Introduction
Dr. Eric Westman: Hi, I’m Dr. Eric Westman, and this is the Keto Made Simple podcast. Hi everyone. Dr. Eric Westman here, and as you know, on my channel, I typically review and debunk nutritional misinformation online. Sometimes I like to interview movers and shakers in the low carb keto well or general nutrition and health sphere and it’s my great pleasure to have Nick Norwitz with me today. How are you, Nick?
Dr. Nick Norwitz: Excellent! Thanks for having me on. Dr. Westman.
Dr. Eric Westman: My pleasure. And for those who don’t know who you are, who are you and how did you come to where you are today, in the medical influencer world? I would say you’re a rising star.
Background and Introduction of Dr. Nick Norwitz:
Dr. Nick Norwitz: Thanks. I appreciate it. I feel very lucky to be where I am in my life. I recently graduated from Harvard Medical School. It was five months ago after doing my PhD at Oxford. And I’ll kind of back up to the beginning, because I could never have imagined that I would be in the nutrition space or the metabolic health space. And this really started for me at the end of college. I always knew my entire life, I wanted to go into medicine and go into science. Both my parents are academic physicians. I come from a house of MD PhDs. There are five of us in the immediate family, and among those, nine doctorates. So that was the environment I grew up in.
Dr. Eric Westman: Where was your undergraduate?
Dr. Nick Norwitz: Dartmouth. I went to Dartmouth in Hanover, New Hampshire, and really enjoyed my time there. I majored in cell biology and biochemistry, and as I was getting to the end of college, I knew I wanted to go to medical school, and I also knew I wanted to do science. So I was lucky enough to actually get two placements, one at Oxford for my PhD, and one at Harvard Med. And Harvard let me differ. So I had a few years to go do my PhD studies. But then something serendipitous happens. I got kind of sick, actually. I got really sick. I had been healthy most of my childhood, but I started developing GI issues—in particular, inflammatory bowel disease, and apologies for getting a little bit graphic, but this isn’t your run of the mill “my tummy hurts”. It’s like bloody diarrhea 12, 20 times per day, and my life really started to fall apart. I don’t need to go into the gory details, but what surprised me is how ineffective conventional medicine was. Not that conventional medicine is bad for what it’s built for, but for a lot of chronic diseases, this won’t be news to your audience. It’s not built to address them at their root cause. So despite engaging in the best “evidence-based care”, I wasn’t getting better. And I am someone who had all the resources, financial, familial, I was hooked up with the best healthcare systems. I had two double doctor parents advocating for me. Despite all that, I’m not getting better.
And so it got worse and worse over the timeframe of a couple of years, to the point that I was in and out of the hospital, intensive care, while doing my PhD. And I had gone from being a high-achieving academic and athlete to being socially withdrawn, physically very frail, like I had gone from running 2:45 marathons a couple years prior to being like, it’s exhausting to go to the bathroom. I deteriorated very quickly, and I got to a place of just hopelessness and desperation. And when you’re in that place—anybody who’s listening, who’s been in that place—knows you will try anything, not because you expect it to work, but because you have nothing to lose. So I started doing fringe dietary therapies. And low down on my list of things to try was keto. I eventually tried it. And you can guess what happened next.
Dr. Eric Westman: You mean, keto is the lowest of the fringe.
Dr. Nick Norwitz: It wasn’t my mind at that. I mean, like my entire exposure was “magazine keto”, like the worst of the worst that you can imagine was just like what I had been exposed to. That was my concept of it. And I also just considered myself quite attuned to my nutrition, like I knew how to read a nutrition label, I knew how to eat a “balanced diet”, and I had internalized that as the gospel of nutrition. And prior to that, it had always kind of worked for me. I was always a very carb-fueled high performing athlete. And so to consider that the prevailing knowledge had worked for me, at least in terms of body composition and appearance and performance was, I think the thing is, when you adopt it, but bottom line, that’s yes.
Dr. Eric Westman: Then the saying is, when you’re young and healthy, you can get away with things.
Dr. Nick Norwitz: So that’s what I thought personally, because for me, obesity wasn’t a canary in the coal mine. So I could get back from a long run and literally, like, drink a jar of Nutella. I kid you not. Boston, go on a 22 mile run in like, zero degree weather. You get back, you’re a teenager, and you slam a jar of Nutella. And also, just the culture in college, you work out with the athletes. You get back, go to the dining hall, and you all share in the pasta and cookies. And there’s this idea that you can burn off the “empty calories”. Now that’s become a big pet peeve term of mine. I don’t think there are such things as empty calories. We can get into that. But yes, I tried keto.
Dr. Eric Westman: Remember, I watched a video of this story, and it’s a little hard for me to find if someone wants to watch the video you did of being healthy and then getting sick. Is that at your website, or is it?
Dr. Nick Norwitz: I think it was the first video I ever put up on YouTube. A friend made it after my recovery story about my food is medicine, medicine journey for like, five minutes. But, yes, I mean, I was in a critically ill condition. My mom flew over from the US because she thought I was dying. I was like a palliative care ward with a heart rate, bradycardia, to the 20s. But then I tried keto, and lo and behold, I just came back into myself, and went into our mission.
Dr. Eric Westman: First, which keto did you do and how fast did you find improvement?
Initial Experience with Keto and Health Improvement:
Dr. Nick Norwitz: My keto was more Mediterranean style to start, like a decent amount of vegetables, a lot of fatty fish, a lot of olive oil. I kind of was blending what I thought of as healthy at the time with a macro ratio that would be ketogenic. So I got into ketosis, and after a few days, I was feeling more energetic. Within a week, my bloody diarrhea had gone away.
Dr. Eric Westman: And so fast. That’s fast
Dr. Nick Norwitz: It was very fast. It was.
Dr. Eric Westman: You said that really fast, your bloody diarrhea was gone in a week.
Dr. Nick Norwitz: In a week, and then it was a while before my next colonoscopy, which is the gold standard for you to go into the colon, you take a biopsy of the colonic wall, and then you can look under a microscope. Is there intestinal inflammation? And on my next colonoscopy, there was actually no sign of disease. So this wasn’t just like, I feel I feel better, uninflamed, better off, and there’s no disease.
Dr. Eric Westman: Was that the colonoscopy a few months in or later?
Dr. Nick Norwitz: I don’t remember exactly when it was, but yes, so it was, wow. It didn’t advance. Let me put it this way: it didn’t evangelize me to keto. I knew this was an n = 1, not documented in the literature, but it was a sufficiently powerful experience to at least get me interested in the metabolic health space. So I’ll kind of fast forward a little bit to bring you to where I am now, and just make the point that personal experience was the experience I went into medical school with. So it framed my entire medical education, and what I came to see is the limits of “evidence-based medicine”. It sounds like a great term. It’s a nice virtue signaling, and it has its pros. However, what I came to realize, to make it very concise, is evidence-based care is not the best care. And what I mean by that is, the standard of care is determined by what gets studied and what boxes are checked. And what determines what gets studied and what boxes are checked is a business model behind medicine. It’s not to say anybody’s evil; “Big Pharma” is out to get you. It is just the incentive structural reality of what we have, and it is also the basis for why we are where we are, where people are suffering with chronic diseases and continue to suffer, because the evidence-based model we have isn’t looking under the proverbial lamppost, if you know that.
Dr. Eric Westman: Well, I remember this maybe 20 years ago, when in the society of general internal medicine, it’s the kind of teaching group within internal medicine. There were thought leaders who created the field of clinical epidemiology, actually, and then the ladder of evidence-based medicine. And then the critics were saying, well, if you make the bar so high for evidence, Pharma is the only strategy that’s going to be able to afford to get in the game and create the evidence unless there’s some other source of information. So if you require the bar to be that high, you basically exclude a lot of knowledge. And actually, I’d like to get into that in a little bit—how do we value and learn from the grassroots movement? But back to your story, that if the reversal of a major medical life-threatening disease didn’t get you into keto, what did it take?
Impact of Personal Experience on Medical Education
Dr. Nick Norwitz: Well, that got me interested. That just got me interested in the space. And then I started delving into the hard sciences, like waking up every day, 4 or 5 a.m. and I’m just reading Cell Science Nature and having my eyes opened to how incredibly interesting and hard a science this is and also, at the same time, I’m just dabbling with social media, getting into groups where I can hear other people’s stories. And one thing I say on repeat is that the most remarkable thing about my story is that it’s not at all unique. I’m an oddball in certain ways. But the motif of struggling in the system, becoming desperate, trying something “fringe”, and then finding it works for you, and wondering how nobody told you about it before is a pattern I know you see again and again.
And so that’s what compelled me to put more of my effort into delving into this space, communicating around metabolic health broadly, because when you start to unpack, the basic science even is distinct from the “top of the hierarchy” of evidence. And I have an issue with a hierarchy of evidence that I can explain. It’s so remarkable, from a scientific perspective. It just makes me smile and get goose bumps all the time. In fact, the newsletter I put out yesterday actually opens with a photo of my arms getting goose bumps because I read the paper. I’m like, this is so cool. And I just needed to talk about it.
Dr. Eric Westman: With mitochondria jumping, yes, and it is mindblowing. But I learned what I do through two of my patients who did it without me. Hey, my patients taught me. I’m practicing at the VA in Durham, here in Durham in 1998 and two patients lost over 50 pounds each. And this was remarkable. I sent my patients to the dietitian. It turns out I was a rare bird. I was a preventive-minded internist, which, at the time, well, even today, is kind of an oxymoron, because we usually react to things with medication. So, two of my patients lose all this weight. And I said, I’m curious, what did you do? And one of them looked at me and said, all I did is eat steak and eggs.
And I fell out of my chair and learned by going to visit doctors who were doing this at the time. Now, as someone comes in, I’m eating steak and eggs, they go, oh, you did carnivore. That’s great. So, 27 years later, I realized that it’s actually fine, the steak and eggs. But so my problem with the academic world at that time, and even today, is wanting to find the mechanism. There were too many, so we started publishing papers on obesity and then diabetes. And then they said, well, but they reverse. Improved the diabetes reversal, it wasn’t shown until the Virta studies later, years later. But diabetes is better, but people lost weight, and you change the diet and so you don’t really know what it was: was it the diet or the weight loss? And I was like, well, it did both. So when you have a multifactorial kind of approach, and you’re in a mechanistic, we want to know the one variable world that doesn’t fit. So you’re coming to this—you’re in medical school at one of the best medical schools on Earth—was there any mention of nutrition, let alone keto metabolism?
Dr. Nick Norwitz: Any serious mention, no, and nutrition isn’t required in the curriculum.
Dr. Eric Westman: Oh no.
Dr. Nick Norwitz: Oh yes. There were worse experiences than that. I’m going to not try to bad mouth my experiences, because there were a lot of great things that I experienced at Harvard Med. But well, it’s not Harvard particularly. Nutrition is just not well taught. And when it is even taught at all, I don’t think it is taught with a mind to the rigorous sciences that should be the basis of guidelines. Even if there are any guidelines, it’s more a repetition of the guidelines, as far as what I’m hearing from peers at other medical schools as well. But I do want to emphasize something very positive, which was the student body, my peers, were very open and interested.
Dr. Eric Westman: You did a study with CGMs with you.
Dr. Nick Norwitz: So there was one day, and this is when I only had, like, a Twitter presence. I wasn’t big on this, It was first year medical school. I’m just kind of dabbling around. It was a moment. It was in our first year, and after class, a student got up and said, hey, we were just talking about fundamental metabolism. I’d really like it if Nick can get up and talk to the class. And I was just kind of like, I guess I will. So I got up and I babbled. I thought I was an idiot. But after that, a cohort of students stayed after class, which, medical students are busy. They all have their own things going on. For people to stay after class to talk to me was awesome. And we just ended up standing around in the hall for like a half hour and after that forged a little pilot trial of using CGMs for medical education.
So I basically just got hooked up with a bunch of Dexcoms, gave them out, and then we use that as kind of like, just wear this, see what it’s like. What do you learn? And then use that as a nucleus for discussing some literature. And what I found in that experience, and then just throughout medical school, is that students are really interested and engaged, and that has just developed and evolved beautifully from where I am now, like we now have all graduated. We’ve gone our different ways, but I have friends in various expertise, and then something comes out, and they DM me, like, hey, Nick, this is a really cool paper. Do you want to cover it because of what you’re doing? And so we continue this dialog. I just think I’m really grateful to my classmates for being amazing people, and then to learn from each other. That’s what you need in medicine. Medicine is a team sport.
Dr. Eric Westman: And you also had unusual access. I saw the interview you did with Professor David Ludwig. Recently, you had access to Dr. Ludwig.
Dr. Nick Norwitz: Professor David Ludwig was a rock star in my corner. I won’t go into the details, but I did get myself in trouble more than once. David was there to talk to me. We just had a barbecue. He was over—he lives in Denmark a lot of the time now—but he came back and we had a barbecue at my house. So he met my parents, and one of the first things he said when I met my dad, David says, “I’m sorry I couldn’t keep Nick out of trouble.” And then my dad’s like, or I’m like, “It takes a village to keep me out of trouble.” So, collectively, my family and David made sure that I didn’t get kicked out of Harvard.
Dr. Eric Westman: Can you talk about this publicly?
Dr. Nick Norwitz: I’ll tell you off-air. There are some things I’ll explain. I can’t say it publicly yet. At some point I will.
Dr. Eric Westman: It wasn’t until I was in residency that I started to ruffle feathers.
Dr. Nick Norwitz: And I will just say I will emphasize all of my behavior I feel was very ethical. Let’s leave it at that. Sometimes when you go asking questions that people don’t want you to ask, you get in trouble. But that’s what’s got me in trouble. It’s got my dad into trouble his whole life. My dad, I’m going to blame him for this. When I was little, he always told me, “If you’re asking a question and you don’t get a satisfactory answer, keep asking. If you keep asking and then people get angry and still don’t give you a satisfactory answer, it means you’re probably on to something.” So you definitely should keep asking the question. So I’ve lived by that my whole life. It’s got me in trouble once or twice.
Dr. Eric Westman: Now I can imagine you’re at the sandbox and your parents are having you do experiments in the sand while you’re a little toddler. I know a couple children of MD, PhDs anyway, but that’s great. And so now your ulcerative colitis is in remission years later.
Dr. Nick Norwitz: No, the first day of trying keto, was June 1, 2019, and basically since then, it’s been in remission, with the exception of one episode following. I do some n = 1 experiments, and I got a little bit cocky.
Dr. Eric Westman: Can you sacrifice? You’ve sacrificed your body for science and your Oreo experiment?
Dr. Nick Norwitz: Thing is, these are easy, and not easy. They can be pretty unpleasant. So anyway, yes.
Dr. Eric Westman: Well, I see these as kind of straw men for other people to either replicate or refute, especially one of your one trials, where I believe what happened is you ate a lot of calories, many more calories than you needed, and you gained weight, but you didn’t gain as much, and your body heat went up. You measured your temperature.
Dr. Nick Norwitz: Yes, it was a 6000 calorie overfeeding study. I didn’t even gain, like, even a pound. I’ve done various studies.
Dr. Eric Westman: Who factors that into the weight loss studies – the body temperature?
Dr. Nick Norwitz: Well, the thing is, calories in, calories out, isn’t a model of obesity. Really, it’s not even a model.
Dr. Eric Westman: But the way I see it is that you burned off the calories.
Dr. Nick Norwitz: Right.
Dr. Eric Westman: So it’s the “thermogenic effect of food” in the old world discussion.
Dr. Nick Norwitz: There are a lot of variables. There are the calories you excrete. There are the calories you burn off as NEAT. So many things, though. You’re not shoveling things into a bomb calorimeter.
Dr. Eric Westman: Although it was kind of an advanced discussion of it. I have to say about the calorie in, calorie out, carbohydrate, insulin hypothesis—I watched your video with Professor Ludwig. I thought it was great. Except there’s some time in there when, nobody knows what a tautology is. And I have to explain that to people. Gary Taubes would say, in his language, that this is kind of stupid. I mean, everyone knows that if you’re gaining weight, you have to have more energy going in. And so Professor Ludwig, in the paper that put all these people together, and I am an author on it, he used the word “tautology,” and I had to look it up. I mean, I’m a history major. And yet that word is kind of a way to code something that’s kind of silly and obvious.
Dr. Nick Norwitz: It’s circular logic, basically, yes. So the idea that, how do you define… how do you operationalize … and I’m using another word, basically, but what is the consequence of calories in, calories out? You’re saying, if you overeat calories, you gain weight. But how do you actually define overeating calories? By gaining weight. So the dependent and independent variables are effectively the same thing. This isn’t even a model of obesity. It’s just a description of what happened. It’s just not functionally useful.
Dr. Eric Westman:
I’m so glad someone like Professor Ludwig can be so articulate and spend so much time on this, because to me, that’s too much work. I want to get in front of my patients and get some results. So back to you, so you’re now in medical school. Your published paper on giving students a continuous glucose monitor is brilliant. I wish every medical school would do that, even if you had dental students, I think as well, just to see metabolism. When I was in medical school, we did blood pressures and we had a tennis ball and watched our blood pressure go up, and showed the dynamic aspects of it. CGMs hadn’t been developed yet, so that’s pretty awesome. While we’re still at this phase, what should other medical students do? What did you come up with as ways to teach and for yourself and for others?
Challenges in Medical Education and Personal Research
Dr. Nick Norwitz: So my off the cuff answer is going to be a little bit pessimistic but realistic, which is that medical school is a very busy time. The curriculum is very compressed, so there’s not a lot of time in the formal curriculum for metabolic health education. It then falls upon the students to seek out this information by themselves, which you’re just busy, you’re studying for exams, you’re doing rotations, and you’re doing your extracurriculars, in your research for residency, if you want to go into academic programs. And so it really needs to be internally motivated right now. I do see that changing. But I think to your earlier point, or what you alluded to, I think it’s going to be forced by grassroots, bottom-up pressure.
Dr. Eric Westman: The group—physicians—ought to care. And it was an anti-smoking group, really anti-tobacco, tobacco group, but it was an organization at the medical school level that it would be cool to get a metabolic health organization that there’d have to be some external support to get it started, but to band together, students were interested about it, but I don’t see the same anti-sugar groundswell at the moment that there was for anti-tobacco years ago. But so at a medical school level, though, when I have tried to interact and change things, they say it’s full. But then I said, well, what drives what you teach? And they say, well, we need to teach the medical students how to understand what the drugs are going to do, the drugs that they’re going to be prescribing. Like, wait a second. And so I started watching lectures on cholesterol, and then the biochemist would bring in the “and here’s where we block the HMG CoA reductase, and this is where it’s going to be important for your life”. And, it’s like, wait a minute, what if you don’t use an HMG CoA reductase inhibitor? So, gosh, I mean someone that really does kind of take a view of, does what someone puts in their mouth matter for human health?
Dr. Nick Norwitz: Yes, so here’s what I think is going to happen. I think both you and I probably share the opinion that things could be reprioritized, and basically the entire curriculum could be rewritten. Realistically speaking, neither you nor I are going to make that happen. However, I do think most doctors really want to help their patients, and most doctors in my generation are also seeing what we’re currently doing is not helping, so they’re looking for solutions. And where are they best looking for solutions, or they should be, is in their patients. So just that, the experience you had, you said, 27 years ago, I see that’s going to be happening more and more with people having access to information via social media, just the internet, bringing it to their doctors, going through their own journeys, and their doctors just discovering, look, this is undeniable that we need to change the way we approach chronic disease still build on some of the amazing innovations that conventional medicine brings for like acute care.
I don’t want to discredit those, but I think there is going to be a shift, both with patients bringing information, but just also with, I think, a revolution in biomonitoring technology and personalized care. Right now we talk about that hierarchy of evidence. You kind of put these randomized controlled trials (RCTs) on the top, and at some level, that makes sense. However, an undeniable truth of that approach is these trials are still done on heterogeneous groups of humans, and so you can get a statistically significant result even with an intervention that does not help the majority. So the real question is, how can we approach this with more precision, and as we are developing tools to identify with finer resolution what’s the unique pathophysiology in an individual, and I can give examples of that in the diabetes space. I think there’s going to be a shift towards the RCT not actually being the gold standard anymore, and the gold standard being using machine learning and AI to direct personalized care targeting what are the dominant pathophysiology in a given individual?
Dr. Eric Westman: So there are times when all you need is one person. To show penicillin for meningitis, if something is uniformly fatal and you administer a dose… so penicillin never went through randomized, controlled trials. It didn’t have to, but the idea of knowing the safety of something, so you can know something works, that’s pretty easy to demonstrate. But the problem with safety is either—and I’ve seen surgeons get up… well, any medical person who has a new treatment, and they’ll say I’ve done 10 in a row and there’s no problems. Well, let’s see. So the three over N rule says the upper 95% confidence limit of having no outcomes in 10 people means it still could be 30%. A 30% death rate. So the more people you have, the more confident you are on the safety of something and tolerability. So wrapping up in your personal story I wanted to get to a more scientific question, but nowadays you’re healthier, and you continue to eat in a low carb kind of way.
Dr. Nick Norwitz: Yes. I have no reason to stop.
Dr. Eric Westman: So I’m seeing a lot of young researchers and doctors not even having many vegetables at all. Certainly you must have fruit every day. No, okay, you don’t have to have fruit. And then I’m getting more comfortable with the idea of no vegetables, because there you can get all the nutrition you need. And yet, these other scientists are looking at pretty careful biologic measurements. And the study by Isabella Cooper, where she took 10 women already on keto for an average of, I think, three to five years, and all the metabolic parameters look great and then look terrible. After just a couple weeks of the UK 280 gram/day carb diet, and then went back to low carb keto, things normalized again, starting answers or give some insight into the question, maybe you didn’t really need to eat carbs at all, even before your medical issue that came on. And that’s a huge leap. So we’ve come through the last 20 years where I think it’s pretty accepted that using low carb and keto is a therapeutic tool to reverse diabetes. You have the Virta studies now, but then get them off (of keto). My colleagues will say, “But once you’re there, get them off that diet, because it’s going to hurt them.” That was a slide from 25 years ago, and it was called the Atkins diet. There was a cartoon of the doctor going, “I know it reversed your diabetes and obesity, and you’re feeling better, you’re off your blood pressure medicine, but that diet’s going to kill you.” It was a joke, but now we have to be honest and say no, there’s no evidence that getting off it is bad.
Dr. Eric Westman: Yes, staying on it may be okay. And the other thing is, we’re not using research that’s been done before. We’re following people in real time, in their own lives. Like you’re saying we can’t study everybody. And the personalization of this is to a point where, if we can examine the insides of the coronary arteries of somebody to see if what they’re doing is harming them, that’s going to help combat the big naysaying that this is necessarily bad. But so you decided to continue a keto diet. That’s great and so now my question for you, and I need help on this one, is how to value—or not—the grassroots movement. So when I started to look online 25 years ago, there were some pre & post pictures of people doing Atkins.
They’re heavy, and then they’re skinny, they’re heavy, and then they’re skinny. And so people can climb Mount Everest, but not everyone can. So you can see that people are doing it and that are maybe not. Maybe we don’t trust internet information. Maybe, are there validated questionnaires or comments sections, with this grassroots chain and change in this enormous amount of information, how can we harness that information? Or maybe we shouldn’t. I’ve seen surveys done of self-described carnivore eaters, and we’ve done surveys of Facebook groups and things like that. How are you looking at this as a new source of information? Someone writes a comment on your video, on YouTube video, does that have value? I mean, it could all just be selection, but it could all be bots. So how do we handle the information and figure out for whom, as you’re saying, this might be good or might not be good, with new data synthesis tools we have?
Dr. Nick Norwitz: So I guess the infinitely difficult question is, what is the source of truth?
Dr. Eric Westman: Well, let’s say the health of the human in front of me.
Dr. Nick Norwitz: Yes, no, no, I’m unfolding. So I guess the juxtaposition could be this idea of a hierarchy of evidence, like the most rigorous evidence, the metabolic ward, controlled trial. It sounds nice. It has the bells and whistles, and so you want to put it at the top of the pyramid.
Dr. Eric Westman: But if there’s only two weeks.
Dr. Nick Norwitz: This is actually my point. You can have something that looks rigorous, has the bells and whistles, has gone and through and gotten the stamp of peer review, and it can be tremendously misleading. Now it’s true, the internet, on balance, has a higher chance of being misleading, but I guess what I’m saying is there’s no direct and easy answer to saying this is where you can find truth, because all the data pools are a little bit messy. So I think the best solution we have is to have open and nuanced discussions, not settle for simple answers, and provide frameworks and ways to think about things and provide tools for people then go safely experiment on themselves. I can provide you all the information from the basic metabolic studies or randomized control trials. At the end of the day, the question the patient needs to ask themself is, how can I experiment with this safely on myself, and does it work? And then who can I ally with, like a physician, to help me work through this process as an ever ongoing journey? So there is no clear answer to the question, how much value does x have versus y, because the answer to that is going to depend on who the receiver is.
Dr. Eric Westman: But if you’re in an echo chamber of even, I suppose this happens, probably on vegan YouTube…. I don’t follow them. But on keto and carnivore YouTube, there you’ll get people who tend to be your followers, or that echo chamber reverberates. And then if someone comes in saying, hey, that’s not the only way, they’re called a troll. I mean, well, hang on, this isn’t the science.
Dr. Nick Norwitz: It comes down to individual responsibility. I mean, fundamentally—and this is important—science is not a democracy. It is not determined by the vote of peer reviewers. It is not determined by the vote of the public. It is a process for approximating truth. And that means my challenge to the listener, my challenge to myself, is how you most authentically interpret the data and stand up for what your perspective is, being willing to be in the minority, being willing to be wrong. That’s part of what the scientific process is. So as humans, we are tribal. We are influenced by our social circles. We are influenced by the mere exposure effect. And the best we can do is be aware of that and then try to compensate for it and be courageous enough to say, hey, this doesn’t make sense to me, and here are my questions.
And then seek people who are willing to approach the conversation with that authenticity and have discussions openly and be willing to be wrong. That shouldn’t be a sinful thing. In fact, my last tweet earlier today, I got a comment on, I thought, a respectful response video to Peter Attia, talking about causality in apoB, and somebody wrote in the comments that I was challenging Peter, who takes on the experts, and they use this word. This is not my word. He regurgitates the opinions of the experts, and that I am challenging that and this is not a commentary on Peter. This is the comment. The accusation to me was that I wasn’t regurgitating the opinions of the experts. The accusation was, I had the audacity to think independently. So I don’t know if they intended to basically say, hey, independent thinking is a sin. And when did that happen?
Dr. Eric Westman: I wouldn’t say it’s a sin, but there’s always been hegemony or influence or paradigms, if you will, where we as scientists see things through a certain lens. It finally occurred to me that Jeff Volek and I had broken a taboo on studying high fat diets. Best I could tell, there was no law against studying it. In fact, there was no study that said a high-fat diet was bad. It was just kind of understood that you wouldn’t study it. The study sections wouldn’t allow it. I finally got to talk to one of the researchers, Mary Gannon, a very wonderful person, and Frank Nuttall, in Minneapolis. They had no particular diet. She looked at me and said, but if we were going to study lower carb diets, we’d have to increase the fat, and we couldn’t do that. So, it was as if the medical world said fats are bad without any evidence. And then the researchers were—who are not medical, they’re PhDs—were beholden to this kind of artificial taboo. Gary Taubes’s book, Good Calories, Bad Calories, the first half of it tells the story that was so helpful for me that the science was not solid about low-fat diets. And even yet, there are organizations that will always say fat is bad, because they were started on the idea that fat was bad.
Dr. Nick Norwitz: Like, with guidelines, there are the acceptable macronutrient distributions. Do you know where those come from? I looked this up because I remember getting a lecture, and the person gave us these guideline-based acceptable macronutrient distributions.
Dr. Eric Westman: Probably what people typically eat?
The Role of Personal Experience and Grassroots Movements
Dr. Nick Norwitz: So they were saying, carbs between, I don’t know, it’s like, 40 and 60%, and when I went and did some digging, the logical chain was as follows: high cholesterol is bad. If you eat saturated fat, cholesterol goes up. If your total fat is increased, that means your saturated fat is going to go up. So in order to keep your total fat below a threshold, so your saturated fat is below a threshold, we need more carbohydrate calories, and that’s where the carbohydrate fracturing comes from.
Dr. Eric Westman: 20 years ago, I presented the low-carb, the Atkins induction paper to a group at a local nearby Pharma company, just thinking they might be interested. And they said, well, you’re out. The LDL went up five points. And I said, well, yes, but it wasn’t statistically significant. But no, that’s a dealbreaker. FDA says no, a drug cannot raise LDL cholesterol. I mean, this is even before small LDL.
Dr. Nick Norwitz: SGLT2 inhibitors raise LDL.
Dr. Eric Westman: We’ve come a long way, I’m trying to say, in and be able to study. And it finally occurred to me that science is a self-writing endeavor. Eventually you will find the truth, but only if you can fund or get access to funding for every question, right?
Dr. Nick Norwitz: That actually is poking me in the brain about speaking about pushback about ideas. Did you see what Peter McCullough wrote about Jan Baszucki?
Dr. Eric Westman: No.
Dr. Nick Norwitz: So this is real. So they were at a dinner, and he ended up, then thereafter, posting a blog post where he calls her—he didn’t name her, but I had permission to then share—it was her. She actually reached out to give my two cents. He calls her a twitchy, keto-crazed conversationalist, based on the fact that she was talking about keto. And I bring this up in this context. It’s not a non sequitur, because she and her family just put $50 million into the Coalition for Metabolic Health to do unbiased research that is free from the current business model. And it’s so interesting to see the pushback. I guess in some ways, it’s competitive. But when a family of philanthropists and altruists, through their own suffering, wants to fund research into metabolic health, questions that are genuine, open questions, that’s taboo.
Dr. Eric Westman: There are those who come to keto to be nihilistic and anti-establishment. I saw that during Covid times, where the people who came to keto, who wanted to just rabble around, they thought widely beyond what science was saying, but they were rabble, so keto can be perceived as kind of quackery and way out there by people in the mainstream. But the idea that a family affected by someone is influential started best as I can tell with the Charlie Foundation, where the child, happened to be, fortunately, the son of a movie producer. And so Charlie Abrams, his parents start looking, and the experts said, we want to operate on your child for epilepsy. And they said, hey, wait a minute. Let’s go look. And so they found this person at Hopkins. There was one person still teaching the keto diet for epilepsy, and they went and created this fire starting to burn again. And Charlie, best I can tell—I saw him at a metabolic health meeting, Metabolic Health Summit meeting a few years back—he doesn’t need to do keto anymore. I mean, he’s a grown man, and he kind of grew out of his seizure disorder. But we need to be able to get access to funds beyond just family of people affected, but your parents haven’t started a foundation yet.
Dr. Nick Norwitz: My parents. You think my parents have the wealth to do that? They’re physicians.
Dr. Eric Westman: I’m just joking, but that’s sad that it has to be a grassroots, people-funded sort of thing. And I hope there will be other sources of funding for the research at the same time. I’ve been using this in my clinic for the last 20 years, when I visited Dr. Atkins in 1998. I said, you need to do research. And he looked at me and said, “Why do I need to do research? I’ve been doing this for 30 years. I know what your research is going to show.” And he’s got a point. He’s got a point, but I convinced him that the world didn’t believe him. So there was this big disconnect. And so he funds the first science with Volek and me with a check from his personal checking account. They create a foundation then, and sadly, he dies, and the money is used in other ways, gets lost in the recession, that sort of thing. So in the first paper, we wrote and submitted to the JAMA, Journal of the American Medical Association. One of the reviewers said, we’re not used to seeing papers funded by doctors. How is that for a non-scientific reviewer?
Dr. Nick Norwitz: I’ve gotten similar weird pushback. I remember when we did a case series on carnivore diet for inflammatory bowel disease. And to be clear, this is a retrospective case series. We did have medical records. These were confirmed cases, but for a retro, because this happened to the patients, we just want to report on that, but we still want to dot the i’s and cross our t’s. So we went to an IRB (institutional review board). Weirdly, they wanted to have us go through the whole process. It should have been an exemption, because it wasn’t a human clinical trial. Research has been done. We had to go to six IRBs before we got in one door and then the reviewers, oh my god. We were getting pushback from reviewers and like, did you control for water intake? And I’m like, “What is the biological plausibility of 38 versus 40 fluid ounces of water affecting their ulcerative colitis?” Give me a break. There is pushback about things that are outside the mainstream, and it’s anti-scientific. There shouldn’t be taboo conversations.
Dr. Eric Westman: Well, fortunately, so another thing that happened, Richard Feynman, the other F-E-I-N-M-A-N at SUNY Downstate, we’re at a meeting, and he says, “You know, I think we need a new journal.” And I said, “You can do that.” I am like, I didn’t know, I’m a professor at Duke, but I didn’t know you can create your own new journals. And I said, “Well, that’s a lot of work.” He said, “Well, I’m going to do it.” So to get a fair peer review, we had to create a journal called Nutrition and Metabolism. Of course, you have to find all the editors and all that, and it’s not trivial to do that. Fortunately, today, the Journal of Metabolic Health, I’m working on a case study where someone just kind of signed the form that said we didn’t need to go through an IRB, so it depends on the journal.
I’ve even had professors tell me, well, you can’t get it published unless you have an IRB approval. Well, it depends which journal and it depends on the level of the story you’re trying to tell. We’re just telling an anecdote. I mean, you know, in the medical world, it doesn’t carry much weight. But the point is that you can use an anecdote then to market something inappropriately so the safeguard’s there, for sure. But people need to know that it can be a lot of work and hassle to get into that medical publication world, and if you’re doing it in your spare time and you’re not hiring someone else to do it, it’s a lot of work to do that.
Dr. Nick Norwitz: Yes. I mean, most clinicians aren’t academicians, so if they’re busy with the clinical workload, it’s not something they’re necessarily trained to do. It’s a different skill set. So it does create barriers. To circle back on something you said earlier, just to kind of emphasize, when you’re talking with Dr. Atkins, he’s like, “Why do I need to do the research? I know how it pans out.” I think the term there is scalability, and this is great for the individual listening, because you don’t need to wait for standard of care to change, to take information accessible to you now, even via the internet, and apply it. However, if we want to treat the masses, there is going to need to be a shift in what convention is, and the only way for that to happen is for the evidence base to evolve, which I do see happening. I mean, yes, we need more than the Baszuckis giving $50 million, but those kinds of efforts create breakthrough points, and eventually this becomes self-fulfilling.
Dr. Eric Westman: Well, I think there are places, Michigan is one of them, Alabama is another one, where there’s a group of funded researchers through NIH, through other means and the other but the hard battle, it’s easy to get a K award relatively through NIH and then these folks basically need to continue to get funding. Then leap to the RO1 level through the K awards. And now I think Laura Saslow at Michigan is just full. She’s over-subscribed to grant. So if anyone wants to do research on this and can’t find money I think, UAB, Michigan, we don’t have that at Duke at the moment. Someone wants to do research here. I said, well, I have a clinical group. Well, there was a medical student who, for his continuity year, stayed in my clinic, got to know the patients—many of mine come back over the course of the year—and he wrote a case series. It’s now accepted for publication on heart failure. So he’s interested in cardiology.
He had learned that low-fat was best. And then he came, saw this clinic, and is like, whoa, there’s another way to go about this. And I think a couple hundred people. He just searched the medical records for keto clinic and heart failure. He presented it at a meeting, and now it’s going to be a paper. Of course, this is a very interesting twist, isn’t it, that the SGLT2 inhibitors—which reduce heart failure events—is probably working by giving ketones. And so cardiologists know about ketosis through the drug treatments, but they think eating dietary fat is bad, and so therefore they can’t understand that a keto diet might actually be doing what the SGLT2 inhibitor is doing without the risk.
Dr. Nick Norwitz: You just pointed out something very important, which is that attention in medicine is determined by what pharmacological interventions are, like pointing the spotlight. So like Lp(a), it’s the hot kid on the block. Now, I wrote a newsletter on it that I thought was like, this is esoteric and academic, and ended up being one of my most popular. Why is it in the spotlight now? Because there are five drugs under trials to treat it, and you’re getting these NEJM papers (New England Journal of Medicine), and now it’s a hot topic issue. When you start to look into a lot of these conditions, they always have some degree of metabolic underpinning. I’ll give you another example, like depression. Now there are a lot of examples when it comes to depression, but an interesting paper came out early this year in Nature where they were looking at autophagy in the brain, this basic cellular recycling process, and they found that autophagy was dysfunctional in one particular area of the brain, and that led to basically over expression of glutamate receptors and excitation.
So basically you’re turning the knob up on the depression center. But this is why I bring it up. How do antidepressants work? Different antidepressants have different mechanisms of action, but we still don’t really know. So for example, selective serotonin reuptake inhibitors—SSRIs—you might just think they increase serotonin, but when you start taking them, they increase serotonin very quickly, but they take a while to act. So it’s not a direct serotonergic effect. There are kind of maybe metabolic and adaptive changes that occur over time. Guess what? SSRIs increase autophagy in this part of the brain, as does ketamine and other antidepressants. So when you start to look under the hood, a lot of these interventions hit nodes in the metabolic web. And I do like the idea of a web, because you said earlier, we’re always looking for the answer, the linear pathway. The way I think about it is, every new, really cool paper, it’s not be-all, end-all. It’s like a new thread in that web. And as we study it, it just develops this better resolution. And you’re right, from the clinical level, this thing’s working. Doesn’t matter what it is. It could be a placebo. Patient doesn’t care. They’re better.
Dr. Eric Westman: But it’s harder. So it’s easy to prove efficacy. It’s harder to prove long term safety, and that one thing is better than another. And I’ve kind of just kind of diplomatically agreed that there are a lot of ways to be healthy. I went to a couple meetings in Europe this summer, and the Cooper paper kind of blew me away. I hadn’t seen it. It’s been out a couple years, and in the end, she had no trouble recruiting people already in ketosis. Turns out, I think she was one of the people in the study. And then I also met Adrian Soto Mota in Europe. I know you met him. And the first time I met him, he’s solid. Wow.
Dr. Nick Norwitz: Dude saved my life.
Dr. Eric Westman: And actually we’re chatting, and I remembered a colleague of mine in Canada within the evidence-based medicine world, and he said, well, you know, I got on the exam board and we put likelihood ratios on the exam that doctors have to study for. Oh, and actually, Adrian said they asked me to write a paper for the Mexican board. And I said, get on it, make sure they know because people will study for the test, right? So if you’re going to drive curriculum, at least in some ways, you can change, alter the test that people have to be trained for. So a lot of these things come around, you know, just in a different form, which reminds me of my 90-year-old patient, who was the oldest one to march at West Point. He told me he was in Durham but would go up to West Point every year. He said, I’ve seen everything twice. A lot of times it’s the same kind of things, recycling, and we can learn from the fact that the powers that be have different motivations, and the patient in front of me was always the kind of clinical epidemiology purpose applying statistics to this. How do we know? How many people have done a carnivore diet? How can we know?
Dr. Nick Norwitz: I don’t know how, but it matters, because here’s the thing. Well, not that it doesn’t matter entirely, but I think people get wrapped up in these really weak heuristics, like a larger sample size makes a better study. That is not true at all. What question are you trying to answer? And is this study sufficient to answer the question? The end value of that material, it can be depends on what question you’re asking, but it could be that if 1000 people had done carnivore rigorously and got X results, it doesn’t matter if it’s 1000, it doesn’t matter if it’s 10,000; it’s sufficient to propel the next question in the next study, I think.
Dr. Eric Westman: Yes, I guess, as a died-in-the-wool clinical trialist, trained in randomized trials and all that, I guess before I give a policy to my patients, I want some sort of framework. So a doctor today, internists like me, and then I went into obesity medicine as a sub-specialty, if you will. The doctor has no qualms saying, well, here’s a GLP-1 or here’s an SGLT2 inhibitor. It’s FDA-approved, which means it’s gone through some vetting, some studies, and a doctor doesn’t pitch it like, “Well this might work. It might not be good for the long run. And you don’t want to stay on it too long.” So how can we tell doctors? And this is like an FDA-approved drug—with that kind of emphasis and confidence you can tell people to do this. Of course, the way you teach it, pharma is brilliant, because they put it in a little pill, and if the pill is too big, you can put it in powder.
And so we’re teaching something that needs to be simple, I think, and for it to be doable and sustainable, that scalability thing. And so getting back to where Dr. Atkins said, “I know what you’re going to find,” I realized that, no, there’s selection bias. He might have taught someone and they might have died, and he never knew about it. So in a clinic, you can’t see the people who don’t come back. I had a father who was an academic psychiatrist, and the old joke back then was doctors bury their mistakes, that being the surgeons and the errors that they have. So that dark humor was in my mind when I said, well, an obesity medicine specialist like Dr. Atkins, one can’t necessarily know unless they do a systematic study of what happened to all those people. So, how many people have done carnivore without any side effects? Or, you know? So I did a ‘Reacts video’, and some of these people were like, well, I didn’t feel right. Or I was a little tired, and it was like, they didn’t drop dead. They are doing a carnivore diet. But great question, why do we need to know? I wasn’t expecting that reply. That’s good.
Conclusion and Final Thoughts:
Dr. Nick Norwitz: Let me evolve that statement. I don’t need to tell you, the art of medicine is making difficult choices with imperfect or incomplete information, and I think we just need to have more evolved and open discussions about what we don’t know and what we might speculate on. So I’ll give an example that came up recently. You probably saw it circulating around the internet because I made kind of a hullabaloo around it. It was this paper on cell metabolism around statins and GLP-1. And this was a human controlled trial showing that statins slash GLP-1 levels—GLP-1 being a very important hormone for metabolic health. It was a 16-week trial, and in humans, they just tanked. Straight line down GLP-1 levels.
Now my purpose is not to scaremonger about this. It is not to say if you take statins, then you’re going to have x, y and z, but it does fit into the broader literature, and it begs questions. If you’re using this in a healthy person for primary prevention who has isolated high LDL, what is the risk-benefit analysis, and what are going to be the long term consequences of, say, slashing GLP-1 levels? So what I’m just saying is, how do you have that conversation? Because you can’t have that conversation with the utmost confidence, and it’s the same way with other drugs that we just, you know, brush under the side effects of other drugs. PCSK9 inhibitors, people talk now about Mendelian randomization, how they’re great for prooving causality. But then what happens when you see a forest plot in a study where it says PCSK9 inhibitors “cause” an increase in Alzheimer’s disease risk? It’s not proven without a shadow of a doubt, but we’re not going to have that complete information. So then, how you have an evolved discussion saying, “Here’s the risk benefit analysis at the individual level, but quite honestly, for both the risks and the benefits at the individual level, there are a lot of unknowns, and I don’t think there’s a simple answer.” I think it’s a matter of saying, “Hey, this is never going to be simple, but let’s just have an evolved conversation about it.” And these shouldn’t be taboo things, provided we come with humility to the conversation.
Dr. Eric Westman: I want to be respectful of time. Thank you so much. You’re welcome anytime to visit my clinic at Duke. You could come for a day. I’ll teach you everything. Come for a half day. Come for a week. I’ve set up the clinic here in part to be a teaching platform. So because there’s so many things that are different, and as you know when someone reverses a serious medical disease, you don’t worry about this hypothetical red meat down the road problem that fixed you. So those tradeoffs become decisions we make without randomized trials. And I love that you’re trying to inform people as best they can. But there’s some times when people are so vulnerable. And you were in that situation. They’ll look for the weirdest, craziest thing. And then you found keto. That’s so deliciously ironic.
Dr. Nick Norwitz: And you roll the dice sometimes in life.
Dr. Eric Westman: And yet everyone goes into ketosis when they don’t eat for two days. So, how would we all have survived evolutionary pressure if ketosis was bad? And that didn’t occur to me ‘til, like, 25 years after I saw those patients who had done this, so I’m just trying to erode some of those barriers. And maybe they’re not there again. Nick, how do people find you? What’s the latest?
Dr. Nick Norwitz: Yes, Nick Norwitz is a pretty unique name, so you look it up. You can find me on any socials. My biggest right now is probably YouTube, although my favorite and where people can find the most information up to date is at staycuriousmetabolism.com. That’ll take you to my Substack. So at least three times a week, I publish deep-dives on all things new in the basic and translational science journals, and I just have a blast with it. So yeah, staycuriousmetabolism.com, any socials, and thank you so much for your generosity and hosting me, and I look forward to the future conversations and collaborations.
Dr. Eric Westman: Yes, let’s talk again. Keep it up.
Watch the full video here.
Speaker Bios
Eric Westman, MD, MHS, is an Associate Professor of Medicine at Duke University, the Medical Director of Adapt Your Life Academy and the founder of the Duke Keto Medicine Clinic in Durham, North Carolina. He is board-certified in Internal Medicine and Obesity Medicine and has a master’s degree in clinical research. As a past President of the Obesity Medicine Association and a Fellow of the Obesity Society, Dr. Westman was named “Bariatrician of the Year” for his work in advancing the field of obesity medicine. He is a best-selling author of several books relating to ketogenic diets as well as co-author on over 100 peer-reviewed publications related to ketogenic diets, type 2 diabetes, obesity, smoking cessation, and more. He is an internationally recognized expert on the therapeutic use of dietary carbohydrate restriction and has helped thousands of people in his clinic and far beyond, by way of his famous “Page 4” food list.
Nick Norwitz, MD, PhD, is a researcher-educator whose mission is to “Make Metabolic Health Mainstream.” He graduated Valedictorian from Dartmouth College, majoring in Cell Biology and Biochemistry, before completing his PhD in Metabolism at the University of Oxford and his MD at Harvard Medical School. Nick has made a name for himself as a clinical research and metabolic health educator, speaking and writing on topics ranging from brain health, the microbiome, mental health, muscle physiology, mitochondrial function, cholesterol and lipids, and more.
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