Deprescribing refers to taking people off medication. You might not have ever heard of the term; it’s kind of new. There’s a pharmacist in Vancouver who came up with the term. Regarding diabetes and high blood pressure, there has been this term used for taking people off medication as they get older in the geriatrics world but never really in the diabetes and hypertension world because there haven’t been that many treatments that can lead to deprescribing.
Sean McKelvey, the pharmacist there, has put on a conference on deprescribing, and now we can talk amongst ourselves. It was at that meeting that I learned that the Cleveland Clinic has a keto arm in its clinical program. I haven’t seen it broadcasted anywhere or advertised, but the dietitian who was working at the Cleveland Clinic gave a talk at this seminar.
Before I get to prescription medicines, I wanted to briefly talk about supplements and nutritional vitamins. I’m not a big supplement guy. I know some people grow up thinking that they always have to have a supplement or that food is devoid of all the vitamins and minerals that you need. I guess I’ve never really seen a lot of science to support that. Not that it would be harmful. The old saying is if you have good kidneys, you’re going to be able to urinate and get rid of any of the extra vitamins and minerals that you’re taking. Some people joke that we have the most expensive urine on Earth because so many vitamins and supplements are taken.
My approach is to wait if you have a symptom – then you might want to use electrolytes as a supplement. Sodium, magnesium, adding that back in if you have a symptom of ‘keto flu’ or muscle cramps, constipation, that sort of thing. Some people have the approach that everyone should take them, and funny, those are people who usually are selling them! Strong correlation there. Maybe if I start selling electrolytes, I’ll say everyone needs them. But again, my style is not to have everyone do something that they don’t need to do. It’s an efficient thing for me. I like the parsimoniousness and efficiency of only targeting people who need something. It’s cheaper and it’s easier for you as well.
So, you might take a multivitamin, which is a general recommendation for any dietary program because they’re so cheap. Then you would ask me which one. I don’t know which one. A funny thing, every owner or promoter of a vitamin says theirs is the best. Funny how that can be. I have to just chuckle when people say that; that’s the marketing and the entrepreneur stuff there. I think a store brand is sufficient, a Centrum equivalent matched to your age and gender.
Some people ask, “Why shouldn’t I take iron?” If you can’t absorb iron after weight loss surgery, then you want to take iron. If you’re a male or you’re a postmenopausal female, you don’t want to take extra iron. It’s an oxidant, and it actually can be stored in the body and not removed easily. There’s a small rate of hemochromatosis; that is the elevation and storage of iron that you can’t get rid of. It’s not that iron has carbs in it or that it has an issue to do with ketosis. It’s more being careful about adding something that your body can’t get rid of. I don’t add supplementation until someone has symptoms. Sodium, potassium, and magnesium are all important electrolytes. Fortunately, they’re all in the food. Maybe early on (on a keto diet), you may need to supplement to get through a transition, but most people don’t have to.
I had a patient where when the time was up, this fellow said, “Oh, do these matter?” and he gave me this list of about 30 different supplements he was taking. He neglected to tell me that at the beginning of the appointment. None of them really have any scientific evidence behind them. I had to admit that I really don’t know if there’s a gram of carb in each pill then and he’s taking 60 pills over the day which could be a factor for fat burning in ketosis, but most of the time you aren’t taking that many of those things. There doesn’t seem to be a strong signal for me to have to take those kinds of things. I might save you some money!
Plus, there’s the possibility that a symptom that you might have had or a food you might not have been able to eat before might be tolerable now. (If you’re healthier or your body is different because of keto.) If you’ve gone through the transition phase, keto-adaptation, you might be able to get away without a pill that you’ve taken for a long time.
The other thing is a pill might start causing a side effect that you never had before, and the most common time I see that is with the pill called metformin. It’s so commonly used these days because so many people have pre-diabetes and diabetes. Metformin can cause nausea and loose stools or diarrhea, and it can start after you’ve changed the diet (to keto), even though you’ve never had a symptom like that before. That’s one of the things I suspect if someone asks me about nausea. It’s not common, I should say. It’s exceedingly rare when someone eats the real food type of program that you’ve been instructed in. Then, diarrhea is pretty uncommon. It’s usually the other way around, going to the bathroom less often, not more often. Suspect drugs for side effects if you’re not feeling right, and they might have started causing side effects just because you’ve changed the diet. I don’t know why – a lot of things change in the microbiome in the gut, it could be that, or it could be the stomach acid changing, which leads me to my next medicine that you can probably drop – either over the counter or prescription – and that’s heartburn medication.
That is pretty amazing – who knew that carbs cause heartburn?! I learned that the hard way – someone told me and I didn’t believe it. I put her to task to test it out on her own and it was within the context of one of our first studies. I said, “Well, that’s interesting. You think carbs cause heartburn?” She said, “No, I KNOW it does,” “Well, why don’t you go home and try foods with a different combination of food?” Sure enough, she would come back every week, and say, “I had the spaghetti sauce and the meatballs. I didn’t have heartburn.” And then I said, “Well, okay, go back, try another thing.” Well, she had spaghetti sauce and meatballs and the spaghetti, she had heartburn. I told her to go home, do it again. Every time she had either spaghetti or the bread, she got heartburn.
That took me down the path of okay, it’s really hard for me to dismiss this as a random thing. Meanwhile, there was another book out there by Norm Robillard called Heartburn Cured that said you can fix your heartburn on a low-carb diet. Of course, I didn’t trust that as science. We talked to some other people, wrote up a paper, and published it. I started getting interest in it from other people. A trainee in medicine, a gastroenterology fellow, decided to do a study where you put pH probes, these little tubes, down through the nose into the stomach, to measure the acidity. It measures the pH. I had one of these studies done when I was a medical student. I wouldn’t advise doing it just for a study or for fun, but you can actually get the acidity reading all day, and we did it for three days. Over that period, Greg Austin, the GI fellow, did the study, and the pH changes – acidity goes down, which means the pH goes up when you don’t eat carbs. For these people who had refractory heartburn (refractory means difficult-to-treat or doesn’t respond to medicine), the heartburn went away, and they’ve been refractory to even proton pump inhibitors, which are commonly prescribed these days.
Heartburn is a big one where we can get you off the medicine. If you’re on the medicines, continue them for a while and one day when you wake up and forget to take it and notice, “Hmm, I don’t have heartburn,” try without it for a while. The rocket science is, if the heartburn comes back, go back on the pill. A lot of these symptomatic things you want to just test on your own. If the symptom comes back, just get back on the medication.
Another one that commonly gets reduced is pain medicines. Fibromyalgia, pain syndromes, or joint pains like knee pain or hip pain can often get better, and you just, on your own, try to reduce the medication if you can. There is a condition called Barrett’s esophagus, which you’d want to stay on medicine even if the symptoms weren’t there anymore. You don’t want to change the stomach acid medicine if you have Barrett’s esophagus.
More and more I see people who are just sicker and sicker on more and more medicines and they’re starting the diet on their own without consulting anyone. I had the experience lately of someone coming in, feeling dizzy, and it was the first time I saw them. It turns out the person was over-medicated already before I even saw him because he had already started changing his diet.
We’re in a conundrum where doctors don’t think diets are strong, and so they say, “Oh, just change the diet,” when the truth is, you need the doctor to help get you off the medicine safely. So, again, a caution about being on prescription medicines, especially diabetes and high blood pressure medicine: you want to be monitoring these things at home. Yes, you could say, “Oh, I’ll have the doctor do it,” but I’ll see changes occur between a visit, even if I see someone every month. I know most doctors don’t see you every month in the clinic. So, monitor that – whatever the disease is – blood sugar and blood pressure are the most common ones. When you get to a low, normal range, contact the doctor and say, “I’m losing weight. I’m feeling good but look at my number. My blood sugar is 100 now, it used to be 200. I’m on (let’s say) metformin, and I have GI upset from metformin. Can I go off it?” I hope the doctor will get the drift and say, “Yeah, that’d be okay if you still monitor the blood sugar.” Of course, I say the same things. You want to just be monitoring whatever disease process it is.
Regarding blood sugars, again, I can take someone from 100 units of insulin to 50 units of insulin on the first day with an improvement in the blood sugars (because of a keto diet). This is powerful stuff. If you’re changing the food, you’ve got to change the treatment. As long as you’re monitoring the blood sugars, you’ll see how fast it comes down. I can’t predict … most people have immediate reduction and then can get off the blood sugar medicines in a matter of weeks. Not everyone.
For example, I’m seeing someone who has a 300-pound weight loss journey and is in this process and is still on diabetes medicine two years into the process. Now, I have to say, he hasn’t taken the Keto Made Simple masterclass. He’s not strict, but I still see people who are doing the best they can. Remember, progress, not perfection, but the stricter you are, the better it will work. No question. That’s why I like to teach the strictest version of this. Years into it, he’s still on diabetes meds and a high blood pressure medicine, but that’s because he’s not yet near his physical goal. In that case, he should be off the diabetes medicine; he might not be off the blood pressure medicine. That’s an interesting thing because blood pressure is multifactorial; it’s because of several different things going on. One of the things is diet, one is the volume that you’re carrying around in the blood. That’s why diuretics are used a lot for blood pressure, and one is the stiffness of the arteries, which happens over time. You might have been put on medicine when you were younger, and now that underlying disease process of atherosclerosis or hardening of the arteries has made it so that you’re going to be on the blood pressure medicine forever. I don’t know; I don’t predict those things. I don’t have a crystal ball. But you want to just keep measuring whatever it is, including the blood pressure. Don’t be discouraged if you’re not off the medicine in a week like some people are, because some people aren’t.
The main thing is to not focus on that as a bad thing; it’s just that’s just the way it is, and hopefully, you focus on all the other positives that are going on for you. I’m a strong believer in checking not only blood sugars at home if you have diabetes but also blood pressure at home. I’m a strong advocate of fixing those problems so you don’t have to measure those things anymore! I have to say that it gives a jaw drop to a lot of my patients because they’ve never heard that they don’t have to have diabetes if they’re type 2. That’s fun and rewarding, and people like to be off medicines that require monitoring and make them feel bad too.
The other class of medicines, the blood pressure ones, have beta-blockers in them. Beta-blockers tend to make people feel fatigued, maybe even depression is part of it. I gain favor by taking people off medicines that have these negative side effects.
Diuretics are used quite a bit; the most common ones are hydrochlorothiazide and Lasix. I don’t always know why a doctor prescribes them. These can be used for a couple of different things. Some doctors will prescribe a fluid pill. Some people do it for cosmetic purposes; the doctor will give you that whenever you have extra fluid. Other doctors won’t do that, but they’ll use diuretics for treating blood pressure. Hydrochlorothiazide (HCTZ) is one of the most common ones for using a diuretic for blood pressure. With those medicines, you want to just be sure to be monitoring your blood pressure.
The third use of Lasix is treating a serious condition like heart failure or edema, with cirrhosis or kidney failure. You would know if you have those things – please work with your doctor if you’re going to be adjusting those things. I commonly take people off those diuretics as time goes on, using the blood pressure as a tool to follow and also the weakness or dizziness when you stand up. If you get weak or dizzy when you stand and you get tired or you don’t have energy and you don’t know why, suspect that it’s the blood pressure if you’re on blood pressure medicines. (Your blood pressure might be getting too low.)
For friends and family, if they’re on medicine and they do something like this (a strict keto diet), they’ve got to be careful. It’s like me renting a motorcycle. I’ve never ridden a motorcycle. It can’t be hard; I see people riding motorcycles all the time. But no, there’s a risk to it, and you want to know that you’re safe with it. If your friends and family want to do this and they’re on medication, please tell them to wait, make sure they understand what the medicines do, and monitor or work with a doctor who is keto-friendly and who understands it because you can hurt yourself if you don’t do it safely. If you’ve got low blood sugar, and you were driving, and you passed out, that could be life-threatening; we don’t want to be involved with anything like that.
Q: My husband and I have been keto for two and a half years now, been faithful, with very few slip-ups. He is pre-diabetic with high blood pressure, taking meds for blood pressure and cholesterol but not diabetes. I cook all our food except on rare occasions when we eat out. He can’t seem to get blood pressure down or his numbers down from pure diabetes.
A: If there’s still weight to lose (if he’s not near his ideal body weight – you can use some formulas: the BMI, the body fat percent, or what you weighed when you were in college, when you got married), insulin resistance can occur even at very small amounts of weight gain. Someone with diabetes has to be really strict. You might go from 30 total to 20 total carbs, and it’ll work. Don’t be loose about it; it’s got to be strictly using total carbs with diabetes because there are only five grams of sugar in the entire bloodstream. When you eat an apple, which has 20 grams of sugar (glucose), it will double your blood sugar. It’s four times as much sugar if you dump it all in at once. But you absorb it gradually.
Q: Why do I have muscle cramps?
A: Muscle cramps generally are from either transition symptoms and probably from fluid shifts. Muscle cramps respond to bouillon, extra salt, extra fluid, and also magnesium supplementation. One teaspoon of milk of magnesia at bedtime for a week, and the reason I use that is that it’s readily available, it’s inexpensive, and the liquid form gets absorbed well. If you want immediate relief from a muscle cramp or a charley horse, the best thing is consuming a squirt of mustard or pickle juice, which is unbelievably effective. No one’s marketing something for it, so you never hear about it. If you have recurrent muscle cramps, then you want to use the preventative teaspoon of milk of magnesia at bedtime for a week, adding extra bouillon.
Q: My heart rate’s running in the 80s while sitting instead of my usual low 70s. It started about a week into the KMS class. I don’t think I’m dehydrated. Any thoughts? I’m down six pounds; I am taking potassium.
A: If you’re checking your pulse, and it goes up into the 80s, that’s just fine. It’s still normal, but I think it may be because you have gotten rid of a little bit of fluid. That’s the salt and water that people lose during the beginning phase of this because the insulin goes down. Insulin not only lowers blood sugar and makes you store fat, but it also makes you hold onto sodium. If you’re eating lots of carbs – the typical American diet – you’re holding onto extra salt and water. When you go on the keto diet, you lose that salt and water, and that can raise the pulse just a little bit. That’s a minor change. The reason the pulse is up a little bit is you have a little less fluid going around in your bloodstream, probably; that will normalize or equilibrate over time. It might be that that’s a better place for your pulse to be. I don’t quite know, but I wouldn’t worry about that.
Q: For the KMS 3 cohort, do you recommend we stick to the KMS carbohydrate restriction, or do we need to follow the phases?
A: That depends on where you are. I think the first phase is the weight loss phase. If you have more weight to lose, and generally that goes, I say that it’s also the diabetes phase. I’m assuming that they go hand in hand for most people.
Q: Will weight loss take longer if I’m only eating once a day? I’m not hungry, but it seems slower when I don’t eat.
A: No, that doesn’t make sense to me. I really am a believer in the old school thought of how much you’re eating, not when and how frequently. I think it’s a function of just sticking with it. It doesn’t really matter when you eat. Yes, you can go to bed on a full stomach; it’s okay because you’re not eating carbs. You don’t have the sumo wrestler effect. That’s the effect that happens when a sumo wrestler eats voraciously – including carbs – and then they have a method of taking a nap right after they eat so that all of the energy is put into the fat. None of it is expended even in being awake. If you really want to store fat, eat a lot of carbs with fat and meat. Now that you’re not eating carbs, you can go to bed and because you don’t have that insulin signal, you don’t store the fat like a sumo wrestler does.
Q: My blood sugars and blood pressure are down to normal levels. I’ve been feeling lightheaded and a little blurry. Is this just my body getting used to new lows?
A: If you’re on medications for blood sugar and blood pressure and you don’t feel right, then you’ve got to watch those medicines and taper off them with monitoring (from your doctor). If you’re not on medication and you’ve been living at higher blood sugar levels, you might feel a little funny when it’s normal now. It may take time to get used to that. But blood pressure, I don’t really hear that much. If your blood pressure is normal or you don’t have high blood pressure and you don’t feel right – a little lightheaded, a little weak – add some bouillon in. I know about 50% of people won’t do it because it’s salt. Use the salt, please! In fact, Steve Phinney, one of my teachers, says you need five to seven grams of salt per day when you’re fully keto-adapted, and probably if you’re cycling like a maniac like he does (bicycling). A lot of it depends on your activity level, what you do, where you live. If you’re not feeling right, try a little bullion. You’ll know whether it’s the bouillon or the salt that’s the factor, because within just five to ten minutes, you’ll feel an effect from it. It’s really remarkable.
Some people even use bouillon or broth as a tea break in the afternoons. If you’re feeling low energy, try some bouillon. I don’t know if you have some coffee or caffeine or something like that. I’m not morally opposed to those things either in terms of carbs.
Q: I take Jardiance, Valsartan HCTZ, and Metoprolol. Do any of these drugs hinder weight loss?
A: Well, before you even talk about weight loss, we have got to talk about diabetes and blood pressure. Please monitor that. If the blood sugars are normal or even just mildly elevated, I would have you stop the Jardiance. There are some drugs now that are really powerful and, in fact, they have really bad side effects, too. The more drugs doctors develop, drugs that work really well, they also come with strong side effects.
Jardiance is one of those that can make ketosis happen even when you’re not on a keto diet, so you’re at higher risk of having a ketosis problem (ketoacidosis) on a keto diet when you’re on Jardiance or any of these SGLT2 inhibitors. I don’t think the other ones will inhibit weight loss. I’ve had a lot of patients on all of those medicines, but please monitor the blood sugar and blood pressure.
Q: If you have high cholesterol, diabetes too, and weight to lose, does it make sense to keep taking a statin until the other issues are under control?
A: High cholesterol is not a disease. It’s a risk factor, but right now, even though the science is not solid for using it in every instance, a lot of doctors think it is, and so it’s a political decision rather than a scientific decision at the moment. It’s probably okay (to stop the statin), but your doctor might be upset. You probably don’t need it, but I can’t make that judgment for you, and a doctor might get upset if you do it. My approach is to fix diabetes. You’re probably on the statin because you have diabetes, but if you fix the diabetes, then you’re not needing the statin medicine anymore because in the doctor’s mind, you’re on the statin or there’s another pill for renal protection because you have diabetes, but if you’re no longer diabetic, then you don’t need those protective medicines. If a doctor is holding tightly to that other prescription, relax and fix the underlying diabetes, then address it. If you couldn’t afford a certain drug or things like that, I mean, that’s a different issue. And if you’re having a side effect from the drug, that’s a different issue.
Q: Is there any benefit to metformin? If the A1C is in the normal range, my endocrinologist said it has other benefits.
A: Well, so does the keto diet. I’m sure your endo doesn’t know about it. We’re now into the land of theory and philosophy and what makes sense. If a doctor has never studied metformin in people for longevity, they might still say you’ll live longer on metformin because it’s so benign. I don’t think any drug is benign, meaning harmless. I’m not convinced about adding metformin to a low carb diet. Your doctor may only understand drugs or medication. You have to remind your doctor that you’re taking an active lifestyle change into your own hands. You’re doing so many things to improve your health that aren’t related to drugs, or your doctor may not be aware of them.
I’m not a drug pusher. I don’t make excuses for the side effects of drugs anymore unless you really need them. I think there are drugs that can be helpful, but you want to be careful with lifestyle drugs.
The main point is to be careful about medicines because they can become too strong (when you follow a keto diet). Diabetes and high blood pressure medications are the ones I take away from people most often and I really want you to monitor those conditions at home to be able to come off medications in the safest way possible. Watch the full video here.