This blog is an adaptation of Dr Westman’s video on ‘Keto vs Low-carb Diet: Which is better?’ which we have included at the bottom of this article.
Q: What is the difference between a therapeutic keto diet and a low-carb diet ?
A: The low-carb approach is something I’ve been working with for over 20 years in the research and clinical setting. It’s been around for 150 years in Western medicine. The low-carb approach is not as strict as the therapeutic keto diet. For some people, therapeutic keto will seem complicated at first. When you start to learn about it, you might think, ‘Oh my gosh, do I have to do all these different things? Is this what keto is?’ In my experience, and in what I’ve taught thousands of patients, no. Keto mostly means very little carbohydrate, which is not so complicated and doesn’t require measuring multiple different things and using gadgets and apps every time you have a meal. Let’s explore the branch point between therapeutic keto and low-carb.
If you’re just entering this, just be aware that there’s a range of difficulty and use of different things. My comfort zone is using low-carb, because I’ve been doing that for so long with so many different people in a clinical setting and just for healthy eating. So I know more about low-carb than therapeutic keto.
Q: So, let’s say, for example someone had type 2 diabetes, hypertension, metabolic syndrome and other metabolic related illnesses or conditions. How would they know which version is right for them?
A: I use low-carb diets for those things all the time. I keep the carbs so low that you’re going to be turning into a ‘fat-burning machine’ and using ketones without measuring those sorts of things. Severe metabolic diseases can be helped and fixed if you do this long enough and stay with it by maintaining a very low carbohydrate level. When I think of a therapeutic keto diet where you have to measure your blood ketones, (urine isn’t good enough) and you have to be sure about your macros and the amount of fat you’re eating every day, you don’t have to do that level of difficulty if you’re type 2. If you’re affected by type 2 diabetes or obesity, no, don’t be daunted by the therapeutic keto sort of approach.
Q: And so let’s say one was following a low-carb or a keto type of diet, does this mean that 75% of your calories needs to come from fat or is there some sort of flexibility?
A: There’s a lot of flexibility with a low-carb approach. In fact, I don’t ask people to check their macros or put their food into apps and all that. That’s something that’s come about in the last five years or so, borrowing from the ketogenic diet for epilepsy, where children have to be very careful about the ketone levels and need to stay away from sugar and starch. It’s something new because of the science around cancer treatments and therapeutic use, potentially, of ketones to treat diseases and to prevent inflammation. The idea of keeping your fat percent the same every day and watching your protein exactly every day is something very new. There’s not a whole lot of science about it, so my approach is to be much more flexible and let people eat different things on different days and in different amounts. I don’t think we really understand the level to which you have to measure all the different ketone levels and macros and I mean there are a lot of apps and computer assisted ways that it will tell you, you have to, but I don’t think the science is that clear there yet.
Q: Let’s say someone has been on your Page 4, for example, which is 20 grams of total carbs and under, to treat any of those conditions that I spoke of and they’ve actually reached their goals. So let’s say, for example, they had 20 pounds to lose and had type 2 diabetes and hypertension and they have successfully come off their medication, they’ve lost the 20 pounds, they’re feeling great, they’ve been on this kind of lifestyle for a year or so. Once they’ve reached their goals, is there some sort of flexibility to move onto more of a low-carb diet where they don’t have to stick to under 20 grams of total carbs?
A: Yes, definitely. When I am explaining to someone who’s just starting – remember I’m in a clinical program, for the most part, still at Duke University – people come in, if they have no real understanding or they’re worried about, ”Will I never be able to have fruit again in my life?” And no, I don’t want you to have fruit at first! But, I explain that what I want to do is get them from point A to point B. Once you get to point B, where your weight is gone, diabetes is gone, hypertension is gone – yes, you can fix all those things! – if you’re at a lower weight, you can go back to eating more carbohydrates, but I reassure people along the way that if they don’t want to, it’s fine. I mean after you go several years, I’ve gone 20 years without eating many carbohydrates, they don’t have the same calling and allure.
So yes, you can go back to eating some more carbohydrates, but if you go back to eating what got you in trouble in the first place, it’s just a matter of time before you develop diabetes and obesity again, and that’s called yo-yo dieting which we don’t want to have happen. So, don’t be concerned that you’re never going to be able to eat carbs again. I can’t entirely predict who will be able to eat more carbs and not develop diabetes, metabolic syndrome, or obesity, so it’s really trial and error at this point.
I will measure those things, reintroduce carbohydrates and keep measuring the weight – hunger is a good measure of that. I wish I could predict who would do better with more carbs. I mean there’s a general kind of feeling I have that if you have a couple hundred pounds to lose and all these other medical problems, you’re probably going to have to keep the carbs low for a long time. If you’re just coming in for 20 to 50 pounds of weight loss or you’re trying to fix some other sort of metabolic problem, you’re otherwise active and young, yes you can have more carbs, maybe even more carbs now as you fix the metabolic problem by changing the food. So there’s a lot of flexibility in the low-carb approach.
Therapeutic keto would be, ‘No, you have to do this every day, you have to measure the ketone level and make sure it’s within a certain range’. The excitement around therapeutic keto is that it might actually fix things or help fix things like cancer, Alzheimer’s — things we don’t have great treatments for. So I’m watching the science on therapeutic keto with great optimism and hope, but it’s not nearly as solid as using the low-carb diet, which has more flexibility.
I’m still not convinced that we all should be going around in ketosis, although I know a lot of doctors and researchers and people who were kind of in the zealot keto area that believe that already. I don’t think we know that for sure. Getting carbs, getting sugar out, probably the most important thing: get sugar out of the drinks and the foods. I’m not convinced yet that we all should be walking around worrying about being at a therapeutic keto level. You can incorporate carbs back into your diet, especially if you’re young, active, if you haven’t had a huge, long weight loss or diabetes journey.
Q: If you’ve reached your goals, how do you progress to the next level? I think it’s pretty important for folks to understand that; if they are going to add carbs back into their diet, how would they do it, how will they test? I mean if their weight is at their goal weight, I’m sure you wouldn’t advocate them just jumping up 20 or 30 grams of total carbs in one go. There needs to be a methodology in terms of how one could do it.
A: Right. But in what you said, if this is someone new to the diet, 20 grams of carbs might be just one apple a day. So in the big picture view, you want to change things slowly. What might seem like a small amount of carbs to someone is probably a lot. So it depends on the individual, definitely.
Q: If someone has achieved their goals, can they replace some of their fat calories with protein in their diet?
A: Probably. I mean that’s the interesting thing about flexibility. I have people who measure all of these things. They bring in reams of information; they know all the apps and the downloads and they try to make sense of a human body that has variability and is not like a machine. It’s not like an engineer would deal with a machine. There are adaptations that occur and I think there can be variability in the fat and the protein.”
You know, the trouble comes in when the mind, the taste, the, ‘Oh, I just want to eat all of this’; when you over-consume based on other factors than your basic hunger – you know if you’re a foodie and food just tastes great and you can’t stop doing that, that’s where the behavioral side of what I do comes in. Understanding of metabolism as a fat-burning machine takes you a long way. It doesn’t totally fix everyone, and there’s still a need for coaching and helping people figure out the individuality of their circumstance.
Q: So obviously we spend a lot of time together at all our Adapt events, and so I’ve had the luxury of listening to you speaking and presenting many times. We’ve also had many discussions, and I know that you are an advocate of using your own body fat stores rather than ingesting additional nutritional fat. Do you want to just give us your thoughts on tapping into your own body fat versus eating calories that specifically come from fat, or trying to hit a macro goal or target specifically by eating fat?
A: Again, it will depend on the context or what someone is trying to achieve. Most people who come to me in a clinical setting are trying to get rid of the extra fat. They’re obese. They come to me for weight loss or they come to me for diabetes.
To become a fat burning machine, the simple answer would just be not to eat anything, right? Your body will start using its own body fat. That’s not the healthiest way to do it though. Adding some protein back with the idea that you’re not eating the carbs, well, actually you’ll be a fat-burning machine as well. And so, this new idea of bringing ketones and having fat and all, comes from Dave Asprey with Bulletproof coffee, who saw people in a remote area of the world eating and drinking butter, which gave them a lot of energy. He got the idea of using Bulletproof coffee as a way of getting oils and ketones and energy. But when you’re trying to get the fat energy off your body, anytime you drink oils and butters and energy that way, you stop the burning of your body fat. It does trip up some people if they come into the keto world today without understanding that low-carb is more important. They might be drinking ketone drinks, thinking that’s the answer. Every week people come in asking me about the keto pills and products and I say, ‘No I just want you to eat real foods. Get it really basic.’ But, some people can have the Bulletproof coffee, feel alert, and have no brain fog – but I don’t really want people to use those in a big way when they’re trying to lose weight or fix their diabetes.
Q: I’ve got a couple of questions from our viewers. Amanda asks, ‘How do I know I’m actually compliant with my keto or low-carb diet? Do I need to test blood sugar, ketones, insulin etc.?’
A: Well, you know you’re compliant because you’re sticking to the list of foods in the simple system we have, a certain set of foods that don’t raise the blood sugar, don’t raise the insulin.
But, you could do any number of keto, even keto vegetarian, keto vegan. The way you know that you’re a fat burner, which to me is what keto really means, is that your hunger will go down or go away totally and you’ll start burning your body fat. So, in a clinical setting I don’t really need a scale. If someone tells me they don’t have any hunger, their clothes are getting looser, they’re losing weight, then I know in the big picture that they’re burning fat.
I do ask people what they’re eating, because it is important to get proper nutrition. That’s where the adequate protein comes in. You know, as a dietitian doctor, I blend those together in my training; I need to make sure that people are getting adequate nutrition. So that’s part of it, too. If you’re not sure of where to begin, there are lots of programs that are reputable, that can get you started. The application can be different foods, knowing that you’re at keto means that your hunger goes down or is gone, you’re losing weight or inches.
Q: Martin asks, “Are there different levels to therapeutic keto, i.e. following some of the groups using therapeutic keto for cancer? They speak about a one-to-one ratio and that their blood sugar and blood ketones need to be the same. Is this true for other metabolic conditions, or other types of therapeutic treating, other types of therapeutic conditions using a keto diet?”
A: Right, so now that you know you can check blood glucose and you can check blood ketones, you can take the ratio of the two. From certain animal studies, meaning not human studies, there is an idea that keeping the ratio in a certain area has special therapeutic benefits. And you know, I’m a human researcher, clinical researcher. I don’t discount animal studies, but I know the metabolism of a human is different from the metabolism of a mouse or a rat. So, I don’t know that these ratios really apply the same way in people yet.
So what’s happened is — it’s always happened — where an animal study will come out in mice and you’ll hear it in the news and then people just assume that a human should do it. Well, there’s a process of applying those same principles from animals, then to humans, and that usually is a period of years and many different research groups and making sure that there’s safety and that it works. So, I am very cautious to say, ‘For sure! That’s going to be the same level, the same ratio.’ And I know a lot of people are advocating that and it gives people something to do, but we really don’t know for sure in humans yet if those levels are really important to check and to do. So, I don’t know. I know if someone’s coming to me for treatment of cancer or Alzheimer’s or pre-Alzheimer’s or minimal cognitive dysfunction, I’ll explain that I want you to do everything your doctors tell you to do and think of the keto diet as an adjunct, as something to add on to those treatments, because we just don’t have the human research yet to say that the keto diet alone is enough.
But, there are plenty of resources. Miriam Kalamian is a good friend who has the ‘Keto for Cancer’ book, if you want a deep dive into how to do it. But, you have to be, you know, eyes wide open, that we don’t have clinical trials to say that this really will be helpful. You know, is it possible? It could be harmful, I suppose. In my view, I’ll help someone do a keto diet for cancer or Alzheimer’s, but only under the condition that they still follow their doctor’s recommendations.
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