I hope you’re all well. I had a few questions I was asked to answer, and I’m happy to answer questions.
Have you ever taken a patient off of Synthroid after following phase 1 or 20 grams total carbs or less?
Phase 1 is the language in End Your Carb Confusion; it’s “Page 4” if you come through the Duke Clinic and get my patient handout.
I have to say no, I’ve never taken anyone off Synthroid. I’m not pushing yet to take people off. For example, high blood pressure medicine – what is pushing me? High blood pressure medicine, If you’re low-normal, meaning you’re still in the normal range but you’re on medicine, I’ll occasionally taper the medicine down to see if you still need the high blood pressure medicine, especially if you have occasional lightheadedness and dizziness when you stand. To me, that’s pushing down to see if your body adjusts, and the blood pressure stays the same. For Synthroid or any kind of thyroid replacement, I am open to the idea of using other types of thyroid replacement like Cytomel, and NP thyroid, other than just Synthroid. This is an obesity medicine teaching. I’m the past president of the Obesity Medicine Association. Most traditionally trained endocrinologists don’t think about anything other than levothyroxine or Synthroid, and they say that it’s just more consistent. I’ve had people change over from Synthroid to these other formulations, and they feel a lot better. I’ve learned that the management of the thyroid in the clinic is not just based on blood tests. It’s based on how people feel. If you don’t feel like the thyroid is correctly adjusted, even if the blood tests are in the normal range, it’s worth either tweaking the dose or changing to a different formulation.
The reason thyroid is so important in the weight loss world and thyroid medicine and the thyroid gland, in general, is that it’s the main controller of the metabolic rate. If you have low thyroid, that means your metabolism is going to be slow, and that means it’s going to be hard for you to lose weight because you’re just not using much energy. If you’re going to use diet as the method of weight loss, and you have a very low metabolic rate, you have to get the energy intake really, really low. Thyroid is really important. We check it at the beginning of every program, or I make sure someone has had it in the last year, for example. I don’t repeat it unless someone hasn’t had it fairly recently. Most people have had that checked. In fact, it’s kind of a joke that the average doctor checks the thyroid and then goes, “Oh no, that’s normal. Don’t know what could be causing this obesity.” You know, and with the diet being the elephant in the room.
I’ve heard other doctors and other patients say, though, that they’ve been able to get off Synthroid or other thyroid medication. Own Your Labs is a company that Dave Feldman and Siobhan Huggins started to be able to offer lab testing outside of the typical electronic health record system so that you could have your labs be checked at the lab, but they’re kept separate from the system. Sometimes the system is shared among other folks. I think the company came about because there are a lot of people who had high cholesterol levels, and they were even given higher insurance rates or not insurable or something like that. It was a way to be able to check the cholesterol or even any blood test and not have it be in the system. You can get your thyroid checked at your doctor’s office or outside now, in most states, but you have to check if it’s available in your state.
Thyroid is not something that I typically see getting fixed (on a keto diet). Changing the medicine to another formulation if you’re not feeling well is a good idea.
How often are scans like the coronary artery calcium (CAC) score and DEXA scan done – every year or more often?
Let’s take those separately. The DEXA scan is a way to check your body composition. You can actually look at bone density and fat composition and the amount of fat on your body. I don’t really ever recommend the DEXA in my clinic. I use something called a bioimpedance machine. It’s free because I have the machine in the clinic, and it doesn’t have any radiation. It’s just a little electrical signal sent from one arm to the other, and part of the electrical signal is blocked by your body. Then it has a formula that calculates your body composition, fat percent, the water weight, that sort of thing. I do that measurement in the clinic every time you come back because it’s free. It shows you the fat loss directly. I think that really varies by the clinic, how often they do a DEXA scan. If you’re paying out of pocket, there’s this interesting correlation that if you have to pay and the doctor makes money from something, they tend to get it more frequently.
I don’t know how often. The measurement of body composition, to me, is almost biohacking and too much information. I don’t overvalue it. In fact, I don’t know that it has that much value unless there’s some extreme case. I never order DEXA scans, but some clinics do. Endocrinologists who are trained in looking at the bone mineral density and things like that may order them for different reasons, not just weight loss and fat mass calculation.
Switching to the cardiovascular system, the coronary artery calcium score is a way to measure the arteries directly. If you haven’t heard me talk about this before, I’ve really become less focused on the blood components for cardiometabolic risk. If I do look at the blood, I look at triglyceride and HDL and glucose and insulin. I don’t really look at total and LDL cholesterol much anymore. But even then, cholesterol is not a disease, and I know I’ve had everyone repeat after me: “Cholesterol is not a disease.”
The disease we’re trying to prevent is atherosclerosis. It can occur in any artery throughout the body. The weird thing that occurred to me and occurred to other folks in the keto space is that there are a lot of people being treated for cholesterol who don’t have any atherosclerosis and who aren’t at risk for getting it. There’s an amazing assumption that every American is going to get atherosclerosis. That’s not a great assumption if it hasn’t run in your family, and your family ate and lives in the environment of where you are, and you don’t have the genetics, the loading, to get atherosclerosis. I think now, and the Miami group who does a lot of calcium artery calcium scores recommend that if your calcium score is zero, you don’t need statin treatment; there’s no benefit from it regardless of what your cholesterol is, regardless of what your LDL is. In this really fantastic preliminary presentation by Dr. Budoff, the study looking at lean mass hyper-responders – basically, half of the people who had super high LDLs on a keto diet, on average about 4 to 4.5 years – half of them, 40 out of 80, had no atherosclerosis or narrowing at all in any of the coronary arteries. This is just the baseline data from the study. They’ll be following these people over the next year and repeating the scan. In the comparison group from Miami, the Miami Heart study of otherwise normal people, it was a very similar picture. Most people did not have atherosclerosis – about 50% – and in those who had atherosclerosis, it was very mild. Of course, remember to add on every study at the end under the conditions studied. The Miami Heart Group, they’re carb eaters; the lean mass hyper-responders are not carb eaters, and they have a very different metabolic profile. And so the effect of LDLs in this study going forward is going to be fascinating.
There was someone with a baseline LDL of almost 600 (15.5 mmol/L) in this study. I showed that to a medical resident who’s going into cardiology, and he was shocked. I said, “Hang on. Is there ever an LDL level where you would hospitalize someone?” He said, “Well, no.” “Okay, relax. What in the blood do you send someone for hospitalization if it’s super high in the cholesterol family?” And he said, “Well, triglycerides. If the triglycerides are 10,000 or 15,000” – normally they’re 150 or less (1.7 mmol/L). Hopefully, yours are under 100 (1.1 mmol/L) – a low-carb keto diet keeps the triglycerides really low. If you have a high triglyceride – going from 150 to 10,000 or even if you’re over 5,000 on the triglyceride – there’s an increased risk of pancreatitis. If there’s any blood marker in the cholesterol family and things that you would hospitalize someone for, it’s triglyceride elevation, not an LDL elevation. That person in the lean mass hyper-responder baseline data who had almost a 600 LDL had a zero score on the coronary artery angiogram.
An important point going forward, and I will talk about this study again and again and again so you can spout off things, but it’s not the calcium score we’re talking about; it’s the coronary artery CT angiogram. They’re actually looking at the artery – the inside of it, non-invasively. What a great study! It’s been a long time coming, and now because of the rolling start of enrolling people, it’s going to take a year for the hundred people to go through to get the next scan. The fear that you’re on the edge of the cliff – danger! – because your LDL is too high, I just don’t have that fear anymore. Am I to say that it’s totally harmless? No. But it will be very interesting to see.
The calcium score is one other way to look at calcifications in the coronary arteries. The popularization of it recently in the low-carb keto world because of Ivor Cumins and Jeff Gerber, who wrote a book highlighting the calcium score. There’s a movie called The Widowmaker, where someone who had no symptoms of coronary disease had a calcium score. The location of the calcium was right at the start of the two main arteries to the left ventricle, called the left main. The movie is named The Widowmaker because if you have a blood clot right there, it basically creates a widow due to sudden death unless you’re in a hospital or get help immediately. It’s hard for the heart to recover from the lack of blood flow to the entire left ventricle. Because of this serendipitous finding, this person’s life was saved. They did the necessary repair and he set out to popularize the notion of getting the calcium score.
The problem is, I don’t know how frequently that happens; nobody really does, although I suppose the Miami Heart Group, with thousands of scans now, will be able to say how many widowmakers were found. But the calcium score, as it exists today, if it’s zero, studies among carb eaters suggest that the next heart attack risk over the next 10 years is very low. Not zero, but very low.
How often can you do the test? It’s fascinating. I got the chance to be at a meeting with Dr. Arthur Agatston (who created the calcium scoring system), and he said not to do the calcium score every year. Shockingly, he said every few years is fine. They’re not really looking at the number anymore; the number can go up. They’re looking at the location of where the calcium is. That requires someone like a cardiologist or a radiologist, someone trained in actually comparing these scans. I suppose you could overlap scans yourself to see. But calcium is a sign of healing in the artery, meaning there was some damage, and your body is healing. If you start having new areas where there’s calcium, that means there are new areas of inflammation and damage in the coronaries.
I don’t recommend these tests for everyone. It really came about as a result of how to deal with someone who has really high old paradigm blood tests – triglyceride and HDL not in the equation, total and LDL really high. Other doctors are worried about it; you may be worried about it; your doctor may strike fear of danger in you. As I got into this, I don’t use these in everyone. But if you decide to do any kind of diet – and there’s some atherosclerosis risk for all of us, some more than others – it just seems reasonable, especially in an area where we don’t have long-term clinical trials, to just monitor what you can and do the best you can. But it’s not a perfect test; even the CT angiogram that is part of this study now, Dr. Budoff and the lean mass study, is not a perfect study. The criticisms are that they don’t show non-calcified plaque. But again, the big studies say that if you have a CAC of zero, calcified or noncalcified plaque is kind of irrelevant because those people went for 10 years without any heart attack or heart risk.
The other weird thing is that cardiologists aren’t all on the same wavelength. Some don’t want to do it; some don’t know how to interpret it. Different parts of the country have different practice styles. In the southeast where I am, Duke has a lot of influence in our area. If you were in the Midwest, it’s probably Mayo. What does Mayo Clinic do? I do occasionally go over the cardiovascular risk assessment, of course, based on carb eaters. You can go to the Statin Decision Aid tool that the Mayo Clinic has – the Mayo Clinic Statin Decision Tool – put in your data, and you can get your risk. Then you can see what the risk would change to if you took a high-dose statin, for example. Most people who I show that to are underwhelmed at the change that they see. It’s really your decision whether you should be on a medicine like that, a statin medicine.
What actions, if any, would you suggest taking if Lifeline or CAC scans show blockage? We are already following the best way of eating by following Phase 1.
I think this (keto) is a good way, not the only way, but a good way of eating, and I’m not sure if I would do anything different. You have to remember this absence of pro-inflammatory foods, especially if you’re under 20 total carbs, you have ketones going around; it’s a therapeutic intervention. If the doctor says you need a drug for this, you say, no, I’m doing a diet. Remember, if you want to smooth the emotional response, say you’re following a Mediterranean diet. At this last meeting, someone came up to me and said, “You told me to say ‘Mediterranean.’ I did, and the emotional response was totally different.” It’s not a scientific response; it’s an emotional response. Or you could say modified Mediterranean if you want to be a little more precise. I think you’re already doing the best thing.
At this last meeting, again, Low Carb USA or Society of Metabolic Health Practitioners, I saw some really interesting presentations, met amazing people, and heard great stories. I spent a day with parents of patients with type 1 diabetes or even people with type 1 diabetes themselves and heard some remarkable stories of success, remarkable stories of doctors bullying the parents because their kids aren’t eating enough carbs. Even in that world, the one person there was threatening to get Social Services involved because they weren’t feeding their children enough carbohydrates, which would raise the blood sugar. I suggested that, why don’t you just create a form where the first checkbox is carb counting? That’s what doctors want to know – that you’re counting carbs. Don’t tell them how many you’re having, though. And then what you do is you show the glucose monitor, which shows perfectly normal flatline glucoses in these type 1 patients because they’re not eating many carbs and they’re taking insulin. That keeps just enough insulin to keep the glucose not too high and not too low. And then the A1C, which is the summary measure, so you have the checkbox on Monday: carb count, here’s the glucose here, and then the A1C. Then just show that to the doctor. Just focus on the outcomes, not the process variables, not how you do it.
That’s come to me by other people telling me that the doctors sometimes say, “Don’t tell me what you’re doing; just keep doing it because everything looks good.” I can’t write down your high-fat diet, that’s what they’re saying, because that might get me into trouble, or not actively discouraging you. One of the parents said, “We tried that and the A1C is so low that they figure it out.” The children are so well controlled; it is so different than what they typically see in the kids who eat carbs that they go, “Your A1C is 4.5; you’re not eating enough carbs. Oh my goodness!” This is the type 1 diabetes community, the Facebook group Type One Grit, although one of the parents spun off and has a company to help parents do this. Another parent helped Adapt Your Life Academy to write a course. There’s also a nonprofit called Let Me Be 83, which helps people with type 1 diabetes. Let Me Be 83 is based on Dr. Richard Bernstein’s idea that the perfect glucose is 83 mg/dL (4.6 mmol/L). Dr. Bernstein strives to stay at about 83 by checking blood sugars and even having a little glucose if the sugar is too low. He really micromanages it, and now he’s almost 90 years old with type 1 diabetes. He had kidney failure in his early life from diabetes and reversed that. So it’s a great story.
We talked about Dr. Bernstein; we talked about Dr. Keith Runyan, who has type 1 diabetes. Ellen Davis helped Keith write a book on his method of doing it. So that was all at this recent meeting. There was another talk by a cardiothoracic surgeon, Dr. Philip Ovadia, and I was impressed. I really liked the talk about inflammation and heart disease. Of course, in a book that I helped to write a decade ago, we wrote summaries and sometimes verbatim interviews from the researchers of cardiovascular disease. They were talking about inflammation ten years ago. Now the research is still among carb eaters. Of course, the research is about giving drugs to change inflammation or just the association of inflammation and heart disease.
Curiously, Dr. Ovadia didn’t know about the Virta Health study, so I sent him those papers. Hopefully, he’ll add that to his data because, in the Virta Health studies, they’ve shown that they can reduce inflammation better than statin drugs. This is the study they did with type 2 diabetes. Seventy percent of the folks got off insulin in the short time they had with them, and that company has done well, connecting with health organizations, even the VA (Veterans Affairs.). I hope that grows. My concern is that it’s pretty high-tech, coming out of Silicon Valley, where everyone’s high-tech. Not everyone wants to check their glucose, ketones, and step on a Bluetooth scale. Not everyone has, well, now everyone does have a cell phone, but talking to a doctor to get off the medicine, that’s the method of the Virta health model.
The diet change you’re doing is lowering inflammation, like taking a drug. I know that might be hard to understand, and it may even be harder for doctors to understand because today it seems to me medical care has become medication care – a doctor prescribing this and then even prescribing a medicine for the side effects of a medicine. One of my friends who does a lot of the Ozempic and Saxenda, they hand out a prescription for nausea at the beginning. That’s one way to do it. Recently, this medical resident who had great training and even nutrition training in his past was just shocked because the discussion is different. The concerns are all valid, but the idea that you have to give them medicine, it really has become an indoctrination. It’s a practice model that’s not the only way to do it. I’m not sure what to add to what you’re doing already if you have coronary artery disease.
Dr. Ovadia – this is why I thought of it – recommends an antiplatelet agent and vitamin K2 because in the context of those who eat carbs, there’s some benefit for those things. But what about the side effects? These things are not totally benign. To take an anticoagulant, even if it’s a mild one, has some issues. I’m reminded of the one health concern that the Inuit had when they were studied in their pristine situation. They weren’t affected by Western food yet. The one thing that they seem to have an issue with was nosebleeds. Thinking back, they may have had the fish oils, the omega-3s, that can actually make the blood a little thin. So you may actually be getting an anticoagulant effect by the foods that you eat compared to those who eat carbs and are eating the fish, the meats where the omega-3s are. It’s a conjecture. I’m not sure until a drug is studied among those of us who don’t eat carbs, you don’t know if it’s going to be helpful; it might even be harmful. I don’t mean to make you worry. The risk is low, I suppose, if you’re on a drug when you ate carbs and now you’re not eating carbs. It depends on the drug. Scientifically, a statin medicine given to someone who doesn’t eat carbs might harm them. Adding even things like vitamin K2 and the nattokinase is what they’re saying you should have if you have coronary disease. I’d like to see that study in people – in more than 50 people. This is my classic, “Show me a study: 50 people over six months, and I’ll comment on whatever you’re talking about.” That means you’ve actually assembled the information systematically.
How about the topic of taking any recipe and making a KMS (Keto Made Simple) version?
I look at all the food pics here, and for the most part, the meals are pretty basic. I had someone who was so thrilled with her successes that the resident who was shadowing was just overwhelmed that you could have fun in a medical clinic. Boredom can happen with the food on keto. That’s one reason why we ask people to come back or to talk about it. Not everyone gets bored, though, eating the same things over and over. Chef Scott Parker put together the End Your Carb Confusion Cookbook, the companion cookbook to End Your Carb Confusion, the book Amy Berger and I wrote. Chef Scott has worked in Michelin starred restaurants for 20 years, put together a great volume on how to make things quickly, tasty, all fresh ingredients. He has the book, and then he even wrote a course for the Adapt Your Life Academy (Low Carb Cooking Made Easy).
What happens when you’re a yo-yo dieter? How bad is that for health?
I’m not sure what the definition of a yo-yo dieter is. The concept is the idea that you lose weight, then regain it, lose weight, and regain it. How much weight probably matters in terms of how it is good or bad for your health. If you looked over the lifetime of somebody – and weight is a factor harming the joints, having metabolic illness – and half your life is in a lower weight, half your life is in a higher weight, I don’t know if the process of gaining weight and losing weight is the issue. It’s where you are in the inflammatory, the weight-bearing problem that happens. I know a lot of people knee-jerk and say, “Yo-yo dieting is bad, and therefore take these pills or take the shots.” If you follow a program like this one that’s simple, it’s easier to follow.
In the past you might have followed some stars who lose a lot of weight, then get off their program, then they regain the weight, and now the medications seem to help some people so they don’t have that. The particular star I’m thinking of is a “carboholic” going back to Jackie Eberstein and Dr. Atkins’ era. If you never wake up one day and say, “I am a carboholic, I really can’t have sugar,” then you’re going to be struggling. That’s just what’s going to happen, and medicines can help for that. I’m not against using medicine, but it certainly shouldn’t be the first thing you try. What I’ll do is say, “Here’s the low-carb keto diet; we’ve been using it for 25 years, we studied it, published papers on it. If you want my advice, I’d say let’s start with the diet by itself, and if you learn a simple system, it’s easier to follow. This is a way to keep the weight off really forever, and you don’t have that yo-yo problem.”
There was a popular study based on that TV show called The Biggest Loser, and they found that the metabolic rate of these folks who lost a massive amount of weight fast, using exercise and basically not eating much – the dietitian from The Biggest Loser show came to the Obesity Medicine Association and gave a talk, and said, “I’m upset with the show. I have no control. What people do basically to try to win is they don’t eat anything.” She said they have a fridge of great food, so give it a calorie counter, but there’s no enforcement of eating. She was concerned because what would you do if you’re trying to win – I don’t know how much money you would win – and you wanted to lose this fast? Well, of course, you wouldn’t eat; you would starve and then exercise. That’s why they were passing out and all. It’s great TV, but it really was torturing people. I guess it was self-inflicted.
The metabolic rate can go down and then you’re struggling with, again, that situation of a very low thyroid where you can’t eat much if you’re going to draw upon your body fat store. The idea of using medications is worth thinking about. Again, I start with a low-carb keto diet as a first-line treatment.
My magnesium level is low; I am trying to normalize it. I was told it can hinder weight loss.
This is interesting. Renowned researcher Steve Phinney says, “We measure the blood because it’s convenient, not that it really tells us much that’s important.” Wow, what a statement! I ruminated over that through the years, so magnesium in the blood is not a good measure of magnesium in your cells. There is a measurement of magnesium in the blood cell itself; we have to send off a special one. This just complicates the whole picture, but you want to add magnesium if it’s low.
The only time I’ve had trouble getting someone’s blood levels like that up – even iron levels – is if someone has had weight loss surgery in the past, and they have had a rerouting of the intestine or lopping out of part of the stomach where you can’t absorb the nutrients correctly. A subset of folks who have undergone gastric bypass – specifically the strongest version known as Roux-en-Y gastric bypass – may experience severe side effects. Approximately 30% of these individuals develop iron deficiency anemia, necessitating continuous iron supplementation. However, iron supplementation often leads to constipation. For some, iron infusions become necessary, and in our area, these are conducted at the cancer center since they are the primary providers of iron infusions.
A peculiar aspect of iron infusions is that they cannot be administered too quickly for safety reasons. Not every nurse or clinic is equipped to handle this procedure, making the cancer center the go-to facility. Consequently, individuals with this condition must undergo monthly visits for iron infusions due to their inability to absorb it. So no, I have not heard that it hinders weight loss, but I certainly think it possibly could. I suppose magnesium is such an important electrolyte.
I’m hearing a lot about ultra-processed foods – I wonder how many of our ills are attributable to them. It seems there are very few high-carb foods that are not ultra-processed.
One of the commonalities of all the diets that worked or have been studied, and you lose weight or have improvement in metabolic health, exclude sugar and ultra-processed food. Is it possible that all of these diets are healthy just because there’s no junk food? That’s a major reason why. Our little spats about what the best diet is are irrelevant or overvalued, or it’s a false choice. There was a sub-analysis of a Stanford study that looked at the two extremes and an ultra-low carb and ultra-low-fat diet. Those who were following them, they both had good reduction in insulin resistance. They both worked; people lost weight, they had improvements. The tactic of how you do it may be less important than the fact that you just cut out the junk foods.
Be careful; there are keto junk foods out there now. The saying is, if it says “keto” on it, be very careful. Always look at the total carbs, not the net carbs. To me, net carbs are like over-the-counter medicine. They can work for some, but if you want prescription strength, use the total carbs.
Does the End Your Carb Confusion Phase 2, up to 50 total carbs per day, provide similar benefits as compared to Phase 1?
I haven’t seen it studied yet, which would be the best way to determine it. Let’s say you cut carbs down, and the carbs are pro-inflammatory. So you’re getting the benefit from not eating the pro-inflammatory carbs. That should apply to Phase 1 and Phase 2. With Phase 1, if you’re ketogenic, the unanswered question is what is the added benefit of the ketones? It’s in its early research. There are those who are early adopters and say, “You need ketones around; it’s so great; it’s anti-inflammatory, and here’s the number you need, and here’s a meter to check.” I’m not so convinced yet. I’m open to that idea – that you may get added benefit from extra ketones.
If you remember back to the whole hoopla about metabolic advantage, Dr. Atkins said, “My diet has an advantage,” and it’s because the hormones are different. People said, “You’re a quack. There’s no advantage; a calorie is a calorie.” We have science now that basically says the metabolic advantage is on average 100 calories a day. Is that a lot? It is, and in some ways because it’s been argued that if you’re just 100 calories off per day, that means over a year, you’re going to gain 10 pounds.
Regarding the extra ketone benefit, how much is it? I don’t know. There’s word on the street; there’s a continuous ketone monitor being developed so you won’t have to do your finger sticks for your ketones anymore. I don’t know what the incremental benefit is of being in ketosis. I think if someone wanted my best advice on treating something like cancer or epilepsy or Alzheimer’s or something that’s serious like that, you might want to check the ketones. I do that extra effort because at least in those areas, it seems like having ketones in the blood is especially a good thing. It’s still early and mostly theory or animal studies, rodents, not humans. If it’s easy for you to be in Phase 1, why not stay in Phase 1? If it’s not, if you like to be in Phase 2 for the variety or the flexibility, that seems reasonable to me at this point. If you were an avid exerciser and you had the natural tendencies to burn fuel really easily like one of my brothers, you might do Phase 3. If you’re exercising all the time, you’re running on the beach for hours, that allows for up to 150 carbs per day. Of course, limiting or eliminating the highly processed sugar and junk foods.
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