Dr. Eric Westman: You’ve sent in questions, you’ve sent in comments, and here are some replies:
1. Restoration
Q: I’ve been struggling with high blood sugar for about 10 years. Labeled pre-diabetic but trying to change through lifestyle, I’ve yo-yoed up and down. My last A1C was 5.7. Recently, I started using a continuous glucose monitor and discovered that my fasting blood sugar rarely goes below 105 mg/dl (5.8 mmol/l), even with an extended fast of 16 to 20 hours. It usually averages 112 or so, often increasing to 120 to 128 (6.7-7.1 mmol/l) when I exercise. My question: I’ve been dedicated to keto for a little over 2 months and still, blood sugar is high. It rarely goes above 140 mg/dl (7.8 mmol/l) but rarely goes below 105 mg/dl (5.8 mmol/l) either. Has my yo-yo dieting over the years destroyed my chance to heal my body?
A: Thank you for this question. It’s a common theme of “please be patient.” If you’ve just started onto a keto, carnivore, low-carb diet or any healthy diet compared to the standard American diet, it takes time to normalize the blood sugars. For some people, it is overnight, but for most people, it takes months – maybe even years – to normalize the blood sugar into the 80-90 mg/dl (4.4-5.0 mmol/l).
It’s fantastic that your hemoglobin A1C is a measure of 3 months of the blood sugars. It’s great that it was 5.7, which is in the normal range. A continuous glucose monitor, or CGM, is a little disc that you can put on the arm or body, and it measures your blood sugar every 5 minutes without any finger sticks, any kind of blood meter like you used to have to do in the past. I think it’s a great tool, but I don’t want you to be too obsessed over the blood sugars.
They do go up and down, and to be under 120 and 128 when you exercise is fantastic, because here’s one of the things that you need to learn when you get a glucose monitor: the blood sugar will go up when you exercise because your body is using more blood sugar, and so it’s going to supply more to the body. But if you’re really running on fat during the exercise, you won’t be lowering the blood sugar level as much as you would have before.
You have to understand that there are ups and downs in the blood glucose even when you’re not eating any carbohydrates. But I think this range is just fine, and I would just continue to do what you’re doing.
As far as yo-yo dieting destroying the chance to heal your body – no, I don’t think so. It’s something that your body will figure out. Give it time, and the main thing is to be patient with that blood sugar.
2. Dealing with Allergies
Q: I’m a 55-year-old male and have had severe skin issues my entire life. My problem is that I am allergic to omega-3 fatty acids, and my symptoms are life-threatening with animal and plant sources. I currently eat a ketovore diet after being a carnivore for four years and keto for 15 years, without any changes with said allergy. Thank you for this opportunity.
A: Well, not to worry. An allergy to any kind of supplement is not a dealbreaker because I don’t want you to have supplements. There are many approaches out there in the keto-verse, the internet, and I prefer an approach that has real food as the basis. You don’t need to take supplements like a lot of the influencers out there say you do.
So, ketovore, carnivore, low-carb – all of these are healthy approaches, and I wouldn’t worry about an allergy to a vitamin or a supplement like that, because you really don’t need them. So, keep it up.
3. Evidence for Skeptics
Q: Dr. Westman, what are the best clinical trials or evidence-based studies to show other physicians that are skeptical about low-carb benefits? How best to be able to work with other doctors that are lifestyle med docs or very much on the plant-based diet thinking without burning bridges or creating rifts? Asking as a family medicine physician sharing low-carb with my patients.
A: Thank you; it’s great to hear a question from a doctor. I’m a doctor, and 25 years ago I had to learn this for the first time, and I learned it through my patients who were following an approach by reading books – which is always reassuring to me, because I realized that you’re really in charge of picking and choosing the food. Food is medicine if you get it right. You don’t need a doctor to prescribe you a pill or a shot; you can use food as your medicine.
I think the best evidence now is a textbook. It’s a yellow and white book with an egg on the front of it. It’s called Ketogenic: The Science Behind Therapeutic Carbohydrate Restriction in Humans. It’s a textbook that came out, I would say, two years ago now, and it’s about $100. You can get it at any bookseller. It’s a textbook about low-carb and keto diets. It’s an edited textbook with contributors from around the world. I contributed chapters on diabetes, obesity, and basic low-carb nutrition.
As a doctor, you might not want to send everyone a textbook – you might actually want a specific reference, I understand. There are now so many references on low-carb and keto diets; where do you begin? Depending on the time you have, if I’m in a clinic room with someone trying to convince them and they’re a doctor, I simply go to the PubMed website – the database where all of the science is. If that person understands PubMed – it also used to be called Medline – I type in my name, “Westman EC,” and press enter, and I show the data that I’ve helped to accumulate through the years in peer-reviewed form. Then I type in “Yancy Jr.” and all the papers that my colleague Will Yancy has published on low-carb diets come up in that database.
If someone needs information on PCOS, heartburn, diabetes, or obesity, I’ll pull out those specific references with my name or Will Yancy’s name on them. That’s probably the best way to specifically get the scientific sources – look up the authors that contributed the seminal papers, if you will. Dr. Yancy’s first randomized trial was published in 2002.
There are meta-analyses of randomized trials – meaning studies of studies. I think there are five of them now, on diabetes and low-carb diets for obesity. The data is out there. It’s almost now too much. Finally, if someone just needs a book to follow, I would recommend my latest book, End Your Carb Confusion. It actually got an award at a keto meeting recently as one of the best books of the year. If you want to just give a source of information, that’s evidence-based as well.
4. Undereating
Q: Thank you for the opportunity, Dr. Westman! How can I deal with undereating on carnivore? I have developed a very small hunger and appetite since I began, and I’m certain that I need to eat more. Some days I’ll not even eat 100 grams of meat and an egg – plenty of water, though.
A: How do you know you’re undereating? The longer I go following this kind of approach, seeing other people follow this approach, and following the science of nutrition and longevity, the more I’m learning that animals – and even humans – live longer if you eat less, not more. It really depends on the context, and that’s going to be a major theme that I’ll just have to keep hammering away each time.
If you’re young, healthy, active, in the gym, and you’re not feeling like you have enough energy, you might need to eat more. If you’re older, like me, and you’re not in the gym every day, then you don’t want to be eating as much as everyone says you need to eat. You don’t want to follow an app to say you need more protein, and you don’t need to follow what your spouse, neighbors, or even your family doctor or internist says, these days.
I’m impressed that, as time goes on, we’re learning the benefits of eating less, not more. Haven’t you seen that? The idea that intermittent fasting – where you have a time of day where you’re not eating – or even total fasting, these are ideas that actually give your body a chance to heal itself when you’re not eating so much or so frequently, not eating all the time.
I guess I’d push back and say, how do you know you’re undereating? That determination would be something I make in the clinic depending on how you’re feeling, whether you’re able to do what you want to do, and how the blood work looks.
5. Keto and Pregnancy
Q: Hi, Dr. Westman. I’m currently 24 weeks pregnant, and I’m wondering if it’s okay to switch to keto mid-pregnancy. I already eat lower carb than the standard American diet – around 100 grams of carbs a day – and I’m wondering if it’s okay to progressively lower my carbs over a couple of weeks. I get migraines, brain fog, and upset stomach whenever I eat any carbs besides broccoli or cauliflower, and I just want to feel better and have a healthy baby. There’s so much information out there against keto in pregnancy, and it’s hard not to be deterred by that. I know those studies are probably all actually about starvation ketosis and not nutritional ketosis, but it still makes me a little nervous. I know you have a video about keto and pregnancy already, and it’s wonderful. I just wasn’t sure if it’s okay to switch to keto while already pregnant. Thank you for your time.
A: Of all of the areas in medicine that we are a little skittish about, like you are, is pregnancy. Skittish meaning you want evidence and hopefully clinical studies before you give recommendations in that particular area, because nobody wants to mess up a healthy pregnancy.
My clinical hat would be: don’t mess with success and just keep doing what you’re doing. If you’re eating carbs, you don’t have a diagnosis of pregnancy diabetes – gestational diabetes is the technical term – don’t rock the boat, and maybe keto-adapt for the next pregnancy.
The reason I say it might be okay if you keto-adapt prior and then get pregnant is there are a lot of people who have already done that. It’s not in clinical trials – it’s a grassroots movement that we’re watching happen. People do it, they tell their results. A group called Type 1 Grit – where these people have type 1 diabetes – many of them have become pregnant and had keto babies.
I visited Indonesia, and the doctors there were telling me that they have a lot of people who are keto mothers and then have keto babies, and then they even progress really well without carbs as they grow as a child. But that said, in the US and everywhere in the world, we have a particularly cautious approach to making recommendations in the world of ob/gyn and pregnancy. That said, I wouldn’t change anything right now, but maybe the next time.
6. Carnivore and Kidney Stones
Q: Good day. I’ve been on the carnivore diet coming up to a year. It’s going really well, and I have many health benefits. However, I’m constantly worried about getting kidney stones. I’m a 59-year-old male. Should I be worried?
A: I want to relieve worry. If you haven’t had kidney stones yet, that’s probably the most important history. Kidney stone development in any kind of diet typically happens because of dehydration, and it can happen early on in a diet change if you’re not keeping up with fluids – you’re not drinking salt and getting electrolytes early on.
I don’t worry about kidney stones. I see them from time to time, just like people on any kind of diet can get kidney stones. Typically, the way to prevent them is drinking plenty of fluid, keeping the kidney urine flowing so the stones don’t get a chance to form.
There are some specific conditions if you have recurrent kidney stones, where most of the kidney specialists in my area will ask or prescribe a nutritional supplement called potassium citrate. That changes the pH and the quality of the urine so that you’re less likely to get kidney stones. That’s typically reserved for people who have already had one.
I wouldn’t worry about it. Stay hydrated and you’ll probably be fine.
7. Keto and Thyroid Health
Q: Is keto really harmful in the long run for the thyroid?
A: Not that I’m aware of. Yes, there’s a lot of internet noise about this. Do the blood levels change? Possibly. Do you have to change the thyroid supplementation after a while if you’ve lost a lot of weight or you’re changing the metabolism to a fat-burning condition? Maybe.
Like any kind of dietary change or weight loss program, you’re going to want to measure the thyroid, measure how you feel. And in pretty much all cases, there’s a way to adjust if you’re wanting to continue this. I don’t see any evidence that it’s harmful for the thyroid.
8. Mental Health
Q: Is there a medical ketogenic diet for the mentally ill or a different one for other issues?
A: Yes. How the keto diet is taught can depend on the condition that it’s being used for. Classically, 100–150 years ago – like the keto diet for diabetes and obesity – there’s a keto diet for childhood epilepsy, and now adult epilepsy, too.
A different doctor in a different area, going on the history that starving or fasting could be helpful for seizures, figured out that a keto metabolism – not eating carbs and doing it very strictly – could actually cure, fix, or reverse childhood epilepsy. It’s not in everyone, but most children have some improvement if they change to a keto diet. Some children have total resolution of the seizures.
That diet is very strict, and you may even want to check ketones with blood, breath, or urine if you’re using a keto diet for epilepsy. The reason I started with epilepsy is that that’s a brain issue. So now there’s all this research being started on using a keto diet for mental health problems. There’s a new initiative with funding to get this started and raise awareness about keto diets and mental health issues. Under that circumstance, yes, you might want to be very strict, measure ketones – breath, blood, or urine.
There’s another growing area of science related to cancer treatments. In this situation, you may want to check blood, breath, or urine ketones. If you’re using keto for diabetes reversal, other metabolic issues, weight loss, PCOS reversal, or pre-diabetes reversal, you don’t have to measure ketones. You don’t have to be that strict – it can be more informal and still have tremendous benefits. There are different types of keto diets depending on what condition you’re treating.
Watch the full video here.
Speaker Bios
Eric Westman, MD, MHS, is an Associate Professor of Medicine at Duke University, the Medical Director of Adapt Your Life Academy and the founder of the Duke Keto Medicine Clinic in Durham, North Carolina. He is board-certified in Internal Medicine and Obesity Medicine and has a master’s degree in clinical research. As a past President of the Obesity Medicine Association and a Fellow of the Obesity Society, Dr. Westman was named “Bariatrician of the Year” for his work in advancing the field of obesity medicine. He is a best-selling author of several books relating to ketogenic diets as well as co-author on over 100 peer-reviewed publications related to ketogenic diets, type 2 diabetes, obesity, smoking cessation, and more. He is an internationally recognized expert on the therapeutic use of dietary carbohydrate restriction and has helped thousands of people in his clinic and far beyond, by way of his famous “Page 4” food list.
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