This blog is an adaptation of Dr Westman’s video on ‘Foods to Avoid’ which we have included at the bottom of this article.
Q: First question I’ve got for you is concerning your Page 4. For people that don’t know – Page 4 is a famous food list that Dr. Westman has come up with over the years, listing foods that people could have and be sure to stay under 20 grams of total carbs per day. So, how did you come up with this list?
A: Well, Page 4 literally is the fourth page of the handout we’ve used at Duke for 20 years now. It started in the research setting; I borrowed Page 4 from Dr. Atkins and Jackie Eberstein who had actually used it for 30 years. So my story – I got into this because two of my patients did the Atkins diet, and although they had great success, we were worried about the safety of it. So, Dr. Yancy and I contacted Dr. Atkins and we learned about what they were doing.
We didn’t just start doing it though. We first studied it, borrowing a list of foods that had been used for 30 years. Now, studies have been done all over the world. We continue to use that list of foods which has turned into a chore, because it was the fourth page of the Duke handout. It has become the simple way of teaching what to do – ‘Here, just follow this. If it’s not on Page 4, you can’t have it.’ For those who really want it to work, if they follow the guidance, it’s really effective.
Q: So before we get into the foods to avoid, I know that one of the hallmarks of a keto and low-carb type of diet is that you don’t starve yourself. On your list, you’ve actually got foods which you can have in unlimited quantities. What are they?
A: Well, this type of diet program for weight loss is unique in that the hunger goes away. The hunger should go away in a day or two if you’re doing it correctly. On the list of foods I do say, ‘Hey, you can have an unlimited amount’, but really people eat less automatically. You can thwart it – someone once came in and said, ‘You know, Doc, I had three pounds of bacon every day because you said I could eat as much as I wanted.’ Well, the thrill of that wears off after just a few days.
You can have an unlimited amount of meat, poultry, fish and shellfish, and eggs, because they have no carbs, and they don’t raise blood glucose. Because they don’t raise blood glucose, they don’t raise the blood insulin, which is the fattening hormone. That’s why you can have meat, like burgers without the bun, or bacon, which is surprising to a lot of people, because they’ve been taught the other way of doing it – low fat, low calorie – where you are supposed to limit a lot of these foods.
And just to go over ‘limitation’ again, it’s actually ‘self-limitation.’ So, I can tell people, ‘You don’t have to limit it’, but they do it automatically. At first it sounds misleading, because psychologically there is no external restriction on what you can eat – that’s huge; if someone has been in a calorie-restricted type of program and that’s the only thing they know, they’re always trying to wonder if they can get more and get more. But on a keto, low-carb diet, the hunger goes away from within and you’re satisfied with less. There is no longer that psychological, ‘Oh, but I have to…’ You can always eat something on a low-carb keto diet, which is different to the traditional way of doing things.
Q: Which is huge, absolutely huge, because as you said, most people find themselves thinking about what they can or cannot have all day long.
A: Of course.
Q: And it’s almost impossible. This way, when there are foods you can have in unlimited quantities, it kind of gives someone that comfort that they’re not going to starve.
Q: I’m going to ask you for three different foods we shouldn’t be having. Is fruit juice high up on that list? For many years I was doing sport and was very involved in being an athlete; I was always under the impression that drinking a daily glass of fresh orange juice was healthy for me. You often see people on a diet program who are trying to lose weight, drinking their fruit juices, which are very high in sugar. Would you say that fruit juice and other types of juices are one of the worst ‘foods’ to consume on a low-carb diet?
A: Yes, and for that matter, in any type of diet. Fructose is a sugar that goes directly to the liver – Dr. Robert Lustig, a Professor at the University of California in San Francisco, has talked about this for a long time, about fructose being like alcohol to children. He’s even gone so far as to say that it should be limited for children. Fruit juice or really any sugary drink is not a good thing to have on any type of diet program, including a low-carb keto program, where you want to avoid foods that raise the blood sugar. That’s kind of the theme of a low-carb keto diet. If you drink a drink that raises the blood sugar, it works against the body’s ability to burn its own fat or the fat that you eat. So, the common theme is: don’t drink or eat things with high sugar. Fruit juice is especially important to note, because we were all taught that it was great.
I’m reminded of a story that Dr. Lustig told, about how he got into the low-carb world: He was out at a migrant worker farm and a mother was asking why she was able to get all of this fruit juice, yet her child was obese; why would the government let her buy this if it was unhealthy? And you know, the bells went off in the doctor’s mind that, wow, this is a major public health issue. So many people think it’s great and that sugar is just, you know, either you burn the sugar or it gets turned into fat. That is one of the metabolic physiologic things that most people don’t know. I still get people who are surprised to learn that sugar gets turned to fat in our bodies. That’s how we store energy; it makes perfect sense to me, but it might not make sense to you.
So yes, no fruit juice. And for that matter, be really careful with fruit. You know, fruit has changed, so that there’s less fiber and less of the healthy stuff in it. And fruit juice, being the processed form of it, doesn’t give you any fiber.
Q: The other thing that people tend to lose sight of, is that when you’ve got a full glass of fruit juice, it’s typically not just one fruit that they’ve had to put in. It’s probably three or four types of fruits that they put in there. Not only that, but they’ve used a blender to break open the fiber and actually release all the sugar. So, it’s almost like a triple whammy. You’re eating three times the amount of fruit that you would normally eat if you had just one fruit and then, it denatures the fiber and releases all the sugar. What would you say is number two on the list?
A: Well, in my area or in the U.S., it’s the starches that have worked their way into the diet – bread, pasta, things like tortillas, spaghetti, linguini – it’s the processed starches. I’ll joke in my class sometimes, saying, ‘Have you ever seen a bread tree or a pasta bush?’ and young people think it’s a crude attempt at a joke, but it’s just to point out that these are processed foods. Because people have always had it, they think it’s normal. These starches get digested to sugar. So, all you need to do is check your blood sugar an hour after eating bread and pasta, and your blood sugar goes up. Blood sugar going up causes insulin to go up – insulin is the fattening hormone.
Bread includes bread in any form. I mean people say, ‘What about whole-grain bread?’ and no, that’s still bread. That’s why we teach the total carb method. You can make your own bread substitutes – there are some interesting products coming out that are mimicking tortillas made out of cheese and made out of egg whites and cauliflower. So, you know, it’s interesting to see that yes, these are processed foods, but they’re much lower in carbs.
And then pasta, there are some substitutes: you could always do the zucchini noodles known as ‘zoodles’, spaghetti squash, or shirataki noodles, which are a kind of a root that is not very starchy that’s made into the noodles, so you can have the feel of pasta. Those are available just about everywhere in the U.S. The downfall is that people will just gravitate back toward these foods if they get them around the rest of their family. For example, at the holiday season where other family members are still eating those foods. The good news is that you can start over; you stop eating these foods and after a day or two the craving is gone. But it’s just best to avoid starches – bread, tortillas, pasta, these processed starches.
Q: What is the third food group that you would avoid?
Well you know, again it’s a thing that I see misunderstood – I would say corn. Corn and its byproducts – corn syrup. There will be times of the year when my patients will say, ‘But everyone’s having corn on the cob’, and corn might work its way into some sort of dish. But, it’s very starchy. So as far as something to avoid, that would be corn and potatoes. I didn’t say potatoes yet; I’ve kind of put them in the same category because they’re just so starchy and they can be made into so many different things. You know, someone might come back saying, ‘Well you didn’t tell me I couldn’t have french fries’, even though I told them no potatoes… you really shouldn’t have french fries.
Other good news though, is that there are substitutes coming out for different types of tortillas – instead of corn tortillas you have these newer types of tortillas. The potato substitutes – mashed cauliflower…there are now even ‘cauli tots’. ‘Tater’ – the name came from ‘potato’. I never really thought that through, so these are not tater tots, they’re cauli tots because they’re made out of cauliflower! Yes, it’s processed food, but so many people want that convenience factor. So it’s really great to see the industry in the U.S. coming around to making these lower carb substitutes for what so many people grew up with. Just because we grew up with something, that doesn’t mean that it was healthy. What we went through in our generation is just kind of bizarre in terms of food, you know, getting the marketing on TV for sugary cereals and maybe that should be on the list, that’s another talk!
Q: Yes, cereal is a huge one. Before I move onto another question, I want to just go back and revisit fruit. Something that struck me when I went to your practice – you’ve got your two consulting rooms and in there you’ve got a poster there saying, ‘Fruit is nature’s candy’. And again, not only did we grow up thinking that fruit juice was so good for us, but we also used to think that fruit is generally wonderful for us. While I imagine that for some people (those who don’t have metabolic related issues, they’re younger, they’re very very active) fruit is just fine, for the people that you are seeing in your clinic, fruit is nature’s candy. What are your thoughts on that?
A: Yes, well it brings home the idea that just because it’s natural, that doesn’t mean it’s good for you, metabolically. I think you made an important point that not everyone has to be careful about these carbs – that gets misconstrued. People think that I think that carbs should be eliminated from Earth, and I don’t. Some people just have to be very careful to avoid them.
The other thing about fruit is that the serving size can be changed. A piece of fruit doesn’t have to be consumed all at one time. I was struck by living in other countries; I was in France in college and they would have a thin slice of apple, for example, with cheese, rather than having the whole apple just by itself. Getting the sweetness but reducing the serving size is a way to have some fruit. But, avoiding it if you have a metabolic intolerance, carbohydrate intolerance, is really important. Grapefruit is the lowest carb fruit. Because when you think about it, taste it, it’s not sweet. Some weight loss programs use grapefruit as the morning fruit, half a grapefruit. I don’t use that in mine, but I think it’s because it didn’t impact the blood sugar much.
As a general principle, fruit is nature’s candy, meaning you want to limit how often you have it. In some areas when I was growing up, or the generation before me, fruit or dessert was like a once a week treat. You know, an ice-cream you had on Sunday, right? And fruit, being nature’s candy, you know, that’s right next to the sign that says ‘fruit makes you fat’. I have to kind of say things directly to get through to some folks.
Q: Something that isn’t so obvious, is whey protein. Whey protein has been known to spike your insulin. It doesn’t really affect your glucose number, but it can spike your insulin. What are your thoughts on that?
That kind of goes into the general theme of having real foods instead of products. If whey protein is in a food, you’re going to get less of it. So, I have a lot of people who would use it and do fine, but it’s something to be aware of. I’m not a big proponent of taking protein powders and things like that, just under the general principle that food will bring you the vitamins and minerals you need to metabolize the food – if you eat real foods rather than some rarefied processed version of protein, for example.
Q: I have some questions from our viewers: Brett asks, ‘Are there any supplements that you would stay away from?’
A: Yes, there are some practitioners and people who grew up with the idea that you need extra vitamins and supplements and that a diet is deficient. I’m not convinced of that yet, although I am open to the idea. So, I’m not a big supplement promoter and I think the bottom line in terms of blood glucose and insulin is that you want to avoid supplements that negatively impact the blood glucose.
You know, someone once said that I’m always thinking out of the box, when actually, I just follow data. Just because the mainstream hasn’t followed data, that doesn’t mean I’m out of the box, out of the mainstream. No, we create our own mainstream with new sources of data. So, if data comes out that proves you need these kinds of supplements, I’ll be open to that, but I am not really convinced that you need to do anything other than get your food fixed, you know, taking away the junk foods, eating a well-formulated type of low-carb diet.
Q: Ted asks, ‘Is there any other fruit, other than berries, that are also low in carbs?’ I know that you mentioned the grapefruit, but are there any other fruits that are also relatively low in carbs, other than berries?
A: Yes, berries really are fruits, but they’re just small, right? So the serving size is smaller. They will still have the same, or relatively the same impact if you eat large quantities of them. So no, I’m watching these other lower carb fruits and there’s a lot that is being introduced – different kinds of nuts and fruits. The way I would look at them is how they impact blood glucose. The interesting thing is that there’s an individual variability with the impact on someone’s blood glucose; it might affect you differently than it affects me. I guess I try to whittle away at the idea that you have to have that, always trying to get back to what you had and be satisfied with a new set of foods that may not have all that same sweetness and sugar that caused the negative metabolic impacts.
Q: Amanda says that she’s an athlete. She asks if she can have some foods that are higher in carbs. We’ve just mentioned that people are affected differently, so she’s an athlete, as are many people that may be watching this episode. Can they have foods that are higher in carbs?
A: Yes, I think so. You know, the experience of folks that I’ve seen is that you don’t have to eat carbs. In a recent paper that I was an author on with a young doctor, Justin Tondt, we looked at the information on whether you have to eat carbohydrates — whether the carbohydrate is an essential nutrient. It turns out that it’s not. You can exercise and run on fats for your fuel. That’s the whole ‘Cereal Killers’ movie, ‘Cereal Killers 2’. If you want to reintroduce carbs, you can and it really is trial and error. Some people feel better when they’re eating more carbs when they’re exercising. So, the relative amount will again depend on what you’re trying to accomplish.
If your performance is better, you feel better at a certain carb level and you’re not having 300 grams of carbs, I think it’s ok. I would push towards carbs that are in real foods, like berries and fruits. The more starchy vegetables would be something to also consider as something to introduce, but stay away from the processed, middle of the grocery store. Certainly you can eat more carbs the more active you are, the younger you are.