.
Dr. Eric Westman: It’s important. If you’re not a physician or healthcare practitioner, we often are asked, “What guideline are you following?” or “Is there a guideline supporting this?”
Now, there’s a guideline supporting low-carb diets for type 1 diabetes from the Society of Metabolic Health Practitioners. I think it’s going to be very impactful.
Dr. Tro Kalayjian: Hope so. Thank you.
Dr. Eric Westman: Until the next time, thanks for your time.
You can watch the full video here.
Speaker bios:
Dr. Tro Kalayjian is a board-certified internal medicine and obesity medicine specialist. Once 350 pounds, he transformed his health and lost 150 pounds through a low-carb approach. He now runs a nationwide telemedicine practice, helping patients improve metabolic health and reduce medication dependence. A researcher and co-host of the Low Carb MD Podcast, Dr. Tro advocates for evidence-based nutrition and employer-driven healthcare solutions.
Dr. Eric Westman is an Associate Professor of Medicine at Duke University Health System and the Director of the Duke Keto Medicine Clinic in Durham, North Carolina. He is a past president of the Obesity Medicine Association and a fellow of The Obesity Society. Dr. Westman has over 20 years of experience researching low-carbohydrate ketogenic diets and has authored more than 90 peer-reviewed publications. He co-founded the Adapt Your Life® Academy to provide accessible, research-backed education on the low-carb lifestyle.