A story and a metaphor
Dr. Eric Westman: I thought I would start with a story and a metaphor. I would like you to help me with this metaphor. Let us imagine we are explorers. My apologies to the non-Americans on the Zoom. I am going to give the story based on the North American-centric view of exploration that we were all taught as children in the US. 25 years ago, you and I decided to leave Spain. So the metaphor is we are going to go from Spain to the New World – the Old World to the New World. The metaphor is low-carb diets. You will get the mixture in a minute. 25 years ago, I had a slide at a meeting that said we are exploring here. We are leaving the Old World, going to the New World, and I am not quite sure where we are going. I had a little cartoon that had the USS Low Carb for the maiden voyage of leaving Europe, and exploring the New World. You could use it for any other country where the first people were visiting. You have to remember the reason we left.
25 years ago we left Spain, we started a low-carb diet 25 years ago. We did not know where we were going. People said we would fall off the end of the Earth. It did not happen. We found land. We had to go through stormy seas along the way, and people might not have thought it was a great idea, but we did it because we were leaving a certain situation that we couldn’t stay in. Whether it be the religious lack of religious freedoms, or you would be put in jail for something minor so we all embarked on this journey. This was 25 years ago in terms of the diet. We made it to land. We learned how to use the New World. We were taught by people who already lived here. We found out the hard way that things that looked edible in the Old World were not, and they were poison. We did not listen. We ate those things. Some of us died along the way, but we feel happy and healthy. We might miss the Old World, the old paradigm, the old medical view of things like taking medicines. The doctors make you feel comfortable taking medicines. “Do not worry, we’ll manage you. You’ll be fine.” But it wasn’t fine. We left that.
The new world
I have to remark that we have been here 25 years, and nothing bad has happened. We have thrived. We built our communities. We have had children and grandchildren, and we have a new world. We might miss the old way from time to time, but we had to leave. We found, against everyone’s expectations, a new place to live, and we are thriving. But the rules have been different. We did not like the old laws and guidelines in Europe. We wanted to leave there. The current medical guidelines are not right for us. We left that. We are in a new place, and we are in a new metabolism. That is the twist here. That is not the new world, geographically. It’s exploring a new metabolism. There are going to be some things we do not know, but after 25 years of my life doing this, and remember, it was not me that made this up. If you do not know my story, two of my patients did a low-carb diet, and they taught me that they could do it, without me, by reading a book. They are the real pioneers. So were Dr. Atkins, Dr. Eades, Dr. Rosedale, and Dr. Bernstein. Let us go back to Spain or leaving Europe.
Exploring new areas
We heard that people visited the New World. They said it was great. Most people did not know about it. Most people were against it. It threatened the ideology that the Earth was flat and that the Earth was the center of the universe. All these different paradigms clash. On a low-carb diet, sometimes your cholesterol level will go up compared to people who eat carbs. The older paradigm view. I say I do not know if it is harmful. Yet, you’ll meet people who say they know it is harmful when they do not. We left that world of “Here is the way to do it, there is only one way to do it,” and now we are exploring a new area. Getting to diabetes, we do not know the proper level of blood glucose when you are on a low-carb diet, the optimal level we do not know. If you are just starting out, trying to fix diabetes and you cut the carbs out of the diet, the blood sugar will come down 50 to 100 points on the first day compared to what you were eating before. That means that we have to cut back on the medication on the first day.
The old way was to let you eat anything you want. It defies explanation why people with type 2 diabetes come to me drinking sugar. This should be the first thing any doctor asks their patient with type 2 diabetes: are you drinking sugar? That will be directly absorbed and raise the sugar, but it happens all the time. The diabetes medicine has to be reduced and the idea we are in the new world, we are learning. It might be hard work to transition people here to get them off the old way of thinking. The other main thing with diabetes is, if you have cut out the carbs, your blood glucose might not normalize on the first day. It is not just the blood glucose response to the diet and the drinks, but there is also the weight loss. You have to have a resolution of the underlying insulin resistance, which is from the extra weight.
Normal blood glucose and extra weight
The expectation of a lot of people is “I cut my carbs; why isn’t my blood sugar normal?” If you have a journey of weight loss to go down 50 to 100 pounds (25 to 50 kg), then your blood sugar is not going to be normal until you are down by that weight. It might take a year to get normal blood glucose if you have insulin resistance from that extra weight.
Everyone wants things immediately. Instant gratification isn’t fast enough. You wanted it yesterday. Everyone said keto and carnivore would fix the blood sugars. You get a dramatic reduction by cutting the food carbs but you might not get normalization if you have a weight loss journey. Let us say you are at your goal weight and you have a blood glucose that is 110 mg/dL (6.1 mmol/L). I recently said you are a biohacker when someone who did not have type 2 diabetes was wearing a continuous glucose monitor. We chatted about it and it is very common for people to be concerned about a blood glucose under 120 mg/dL (6.7 mmol/L) randomly throughout the day or first thing in the morning even though the three-month average is normal or even below normal or maybe even a little high.
We do not know about blood sugar that is a little bit higher than the diagnosis of diabetes. We do not know if the categorization that was used in the old paradigm of people eating carbs, people being treated with medicines, there may be other factors including the carbohydrate oxidation of the food you are eating. The food that you eat becomes the food that you burn for fuel, and if you cut the carbs way down you will have an improvement in that oxidative stress even though you are still not having a totally normal blood glucose. I am trying to reassure you that if your blood glucose is not between 80 and 100 mg/dL (4.4 and 5.6 mmol/L) all day long it is okay. Even if you are at an optimal weight, you feel great, you are eating foods you love, I would discourage the use of obsessive monitoring of the blood glucose as it is going to cause anxiety. It would be like back in the old world. We cooked things a certain way and we had certain foods but now we do not have them here in the new world. We will find a new way to cook, we will find other foods to have.
The old paradigm and the new paradigm is a metaphor. This includes fear. People are afraid that if they have a little bit of blood sugar elevation they then have type 2 diabetes or pre-diabetes. I am trying to say that this categorization was based on studies where people were eating carbohydrates, and the rules are different. What is the data I have? It is the fact that people are following a healthy diet. Everything else is optimized. This is the same kind of probability or common sense rationale. An elevated blood glucose or blood cholesterol in the context of a low-carb diet isn’t going to have the same connotation or you should not have the same worry as if you were a carb eater with the same level of cholesterol. That, again, is our perspective being in the clinic. Do we have randomized control trials about that yet? No. There are observational studies that are being started.
Remember, we left the old paradigm of medical care, the old world, because we were not satisfied with a medical system that did not ask you what you ate. When was the last time a doctor asked you what you eat for breakfast, lunch, and dinner? We were not satisfied with a medical system that did not consider diet as a major factor for health. When you go to a veterinarian with a sick pet, the first thing they say is, “What are you feeding them?” The medical system has gotten off track and they will diagnose you, they will put you on medication, yet there is no consideration of lifestyle, the importance of lifestyle. I coach people to say to their doctor, “I know my cholesterol is elevated but I am using lifestyle to treat it”. That will get you a certain way and then the advanced course is that we focus on the metabolic syndrome, which is the triglyceride and HDL in the blood. We do not focus on the total cholesterol and LDL. If you want to do the LDL story you can check for small and large LDLs. You can look at the LDL insulin resistance score or LPIR score. There will be an insulin resistance score on the NMR lipoprofile. This is one reason why I do not think we should focus on the blood so much and we should focus on the arteries themselves. Cholesterol is not a disease. The reason we focus on it is to prevent atherosclerosis to prevent the hardening of the arteries, and the narrowing of the arteries. What you want to do, if you can, is to measure whether you already have the arterial disease. You can do that with various measurement tools. I understand some people are not satisfied when I say we do not know. We are exploring a new world. Should we start going west from where we are now? We do not know. In exploration there is the North American explorer metaphor or, do we just stay here? Except, there are a lot of people here so some of you will want to go West and learn the idea though that everything from the old world or old paradigm would apply here in the new world. It is obvious it cannot. If we look at the stars, the stars are different from where we were before.
I am trying to get you into the mindset that there may be differences in comparing your lab tests. The food you eat and what other people say about the food you eat. There may be differences in the health consequences. Remember we have been here 25 years with science. As I reflect on it, other people were doing studies to prove that this was bad. I have reflected on this over the last few years. Gary Foster did one of the first studies in the New England Journal of Medicine and he was disappointed that he did not find that the low-carb diet was bad. He has gone on to be the Director of Weight Watchers and other places. He is a PhD. I remember that study and the purpose of the study was to show that the low-carb diet, the Atkins diet, was bad, and it was not. There have been meta-analyses of studies of low-carb and low-fat and the low-carb diet wasn’t bad. It was better than the low-fat diet in every instance.
There are now studies of studies (reviews and meta-analyses). When people say that leaving the old world and finding the new world is going to be dangerous and terrible, we have proven that it is not true, we made it. You might be new to this way of eating and way of thinking but it is not new in terms of the science and the credible evidence of its safe use that is unlike any other diet that we know about. The low-carb diet has been studied over and over and over. The sad reality is it was studied with the intention of showing it was bad, and it was not. They never did the second study. Fortunately, now, 20 years since our first study, the NIH, the National Institutes of Health in the US, is finally funding some research, but it had to be done by a trainee. Our system is set up to find out the mechanism of how things work rather than fixing the human disease. That is the reality of the mission of the National Institutes of Health.
It was surprising and disappointing to me when I went to our Duke-funded researchers on fatty liver and McArdle disease, where I had evidence that you could reverse these conditions, and they did not pick it up. They were funded by companies trying to find the mechanism of fatty liver and the companies trying to put genetic changes into the cell so that it did not matter what people ate; they could fix the problem independent of the food intake. If I put everyone in the fatty liver clinic on the low-carb diet, they would not have anyone for their studies. One might argue that that is not ethical. I hope they put in the consent forms that there are other effective ways to fix fatty liver and weight loss of any method. I have not got to that level of being a pest or a thorn in someone’s side.
Medications and bad side effects
With diabetes, what I am seeing is that medications are being used over and over, and yet the medications have terrible side effects. You can go down that path of eating whatever you want. The doctors do not give you grief, but you are put on medicines that have bad side effects. The one that grates against my sensibility is the medicine that allows the urine to leak glucose. You are not supposed to have glucose (sugar) in the urine; all sorts of bad things can happen with infection and loss of energy. The medicines are called Jardiance or Invokana, the ones with the fun jingles and fun people on TV. They are in the fine print. They are forced to say that ketoacidosis can be life-threatening and genital infection can be life-threatening. I have seen now over and over people who have been on these medicines having infections of the urine, and the doctors treat it as if it was just a common side effect. The terrible reality is they do not focus on the food carbs. They will say, “Just continue what you are eating; we will just have your kidneys leak out the carbs, which is crazy. If you are on a medicine that is called an SGLT2 inhibitor, that allows the glucose to get into the urine, please reconsider and talk to your doctor about that. I had never seen ketoacidosis in my keto diet clinic until these medicines came out. You are at a higher risk of ketoacidosis if you do a keto diet, but you are at risk of ketoacidosis even if you are eating carbohydrates, which is scary. It has a side effect that can be life-threatening and it can happen really fast. Medication care is not the only way to go about things.
New Organization
The reason we left that old world, the old paradigm, is we did not think that was the answer for us or a lot of different people. We found a different way to go about it. Recently I was asked to become part of a new organization called the American Diabetes Society. It is so fledgling it is working its way through being formalized and the idea is to have a society that actually promotes diet and lifestyle as an alternative to medication and then promotes the idea that you can reverse type 2 diabetes. You do not just have to manage it with medications.
The other aspect of this organization is that all funding will be transparent. You can see who is funding the organization and where the money goes. There has been a lot of criticism about the other alternative diabetes organizations where they are getting lots of money from certain entities. They spout out the information of the funders that give them money and they do not talk about lifestyle much at all. They do not talk about the reversal of type 2 diabetes. The American Diabetes Society will be focused on that. There is a small group of people who are still looking for board members and there will be a GoFundMe to start a website. In three days, if we raise $50,000, and it will be raising more money over time, the plan is to become a teaching entity, a resource to push information about diabetes reversal using lifestyle. Certainly, low-carb diets are one of them, one of the lifestyles that work, not the only one, of course, but there will be little, if any emphasis on the use of medications. If you have diabetes and you are on a medicine that leads to weight loss you might reverse the type 2 diabetes, and that is because the weight is typically the underlying factor that caused the diabetes in the first place.
In the US metaphor of exploration, time happened, the towns were built, and finally there was a revolution to leave the oppressive kingdom from before. This is like making a new organization. I know that is a stretch, it is okay to make a new organization based on new principles. There might be tension or backlash from other organizations, but I doubt it. You start a new group, you do not create a lot of friction with the older group. Stay tuned for the American Diabetes Society. There is now a GoFundMe. The few people on it at the moment are all very passionate and we want a group of laypeople, dietitians, and doctors, all of the above. The idea is to create a new group that is not only focused on drug treatment and drug management of type 2 diabetes.
In the course we have I am learning a lot, a lot of questions, people actually reversing their type 2 diabetes who want to make sure they are doing low carb correctly. I am constantly reminded that my introduction to this diet was from two of my patients who did it on their own by reading books. You do not need me personally or someone to teach you how to do it. If you are on medicines that become too strong you have to be careful. The medicines may cause problems, not the diet itself. Do this with someone who understands the deprescribing of the medication safely.
Lifestyle is more important than medications
Going back to that new and old paradigm, there was a book called, Scientific Revolutions, it basically said what is necessary for a paradigm shift, and if you were put into a new world you have to learn very quickly. If you can fix something that someone else cannot fix, that is one of the most important things for a paradigm shift. The more we demonstrate that type 2 diabetes can be reversed and people can do that on their own by changing the food independently, or even against the doctor’s advice, and some people are taught how to do that, then people will gravitate toward the new paradigm that lifestyle is more powerful than medications.
The tools
The other thing with paradigm changes is that you have to give people and doctors the tools to fix things. Rather than me telling everyone that the low-carb diet fixes brain health, heartburn, fatty liver, and cardiovascular disease, we see that is what Dr. Atkins knew and what he tried to tell people, but that does not change the paradigm. What you need to do is allow other doctors to use that information. What happens is they think they came up with it first, which is fine. What we saw in the last 20 years is that a cardiologist – Dr. William Davis – wrote a book called Wheat Belly. He carved out the cardiology part of it and focused on wheat. A neurologist, Dr. David Perlmutter, wrote Grain Brain. This was a book about the brain. They have independent groups that they have continued to follow on their own.
What is needed is that this information has gravitated toward gastroenterologists about fatty liver, heartburn, and irritable bowel syndrome. Interestingly last month, a randomized control trial for irritable bowel syndrome diarrhea-predominant (IBS-D) was published with a large study with three arms: the drug treatment, the FODMAP treatment, where you do not have simple sugars, and the low-carb diet, which ranged from 50 to 100 grams of carbs a day. It was not keto, but the low-carb diet won in terms of IBS-D symptoms and reversals. The drugs were not very helpful. The FODMAP diet helped a little bit, but the low-carb diet was best. It was published in 2024. I looked back and one of the references is Greg Austin’s paper that we helped him do back in 2009. 15 years passed since our first paper was published. It is a proof of concept paper, but now a randomized trial was done that nailed that the low-carb diet was superior to the drugs and to the FODMAP. We have been here a long time, but because the people in Spain do not know that we are here it doesn’t matter. They are living their lives being happy and we created a new world within this metabolic space – not geographic, but metabolic space – and it’s grown. I am very proud of the textbook that Professor Tim Noakes was the major editor on called Ketogenic – the scientific basis of low-carb, or “therapeutic carbohydrate restriction” is the term we use for this kind of low-carb diet.
The journey of learning
This has always been the grassroots kind of change. We have learned a tremendous amount and are still learning. If you just compare the blood levels to the old way of looking at things may not make sense that is why I am focusing on measuring the arteries rather than just the blood. There is a lot of inappropriate focus and fear-mongering about following a diet that raises a blood LDL a little bit even though the HDL is 80 or 100 mg/dL and the idea that blood glucose is not between 80 and 100 mg/dL all day long. That is not the expectation, so please do not worry if you are in that situation without you knowing your complete labs. We are going to find a new normal range that is probably going to be developed by this company OwnYourLabs.com. Dave Feldman has put together the website, the cholesterol code, and the study of lean mass hyper responders, a company where you can get your blood drawn at any lab core facility in the US and they can measure any lab. You have to pay for it on your own though – that is the catch but they keep it in their own private secure database so no other entities can get to it. Most bloodwork that is in the insurance pay system of medical care can be looked at by insurance companies whether you want it or not. On OwnYourLabs.com, if you want to contribute they ask you what kind of diet you are following and then hopefully they will be able to survey, or publish, their information – we had a thousand people who say they are doing a carnivore diet, and here are their A1Cs. We might find that they have a broader range of hemoglobin A1Cs and not be in the same range as people who eat carbohydrates. Same with the cholesterol levels. We will probably see that the normal range of triglyceride is going to be much lower than those who are eating carbs but that range of LDL might have a wider range, the cholesterol as well, wider than the HDL, will probably be higher of course. How long you have been on the low-carb diet will affect that HDL. It may take months.
We have been working on this diabetes study for 2 years and like the Keto Made Simple and other courses at Adapt Your Life Academy, we filmed the lessons, have transcripts of the lessons, and have people in Zoom call so they can ask questions in real-time as they are taking the course. Many of you might be in that course as well. I hope you are enjoying it and, the interesting thing is some people are coming with their diabetes already fixed only wanting to make sure they are doing it correctly. Some people are brand new and they have never tried the diet at all. It is like teaching a math class where you are teaching basic math and calculus all in the same group. That has been an interesting thing. We can get into the details of the personal questions. The course will evolve over time based on the feedback like the Keto Made Simple course. Each time we receive surveys, we changed some of the content and some of the frequently asked questions based on the feedback that we received from you.
That concludes my formal talk.
The boiling frog metaphor
The boiling frog story is a metaphor. That is the idea that a frog can, if you change the temperature gradually, it doesn’t feel that difference. If you have a gradual change, in anything, you may not notice it yourself. That played out recently in someone who did not know that he had actually lost weight. He could not see it in himself. The idea is that you can boil a frog, without it knowing it, if you increase the temperature really slowly. The inability or unwillingness of people to react, or be aware of sinister threats that arise gradually rather than suddenly. That is a good description of the current health debacle.
A foot in the old paradigm and a foot in the new paradigm
If you have any thoughts about the old world, or new world – I created that slide 25 years ago and I ended the talk by saying that I am on the boat, too. I think it is important because if you talk to someone who is not in your same situation it is like the pilot of the plane is on the plane with you. They are going to do everything they can to keep the plane from crashing and have a safe landing. That is similar to the low-carb diet. I learned what it was like to be able to teach people and I did not have any weight loss or metabolic change journey. I liked the way it felt and it was easy to do with hunger going away and I had a lot of energy. I watched every other lab changing and getting better. Going back in time, I dropped someone out of our second study because the LDL went up and 25 years ago I was worried about the LDL. I am not anymore but I was back then.
I have been in the old paradigm and I have a foot in the old and a foot in the new. I think it is important to have that. To be able to have scientific discussions and then also to follow the science. Science has to embrace a new observation that doesn’t fit into the old paradigm otherwise it is not science, we are just talking dogma, more religion and belief than science. The problem with that statement is that science is a self-writing measure. The idea is you will eventually find truth but that is only if you can get funding to do the studies – to actually ask the right questions. Sometimes the studies that are needed are very expensive and you can constrain the research in a certain area by not allowing funding there. We saw that recently. Recently, a colleague of mine in the obesity world got called out because Coca-Cola was funding his lab to study exercise. It never occurred to him that he was helplessly being directed away from studying sugar and diet. He wanted to study exercise. Why not take money from an entity that does not want you to study their diet or their food as a health issue? When that got publicly outed it did not go well and he actually had to move from Denver to sustain that funding. We saw that with the tobacco industry and now with the food industry, where they are going to be funding people to study anything other than their food as a possible cause for a problem. Do not be surprised, and that goes back to the American Diabetes Society, not the Association, ADS, not ADA. The ADS will be totally transparent about where the money’s coming from and where the money is going. If you have an interest in getting involved let me know, it is just at the beginning phases, but we will need a lot of people involved to operationalize the plans to get information out to people and that takes a lot of money.
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