A lot of people are coming to me now, already having started the keto diet. If they wait months for their appointment, many people will already start. I’m reminded of how I got into this – two of my patients did it without me and they taught me about the diet, so I am acutely aware that anyone can do this. It’s just about changing the food.
Caution with medication and keto
There are some issues. I worry about overmedication. If someone is on medicine, they need to be monitored to be taken safely off the medicines. Sometimes it’s not the ones you might think of. We talk about diabetes, obesity, and high blood pressure medicines all the time, but if you’re on medicine that’s unusual, you want to just be sure that a doctor is monitoring you or looking up the side effects of the drugs. There’s one now being used for heart failure and diabetes called Jardiance or Invokana; it’s a drug that makes the urine leak sugar or glucose. Do you know what else likes glucose? Infection. One of the major side effects of these drugs is infection.
The other side effect you want to look out for is something called acidosis. If a drug has the potential of metabolic acidosis as a side effect, then combining it with a keto diet is a risk for ketoacidosis. In 10-12 years of using this approach in a clinical setting with lots of different drugs and people with different illnesses, I had never seen ketoacidosis from the diet by itself until these drugs came out – they’re called SGLT2 inhibitors, making the glucose show up in the urine. The idea is you eat whatever you want and we’ll just get your body to leak it out. I’ve seen ketoacidosis now among my patients. If your doctor wants to put you on this medicine, be sure to not only ask them but to read the drug insert in detail yourself to be sure there’s no side effect known as metabolic acidosis.
Modern healthcare is about “medicine care”
The frustrating thing is our medical care these days is “medication care” for the most part. Doctors think that if someone’s doing a keto diet and they’re on that medicine, it’s the keto diet’s fault if they are experiencing negative side effects. The diet is fine; it’s the medicine being added to it that’s the problem. This interaction with the diet is also probably why this same medicine helped reverse heart failure. There’s a theory that the ketosis generated by this class of drug – Jardiance, Invokana, and the generic SGLT2 inhibitors – create ketosis. It’s thought that maybe ketosis helps with heart failure because they know the drugs help. That’s coming through the back door, that now the keto diet and keto supplementation are being studied without that drug. It seems strange or ironic but they’re learning about the diet through the use of a drug because that’s what doctors do – they use drugs.
Funding for keto research
I’m glad that the Department of Defense is actually funding a study now to look at the keto diet. If you’ve heard me speak or come through the office, I have a poster on the wall of one of my patients who reversed her heart failure and she started with a different diet, but when that stopped working, the keto diet helped her lose 140 pounds and the heart squeeze (how much blood her heart was able to pump) went from 20% to 50%, which is almost back to normal on just diet alone without those medicines.
I’m finding that I often have to make a justification for why someone should be on different food. I see this lack of prioritization common in our area where someone is obsessing about a cholesterol level but they’re not reversing the diabetes. When you look at risk for heart disease, remember that cholesterol is not a disease. It’s atherosclerosis that we’re trying to prevent. Highest on the list is type 2 diabetes as a risk factor for atherosclerosis. If someone isn’t helping you reverse diabetes and they’re obsessing about the drug treatment for cholesterol, that’s the wrong focus.
Using keto to treat anaplastic thyroid carcinoma
Recently, someone came to me who was already lean – he wasn’t overweight – he and his wife were there. He told me the story that he was having neck issues and it turns out that he had thyroid cancer. You might wonder why someone would come to a keto clinic for thyroid cancer. He had done a lot of reading outside of his normal oncology group locally and then went to an out-of-town expert cancer group, he was put on medication and then was reading around about the interplay between keto and cancer. He read that some cancers are glycolytic, meaning they burn a lot of glucose. It’s a specific type of tumor I hadn’t heard about for a long time – anaplastic thyroid carcinoma. They’re very aggressive tumors. The prognosis that this man received was that he should have been dead, that he had about six months to live, and now it was 18 months later. He had had CAT scans and MRIs and the tumor already had liver and lung metastases. This is not a good thing generally when it spreads like this, but the tumors have been stable now for about six months, which is not supposed to happen.
I did some research about the tumor. The first hits that came up were about a surgical group at Harvard using a keto diet to stop the growth of anaplastic thyroid carcinoma. I thought I might email Dr. Nehs, whose name was on the paper. He didn’t reply, so the patient left. I taught him what I knew and said I couldn’t guarantee this was going to help him but I saw no reason why he couldn’t do it. I told him to please do all of the cancer treatments his doctors were recommending. The next day, Dr. Nehs emails me back. He says, “Dr. Westman, I heard about your work. My wife went to an event several years ago and heard you and other people speak about cancer, and it changed my research focus.” He started studying it. As a surgeon, he removes these tumors but knows that the prognosis is very bad. He started studying the mouse model using a keto diet to see if he could slow the growth.
I asked him if in his experience he was recommending this or noticing any change in his patients. He said it’s hard to know. If someone gets meningitis and dies, then 100% if you introduce a therapy and someone lives, you realize this therapy is effective. That’s the anecdotal thing. No study had been done to introduce penicillin use because these people continued living when you gave them penicillin to treat terrible diseases. With cancer, a terrible disease, you might live six months so it’s hard to know if a new treatment, without a randomized trial at the beginning, is helping unless you get people with CAT scans and metastases that are stable and live beyond the expected timeframe. If someone lives two years and that’s never been seen before, you can get an inkling that your treatment is doing something, even though you don’t have that randomized trial prospectively.
When I asked Dr. Nehs, he said yes, but it’s hard to know with something that has a life expectancy and then has a 95% confidence limit around it. I suggested that he write up a case or two of his experience with people. He is a surgeon who focuses on aggressive tumors and he explained to me that these anaplastic thyroid carcinomas are particularly aggressive, meaning they spread quickly. Without some sort of treatment, people don’t survive very long. With a story like this, the patient had been treated with a different kind of medicine from the outside university hospital so it’s not just the diet that’s at play but it’s also the other medications being used. It’s hard for me to know everything that’s being done.
The keto diet has proven success
With the Metabolic Health Summit as a focus of research presentations, there are a lot of new types of diseases and conditions that are being addressed and studied which is pretty amazing. We presented a case of acne reversal at the Society of Metabolic Health Practitioners meeting and several people came up when I was at my poster showing that in 10 weeks one fellow went from pockmarked acne to clear telling me similar stories. I’m not an oncologist and I’m not a dermatologist, I’m just observing the effect on the entire body and all of these different chronic medical conditions by simply changing the food, it’s pretty amazing. If you are interested in this you might read a new ketogenic book – Ketogenic: The Science of Therapeutic Carb Restriction, edited by Tim Noakes from Cape Town, in South Africa. It’s a great summary of a lot of the evidence and theory about low-carb keto diets. It occurred to me that there’s really no other dietary approach that has a textbook like this that goes through every organ system and how the keto diet affects each domain. That’s a great book if you’re into the science.
The keto diet can reverse diabetes
Another book that came out recently is Gary Taubes’ Rethinking Diabetes. It’s very well-referenced and tells the story of how therapeutic carbohydrate restriction was used for the treatment of diabetes in the late 1900s and the early 1900s and then faded away when insulin started to be used for both type 1 and type 2 diabetes.
It wasn’t known until the 1960s that people with type 2 diabetes had high insulin levels. The treatment was already entrenched to use insulin for type 2 diabetes before it was figured out that there was too much insulin already. In endocrinology, the theory is if the hormone is low, give it to raise it, and if the hormone is high you lower it. If someone had stepped back at that time with the knowledge we have now, they would never have given more insulin to someone with type 2 diabetes whose insulin is already high! That’s just a general hormonal principle. If you have low thyroid, you’re given a thyroid hormone; if you have high thyroid the thyroid is ablated with a treatment. You’re given a thyroid replacement if your thyroid level is low afterwards. It’s the same with cortisol treatment. If the cortisol is low, you give it; if it’s too high you figure out why it’s high and try to lower it. That was one of the “aha!” moments I had after reading Gary’s book.
There was one voice in the wilderness, Dr. Gerald Reaven, who took issue with that and said insulin resistance is a thing. You don’t want to raise insulin even more. What you want to do is treat the obesity and other things that are causing the underlying insulin resistance.
Continuous glucose monitors (CGMs)
I’m reminded of the time when blood pressure monitors came out for home use and people were given blood pressure monitors without really being told what normal blood pressure was. Blood pressure goes up and down throughout the day, same with glucose. If you’re under the expectation using a glucose monitor that you’re going to have stable blood sugars all day long, you’re going to be disappointed. That just isn’t what happens normally. If you have an infection, your blood glucose goes up because your immune system needs the glucose to fight the infection. People in the hospital will try to lower your glucose even though it’s helping you to fight the infection.
Some people come to me worried that the blood glucose isn’t normal right away or even ever. “Normal” blood glucose or hemoglobin A1C is probably going to look different for those who don’t eat carbohydrates. Blood is a convenient thing to measure but it doesn’t always tell you important things. Yet, doctors can obsess over something measurable. If you stop eating carbohydrates or you reduce the amount coming through, it has to go through this five-gram blood system before it gets burned around in your body. It’s that throughput with burning the oxidation from the carbs, I believe, that’s the harmful issue going on here. A blood glucose reading of 120 mg/dL (6.7 mmol/L), when you’re eating carbs, is a different matter than if your blood glucose is 120 (6.7) and you’re not eating carbs because you don’t have all these carbohydrates getting absorbed and transferred.
How much do CGMs cost and who pays for them?
There’s an expectation that because you pay for insurance the insurance company should pay for everything. In a system that’s reactive and not very focused on prevention, most plans will cover a continuous glucose monitor (CGM) if you have diabetes. They’re not so keen on paying for it if you don’t have diabetes and you’re just curious. You can buy your own. I’m told soon they’ll be available over the counter so you won’t need a prescription for them. You can see what happens after you eat food with a continuous glucose monitor or you can just stay away from the carbs, which is the best thing you can do to lower your blood glucose. If you want to look for yourself, then doing a glucose monitor is maybe an interesting thing to do.
The reason I don’t push it is that if you stick to that list of foods, you’re going to get the best possible reading on the blood glucose that you can. I’m not convinced that any small variation is a worrisome thing as other doctors believe. All of those studies with HbA1c – your blood glucose correlation with outcomes – are among people who eat carbs and who often are on medications. This is a much cleaner system where you’re eating and burning fat off your body if you have extra body fat.
Measuring the arteries, not just blood
I think it’s important to measure the arteries. Cholesterol is not a disease. The question is whether or not you have atherosclerosis. Most doctors are making assumptions and not measuring the arteries directly. You can get ultrasounds or a CAT scan. I recommend the ultrasound. There’s a saying in the testing world that if you have a very sensitive test that comes back negative, it rules out the disease. If you do an ultrasound and there’s no evidence of blockage, it doesn’t mean there isn’t – if it’s a test there’s some error around it – but if it’s highly sensitive and it’s negative, it’s unlikely that there’s narrowing.
If you do the same thing with the aorta (the large artery in the abdomen) and there’s no block blockage, that’s good information to have. Most cardiology doctors aren’t in preventative mode and would rather treat the cholesterol level instead of worrying about whether or not you have atherosclerosis. I’ve fallen out of that world because many people do get side effects from the medicines that treat cholesterol. I think the burden of proof should be on the doctor to say you have the disease, and this drug will prevent it from worsening, rather than the current conversation which is about elevated cholesterol and giving patients medicine without knowing if there is a blockage. In cardiology, there’s no expectation for the doctor to prove that you have a problem before they give you a pill to prevent it or prevent it from getting worse.
Using the coronary artery calcium (CAC) score
An ultrasound won’t give you imaging of those arteries, so the alternative screening test is called a coronary artery calcium (CAC) score. It’s a brief CAT scan which does use some radiation, so you need a prescription for it. It doesn’t, however, tell you if you have blockage, so each test has its limitations. If you have a calcium score of 0, it doesn’t mean you have no risk, but rather your risk is a lot lower than someone with a higher score.
If you are around 65 years old but you don’t have any history of heart disease or stroke and all of these tests are coming back normal, I don’t think it’s reasonable or a good idea to be put on a medicine for something you don’t have, even by the age of 65. If you have some disease in your arteries and you don’t have a heart attack or stroke, it’s a gray area – some doctors will still say you have atherosclerosis and give you medicine to prevent the progression of that, but that’s not well studied.
Doing the CAC score is a bit of a Pandora’s box because if it comes back anything other than zero, you may have blockage, but it doesn’t tell you how much there might be. Doctors don’t like tests that aren’t perfect. You have to go back to the concept that if a sensitive test comes back negative, you probably don’t have the disease. If you end up having some sort of blockage on these tests, then you probably should go for more formal testing with a hospital or clinic-based tool.
Watch the full video here.