We often hear statements like, “Keto is unhealthy. It’s dangerous, don’t do it long term,” and so many other negative statements. Why do you think this is?
I’ve been hearing those statements now for 20 years. When we got into the idea of studying a low-carb and keto diet, this was 1998. It was even worse than now, where people would come to me afraid that eating without carbs and with fat, even just eating a steak, might kill them. There was the fear of eating fats, which was really bad. I still hear all the same kinds of criticisms. I call it fear mongering now. Even in the medical world, it’s called bullying when you tell someone to stop doing something that has all of this research behind it saying that it’s good.
While these criticisms still occur today, it’s much less than it was 20 years ago because now there’s so much data. If someone’s been paying attention to the medical research data, then they don’t say that sort of thing. How information gets out in the medical world is not freely given, it’s not freely received, and often it’s when I share a patient with another doctor that they’re open to it and that’s a slow process. While I’ve heard this for so long, I put it around the other way. The burden of proof is on all these other people saying that it’s bad, to prove it, because we don’t see it. We’re using it in our clinics, we don’t see that it’s bad. I have to think there’s another agenda going on when someone tells you that it’s dangerous because they don’t know that it isn’t.
A well-known Indian actress died of kidney failure and the keto diet was cited as the reason for this. What are your thoughts on hearing this?
I heard about that, and I was interviewed a few times with some Indian keto groups. The problem was that the information I could get was very sketchy. I didn’t get any details about what the person was eating, how they defined the keto diet, or whether they were doing keto the healthy way or were they doing it in an unhealthy way. As far as kidney disease, if you have pre-existing medical issues, whether it be kidney disease, heart disease, or diabetes, you want to do this with medical supervision – with a physician who understands how to use the diet. It can be very powerful. I can take people off medications often in the first day or two of changing the diet. If you have medical issues, you want to be followed by a doctor. It wasn’t clear to me if the actress was followed by a medical person or not, and then it seemed to me she had pre-existing medical problems.
I don’t know of any evidence that keto causes kidney disease in someone who has otherwise healthy kidneys. When you get into the area of someone without healthy kidneys and you’re under medical supervision, there’s a fear and long-standing teaching that a higher protein diet is bad. When you do keto correctly, it’s not a high-protein diet. When you do keto correctly, you’re eating about the same or maybe even less protein than before. The details were very sketchy in that case and it’s really hard to know what happened. I do know that a lot of people are quick to blame a keto diet because it’s brand new in some areas. But no, actually, it has many years of credible experience behind it if you do it right. I cringe when I see that in the news because if you were blaming a drug, for example, you have the company to come out and say, “Wait a minute, you need to give me more proof before you implicate a drug for causing something.” There’s no one to say for a keto diet, “Hey, wait a minute, you have to have some level of certainty before you blame something.” Right now, you can have a keto diet or any diet for that matter, for doing something because there’s no legal team to protect it. You can just say it, it gets into the media, and then people believe it. There’s no filter, no level of evidence that you have to prove that something’s causal. You can just say that it was.
I’ve read a lot of the anecdotal reports of keto causing problems in the medical literature. There are a few, and if there are millions of people doing it, and there are only a few instances, that reassures me. When you read these anecdotes, they never really ask people what they were eating. They say the person said they were doing a keto diet or the Atkins diet or whatever, without exploring what that means. You don’t know what they were doing if you didn’t ask them and know what they were eating. You’re just taking their word for it. You don’t know if they did it right, you don’t know how they were taught, you don’t know who taught them. It’s just raising confusion. Some people don’t want you to do a keto diet for various reasons and they’ll use this kind of information against the keto diet when it wasn’t the keto diet that caused the problem.
Let me ask you and set the record straight. Fact or myth: keto puts strain on the kidneys?
A myth.
Fact or myth: keto should only be done for short periods.
A myth. I get the trend here. I think the next one’s a myth.
Fact or myth: keto is not sustainable or healthy.
Yeah, it’s a myth.
And last but not least, a fact or myth: keto will clog my arteries.
It’s a myth. That one is tough to swallow, pun intended, because we were all taught that eating fat and following a low-carb diet was bad for us. But we know now that that’s not true. I’ve taught this at medical meetings over the last 10 years, the Obesity Medicine Association is one of them, and I’m a past president of that organization. It’s actually in the medical mainstream organizationally speaking in the U.S.
How do you go about educating doctors who are under the impression that keto diets are harmful?
You can be trained at an advanced level in obesity medicine by the American Board of Obesity Medicine. There are over 2,000 doctors and nurse practitioners, PAs, and most of them understand. If they don’t use a keto diet, at least they’re aware of it and aware of how it can be useful.
It’s tough because you might say, “Let’s bring together experts and see what they say about diets,” and every year about this time of year I have to do damage control for the U.S. News and World Report. It’s a journal, a magazine that rustles together experts about diet and they rank all the diets and keto was one of the worst diets on their ranking list. When you really look at it, it’s about as silly as having all of the judges from one country in the Olympics. For example, I have all the judges from one country and then oh, by the way, all of the U.S. judges said the U.S. figure skater was the best – everyone’s biased toward the people who are from their country. That’s just the way it is in the Olympics so you have different judges from different countries to do the judging.
The U.S. News and World Report get the same judges of the diet and none of them have any expertise in the keto diet so of course it’s going to look bad. If you only look at studies from some places, they say that one of the best diets is one that the doctors in the Obesity Medicine Association never use, so it’s impractical. I would love to see a more diverse panel. Doctors can go directly to the medical literature and read about it for themselves but most of them don’t have the time to do that so going to organization meetings, and taking CME (continuing medical education) in an area like this will give you the proper information and we’re trying to educate as many people as we can and direct to the consumer to use it but then also at the physician and health professional level.
Pre-COVID, the Academy of Nutrition and Dietetics (AND), the new name for the American Dietetic Association, had a meeting in Philadelphia and I gave a talk there. There were about a thousand people in the room, so the mainstream is coming around. Jeff Volek and Steve Phinney, colleagues of mine through the years, were also giving talks at the AND in Philadelphia. I think things are changing but it changes very slowly in the organizations because we were all taught that low-carb was bad. That’s changing, I’m glad to say.
What is your policy about educating those who want to listen and learn?
When I was looking back and reflecting upon how I learned about this, there are a few hurdles that you need to overcome: Does it work? Is it safe? Can you really eat fat? Dr. Atkins invited me to his office, that’s how I got to learn about it, learn about his method and others. We studied it back at Duke throughout some years past and I realized, the only way I could wrap my head around all the different things going on was to invite people to my office. I do that at medical meetings; I can’t just let any person off the street because of the privacy rules and things like that, but for people who understand the privacy rules, I have an open-door policy, meaning, time permitting, you’re welcome to come to my office and sit in for a half day. People have traveled from all over. That experience was chronicled in a recent book called The Case for Keto, by Gary Taubes, because in the introduction, he tells the story of Dr. Sue Wolver, who traveled from Richmond down to Durham to my office, and she catches fire about the keto diet and now she has one of the best academic practices that uses the keto clinic. I think even today that’s an important thing. If you’re really curious about it as a medical practitioner or dietitian, then go visit someone who’s using it in their clinic.
Fortunately, now there are people all over the country, you don’t have to make the trek to Durham like you had to in the past. There are other people practicing keto medicine. But I’ll do that as long as I can to help people understand the potency, the power of it. There’s a whole other field of pharmacists who are developing the training and the construct, the term, “de-prescribing.” This is Sean McKelvey out of Vancouver, Canada, who helps other pharmacists understand how to take people off medication, which is de-prescribing. Once you’re on an effective lifestyle like a keto diet, you can take people off medication for diabetes, high blood pressure, heartburn, and arthritis. It’s cool to see pharmacists come alive and take advantage of the power of a keto diet.
Do you still see patients that you saw right up in the beginning? How is their health?
I do, and one of them is me. I’m not a patient but I learned about the program as I was doing my first study starting in 1998, so I’ve been following the keto diet, low-carb, high-fat, however you want to say it. Many of my patients like to check in; if you’ve had a significant weight loss or a history of diabetes, there’s always this nagging feeling in the back of your mind that it’s all going to come back and so a lot of people want that follow-up over time. It might be that I see someone once a year just to check in but then they know if something comes up they can contact me and I can respond to them.
I have a lot of people who have been using this for 15 to 20 years and in an academic community like this, if I were causing harm, the other doctors around me whose patients I was harming would tell me. They would be angry with me. Other doctors actually send me their patients because I send them back better or then they’re able to operate. Orthopedic surgeons and heart transplant surgeons send me their patients to help them lose weight before surgery because I don’t use drugs and I don’t use weight loss surgery because these are higher-risk people. You want to use something that’s effective but rather gentle compared to those other things.
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