What You Need To Know Before Starting Keto – Adapt Your Life® Academy



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starting keto

What You Need To Know Before Starting Keto

Hi, I’m Dr. Eric Westman. I got started in keto research and medicine in 1998, about 25 years ago. Two patients came to me in the office while I was an ambulatory care doctor at the Veterans Affairs Clinic in Durham, North Carolina, and they lost over 50 pounds each. I got curious, asked them what they did, and they said they did the Atkins diet. I said I didn’t know what that was, and I didn’t want them to do it. They asked why I was concerned, and I said their cholesterol will go up. They suggested measuring their cholesterol to see. I did, and two times in a row, the cholesterol levels got better, even though I was told by my colleagues that that couldn’t happen. The cholesterol will go up; don’t have people do that diet. It’s going to be bad. In fact, the cholesterol levels, however you looked at it – triglycerides, HDL, LDL – it all got better. So, I was curious. In fact, it was through my patients that I learned about this, so I knew already that it could work.

What concerned me and everyone else around me is, was it safe? I went to the bookstore; there were books called The New Atkins for a New You and other low-carb kinds of books. One thing led to another, so I decided, why don’t I call Dr. Atkins, himself? So I did. I said, “Dr. Atkins, I had a patient who had some success with your diet. Do you need some research?” He basically said, “Why would I want to do research? I’ve been treating thousands of patients; I already know what the research will find.” He had a point. If research is being done to show that something can work, he already knew it could work. But I was still concerned about the safety of it, so I decided to take Dr. Atkins’ invitation and go visit his office. I visited several other doctors’ offices at the time who were using low-carb diets. I returned skeptical, but I knew it could work. But still, was it safe?

So, we started our own research at Duke University at the same time that Jeff Volek started his work at the University of Connecticut. Now, Dr. Volek, a Ph.D. in exercise physiology and nutrition, is at the Ohio State University, and I’m at Duke University. We never really worked together, and I’ve opened a clinic to use this. In fact, 25 years after that first event of me seeing those patients, I’m dedicated to using keto medicine. That’s not because I just visited other doctors; we’ve now published over 50 peer-reviewed papers on the keto diet, and many of these studies are actually new data of clinical trials. Our first clinical trial was published in 2002. We did several other clinical trials and opened the Keto Medicine Clinic at Duke in 2006. Because of this research and my interest in obesity medicine, I got into the leadership of the Obesity Medicine Association and I’m a past president of this organization. You might have seen some of my videos at prominent websites on the internet. This is one I did several years ago, Adapt Your Life Academy, to get this information out to people outside my clinic.

So, while I was skeptical at first, I’ve been looking up and down and trying to find something wrong with this approach, and I still haven’t today. What I’d like to do is to share with you things that I’ve learned and, in fact, teach you what’s the most simple and effective way to do a keto diet even today.

At the Duke Keto Medicine Clinic, I’ve focused on treating people with medical issues, and I’ve treated over 10,000 patients there in Durham. It’s kind of known as “the clinic of last resort” – when people have tried everything else. You know, God forbid just changing the food is actually going to fix things. And it fixes so many things. I’ve treated people with obesity, type one and two diabetes, PCOS (a common cause of infertility), irritable bowel syndrome, fatty liver, heartburn or GERD, lymphedema, lipedema, cardiovascular disease – actually reversing heart failure. Go figure! We were all taught that this would cause heart trouble and heart problems, and I’m using it to reverse heart failure. I’ve even sent patients who are too heavy to get a heart transplant, sent by the heart surgeons so that we can get them slimmed down and be healthier to get a heart transplant. Even people who have had bariatric surgery, having pretty heroic surgery sometimes to get people to eat less, and if you’re not taught about the food, you may actually regain the weight even after bariatric surgery. Regarding weight gain caused by medications, today, so many doctors are, I think unwittingly, contributing to the weight gain that people have by giving medicines like steroid pills and shots and sprays, and antidepressants and other psychiatric meds. Despite all of these things, I can still help people in a clinical setting.

Now, I’ve also learned that keto or low-carb diets can work outside a clinical setting without medical supervision. There’s a guardrail for if you have medical issues; you want to be followed by a doctor, but keto works for virtually everyone when it’s done right. And I don’t think there’s any need for medical supervision if you don’t have medical issues. Not all low-carb diets are keto diets. As the carb grams go down, the likelihood of you being in ketosis goes up. Some people start getting into ketosis when you’re at about 50 total carbs per day intake, and just about everyone’s in ketosis when you’re under 20 total carbs per day. That’s where I set the bar. I want to make sure it works the first time, every time. So, I teach a method that keeps the carbs under about 20 total grams.

It all boils down to what the food does to your blood sugar and then what the blood sugar does to your blood insulin. There isn’t much of a glucose or insulin response when you eat a meal without carbohydrates. When you eat varying levels of carbohydrates, even low-glycemic carbohydrates will raise the blood glucose. Then, the body sends out insulin to lower the blood glucose. But we know now that it’s that glucose and insulin and the multiplicative product of the two that leads to the increased risk of insulin resistance, type 2 diabetes, and cardiovascular disease. So, we want to eat things that don’t raise the glucose and insulin much.

A keto diet can be simple. The method I learned and that I teach in my class is that protein comes first, and you can run your body on carbs or fat. It’s a protein-based sort of approach with meats, poultry, fish, and shellfish and eggs being the main places you’ll get your nutrition, with some other things to make the diet a little more flexible and full of variety.

A major thing that I’ve learned to teach people is, you don’t want to add fat if you’re trying to lose body fat. The keto diet on the internet today is full of the darndest things. I don’t know where they come from. We started using the low-carb diet 20 years ago, and I’m using it in my clinic, and people started coming in asking me about exogenous ketones, and they asked me, “How should I calculate my macros? And what if my ketone level is only 0.5? And what if I can’t eat grass-fed beef and butter? And is it okay if I use that Keto Chow? And what are net carbs? And who are the Two Keto Dudes? And do I have to put butter in my coffee?” I didn’t know where these things were coming from, and they certainly didn’t come from some science.

Now, I think we can sort of portray the internet keto diet confusion having these basic roots. The idea of focusing on macros and ketone levels comes from the ketogenic diet for epilepsy, where if you do not have ketones around, you might have a seizure, so you have to be very strict. But that’s not what I teach. The Paleo-Primal diet, hunter-gatherer ancestral health, focuses on food quality – that grass-fed beef thing and putting butter or medium-chain triglyceride in the coffee. That didn’t come from the research using this dietary approach for diabetes and obesity, and it doesn’t really require a keto metabolism. It’s kind of nice if you can afford fancier foods, but it’s not required and it gets confusing.

What I teach is at the bottom of this firehose of information, if you will, called LCHF/LCKD – it’s a ketogenic diet, it’s carbohydrate restriction. We use total carbs as a “prescription strength” version and net carbs as the “over-the-counter strength” version. There’s a big difference there, actually. The keto diet that I teach has now kind of been dubbed ‘lazy keto’ because I don’t make people use apps and monitor things, calculate macros. In fact, it’s been called ‘dirty keto’ because I’m not super strict about having to avoid fast food or restaurants. Where I’ve been teaching this in Durham, North Carolina, if I didn’t have a way to allow people to eat fast food or at restaurants, that would take it out of reach for a lot of people because those are parts of the lifestyle that many people have here. So, what I teach now is dubbed ‘lazy, dirty keto’ on the internet. It’s thought of as something less than, which actually it’s not. It’s just more flexible and easier, in my mind.

Still, we don’t know the role of total fasting or intermittent fasting or the carnivore diet or the exogenous ketones where you drink ketones. These haven’t been scientifically tested, so I’m not going to incorporate them into my teaching yet.

As a practical matter, that distinction between prescription strength and over-the-counter strength is important to know. If you’re looking at products that say ‘zero net carbs,’ but then you look on the back of the nutrition facts label for total carbs it may say something like 7 grams. The net carbs is where you subtract the fiber and sugar alcohols, and it says it’s zero. The problem with using net carbs is it doesn’t work for everybody. And remember, in my clinic, I have taught people who have serious metabolic issues, medical problems, and if you need a prescription strength version, then use total carbs, not net carbs. It’s like using a pain reliever over the counter. Some of them can work just fine, but if you have really bad pain, you want to go get a prescription strength pain reliever.

There are a lot of myths and misconceptions about the keto diet across all domains of metabolism and disciplines. One of the first things I learned years ago – remember with my first two patients – the myth is that your cholesterol will go up. Well, actually, the more eggs you eat, the more your good cholesterol will go up. So, sometimes you want your cholesterol to go up if there’s a good and a bad cholesterol. I’ve learned a lot about looking at lipid profiles and can help you look at those as well.

In general, there’s an old way of looking at cholesterol that’s using the total and LDL cholesterol, and there’s a new way now that focuses on triglycerides and HDL, which are components of the metabolic syndrome. Pretty much 100% of the time, the triglycerides and HDL get better the new way, and about 66% of the time, the old and the new ways look better. But that means a third of the time the old way looks bad, but the new way looks good. And I get many, many people asking me to look at their lipid profiles, and I’ll just focus on the triglyceride and HDL without too much concern about the total and LDL cholesterol.

There’s some active research being done with people with high LDL cholesterol with very advanced imaging techniques looking at the coronary arteries. So, it’s not like this field is putting its head in the sand like an ostrich; we’re actually collecting data on what are the effects of an elevated LDL cholesterol in the context of a keto diet.

What do you need to know before getting started on keto?

  • A keto diet can be simple and easy to follow.
  • A keto diet works by reducing and eliminating hunger. After just a day or two, you’re just not hungry, and you wouldn’t know it unless you tried it. It gets the body to burn its own fat. (We’ve stored a lot there!) If you think about it, everyone becomes a fat burner if you don’t eat for two days.
  • The “internet keto diet” has many differences from the evidence-based keto diet that I teach and that has been used in the clinical setting by lots of doctors now.
  • There are many myths and misconceptions about the keto diet.
  • For anyone taking medications for diabetes or high blood pressure on a keto diet, you should be under medical supervision and especially with someone who’s trained in this approach. I can reduce medicines often on the first day for people who are being treated for diabetes. So just beware that if you have medical issues, you want to do this with medical monitoring.

I’m reminded of a poem by the American poet Robert Frost. You might remember “The Road Not Taken.” I’m going to use this as the backdrop for the talk. The beginning of the poem, “Two roads diverged in a yellow wood,” and the traveler had a choice to go down the well-traveled path where it’s very well lit, clearly, it’s wider, there are more people going down that way. It’s like following the medical mainstream if you will. Or there’s another path that’s not quite as well lit and it’s not quite as wide. That’s the path I’d like you to consider, which is the lifestyle path.

In the medical world today, have you ever really been asked about what you eat and drink by a doctor? Think about it. Did they ever ask you what you had for breakfast, lunch, and dinner beyond what type of diet you’re doing? It’s very rare to have that happen. In fact, I do that all the time now – I ask people what they’re eating. I’ve become a total diet and lifestyle doctor, but I used to be like the doctors today who ignore what you eat and drink. They might talk to you about smoking, but they’re quick to diagnose you with things. They’ll do blood tests or other measurements and say, “Well, we need to give you medication for that.” That’s the well-worn path. It’s the current medication care that we have in the Western world today.

I’d have to say very little time is given to lifestyle. In terms of overweight and obesity, you might have done some diet programs. You might have had some food subscription programs and over the internet and had food delivered for you. Once you hit a doctor, you might be given some prescription medications, some pills, or shots. When those things don’t work, you may even be referred to weight loss surgery to have surgery on your intestines in order for you to live in this world. It’s a lifestyle thing, really. That’s the medical care today.

In terms of things like heartburn and reflux, even something as simple as that. You might watch TV, take some antacids, that sort of thing. You go to a doctor, they give you prescription medicines for this, a daily pill to cut out your heartburn or reflux. Heartburn is “managed” with a drug when, with lifestyle, I can just about 99% of the time fix heartburn by changing the food. When I say “lifestyle,” I really just mean the food. If you use something as strong as a keto diet, heartburn goes away in just a week or so. It’s pretty amazing.

With high blood pressure, again, does a doctor say, “Oh, you have high blood pressure. Here, you might take this special diet, and when you lose weight, you won’t have the high blood pressure anymore?” No, what’s commonly done here is prescription medicine. You have what’s called “essential” high blood pressure or “essential hypertension,” which means we don’t know what causes it. And high blood pressure is managed with medication. I can reverse the high blood pressure with lifestyle. Likewise, with high cholesterol, you might be told to lose weight or fix something in your lifestyle. Or more commonly, you’ll be put on medication. They might be ones called niacin or fibrates or statins. So the high cholesterol is managed with medication rather than, for example, using a lifestyle change.

Type 2 diabetes is a big one because it’s so common today and has lots of terrible consequences. You don’t want to go down this path of managed diabetes, but this is often what happens. You get put on Metformin; if you’ve been told you have pre-diabetes, you’re put on Metformin. Now that’s a wakeup call. Make some changes. You don’t want to keep going down this path because when the Metformin stops working, then you’ll be put on these other medicines like Jardiance or Victoza or Byetta. Basically, diabetes is managed with medications. Once you’re put on insulin, that’s pretty much going to seal the deal. You’re going to have diabetes forever now, because insulin makes you gain weight. Weight gain contributes to insulin resistance, which is the root cause of diabetes in the first place.

So, doctors are unwittingly or unknowingly perpetuating type 2 diabetes when they give insulin. The insulin is already high in someone with type 2 diabetes. You don’t need to add more insulin, but it’s so common today. You might even be told that you’re always going to have diabetes – diabetes is forever. That’s just the way the medical mainstream. It’s all these people down. You might have friends and neighbors who are in the same situation. That’s that well-worn path. But it’s not the only way to go. And the reason you don’t want to go down this path is the end management of diabetes is not a pretty place to be. There are still complications like blindness, kidney dialysis, amputation. If you’ve had friends or relatives, parents, who’ve had these medical complications of type 2 diabetes, you know you don’t want to go down that pathway.

The first thing that we do is we address the carbohydrates, the carbs because on this well-worn path of the medical world, you might even be told to eat more carbs. That’s the crazy thing about type 2 diabetes dietary treatment. People are protecting you from low blood sugar because of the medicine (making your blood sugar too low) and telling you to take more carbs because of the medicine. I’ll get you off the medicine because I ask you to eat fewer carbs. When we recommend people to do a keto diet in the context of type 2 diabetes, this is what I do. We say, “Don’t eat carbs.” And there is a place where you can reverse type 2 diabetes and not have diabetes anymore. That’s down this other pathway. The first thing that I give people is hope: diabetes is curable. It is reversible. (Type 2 diabetes, that is – not type 1.) All too often, people are hopeless. They’ve been told that it’s going to be forever. So the first thing we do is instill hope. On the first day, your blood sugar can go down 50 points by changing the food.

We start doing this thing called ‘de-prescribing.’ You have taken away medications. It’s not something doctors are typically taught to do. We start taking away the insulin so that the weight starts coming off. We take away these other shots and pills, and this de-prescribing process can happen very quickly or it might take weeks or months. It’s hard for me to know. (It’s an individual thing.) That’s why there’s medical monitoring involved if you have type 2 diabetes with a keto diet. But on this other pathway, even if you’ve been on medications for years, you can have no medicines and have no diabetes. It’s pretty amazing. We can help you go down this path and help your doctors understand how to de-prescribe these medicines. It’s an incredible thing to see people happier and healthier at the same time just by changing the food.

Pre-diabetes, again, is a wakeup call. You may not have that type 2 diabetes yet. You can eat carbs and go down that path, or don’t eat carbs or limit the carbs or do some other lifestyle change. That’s a potent one. And you don’t even have to have pre-diabetes. For overweight and obesity, it’s the same deal: on the path over here, the less well-trodden path, there’s no obesity. There’s no pre-diabetes. There’s no diabetes if you don’t eat many carbohydrates.

At the end of the poem, Robert Frost concludes, looking back, that he was at two roads that diverged in a wood: “and I— I took the one less traveled by, and that has made all the difference.” I hope you’re thinking, “Maybe I should take that less traveled road. I’m tired of that well-worn path with medicines and the side-effects of medicines.” We’re very happy to help you figure out how to get started and how to get going on lifestyle changes. I hope that this gives you some inspiration or even at a minimum some hope if you’re feeling that you have no hope at all. This is what I see every day in my practice at Duke University Medical Center. You don’t have to come see me to get this kind of care. We can help you through our internet courses if you can’t make the trip there.

Watch the full video here.

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