Meet Dr. Tro Kalayjian, and learn his health secrets
Dr. Eric Westman: It’s my great pleasure to have Dr. Tro Kalayjian with me. You’re living in Tappan, correct?
Dr. Tro Kalayjian: I actually live in a small little town just north of New York City, called Palisades, but my office is in Tappan.
Dr. Eric Westman: I did a little homework. I went to your site a little back. You guys have these great bio videos, which is awesome. All the staff has their story there, and I could not believe your story, Tro. That’s not you in that video from the past. I don’t know if my membership folks know who you are but assume we know nothing. Your physical look has changed so much.
Can you share your backstory with us?
Dr. Tro Kalayjian: I came from a family where everybody was obese. My mom ended up having bariatric surgery, had type two diabetes, and struggled with weight her whole life. My father also struggled with weight. My older brother and my younger brother both oscillated anywhere from 300 to 500 pounds. I was following in those footsteps.
Dr. Eric Westman: Did you grow up there in that area of New York?
Dr. Tro Kalayjian: Yeah, I grew up outside of New York City. My parents were first-generation Armenian immigrants. They came to the country to live the American dream and worked two jobs. They’re both accountants now. They’re successful but they went to college at night when we were kids. Growing up, we had a mix of Middle Eastern cuisine including pita bread and rice and modern cereal, Pop-Tarts, and whole-grain toast. Then, we went to school and got fed school lunch. I was a product of this standard American diet and the product of immigrant parents who were working and trying to maintain some of their ethnic cuisines. But when you’re busy working that much, you can’t keep that up. I was a product of the standard American diet. I was a product of processed food companies. At the age of 13, I was 200 pounds, which is what I weigh now.
I remember going to my family medicine doctor at the time for my annual physical, it was my birthday, and he looked at me, and I was 205 pounds, and he said, “You’re 5 feet tall, you’re 205 pounds, you’re going to be just like your family if you don’t change things.” I remember sitting in that office for two hours to wait to see him on a hot July morning; I remember thinking to myself, this jerk just told me, after making me sit two hours with a TV and a chair, to go lose some weight. Where is the freaking exercise bike, bro? You’re going to tell me to lose weight? I remember thinking this at 13. I was always questioning authority; I had that stint in me, I had this chip on my shoulder. I was a chunk of a kid.
Dr. Eric Westman: Did you always want to be a doctor?
Dr. Tro Kalayjian: That was the moment. I remember thinking, “I’m going to do better than this guy. I’m going to beat the genes.” He said it’s probably in your genes, and I’m going to beat the gene. I’m going to become a doctor. I’m going to show him.
Dr. Eric Westman: That’s funny. I learned from some people what to do, some mentors, and I learned from some people what not to do!
Dr. Tro Kalayjian: He was a good doc. He was always there for our family, Dr. Addis. I remember him. I don’t think he was a bad doc but he just didn’t know how to deal with whatever it was he was looking at. He didn’t know how to deal with the processed food environment, the modern obesogenic environment, we call it. He didn’t know how to deal with it other than to elicit shame and try to get me to change.
Dr. Eric Westman: Not much has changed in the traditional doctor’s office today, I’m afraid.
Dr. Tro Kalayjian: Not at all. That was my primordial loss. I was like, I’m going to become a doctor. 13 years old was the first time I thought of becoming a doctor. 13 years old, I was like, this clinic could do better. That’s where I came from.
I tried to fight it. I didn’t eat for a month after that. I have shared this before. I didn’t eat for one month after that visit with that doctor. Just to give you an idea I was a troubled kid to some degree. And then what happened? I gained all that weight back, 10 pounds per year despite loving to exercise, despite running, despite being vegan, despite counting calories. I put on 10 pounds per year every year through medical school, through residency, and all the way into attending. I was 350 pounds, and I think those are the pictures you were talking about that you saw.
Dr. Eric Westman: It’s a three-minute bio including these old pictures.
How did you find the low-carb diet or answers? You were clearly searching and probably following what everyone was telling you to do, which we now know doesn’t work for most people.
Dr. Tro Kalayjian: I had a chip on my shoulder. You know me, we’ve worked together on some projects now. I think you have a sense of my character, and most people who follow me on social media or listen to the podcast know I have a bit of a chip on my shoulder.
Dr. Eric Westman: That has a negative connotation. I don’t think that’s what it is. I think you get on something and you hold onto it so you figure it out.
Dr. Tro Kalayjian: Yeah, so that’s how I was with medicine. I remember I was studying medicine avidly. I was the chief resident. I was in a Yale internal medicine program. It was a great internal medicine program. I had all the esteemed lecturers from Yale lecturing me every day and I soaked it all in. I’ve been a lifelong learner interested and curious and eventually, I was chief resident there. I loved medicine. I scored in the 90th percentile in my board exam. I loved to learn and I loved to read. But here I am, 350 pounds, totally blind to my own obesity and what drives it, but yet so knowledgeable in the way that I was training residents. I was training other doctors and medical students. And yet, it was such a blind spot. What I realized was not only was it a personal blind spot, but professionally it was a huge blind spot. That took me years to understand. I wasn’t always this firebrand that wanted to just topple it all down.
When I was 350 lbs, my wife really challenged me to learn what obesity is. What did I do? I read your textbook. I read all of your papers. I read three textbooks on obesity. I went and eventually got certified, 3,000 papers, all the studies that you and others have done. I’m the type that I’m going to go read what the other people say. I’m going to read their citations like we did with the pediatric paper that we’re working on now – the pediatric consensus statement on low-carb that we’re critiquing. That was my thing. I’m going to learn medicine better so that I can train med students and residents better. Inspire them to learn, show them that their knowledge will save lives and that their ignorance will kill people.
When it came to obesity, I was like a sponge, just soaking it all in. When you look at the evidence, all the interventional studies, what would I do if it was pneumonia? I would look at the antibiotics or first determine the etiology of pneumonia, is it bacterial or is it viral? Then, I’d look to see if it’s bacterial, which is maybe the most common, maybe not now in the COVID era, but before that, bacterial was the most common. You look at the antibiotics. What’s the efficacy of the antibiotics in head-to-head studies? What are the side effects? That’s how I approached obesity. I was like, show me the head-to-head studies. I’m looking and it’s like low-carb is better, low-carb better, low-carb is better.
Dr. Eric Westman: What year was this?
Dr. Tro Kalayjian: About eight or nine years ago.
Dr. Eric Westman: Where that first round of low-carb versus low-fat studies was out. And low carb wins, right?
Dr. Tro Kalayjian: Yeah, this is all back then. So, of course, being curious, I would do what you did, thinking, are these guys promoting it real? I’m looking at you and other doctors. Then I thought, I’d better look at the people critiquing those people. Let me go read How Not to Die, see what Greger’s saying, see what McDougall’s saying. I’m just reading like it’s anthropology to me. I’m trying to figure out my own struggle and figure out this field. You start to unpack layer after layer. How did we get here? How did we get to recommending whole grains and multiple meals? How did we get to including five servings of fruit when, actually, one or two is all you need really for the mortality benefit, and after that it’s not a benefit? You start to look at the data and understand that how we got here is a house of cards. The strongest data we have is supportive of low-carb. That was it. I was like, I just want the best antibiotic for my problem.
I started with low-carb like I’m just looking for the “most likely to succeed” solution to my issue. You peel layer after layer, thinking, what are the drives to eat? People eat because they’re hungry, people eat because they have sleep deprivation, people eat because they’re anxious, people eat because they have emotional eating, and people eat because they may have food addiction symptoms. All of these are true for me. I was hungry, I was addicted to food, I ate out of anxiety, I ate emotionally – we all do, it’s human nature. You learn about all of these things and the story becomes so crystal clear. Blood sugar fluctuations modulate most of our appetite, sleep deprivation makes us eat as if we’re hungry, and anxiety makes us eat as if we’re hungry. It becomes clear. Carb-fat combinations make you eat more, carb fluctuations make you eat more. You peel away the science and it’s clear now why I had a lifetime of struggle. It’s very clear.
Dr. Eric Westman: Do you remember the first day you started?
Dr. Tro Kalayjian: I remember it. Right after my wife and I had a miscarriage in between kids two and three, we were talking and we were having a tender moment and she asked, “Are you going to be alive?” It was November 2014 to November 2015 when I was avidly reading. And then, I fully committed. I haven’t had bread since 2015, let’s put it that way. I don’t remember the last orange I ate.
Dr. Eric Westman: You’re still alive. It’s interesting that most people who quit smoking remember the day they quit smoking. It’s like a milestone etched in their mind. This is kind of like you quit smoking; it’s an impactful moment. I suppose you didn’t just have immediate success as if there were no bumps in the road?
Dr. Tro Kalayjian: There have been a lot of bumps. I lost 80 pounds in 2015, and in 2016, I lost about 60 pounds. I lost another 10 or 15 in the ensuing year. I went from 350 pounds to about 195 pounds. I always had a love for exercise so that’s always been a constant – martial arts, running, weightlifting always did it, always liked it. That didn’t really change much, but when my body felt good, maybe I was a little more committed to doing it than historically. Maybe going from two or three days a week to four to five days a week. I lost weight and kept it off.
Then, like a punk, I called Mark Cucuzzella in 2016 and I felt maybe like you with Atkins, where I saw the change in my life and I was like, I need to make systemic change. He was doing systemic change at West Virginia University (WVU). I called him. I tell him, “You don’t know me, but I know you and I’ve seen you talk. Tell me how you did it. Tell me how we’re going to get 100,000 doctors to do what you’re doing,” which is making WVU drop sugar. Unfortunately, they’ve reversed that since then.
Dr. Eric Westman: I didn’t know that part of the story, but I think it’s important to reach out and find that these doctors are real. It was important to me that there was a doctor in practice and the only one at the time was Dr. Atkins in New York City. I visited him in 1998. Did you go visit Dr. Cucuzzella or were you just convinced by phone or learned what to do?
Dr. Tro Kalayjian: I was convinced because it worked for me and then it worked for my family and then it worked for other people. I was convinced because I realized, wait a second, I’m not hungry anymore; why am I not hungry? The data supported it, the interventional data worked for me. What clicked in me was the amount of suffering we have. I went to ACP (American College of Physicians) to see if there was anybody thinking about nutrition there, nobody was thinking about nutrition. Eventually, I went to the ABOM (American Board of Obesity Medicine) but even there they don’t really care about nutrition, they care about drugs. Lifestyle medicine is the vegan front.
I was looking for a tribe because I’m like, okay, this has affected me. Eventually, I found Doug Reynolds and I reached out to Mark Cucuzzella. I’m like, how did you do it, tell me what you did. I’m gonna do it at Yale. Then he’s like, you’re never gonna do this, it took years. He just said it’s going to be challenging. I wanted to be the doctor I wish I had and learn everything. I wanted to make the clinic I wish I had. That was 2017, 2018, when I realized I gotta change my career, I gotta get out of being in hospital medicine and I’ve got to go do this because nobody’s doing it. I shouldn’t say nobody – certainly you were doing it, but there was no organization; we never had this organized group of actors. I thought, “I wish I had a network to pull from.” At the time I reached out to Jason Fung. I was just grasping at straws for somebody to help me get this clinic and do this thing.
Dr. Eric Westman: It’s great that you didn’t have to recapitulate, you didn’t have to do the clinical trials which I felt I had to do 15 years earlier. We didn’t have any data that was published so that’s fantastic that you didn’t have to do those studies. You read them and you were convinced.
What I tried to do some years ago, and it failed, was to do a company within doctor’s offices. We had the method, we had the handouts, we had the clinic idea, but no doors opened. There were a couple of doctors who wanted to do it but then they’d go talk to their management and then the doors were shut. We tried to scale things up but it didn’t work within the system, at least 10 years ago. You decided apparently to open your own shop, to do your own clinic, which is brilliant in a sense because if you had tried to do it just within the medical system as it even exists now you’d get a lot of doors shut in your face. Tell me how the clinic came about.
Dr. Tro Kalayjian: I wanted to create a network. I remember in 2018 or 2019 I went to Doug Reynolds and told him we needed to make a medical organization. We need to make the medical organization I wish I had. I’ve been able to be a part of that, and you’re a part of that; we’re all working together on that and that’s been so fantastic. At the same time, maybe a little bit earlier, I started doing telemedicine consults. The premise was that people don’t want to come to the office, people don’t want to come in; we need to do everything remotely. This was before COVID-19. I had remote scales, remote blood pressure cuffs, and CGMs – I’m a technology guy. I play around with ultrasounds so I was quick to embrace technology. I thought, “I want to make this easy for the person. They don’t need to get dolled up and come in, they don’t want to sit on my waiting room chair, they don’t want to sit in my office. Let’s just make weight loss very easy.” Then that became an app and we have health coaches now and you talked about our team, we have an amazing team.
Dr. Eric Westman: So there never was a brick-and-mortar place?
Dr. Tro Kalayjian: We have a brick-and-mortar place but we are mainly remote. We deal with employers now in multiple states; it’s just completely remote medicine. Nobody’s come in to see me.
Dr. Eric Westman: Then you decided to not be in the insurance system?
Dr. Tro Kalayjian: The problem is that with all these things I just mentioned, they’re not really reimbursable.
Dr. Eric Westman: Yeah! Talking and talking about food? No code for this!
Dr. Tro Kalayjian: Not just that; things like setting up meetings, getting people in social groups, getting people in small groups, creating a sense of community, delivering asynchronous education, and videos that people can watch – none of this is a billable event so it really needed to be outside of insurance.
Interestingly, I didn’t know if I was going to even make it. I was like who’s going to do this, who’s going to want it? Now we have corporations saying, help! We’re building off the data that you mentioned. We’re able to save companies money. Our companies are giving our service for free to their employees; we’re reversing diabetes, which is our mission. The people are getting healthy. The average weight loss in our employee cohort in one year was 40 pounds. Now we found a win-win-win scenario that works. We get the people that I know you get it all the time – they come to see you and they’re looking for expertise. I’ve been laser-focused on the practice I wish I had. Going back to 13, I want the practice I wish I had. I want to be able to text and get some answers; I don’t want to come in to do something if I can just do it online. If we’re going to titrate medications, we can do it in real time.
Dr. Eric Westman: I was kind of skeptical. It’s funny, when people come in for the first time, or if you’re new to the low-carb keto world, some people perceive that I’m a radical early adopter and I’m not. It took me eight years of clinical research to validate and become comfortable with something that was so radical. It was so radical in 1998 to feed people fat that the hospital director was lobbied to clamp down on our first study and to squelch it. Everyone “knew” eating fat would be bad for you – it turns out that’s not true. We’ve come such a long way and the food being the most important thing; it’s really not been appreciated inside the system. I just want to say that one thing you told me that really resonated is that you’re limited with insurance and what you can do. I chose to be within the insurance system just so I could figure out how to do it and to see a wide range of clients in Durham because most people have that insurance, it’s not a big area. But the ability to go beyond what insurance would be paying for and doing it on your own is brilliant. It’s time now, I think, where there are enough people and enough background and guidelines to support this. I’ve noticed that your staff is growing.
Dr. Tro Kalayjian: Let’s take a step back because I should be much more appreciative. I should really be thankful.
Dr. Eric Westman: You have thanked me many times!
Dr. Tro Kalayjian: You talk about fighting against the grain, having to do these trials, and I’m here trying to build off of that, both professionally, as an entrepreneur, I guess, but also manifesting what I wish I had more. Creating the SMHP (Society of Metabolic Health Practitioners) has been such a value to me, to be able to have an outlet. It’s great to hustle for your own business but it’s also really rewarding to make the world one step closer to something you wish you had.
Dr. Eric Wesmtan: I’m so inspired by you and your story that I think it’s going to grow. If someone’s watching and they need help, I get requests all the time, “Can I get a keto-friendly doctor near where I live?” and we have these loose website places that would direct you, but you’re in how many states now?
Dr. Tro Kalayjian: Every state. We have a big team and we’re growing. We have Dr. Laura Buchanan who started with us about a year ago, and she’s still taking patients. I very rarely see patients. I see them either in conjunction with Dr. Laura or with our PA, Mary. She’s awesome. She was my first medical assistant, always inspired. She went off to PA school. She actually came and rotated with me as a PA. We wrote a paper together on an interesting Cushing’s case, and now she’s come back and she’s been inspired by metabolic health.
Dr. Eric Westman: The Society of Metabolic Health Practitioners is really an outgrowth of Doug Reynolds, Pam Devine, but then also your team, Tro, and us. They’re great leaders that are trying to find a home for people who don’t have to be a physician. I really love it because you can be a coach, you can be a dietitian, you could be a PA, and you can be a member of this organization that allows for the fact that you can change metabolism by changing the food. It’s not just a low-carb keto organization, but it embraces that – that’s a sidebar of bringing other people into the fold and also raising the credibility of what we’re doing.
This summer, the ketogenic textbook came out. It’s the first real textbook on clinical use of keto diets for, among other things, diabetes and obesity and metabolic disease reversal. The science in there, pointing toward brain health and autism again raises the credibility of all this. I wonder now in real-time, what’s the response? Are you getting any negative responses from things? I’m predicting that you’re not. The water has parted and you’re going to be walking through.
Dr. Tro Kalayjian: I’m going to be honest. Every day has been a struggle. I left a full-time job in the Yale system in 2018, and I have not taken that salary yet. I am still at one-third of that salary. So, I’ve invested everything into just making the home I wish I had, this vision that I think you share and I share, and a lot of other docs share. You and Adapt have created a community; you’ve done it.
We have four awesome health coaches, two personal trainers; we have a team of 12 now and growing. My wife’s also helping. You’d be surprised when you deal with employers, the contracts that come.
Dr. Eric Westman: If you’re with us and don’t know much about low-carb or keto, this has come so far that to summarize, you’ve been able to use your own personal experience and then the data that had been collected over the prior 15 years to assume that it works and it’s safe and start practicing. Yet, the need is so great that it’s got to keep growing. One area where it just makes such sense is a self-insured company. A self-insured company is paying for any extra health care that their employees have. You’re saying they provide this as a service. They don’t even make the employee pay for it because they know they’re going to be paying less in the long run because they’ve fixed their diabetes. I mean, one person goes on dialysis, and it’s what, $30,000 a year out of pocket for the company.
Virta Health, I think, pushed the envelope, but it’s such a labor-intensive thing. They have their own preconceived ideas of what the diet should be. How would you compare what you do to the Virta program?
Dr. Tro Kalayjian: We’re a lot more invested in dealing with the entire package. We are like a concierge metabolic team. You have a health coach, you have a personal trainer, you have live meetings, multiple live meetings. We have multiple community meetings just like this that people can attend. It’s a little bit more immersive than Virta. I think the nutrition is very similar. We probably go a lot more into cognitive-behavioral therapy and motivational interviewing techniques that they don’t do. We tackle food addiction head-on and bingeing head-on. We deal with comorbidities like sleep apnea. We deal with everything that an internal medicine practice would deal with that relates to it. We’re very lab-intensive also, probably in a six-month time, you’ll get three labs done very systematically.
Dr. Eric Westman: Do you require using an app for food entry and measurement of ketones and things?
Dr. Tro Kalayjian: No, we use a CGM and ketone meter. We support the use. We use remote monitoring. Every patient gets a remote-monitored body composition scale, a blood pressure cuff, a ketone meter or CGM, sometimes at different times. All of it is connected. The average person is meeting somebody from our team at least weekly from the day they sign up to about two to three months. They’re meeting with somebody from our team weekly. Whether it’s a health coach, getting onboarded, seeing a doctor, and they have access to multiple meetings throughout the week that they can attend. They have asynchronous courses they can use. The average person in our program has about 500 to 600 touchpoints in the six-month period, meaning they’re interacting with our medical program in 600 ways, whether they’re going on the app, whether they’re finishing a course, meeting a health coach, texting a health coach, going on the scale, using the CGM, whatever it is. It’s very immersive. It’s very different.
Virta is a little more hands-off in their approach. They do great work, amazing work. They can’t be a concierge metabolic service. I don’t think you can systematically manage food addiction. These are areas that I think we focus on.
We deal with all the comorbidity that you see in your clinic. We do remote home sleep studies, remote ambulatory blood pressure monitors, and remote Holter monitors. If we suspect sleep apnea, we get that sleep study. We also do genetic testing if the cholesterol seems abnormal in that genetic range or if we suspect that there’s a low insulin production due to certain types of diabetes.
Dr. Eric Westman: It’s much more intensive than my approach. I learned from Dr. Atkins, who had a list of foods on one sheet of paper and then had check-ins about every week for that, but with nurses or other staff after a full H&P (history & physical) with lab tests and all. I’ve gotten less strict as time goes on, but I lose success with those who need that high-touch contact that you have with your approach. I think that’s fantastic.
Dr. Tro Kalayjian: Page 4 works and I give it to everybody, but how do you help people who just need more? David Unwin posed the question really well – another mentor of mine, he’s such a beast, I think an absolute force in the field, just like you. He said, “When really smart people do silly things, we have to think about food addiction.” I’m a self-proclaimed food addict.
Dr. Eric Westman: Give me your thinking and how you talk to patients about cholesterol.
Dr. Tro Kalayjian: I’m going to make it more medical and then we can maybe translate it down. I’m a big believer in risk stratification. You know, you try to determine how high-risk somebody is, maybe you use a CAC (coronary artery calcium), maybe you look for evidence of soft plaque. If you don’t have any of those things, frankly, I don’t really care unless I think there’s some genetic issue which we can test for now. I’m going to tell you, less than 2% have some genetic underpinning, meaning 90% of the time, I don’t care (about cholesterol). I don’t want to say I don’t care. I don’t care (about cholesterol) if somebody’s health is improving, their diabetes is resolving, their metabolic syndrome is resolving, their blood pressure is resolving, their weight’s going down, if they’re now more active, if everything is improving, and all we got is a bit of cholesterol, that’s the trade-off I’m willing to accept. In most people, their risk drops.
Coming back to what you said, which is, what do we need to do? I’ve tried to build off of everything that you’ve done and when we work with these employers, we track everything. We tracked the first 12-15 employees that we were working with. Now, we have a hundred employees, and the average cardiovascular risk reduction was 44%. We just plugged in the numbers, plugged in that they remitted diabetes when they did, plugged in their blood pressure, and we calculated their AHA/ACC cardiovascular risk, meaning we did what the guidelines say to do and their risk dropped from, on average, 9% to 5%. 5% is considered low risk, so we made them low risk on average with LDL being neutral, maybe slightly high, like a point or two higher, meaning we’re making people healthy.
Dr. Eric Westman: And it’s just a different tactic or a different tool. It’s a different intervention.
Dr. Tro Kalayjian: I’m probably more trigger-happy than I guess you’d be, meaning everybody can get a CAC, everybody can get a carotid ultrasound, everybody can get a femoral artery ultrasound, and we can just look for plaque very easily. If we have it, then we think just slightly differently, we think a little more deeply.
Dr. Eric Westman: Is there a role for cholesterol lowering, or statins, or other medicines like that if you do have disease? What are your thoughts there?
Dr. Tro Kalayjian: I’m a numbers guy. I believe in just telling me exactly what the benefit is and what the harms are. So, I literally calculated in front of patients, like let’s just extrapolate this from what we know. Maryanne Demasi did a great study that was published in JAMA Internal Medicine last year on the relative risk reduction of statin of around 20% to 30%, let’s say. If your risk is 2% over 10 years, we’re talking about a 0.5% (absolute risk) reduction or less. That’s a lower benefit than the incidence of diabetes that we’re going to cause with statins. With most people, you just present them the data, like here is the risk-benefit, what do you want to do? Most people say, “I don’t want to do it.” Some people, you run their risk, and their risk is like 20%, and or they had an MI, maybe then you’re using a statin and there’s non-statin drugs now. There’s bempedoic acid, there are so many ways to address the problem. There’s colchicine for coronary artery disease. There are a lot of approaches to the same issue.
The problem in modern lipidology, and I know you know this, is the whole population’s been insulin resistant. That makes LDL atherogenic. It’s not the LDL; it’s the insulin resistance. But lipidology doesn’t feel like that. They just pretend it’s the LDL without the insulin resistance, I think because they can’t see that their data sets are contaminated. Their data sets are not pure data sets. These are insulin resistant data sets they’re dealing with and that’s tough for them. They see one way: they see LDL = bad.
Dr. Eric Westman: I have to bring up the case series that you published. I want everyone to know that you’re taking your cases and putting them into the public domain for review. In one of the series for the super high LDL responders, you found that by adding back some carbs, the LDL came back down. What did you end up doing with those people? Are you still worried?
Dr. Tro Kalayjian: I was called an embarrassment by several prominent lipidologists for publishing this because we literally showed that you can modulate LDL more potently than the most expensive drugs. People call me dogmatic, but I’m like, I literally gave people a sweet potato. I’m giving people carbs. If you get very lean, you remain on a low-carb diet, and you’re time-restricted (intermittent fasting), you’re going to see the LDL rise almost like clockwork. Dave Feldman’s theory of the lipid energy model is very palatable and he continues to do research on it – it’s just true and you know.
Dr Eric Westman: Did you end up with the people who, you could lower the LDL by giving the sweet potato and other carbs? What did they end up doing? What did you end up recommending?
Dr. Tro Kalayjian: We gave them a sweet potato. These guys were all exercisers or massive weight-reduced people or people doing keto for a neurologic issue, so you have to be careful. If somebody is bipolar and they’re doing keto for mental health benefits or somebody has seizures or neurologic issues you have to be super careful. I’ve got to be honest, I don’t know, we don’t know what happens with it. One of those patients had a 797 mg/dL LDL (20.6 mmol/L). We gave them back carbs and I think he subconsciously reduced saturated fat. Slightly, but not to any degree. He still eats beef, he still eats eggs, and his LDL got to 180 mg/dL (4.6 mmol/L) with no medication.
I admit that I don’t know. If you look at the observational studies and you look at the genetic studies, it looks linear; if you can approach the mean, why not? That was the thinking of lowering their LDL. That patient is probably one of the highest LDLs in the documented literature.
Dr. Eric Westman: But, maybe it’s a good thing?
Dr. Tro Kalayjian: I don’t know, but you are at the 0.01% and do you want to be? He didn’t want to be and that’s why he came to me, but he didn’t want drugs.
Dr. Eric Westman: I just wanted your opinion because I don’t have the answer.
Dr. Tro Kalayjian: In my heart of hearts, I think it’s sort of like blood sugar. Do you want it to be high? Probably not. Do you want it to be low? Probably not. I don’t know the answer, but I know enough to say this is really deviated. If we can approach the mean with a sweet potato, why not? What’s the harm? What are your thoughts?
Dr. Eric Westman: I’m here to get your ideas because I don’t know. My response would be, let’s follow it. Dr. Yancy, my colleague at Duke who’s 10 years younger than me, is more cautious. I am anxiously awaiting, like we all are, the study that Dave Feldman got GoFundMe money to do with the CT angiogram center, one of the best places. They have a hundred people enrolled with all the coronary angiograms. It’s not the calcium score; it’s actually looking inside the arteries. 100 people who said they were doing keto have all signed up. The scans are in and they have a paper that apparently is under review. It’s following people for a year, documenting what they’re eating and that they’re in ketosis and then they’re repeating the scan again with these really high LDL levels. It will be very interesting to see. No progression (of calcification) is going to be the best result and if they all get worse, well, we’ll have a good result to know the answer. I’m afraid it’s going to be messy, where some people will have progress and others won’t, but the idea that it’s being studied is really important.
Dr. Tro Kalayjian: I’m excited.
Dr. Eric Westman: Dave Feldman went around as a computer programmer without the reputation and the credential to try to get the mainstream people interested and they said you’re crazy, like people who said about your patients whose LDLs went up and then you brought them down. No, it’s not crazy to collect new data and the metabolism is so different (on a keto diet). It’s like comparing what goes on on the moon with what goes on on Earth. The metabolism is so different. It wouldn’t surprise me if the LDL of 750 is actually healthier. It wouldn’t surprise me.
Dr. Tro Kalayjian: I don’t know. If there’s one thing I’ve learned, it’s that a good doctor is somebody who says “I don’t know” often. I just have to say I don’t know; there’s mixed data. You look at the cause of mortality and it’s a U-shaped curve for LDL and the mean is around 140 mg/dL (3.6 mmol/L) and the standard deviations around 20 to 30 so do you want to be 5, 10, standard deviations away from the mean?
Dr. Eric Westman: But that’s among carb eaters.
Dr. Tro Kalayjian: I know, I know, I know. But I just don’t know.
Dr. Eric Westman: The sodium or the potassium level for carb eaters and non-carb eaters we would assume is pretty close. But another project that Dave Feldman is embarking on is the company called Own Your Labs, where you can opt into having your data used to get a normal range of hemoglobin A1Cs for carnivores, for example. That’ll be interesting because some people don’t get the total reduction in A1C that you would expect based on their blood glucose and some people have a little elevated glucose.
I wanted to mention Rosette’s Mix. I have met your wife, giving me delicious cookies at these meetings. Tell me a little bit about Rosette’s Mix.
Dr. Tro Kalayjian: My wife is an amazing person. She really inspired me. She’s an attorney. She, along my journey of being the support system – and her herself having migraines and going low-carb and not having migraines anymore (she used to have migraines about three to four times a month) – she never had an appetite issue or major weight issue. She’s supported me throughout my own journey in dealing with food and appetite. She saw that social scenarios were hard, so she started making low-carb desserts and bringing them with us. Then it became, wait a second, people with celiac or diabetes who want to remain low-carb want easy-to-make things. She’s an entrepreneur. She was like, “Okay, I can do everything that I’ve used on you!” I was the guinea pig for Rosette’s Mixes. She makes low-carb baking mixes and she puts it into these bags. It’s her and her sister Natalie who own the company. I have to disclose that on every single research paper I do, which sucks, but the reality is she’s providing a service. Do I get a lot of flak for it that my wife owns a food company? I don’t know, what am I supposed to tell her – don’t do what you want to do? She’s the lawyer. I don’t win arguments, she wins arguments!
It’s been a huge passion for her to come up with recipes. She’s got a sweet tooth. She doesn’t have a weight issue or an appetite issue, it’s a migraine issue, so she can make these things and eat them. For me and some of my patients, I tell them with these things just keep it as little as you need. You don’t use a spare tire just because you use it when you need it. When you’re dealing with food addiction you’ve got to be careful with sweet foods and savory foods. My wife has been a huge support for me. She makes those mixes and it’s nothing more than if you want easy stuff in your home and you want to bring it with you to a holiday or something, that’s what it’s for.
Dr. Eric Westman: The Society of Metabolic Health Professionals is also for people who are not medical professionals; coaches can also join.
Dr. Tro Kalayjian: Coaches are medical professionals. Health coaches get CPT codes starting in 2024. This is brand new, they’re nationally board-certified. It’s crazy, they make everything a CPT code except keto.
Dr. Eric Westman: Any thoughts about school-age children or how to make a difference there?
Dr. Tro Kalayjian: Let me tell you what my kids eat. My 9-year-old daughter eats three or four quarter-pound hamburger patties when she goes to fast food. She eats three or four eggs in the morning. My son, very similar, my 7-year-old. They have some fruit, they have some nuts, they have tons of cheese. They drink whole milk. This is what my kids eat. They’re all normal weight. They got my genes. I have the MC4R gene. I think we can certainly lower the sugar and the glycemic carbs in our kids without batting an eye. We have a pediatric fatty liver epidemic and the best thing you can do is call people like me and Eric to go talk to the school. We’ll come out to the school, we’ll talk to them. We’ll bring some family medicine docs like Mark Cucuzzella, Laura Buchanan, and Matt Calkins to talk about the appropriateness of lowering carbs in children.
I think the big thing is when you’re dealing with kids, you have to think in a way that doesn’t make them feel deprived. Something simple, like if they’re eating chips, get Quest chips. Not to say that Quest chips are healthy or that Quest pizza is healthy, but kids are used to eating this stuff. If you deviate them significantly, all of a sudden, there could be a lot of deprivation. When you’re dealing with that younger population, just be considerate to that feeling of being deprived and a lot of times you can elicit that shame and guilt, going back to my story. My doctor didn’t mean to cause shame and guilt in me, but he certainly brought that out. Maybe my own vulnerability interplayed there. You don’t want to elicit that shame and guilt because that’s a trap you will not win.
Dr. Eric Westman: We need to work on a five-year plan of development for SMHP. One of the things that I always thought would be a great investment would be to hire people, like a speakers’ bureau that doctors do, but you don’t have to have doctors do it. Schools get the people to come in and give these auditorium-filled educational events. Having that be wrapped around sugar as the low-hanging fruit, pun intended, would be a smooth way of bringing in. I think sugar and too much sugar is kind of accepted now. It would be a safe thing to go into a school and say it should be limited.
Dr. Tro Kalayjian: We’re doing something right now, actually. Eric and I literally just bounced back and forth and we wrote a critical letter on the AAP’s, the American Academy of Pediatrics, guidelines for low-carb diets, which recommended in a supervised setting but more data is needed. But meanwhile, they recommend bariatric surgery and injection drugs. What long-term data is there in 13-year-olds with that? The thing is that I think the onus is on us. It’s not on you. You can certainly do something. You can tell them about the SMHP. You can tell them about Eric and me. But really, I think that lights a fire under my butt to keep doing things like we’re doing now. We just have to make our voice very clear and spread that voice.
One of my patients did a great thing. He lost a lot of weight with low-carb, and one of his kids had gained weight during the pandemic. He made a green, yellow, and stop list. The green was any amount of meat and fish and cheese sticks and vegetables and fruit he put in there. Yellow was nuts and Quest chips and protein bars and stuff like that. Red was basically anything else. He just put this on a big board, and his kid, just following that thing, lost a considerable amount of weight. The kids don’t need much. You could even put a sign in the lunchroom saying, “If you’re interested in getting healthy, ask me about it.” So, then the kids ask you about it. You’re not talking about it. You just got a little sign saying, ask your lunch lady about eating healthy. You may get like five kids saying, “Tell me, what does this mean?” Those are my thoughts.
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