Many of you have never really heard my story and how I got into this. How I got involved was not from my personal experience. It was out of research. I will share some insights into how to talk to your doctor, healthcare provider, dietitian, and family, about nutrition and a keto diet.
What is lymphedema?
If you don’t know about lymphatic disorders, lymphedema is a term you may have heard. You may have it, yourself. It’s a group of folks who have very difficult fat loss issues, even more than the average person. And usually, it’s a body part, the legs, the arms, that are particularly affected. The low-carb keto diet can work. Often, folks with this problem and maybe even like you, will come to it thinking there’s nothing that will work. They’ve tried everything. And yet, keto will work for this. That’s the context. I know I’ll be talking to a group of people who feel like they’re the only ones with the problem and they feel like nothing can help. That’s generally this group of folks.
I’m still an Associate Professor of Medicine at Duke University and the Director of the Keto Medicine Clinic, which we established in 2006. I’ve published over 50 peer-reviewed papers on the keto diet. I try to keep to what I talk about from my clinic and my papers. I try to keep it as scientific as possible. You may not have known that I’m the past chairman of the board of the largest group of medical weight loss doctors in the world, called the Obesity Medicine Association, so I’m well aware of all the different ways that you can lose weight or change your metabolic health.
I’m also co-founder of Adapt Your Life, which has a few keto products, but it’s mainly an education company now trying to get the word out to as many people as possible. I am the author of End Your Carb Confusion with a companion cookbook now out, too. I was also involved with books called Keto Clarity and Cholesterol Clarity.
I didn’t come to this from my personal experience of needing to lose weight, although I have that sort of metabolism. I came to this because two of my patients lost weight at the VA (Veterans Affairs) clinic where I was working in about 1998. It was remarkable because nobody lost weight in my clinic! I was working in an ambulatory care internal medicine setting. And so it was remarkable that two people lost weight. I asked them what they did. One of the gentlemen said he just ate steak and eggs. I thought, “That’s interesting, to eat steak and eggs and lose weight.” These two patients were essentially doing the Atkins diet. I didn’t know much about it and started to learn about it. I said, “Your cholesterol must go up, so don’t do it.” One of them looked me in the eye and said, “Why don’t you check my cholesterol? You’re a doctor.” There was a lab down the hall, so we checked. Two in a row, the cholesterol got better, even if you look at it the old way and the new way. So I was introduced to this area of eating and nutrition by two patients who had success and told me about it.
When we go to the literature, there was a taboo on studying a low-carb keto diet. “Taboo” means there’s no actual written rule that says you can’t study it; it’s just a societal acknowledgement that no one wants to study these things. We tracked back: it was because of this paper in 1980 in the Journal of the American Dietetic Association, where they put 24 obese but otherwise healthy men and women, two weeks on their usual food intake, eight weeks on a high protein low-carb diet, and then two weeks again on their usual diet. Basically, it was a 12-week study: two plus eight plus two. They saw the weight came down; there was substantial weight loss. The triglycerides came down, however, there were significant increases in LDL cholesterol, uric acid, and free fatty acids. The HDL levels failed to rise. Basically, in this article, they said don’t do this diet; it will kill you (because of that LDL). Even though the abstract was lukewarm. This was the study that said no one should study this diet. Meanwhile, Dr. Atkins and the Drs. Eades and all those diet book authors were using it with great success.
By today’s standards, this study is not good enough to say this is a bad diet. By today’s standards, you would make no judgment about a drug or a diet on just 24 people. By today’s standard, you wouldn’t make any judgment on a diet like this without a randomized control trial. The researcher Jeff Volek and I crossed paths at that time doing a literature review, and he agreed that there hadn’t really been any research on this, so nobody knew whether it was bad; it was just assumed to be bad. So we both, in the same month of 2002, had papers come out: Effect of 6-month adherence to a very low carbohydrate diet program and Body composition and hormonal responses to a carbohydrate-restricted diet. I’m the MD of the two groups that did the research, then he’s the PhD, so I’m dealing with real people in the real world going out to live their own lives, and he’s dealing with things in more of an ideal level, bringing in healthy people and seeing the metabolism changes. We published these two papers, and they both were positive papers. People lost weight; the parameters looked good. When someone asked me about a particular diet, I said, “Show me a paper with 50 people in it, where you follow them over six months, publish it in a peer-reviewed journal, and I’ll comment on it,” because that’s what I thought had to be done before you’re ever going to talk about a diet. We did that in 2002, so a long time ago.
The studies kept coming out and people started doing randomized trials, and we did, too. Over the last 20 years now, the studies have really been positive. It’s not that other diets can’t work; it’s just low-carb diets work pretty well and work better in many cases. I started to think, the papers are done; why aren’t people following this? Why isn’t the world changing? Science changes everything, right? That’s the naive, young Dr. Westman. Someone asked me to be on the cover of Woman’s World in 2014 and David Ludwig at Harvard got on the cover of these “peer-reviewed journals” at your grocery store checkout. In 2021 I came up with the term “prescription-strength keto” just because by now internet keto had started to blossom, and people were getting all sorts of strange ideas about adding oils and eating fat bombs and things that I really hadn’t studied and hadn’t learned about. Recently at some of the Adapt events in February a couple people came up to me and said, “I had no idea you did those research papers; we saw you because you were on the cover of Woman’s World!” And so I joke about that; this probably has had more influence than the research papers, although we helped to set the stage for other people to do research. I think looking back, we were instrumental in getting the scientific community to acknowledge that yes, this is valid; this is reasonable to do, and even healthy for many people. Other experts started saying low carbs should be at the table and the best diet is the diet you can stay on; if it’s low-carb that’s great. Getting pop culture to change is a whole different thing rather than doing research.
Obesity Medicine Association
My background is in clinical trials and in the medical community that I had been in at Duke since 1990. I was asked to be part of the leadership of the Obesity Medicine Association, so we started to influence the doctors’ way of thinking and teaching about low-carb diets. The Obesity Medicine Association has a guideline in the form of an algorithm, and because of the science that had been done, we were able to get the low-carb diet into the guidelines of the Obesity Medicines Association.
In terms of diets, you can do a restricted-fat diet; it can be a low-calorie diet. You can do a restricted carbohydrate diet, and then in the medical weight loss world, there are programs that doctors can sell you where they ask you not to eat any food, and they just have you drink shakes and eat bars. These are called Optifast, Medifast, or Robard – not the over-the-counter versions but actually prescription-strength from the doctor. I don’t do any of those programs in my office, but they are available in our area. The low-carb scientists in the Obesity Medicine Association algorithm and the Diabetes Association started to support low-carb diets as well. A paper came out – Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report – which was shepherded by my colleague at Duke, Dr. Will Yancy, which was helpful in showing that the data really are good for diabetes as well.
Society of Metabolic Health Practitioners
There’s a new organization called the Society of Metabolic Health Practitioners that has a clinical guideline on using therapeutic carbohydrate restriction or low-carb diets for obesity and metabolic health improvement, like diabetes. If anyone says that American Heart Association guidelines say or someone else’s guidelines say something, that’s fine, but there are guidelines that support the use of low-carb diets. A lot of these guidelines are political and do not reflect any other sort of science and so you have to understand that there will probably be organizations that are against low-carb diets forever because that’s not the purpose of their organization; it’s not why they were founded. But the clinical practice is supported by national and international guidelines to be able to use low-carb diets. I hope this gives you confidence that it’s not just me talking about it; it’s not just Dr. Atkins or Dr. Berry or whoever the doctor is today. These are groups of doctors getting together, looking at the science, and putting together solid guidelines for people to follow.
It’s taken over 20 years for this to grow. Jackie Eberstein, who’s helped me – she was the nurse who worked with Dr. Atkins for 30 years, sent some videos for us, some interviews – she’s now been in this low-carb world for about 50 years, so I have a lot of confidence in my office when someone comes to me. Someone recently said, “You’re really confident this is going to help me and it’s going to work.” I said, “Yeah, I’ve seen it. This is like a prescription drug: it will work.”
Carbohydrate insulin model
Back to the lymphedema folks, I want to bring back the most important points about the carbohydrate-insulin story. If you want to improve your metabolic health, keep the insulin level as low as you can. To do that, you want to keep the blood glucose level as low as you can after meals, because there is a spike after a meal with carbohydrates. Obesity and type 2 diabetes have a common cause: it’s excessive dietary carbs. I include this because your doctors may not know this; your dietitians may not know. They might still be talking about “calories,” thinking calories are the only thing you have to worry about when it really is about the carbs. It’s because the blood sugar goes up and the insulin goes up; that causes increased fat storage, which causes the blood sugar to come down. You have low energy, mood swings, carb cravings, which leads you to increase your carb intake, and you go around and around, plus you get chronic inflammation as well.
There’s now a big paper that’s trying to change the model of “calories in, calories out” to the carbohydrate-insulin model. It’s written by David Ludwig at Harvard, and I’m an author on these papers. I don’t have the patience to do what David is doing now, to write these papers and assemble all these different experts, but it’s this slow-changing undercurrent that hopefully eventually will at least get into the doctor training that there’s more to it than just calories.
The low-fat diet
When I was trained in the 1980s, low-fat diets were everything. Some of the doctors you meet have to unlearn what they’ve been taught. To help you unlearn things, I used to use a pen in my class and say, “This is the neuralyzer from the Men in Black movie. I can erase everything you know about nutrition, and so I want you to forget about what you’ve learned, which means you don’t have to have breakfast if you’re not hungry in the morning.” I’ve had someone recently who was just so relieved, she laughed! The tragedy is that she’s been eating breakfast all of her life because she thought she had to! She hated breakfast! The tragedy is she had weight loss surgery because no one had told her, among other things, that she didn’t have to have breakfast. Isn’t that crazy? You don’t need a magic wand to reprogram your mind but you might have to erase what you’ve been taught before. It’s okay to eat fat. It’s okay to have salt.
Did it ever occur to you that “medical care” today means medication care? There’s medication for everything and there’s usually one medicine for one condition. If you get diagnosed with high cholesterol, there’s medication to lower the cholesterol, if you get diagnosed with hypertension, there are medications to lower the blood pressure. If you get diagnosed with high triglycerides, there are medications to lower the triglycerides. Dr. Jeff McDaniel in Atlanta says, “There’s a pill for every ill.” When was the last time a doctor asked you about what you eat? To write down everything you eat and drink for a day and to examine it carefully? I do that every time people come back; it doesn’t take much time because I ask people to write down what they eat and drink before I come into the room. I just scan it and I can figure that out pretty quickly.
Metabolic syndrome leads to diabetes, so there are medicines to lower the blood sugar to treat the diabetes. Metabolic syndrome leads to heart disease, and there are medications to facilitate heart function. All of these medicines, I’m afraid, treat the underlying lifestyle. This is the way doctors have been trained. They are trained this way at Duke University today, that there’s a medicine to fix something. They’re not trained to talk about lifestyle or if they are, they’re just taught a very narrow view of it. You have to understand that in order to engage. It’s not your job to teach your doctor or your health provider, I don’t think, but you can try if you want. I wait until the doctor wants to learn before I intervene because there’s always going to be skepticism because they’re not given the fundamental training about what this dietary approach can do.
How are health professionals taught?
It’s good to know this to understand the old paradigm medical teaching is based on. The old way of thinking is that fat in the diet is bad, and that low-fat or Mediterranean diets fix everything, when there’s really no science to back that. We now have a group of doctors or nurse practitioners and physician assistants who are taught to follow guidelines. The thinking is not to train everyone as thoroughly but to just give them some training and then have them follow guidelines. I’m afraid that’s what’s happened in lots of different areas. You have to understand that guidelines are based in the old view that obesity and metabolic disease are a lack of willpower. Guidelines aren’t necessarily old, because there’s new information all the time, but even a new guideline means they were looking backwards on old information. Health professionals also receive continuous education from pharmaceutical companies which drives that thinking of there being a pill for every problem and talking about medication treatment of things rather than changing the food or treating the root cause in the lifestyle, which is the cause of other problems. The treatment of medical problems with medication is profitable for companies and for doctors, I suppose. You see more patients and it takes very little time. It often takes me 15 minutes to just talk about food. If that was the time that doctors had to fix and talk about other things, it changes the focus. Doctors are taught to prescribe medication. There’s very little training in diet and lifestyle.
Guidelines are based on what’s happened in the past. I’ve been on several medical guideline committees and maybe you have as well. You do a review of research studies, so by definition, a guideline can’t address a new situation. We talk about guidelines being something you don’t have to follow in absolute terms but just with a general approach. For example, a guideline that includes something related to gravity on Earth would need to be changed to work on the moon, because gravity on the moon is so different. What we’re dealing with now is the metabolic change of nutritional ketosis or low-carb diets, which is like being on the moon compared to eating carbs.
The guidelines are dealing with addressing problems that have to do with people who eat carbohydrates, which introduces another apples-and-oranges comparison that probably won’t apply (to people who follow ketogenic or very low carb diets). Guidelines are often made because there is no agreement, no consensus. Consensus means compromise, and I learned this a long time ago where there was a consensus conference where everyone disagreed, and the person got up and said, “The reason we’re having the consensus conference is because we know that nobody agrees, and we have to have the image of agreeing on something and compromising.” A guideline doesn’t mean everyone agrees on it, and that’s why you get multiple guidelines and why it’s important to know about the Obesity Medicine Association, the American Diabetes Association, and The Society of Metabolic Health Practitioners guidelines that include low-carb diets.
Medical guidelines often include undercurrents: costs, cost-effectiveness, and an assumption that the financial payment is by the insurance company, or Medicare or Medicaid and not the patient. I learned about this a long time ago when I started working at a clinical practice where very affluent people came. This was a program at Duke where people came to town to lose weight, and it occurred to several people that they would pay for the test if it was needed, if there had to be a payment for it, and that they could go beyond what insurance would cover. That changes the dynamic considerably. Guidelines and what doctors are taught to do most commonly introduce and include the cost of the treatment. You may not have to be limited by that cost, but most people are. Decisions are not just based on what’s best for you as an individual. There’s a population perspective. There’s an idea that we’ll make the decision for you. The medical world says if it’s at a certain level, you should do this when really it’s your choice. We should tell you whether it’s going to help you or not and how likely it is going to help. There’s always that tension between what’s best for the population and what’s best for the individual. It’s not necessarily always congruent; many times, it’s at odds. You may be asked to take a medicine with a side effect because if a million people take it, we’ll save ten thousand lives when your individual perspective is that if you have a side effect, it’s not worth taking because only, let’s say, one in a hundred people will benefit from the pill.
I’m writing a paper on it, explaining statin medication for cholesterol, and in many situations, if you don’t have heart disease, the odds of you getting benefit are about one in a hundred. So for a hundred people given a statin drug, only one will get benefit, and doctors don’t tell you that, do they? So to be totally honest, the doctor would say, “Here’s a pill, and you have a one in a hundred chance of it helping you.” That’s to be honest about statin medicine if you have an LDL of 200, for example, and you don’t have any history of heart disease. I hope the paper will explain this dynamic in detail. The population perspective means that if we treat a million people like you with this drug, then we’ll save a lot of lives, but there are a lot of people who will take the drug and get no benefits from it. I think most people expect that you’re going to get benefit from the drug that you’re given. I would.
Expect some preconceptions
Your health care practitioner might want to reach for a prescription pad or electronic email now rather than talk about lifestyle changes because most health professionals do not receive training in nutrition and lifestyle. They may think the only action they have is to prescribe medications. Most health professionals have never seen their patients take action by changing lifestyle. So actually, you may be the first one to go in and show your doctor or dietitian that you can successfully do this and change your lifestyle! If you want to teach and use that as a point, most doctors don’t see people making a change, so they might get a little bit lackadaisical. They might not try to convince you to change because they don’t think any of their patients change. They don’t believe it’s possible or sustainable. You hear that a lot now – “Oh, that keto diet, yeah, it helps, but it’s not sustainable.” Of course it is if you have support. If you fix your diabetes, darn right it’s sustainable – you don’t want to have diabetes again! But a lot of doctors, most doctors, haven’t seen this. Remind the doctor that you are taking action by changing your lifestyle. That may not be given as much emphasis compared to medication, but given time, I’ve seen lifestyle change do much more than just medication.
How to spot an “old paradigm doctor”
The old paradigm doctor might print out a pre-created instruction that says you should follow a low-fat or plant-based or Mediterranean diet. These are not scientifically backed anymore, but they’re the things that computers print out. They may warn you that saturated fats are harmful for you. Hopefully, I got you through that through the modules on mindset change. They might recommend limiting dietary cholesterol as a means of influencing blood cholesterol level. Again, this is not an important issue.
The old paradigm doctor might say, “Just eat less and exercise more,” although I’m seeing this change. The old paradigm doctor might say, “Don’t tell me what you’re doing; just keep doing it.” They don’t want to know that you’re doing something that’s violating everything they’ve been taught, but at least they tolerate it, and that’s good. They may push on medications for weight loss without even mentioning a change in diet. I see a lot of family medicine, internal medicine doctors thinking that these new medicines are the answer to obesity treatment. While they can help in the short run, they’re not really treating the root cause, which is the diet and the dietary carbs.
How do you influence and enlighten your healthcare professional?
A healthcare professional is a trained advisor, but it is your body. You should be allowed to actually participate in the decision-making process. You’re a consumer of the healthcare services, and you’re free to shop around for a provider who’s a better fit. It might be more difficult than some HMO systems, but usually, if you go talk to a manager, you can find some reason or excuse to find someone new, or you can try to teach your doctor. If you’re at a disagreement and you’re unable to change providers, compromise with it, and ask, “Can you refer me to an obesity medicine specialist?” This is taking away the ego of knowing something. There’s actually a specialty called Obesity Medicine that most doctors are not aware of. It’s kind of an orphan group; there are only 4,000 of us in the US as obesity medicine specialists, but that will allow you to have these discussions with a doctor who is trained in the metabolic issues of obesity and diabetes. If you want to just say something to please the doctor, say, “I’m following a Mediterranean diet,” and that will please the doctor. I bet you won’t even be asked what you eat because nobody really even knows what a Mediterranean diet is! So this is treating ambiguity with ambiguity. It’s just to diffuse the situation, which is what you have to do in certain situations with people. If you’re at an impasse, just say you’re following a Mediterranean diet, and everyone will be happy.
Watch the full video here.