Introduction of Dr. Rob Cywes and his background
Dr. Eric Westman: It’s my pleasure to be able to interview Dr. Rob Cywes.
Dr. Rob Cywes: Rob is good enough. My father is Dr. Cywes.
Dr. Eric Westman: I have known you for years. We’ve gone to meetings together, given talks, and we also are on the board together for the Society of Metabolic Health Practitioners. We might get into that a little later, but I have to say that you are kind of unique, and you’ve probably been told that before.
You are a bariatric surgeon who now has the handle “Carb Addiction Doc” and you treat people remotely. How did you get into this? You have to include your PhD.
Dr. Rob Cywes: Yes, and I’m a surgeon. I’m both a board-certified pediatric surgeon and a board-certified general surgeon. There were two parts that started this. I’m going to take you into the lab when I was in Toronto, and I was working with liver dysfunction. Primary nonfunction in transplanted livers, which was very prevalent, where they reperfuse the liver after transplant, and it didn’t work. When you biopsy that liver, the sinusoids, which are the blood vessels in the liver, were just clogged with this big blood clot. The question was, why?
What we found is that the endothelium, or the cells lining that blood vessel, were triggered by inflammation. You could measure the inflammatory markers in those vessels, and the inflammation triggered the clot. The clot led to a fibrin clot, followed by platelets that became activated, followed by white cells that became trapped into that. The sinusoids don’t get plaque as we do in arteries, but every other element we were seeing started with the inflammation of the vessels.
Research on inflammation
The first part of my time in the lab, my master’s thesis, was done to create a biologic form of inflammation. I’m working in a laboratory where, a decade before, they created the glycemic index for the management of diabetes. The head of that, who was on my PhD committee, was a guy by the name of Dr. Jenkins. He’s a vegetarian and very fat. In 1981, he wrote the seminal paper on the glycemic index. I’m working in a lab also studying cholesterol, cholesterol gallstones, and blaming fat for cholesterol. I started my research, and we think let us look at the different things, different drugs, and different things that can cause inflammation in the liver.
We were able to isolate a liver in a chamber and put flow through that, keeping the liver alive, but testing different elements. We tested all kinds of lipids: polyunsaturated, which was in the TPN (total parenteral nutrition), and saturated fat. Nothing. The liver just smiled and loved it. We tested protein. That didn’t affect the liver. In fact, if anything, it subdued the inflammatory response. Amino acids subdued the inflammatory response, whether they were extracts or full. The immune system showed no response. We tested a variety of drugs, steroids, and things that we used in the transplant process. No major effect. Then we started with dextrose, and everybody knows that you have to have sugar to keep your brain alive. So we used glucose, fructose, and galactose. We actually did it using an insulin clamp, so we maintained the blood sugar, but we had to use insulin. Even though the liver doesn’t require insulin to take up sugar, it does require insulin to transform sugar. We used it under an insulin clamp. We kept the glucose concentration at a good level, but a high volume of carbohydrates going into the perfusate.
What we found, in a dose-specific manner and a substrate-specific manner – from fructose (the worst), glucose (the intermediate), and galactose (the least worst) – and in a concentration-dependent manner, we created the exact injury to the endothelium that we saw in our transplant patients. Then, if we sequentially added fibrin. Not fibrin but a noncellular procoagulant, such as FFP, fresh frozen plasma, which has all the elements to create a clot but no cells. We created an inflammatory clotting response, an intrinsic clotting response.
Then we added platelets, and very rapidly, the platelets were activated. One of my colleagues did their PhD on neutrophils and another on Kupffer cells. Each person in the lab was working on their PhDs, working on a different cellular element. My project was platelets. We proved that platelets were the transition from the fibrin clot to the cellular clot. When platelets become activated, they attract all these neutrophils, and I was able to block that with a variety of substrates, the most important one being a thromboxane A2 inhibitor, which is the trigger for, and I know these are big words, but why thromboxane A2? That’s what aspirin is. So, aspirin is a thromboxane A2 inhibitor, and we could then dissolve the clot using thrombin or antithrombin very easily, which our body is doing all the time.
We proved categorically that sugar was – and we actually used sugar infusion to create the injury that we were then studying the formation of – but sugar was the problem. The issue then is that nobody could believe my results. Your results are wrong. you are doing the experiment incorrectly. It can’t be. For a decade, I questioned – kind of an impostor syndrome – that there is nowhere on Earth, in front of these world experts, that I could possibly be right. It took me at least a decade, and then going back to look at my research, to say, “No, I was right.” But I had to remove the cognitive dissonance out of the way, and we could regenerate the liver very easily.
Dr. Eric Westman: What year would this have been?
Dr. Rob Cywes: This was from 1990 to 1995.
Sugar causes inflammation
Dr. Eric Westman: I was in training, research training, and only got a master’s in biochemistry. I’m in awe that you have a PhD. A lot of people today say it’s the fat that’s causing the inflammation when you showed that it was the sugar causing the inflammation.
Dr. Rob Cywes: Absolutely. Not only did we show the sugar damaging the vascular endothelium, when we put whole blood through these livers, but when we added a sugar concentration, we immediately created fatty liver. We could see these little globules. Fatty liver is not a disease of fat coming to the liver. Fatty liver disease is a production of fat by the liver as it tries to, so you first deposit sugar as glycogen, and we could do that within three hours of perfusate, but very rapidly, the liver starts turning sugar into triglycerides. So, fatty liver by itself is just the conversion of sugar to fat. It’s a benign process. But when you add a higher concentration of sugar, you are getting the sinusoidal inflammation together with the fatty liver, and that’s steatohepatitis or inflammation of the liver. So, you have got fatty liver plus inflammation. That’s the devastating injury.
Dr. Eric Westman: What’s tragic is I have treated people at Duke who have had a liver transplant, and the liver is becoming fatty again, even the transplanted liver. No one has told them not to eat carbohydrates.
Dr. Rob Cywes: And then you add to that steroids for immunosuppression. It’s not a pretty picture.
Dr. Eric Westman: What you found is that even the steroid suppression is not very powerful.
Dr. Rob Cywes: No, not at all. The point I’m making is that in the 1990s, we understood fatty liver disease. Now you’ve got these companies making T3 receptor agonists and selling that, going through the FDA. Resmetirom, it’s called, as a T3 blocker. The problem is when you block T3. T3 is part of the cholesterol production pathway. You are now seeing all this cholesterol, not that I’m worried about it, but you are seeing cholesterol in the thousands as total cholesterol.
Because we’re unable to accept the fact that sugar causes damage, we go down all these other pathways, with lots of money involved.
Getting Dr. Rob Cywes work published
Dr. Eric Westman: To summarize, you knew this a long time ago. That it was sugar causing the inflammation – fructose and glucose in kind of priority – and that it wasn’t fat. Against the teaching of the day. Did you get this published eventually?
Dr. Rob Cywes: It was published in my PhD, but with a lot of caveats because it could – I was being dishonest, I was lying about my data if I said what I have just said to you – because it was so unbelievable. I was very cautious about how we talked about this.
Dr. Eric Westman: Someone would have to go to the university library to get your PhD published on the wall. It never made it into a peer-reviewed publication?
Dr. Rob Cywes: Some of the minor papers made it into peer review, but the big stuff… I will give you an example of how crazy this is. Probably one of the best ketogenic papers I have written in a long time was done by a young woman called Isabella Cooper in the UK. Isabella is a PhD student, and she went two years ago to the IRB (institutional review board). She said, what we’re going to do is we’re going to take a bunch of people on the standard UK diet, the Eat Well diet, and we’re going to put them on a ketogenic diet and study the changes because she believed that that would improve things. She could not get it through IRB because she was going to harm her subjects. Then she flipped it around, and she said, let us take people already fat-adapted on a ketogenic diet and put them on the standard diet because we’re taking very sick people and making them better with a standard diet. Then she proved with blood work that that was a problem. Same thing for me. We just could not get that through the roadblocks of people’s cognitive dissonance.
Dr. Eric Westman: Now with the 20-30 year perspective that we’ve, it occurs to me that we all go into nutritional ketosis if we don’t eat for two days. People who say that it’s terrible and you are killing yourself will be very happy that they are able to have nutritional ketosis if they can’t eat for two days. To me, it’s even like the safe mode. it’s going to be like the …
Dr. Rob Cywes: Let me stop you for a second there, Eric. Very, very few people can go four hours without eating, let alone two days.
No evidence that low-carb diet causes harm
Dr. Eric Westman: I have been in front of audiences and said how many of you have ever gone a day without eating? Rare, they can. They are hungry, and the food is everywhere, right?
I often bring up these reality shows where people, of their own volition, go out into the middle of nowhere. Anyway, the fat-adapted eating, low-carb, high-fat diet is actually a natural thing. We all do it. And yet, it was only this year when I heard Jeff Volek speak again. He’s been studying this as long as you and I have. Well, you have studied this longer than I have. It was about the year 2000 when I started looking into this. He basically said this year there is no evidence that a low-carb diet causes harm.
Dr. Rob Cywes: I would be even stronger with that. I would tell you that a low-carb diet optimizes human biology.
Dr. Eric Westman: Yes, but that’s kind of extreme.
Dr. Rob Cywes: Well, let’s flip it around. The other thing that happened to me was when I was in the laboratory, especially in the last year of PhD, when I was starting to do some surgery, taking some calls, very stressful, I also quit playing sports. I gained 100 pounds in a year, and I can assure you it wasn’t because I ate too much fat. The other part that I could correlate – you asked me the question – what I was eating. My diet went up to about 80 to 90% carbohydrates, and I ate continuously. It would be the muffin, it would be the M&Ms. It was continuous eating little bits here, little bits there, like a smoker, and it was almost all sugar and starch. Whether it was healthy fruit or unhealthy muffins, sugar is sugar by the time it enters your bloodstream. Remember this: what enters your mouth is outside your body. It’s only when it transitions across the gut that it enters your body. Whiskey doesn’t enter your body, alcohol does and apples don’t enter your body; sugar does.
Dr. Eric Westman: That’s a great way to put it. I had forgotten you had a personal experience with weight loss. Did you use a low-carb diet to lose weight?
Dr. Rob Cywes journey in losing weight
Dr. Rob Cywes: No, not at all. I gained that 100 pounds very readily. If I don’t socially distance myself from a donut, I’m gaining 5 pounds. I’m very effective at gaining weight. After my surgical training, I went to Vanderbilt. This is now seven years later, and I was appointed as a pediatric surgeon at Vanderbilt, my first real job. One of my first patients was this young 13- or 14-year-old African American kid who weighed between 350 and 400 pounds. I was taking his gallbladder out, and everybody said, you must not eat so much fat. You’ve got to see the dietitian and eat low-fat, more grains, more fruit. I walked into this kid’s room, and all his family were sitting there. They were all enormous, kind of my size or a lot bigger, and they were not gathered around sticks of butter. They were gathered around sugar and starch, just like my own diet – 80-90% of what they were eating was sugar and starch, and what they were drinking.
I realized two things: number one, it’s sugar, not fat, that’s making us fat; and number two, as a surgeon, I’m very good at taking this kid’s gallbladder out, but I’m useless at helping him with his obesity. There was a moratorium on bariatric surgery at the time in adolescence, and I said I wanted to be able to help him with the core of what he was doing. As I started to get into bariatric surgery, it’s by far the best way to lose weight. I can guarantee you are going to lose weight after bariatric surgery, but 85% of the patients gain their weight back or become metabolic trainwrecks because they don’t change the behavior that caused the obesity in the first place.
When I started to look at my patients, my successful and unsuccessful patients, they all lost weight after surgery. But what differentiated recidivism was a return to snacking and carbohydrates. Then I looked at the diet we were putting them on and said if I were to design the ideal diet to make someone fat after surgery, it’s the very diet we put them on post-operatively: multiple small meals, soft foods like mashed potatoes, grits, yogurt, smoothies, and protein shakes. They are consuming these little bits regularly because they can’t eat a lot at any one time. They still lose weight in the first year, but if they keep those habits, they beat the surgery. The sad part is my surgical colleagues are excellent at getting people to lose weight, but they are also excellent at teaching them how to fail.
Surgery
Dr. Eric Westman: May I shade the language just a little bit? While it may be the most certain way to lose weight, it may not be the best way. We, the obesity medicine doctors, as a medical group, criticize the surgeons because it’s so effective, but many people lose muscle mass because they are not eating enough protein.
Dr. Rob Cywes: That’s not a surgical problem, just like with Ozempic. That’s not an Ozempic problem; it’s a diet problem. When my Ozempic patients, my surgical patients, are dominant in protein – and that’s my job, I don’t like the word protein but animal products – they don’t have that muscle wasting.
Dr. Eric Westman: They need the proper coaching.
Dr. Rob Cywes: Exactly right. It’s when you outsource to surgery and you don’t change anything, of course that happens.
Dr. Eric Westman: I’m a medical guy. Surgery is awesome. I loved every minute I was on a surgical rotation, but it wasn’t for me. It’s just a little too harsh. Even today, I’m chatting with a family friend, and one of her friends had the Roux-en-Y gastric bypass where the stomach is made about the size of a hen egg.
Dr. Rob Cywes: That’s not the issue. The issue is that you are sewing their butt to their mouth. It’s the malabsorption, the metabolic surgery. I don’t do bypass or duodenal switches.
Dr. Eric Westman: I was trying to demonstrate the risk or the downside. She was told not to have carbonation because you can actually expand that little pouch, but she didn’t hear it or didn’t notice it. She had a beer, so she didn’t have carbonated soda or anything, but had a beer and ruptured the pouch. She had an acute abdomen and died. This was just a few weeks after the surgery. I’m like, wait a second, you are worried about a keto diet and yet now you are saying surgery is a free pass? So it’s a big deal, although it’s very effective.
Dr. Rob Cywes: Let me correct one thing about the beer, though. It wasn’t the beer that did that. That was a surgical staple line failure. That would have happened if she had eaten a piece of steak or a lettuce leaf. That was a technical issue with the surgery, not the beer, because I don’t stop any of my patients from drinking carbonated fluids, because the pouch is what it is and the integrity of the pouch is the issue.
Dr. Eric Westman: Then it’s surgical surgeon dependent?
Dr. Rob Cywes: Exactly, exactly right.
Different modalities
Dr. Eric Westman: I’m not a surgeon. I have learned that there are some people I can’t help. It was like your early experience in Tennessee. I see some people in North Carolina, who grow up heavy. They come to my office when they are 30 years old. They weigh 500 pounds. In a medical program, in my experience, even medication just isn’t strong enough. I think there is a role for weight loss surgery.
When someone comes to you, how do you discuss all the different modalities you have?
Dr. Rob Cywes: The important thing, whether we’re talking about GLP-1s – which are, in my opinion, wonderful drugs – the GP-1s or Ozempic and surgery are kind of the same, in that when you outsource them to solve your problem, you are going to fail. A little bit like an antidepressant. You put someone on Wellbutrin or Prozac and you expect their depression to go away. No, they establish a foundation of weight loss, but you have to partner with them.
Your and my responsibility, whether it’s Ozempic or surgery, is to educate and train that patient beforehand. Plus, you are not going to change afterward. When you are losing weight magically, there is no incentive to change. What I do in my practice is I set them up, say, let’s put surgery on the table. we’re going to put it there in six months’ time, and I want you, between now and then, to bust your butt. If you are successful, we will keep postponing the surgery.
As a fat guy, I personally planned to have surgery. I gave myself four months. I topped out at 300, BMI of just over 40, and I said, at the end of this year, I don’t want to be fat. I don’t care what it takes. That’s my priority. And I was an expert – like so many of my patients, I was an expert at failing weight loss programs. I was good at beating Weight Watchers and the others. I could lose weight but gain it all back. So I said, I’m going to put surgery on the table. Now, I would put the Ozempic on the table, but you start by changing your eating pattern, and then if you need assistance beyond that, then of course you do it.
So you crumple up the cigarettes, you throw them away, and if you’ve failed a few times, you take Chantix to help you do better the next time. You don’t just take Chantix and expect to quit smoking. So same thing here, and I think the issue is not the drug or the surgery. The issue is we providers are not managing that relationship effectively, and most of us don’t understand that part. So both of those, surgery and Ozempic, are great when used appropriately as transitions. So nobody should be on Ozempic forever. It’s a transitional drug, just like methadone, but I have seen people who have been on methadone for 10 years. That’s a problem for me because they haven’t changed.
Or you are vaping now, you are vaping to quit smoking, but you’ve been vaping for 10 years. That’s a problem. There is no difference to me, and it loses its effectiveness. GLP-1s, I had somebody this morning, GLP-1s had stopped working. No, it didn’t. You didn’t change. Sometimes we have to coach people and help them to continue to change.
Getting into carb addiction
Dr. Eric Westman: You can imagine if you have a hormone, you give more of the hormone, you are going to develop hormone resistance. There is going to be GLP-1 resistance.
How did you get into carb addiction? There are very few doctors who really talk about addiction as explicitly as you and I do. How did that happen?
Dr. Rob Cywes: The first thing is, I’m a surgeon, so we have a higher threshold for skin thickness. In other words, when I was able to see this so obviously, I was more comfortable talking about it and putting it into practice, even though it created a great deal of risk to me because, as you’ve seen with other folks who’ve gone down this pathway, Tim Noakes, Gary Fettke, a few others, they’ve been crucified for taking a stand. I was willing to take that because of my own journey. I have imposter syndrome, terrible imposter syndrome, which means that I cannot believe, even to this day after 25 years and tens of thousands of patients, I cannot believe that I’m right. So it’s with trepidation that I talk about what I’m talking about because everybody out there, all the experts, must be right. How can I be right? How can I be the only one in the platoon that’s in step?
But the beauty is, every one of my patients reiterated that I was right, and their results every day prove that I’m right. I’m working with Dexcom right now, and it’s congruous for folks like Dexcom and all the endocrinologists to believe or to understand that type 2 diabetes can be put into remission.
What happened with me is I saw very clearly who was doing well and who was doing poorly. The beauty about surgery is that things happen very rapidly; you lose 100 pounds in a year. I can tell based on that why this person isn’t losing weight as fast as everybody else. You look at what they are eating, and we see our patients regularly. That was one of the beauties. I got involved with this with the Lap-band, and I loved the Lap-band then. The reason for that’s because when patients were struggling, they would come to you for an adjustment of the band, whereas when they are struggling with a sleeve, there is no way on earth I’m going to go to my doctor and get beaten up.
While they wanted an adjustment to their band, I was able to get in their head and understand what they were doing. It was always snacking on sloppy carbohydrates or drinking them. It was always the same when they were struggling. Very rapidly, with the volume of patients I was seeing, it became so obvious observationally that I was able to address that side of things in my own life as well as with my patients. I was fortunate to be surrounded by incredible people: incredible psychologists, a weight loss coach, a clinical nurse specialist, and a dietitian who could see this, who were not just the balanced, “Eat a little bit of this, a little bit of that” dietitians. They said, no, look at what you are eating here. You are fat because of that. Can we let that go?
So it wasn’t me, but my team supported me in understanding that. When they watched me eat and they watched me hiding M&Ms in my drawer and my Coke in my office, it was so obvious.
The Lap-Band and what it is
Dr. Eric Westman: Addiction – you can be in denial; you can steal.
Can you describe what the Lap-band is?
Dr. Rob Cywes: The Lap-band is a handy-dandy little device that goes around the top of the stomach. It has got a little balloon on the inside, so with this port, you can tighten or loosen the band. Instead of having this whole thing as your stomach, you’ve now just got this little piece. You eat a tiny amount. If the band is properly adjusted, it sits there and then it slowly goes through. If you are eating ice cream, it does nothing.
Dr. Eric Westman: You could drink through this.
Dr. Rob Cywes: You can eat your way by snacking and eating through it. You can defeat the device very easily. Now, we can tighten it up and bump you forward, but the Lap-band was great for a long time, but it developed so many complications, primarily failure, because people were just slapping them into folks and expecting them to lose weight.
Now we see esophageal dilation, we see problems with it. I still love the Lap-band, but it’s come and gone as a feature because it was so mismanaged and the reputation has been tarnished. One of the things about bariatric surgery is because we struggle to keep people’s weight off, we just went to more and more radical surgeries. We went to gastric bypass; we went to SADI, that’s why I talk about sewing your mouth to your butt and you can eat whatever you want to, but you just poop it all out. So you lose a lot of weight, but you become malnourished. I end up reversing many of those surgeries.
So now the other piece, even if you just buy into the calories in, calories out narrative, which most of my colleagues still believe in, when it comes to surgery, you have to if you are going to reduce caloric consumption. Now what they are doing is they are doing surgery and adding GLP-1s. What they can do is do a lesser surgery, maybe a sleeve gastrectomy, and immediately add the GLP-1 so there is synergy, but still, there is failure over time. Ultimately, and the challenge is, there is no incentive for a surgeon to change their thinking because they never see their patients down the road. Most of my patients who come to me after surgery can’t even remember the name of the surgeon who did it. You don’t fail tomorrow; you fail in four or five years. You start to see that weight coming back.
Dr. Eric Westman: We try organizationally, the Obesity Medicine Association, which is the medical group, and I’m a past president of that group, we’ve tried to connect the surgeons with the medical, and they are very siloed. I remember seeing ECU Walter Pories here in North Carolina, East Carolina University. He created the Roux-en-Y, and he explained that it wasn’t too strong but it still worked; it was right in the middle. Then we were at a CME program for family practitioners, and he said, I need your help to take care of these people because we can’t follow them. I looked at him, I’m like no, you are opening this Pandora’s box. It seemed a little irresponsible to me that you would do an operation and never follow them again. That’s the way the world is, I guess.
Dr. Rob Cywes: I’m a surgeon. I love what I do, but I love the management as much, if not more, than the surgery. The surgery is fun for me; it’s my little enjoyment, and then the management is the hard work, but the enjoyable hard work as you help your patients. Because that really is an understanding. At the same time, most surgeons are happiest and best in the operating room. They are there because they don’t manage patients. I don’t condemn it, I don’t demonize it, but I think we can all do better. I think physicians can incorporate other strategies. Now they are being forced to make decisions about GLP-1s, but the surgeons can also expand this.
The way I look at it you can change a flat tire every day, but until you pick up the nails at the bottom of your driveway, you are not changing why you got the flat tire in the first place. That’s what I discovered. I looked at myself and I looked at my patients, and I realized this was no different than treating an alcoholic or treating a heroin addict. We were dealing with this from a substance abuse perspective, not a nutritional perspective. Nutritionally, you can survive on a low carbohydrate or a non-carbohydrate diet, but ultimately, for every drug that you take, you have to be able to survive in abstinence. You don’t die of dehydration, let me put it this way, if you quit drinking, you would die of dehydration, but you don’t die of dehydration if you quit drinking alcohol. Nobody tells alcoholics what they should drink, but everybody loves to tell fat people what they should eat, and that’s a mistake as well. The default is, you are going to do pretty darn well – whether you go vegan or carnivore – if you are not eating carbohydrates. And I know we can talk about vegan and carnivore, which is better and worse, but ultimately, it’s about carbohydrates that cause the majority of the illnesses. Then, on the vegan side, I think you’ve got micronutrient deficiencies; on the carnivore side, you’ve got macronutrient excess, which is a problem as well. On the carnivore side, we can go down that rabbit hole.
Low-carb diet – not what, but why
Dr. Eric Westman: Let’s say someone wants to use a diet. Take you out of the surgical suite, and how do you look at different diets? There is a lot in common between a vegan and a low-carb or carnivore diet, and that’s the absence of junk food. The Stanford study, Lucia Aronica, looked at the people at the extremes in one of their studies – one group doing the Ornish-like (very low-fat), the others doing the Atkins-like (very low-carb) – and the effect on insulin resistance was very similar. I think it’s a false choice to say only those.
You have the history with David Jenkins and the group with low glycemic diets, learning that inflammation comes from sugar. Is that how you got onto low-carb diets?
Dr. Rob Cywes: I think it was just looking at myself, looking at my patients, to understand what the problem was. Also, not just to understand the problem from a concentration perspective, but most doctors, when they are talking about diet, they are changing what you eat. I realized this had nothing to do with what; it had to do with why. On my way home to dinner, why am I stopping at McDonald’s for a McFlurry? That has nothing to do with nutrition; that has to do with emotional restitution after a long, hard day. Just like coming home and having a shot of whiskey, I’m having a McFlurry. I realized that all the things I was doing that were causing me harm had enormous beneficial potential as an anxiolytic. Not only that, but when I was depressed, I was eating; when I was bored, I was eating. And it wasn’t steak or pepperoni and cheese; It was sugar and starch that was driving every aspect of my emotional restitution. The other thing also, Eric, and you know this, as we get busier and as we’ve families and people take away our time, or we allow our time to be taken away, we’ve less time for self-care. The effort and time it takes – an hour to go to a gym – but it takes 10 seconds to wolf down some ice cream or to drink a Coke.
So we develop an instant gratification approach, whether it’s a cigarette and alcohol, or an ice cream as an instant sedative. Now it’s frowned upon to be sitting with a cigarette. You are old enough to understand that 40 years ago, you and I – well, I didn’t smoke, I don’t know if you did – but smoking was the thing of the day.
Dr. Eric Westman: My parents did.
Dr. Rob Cywes: Even as a medical student, we would go on rounds, and after every ward, we would stop for a smoke break. I didn’t smoke. Now we stop for a donut break.
The narrative has changed. The behavior is identical; the drug has just changed, but the behavior pattern is no different. Pre-1910, the reason prohibition happened wasn’t magical. It happened because people were overusing gin and alcohol as a societal form of emotion management. So we went to the radical step of prohibition. Now, we still have alcoholism, but I think prohibition curbed that to a large extent and created a moratorium, changed our societal approach to favor alcohol, against alcohol. Big tobacco, we changed our approach to favor nicotine where doctors said, “It’s a great anxiolytic, no harm here.” And we switched.
Now we’re saying that the sugars and starches, the whole grains and the sugars, are so healthy for you. Nothing to see here. We’re doing the same thing with marijuana. We’re doing the same thing with vaping – driven by industry, not driven by health.
Looking at the diet
Dr. Eric Westman: In my practice, I learned from a lot of the doctors around 1995 to 2000 in that era, and I do pretty much 20 total carbs or less, it’s a total carb cessation. It’s like a cold turkey – pun intended – sort of approach with getting all the sugars and starches out. Some people then say it’s keto because you do get the nutritional ketosis. I do it kind of one size fits all. I say you want this to work the first time every time, or should we diddle around and try something that might work? Most people will say, I want to try the one that will work the first time, the keto level.
How do you look at the diet?
Dr. Rob Cywes: First step, when you are looking at this from an addiction perspective, when you are looking at it from a diet perspective, today’s day one, here’s your diet, off you go, and you are jumping into the deep end of a pool without knowing how to swim. When you look at positive change with addiction, there is a group called Prochaska that wrote a seminal book called Changing for Good about smoking and the process by which people successfully change with smoking. And the first step is just going from a defensive pre-contemplation to a contemplation of liability harm, and perhaps I could imagine myself beginning to change.
The contemplative phase then goes to the preparation phase, to the, how am I going to do this practically? Then you go into action, and then you’ve got to keep moving forward because you’ve got to be aware of relapses. Understanding that when I first see somebody, depending on how they come in – whether they are pre-contemplative or contemplative or already on the journey and they just need some direction – I have got to know that person as an individual. And one of the little side effects here is that more and more healthcare has become a singular algorithm of best practice that we plug everybody into. But I want to know and was trained to treat you as an individual where you are, not where I would have you. So, I have to get to know my patients first, meet them where they are, and at what stage of change they are, and then help them to initiate it from there.
So, my job with my patients is to reinforce good behavior and help them to alter behavior patterns that can be improved. Not, “This is bad, you can’t eat this, you mustn’t eat that.” I want them to choose not to eat ice cream rather than think of ice cream as being bad. So, in the addiction world, it’s all about empowerment and about choice, knowing that nobody ever quits the first time. Nobody ever quits the first time, and we build in not only the concept of relapse but how to recover from a relapse. Because you only fail when you quit, but you will relapse. And I’m 24 years in, I’m not perfect. I still make mistakes. I have a plan for owning my mistake, which is where the binary nature comes in, but by owning my mistake, we’re analyzing why it happened and not undoing it. I can’t go backward and pay it backward, but to make sure that the next time I’m in the same situation, I’m not going to repeat it.
So, we arm our patients with tools rather than just a diet sheet. The other piece also, I know that you are, and I’m so impressed with this, an Atkins acolyte, but we no longer talk about the Atkins diet even though everybody did really well in terms of weight loss. But the reason they failed, why Atkins failed – and not Dr. Atkins, but the diet – is because people lost a ton of weight, but then they regained it back because they didn’t replace the emotional role of carbohydrates with something else. So, in addiction management, the only person that can quit drinking alcohol is the person themselves. It’s a very lonely thing to do. AA (Alcoholics Anonymous) is there to help rebuild the person with new skills, and new tools from an emotion management perspective to replace the singular role that alcohol had.
Our program is as much built around the replacement, the emotion management strategies – I call it chess – the creative arts, the human connection, the physical activity or exercise, the spirituality or meditation, and the healthy sexuality and healthy sleep. That has to become a fundamental intention. You’ve got to intentionally force yourself to participate in those until they become part of who you are. But if you don’t have a replacement, you are going to relapse every time life throws a curveball at you. And if you don’t walk your dog every day, you are not going to walk your dog on a bad day. You are going to go back to the fridge.
The other part that I also talk about, is if you take your current age and you subtract it from 100, let’s assume you are going to live to 100 that’s how long this has to last for. Most diets last a few weeks – okay, I lost 10, I lost 20, and my diabetes is in remission. Even a year or two, that’s a tiny fraction of forever.
Low-carb diet and additional products
Dr. Eric Westman: You mention the Atkins diet and the perception of that made me think. I haven’t worked with the company that’s Atkins. I think they got purchased, now Simply Good Foods. Now they would have you just eat their products forever as the long-term goal. And now there are keto products, you know, keto ice cream and all.
What is your take on all these aids to follow low-carb diets?
Dr. Rob Cywes: I think they are absolutely fine as an early shift. If you look at my program, I do things incrementally. So we start with a little. I want people to be a tortoise, not a rabbit. A diet is a rabbit where you do it all at once and you crash and burn. Tortoise is when you make slow removal, and replacement changes by category. And getting rid of what I call look-alikes is the last stage of that, so it’s stage four or five in my program. And the look-alikes mean what it’s made of is healthy, but why I’m eating it’s still a reminder of the old. So I’m eating keto pizza, I’m eating keto brownies, I’m eating keto ice cream, and those are eventually things that are on the no list.
The challenge with the Atkins products is, I don’t think – and you are more expert at this than I – they defy Dr. Atkins’ dietary approach. He wasn’t making all these manufactured look-alikes. And the manufactured look-alikes are just permission to eat something that reminds you of the old. It’s like having a light beer or a light cigarette. How good is that for the alcoholic or the smoker?
Dr. Eric Westman: Not good at all.
So at first, I’m using sugar-free alternatives, anything sweet but not real sugar, to get people off the substance. Then over time, whittling it away. Some people, though, transition, and then they never want the sweet again. For others, it’s a slower burn, like you are saying.
Describe how you do it in your program. Are you seeing people locally? Do you see people remotely? What if someone wanted to see you as a practitioner?
Dr. Rob Cywes: Let me slide back to what you were saying there just before this, and then I’ll answer that question. The concept of artificial sweeteners. I like the way you use them. Artificial sweeteners are a bridge away from real sugar. However, there are two types of people. Some are able, like my wife, to use artificial sweetness so that she doesn’t drink the real thing. She’ll have a Diet Coke so she doesn’t drink Coke. There are other people – and Tim Noakes is quite famous for this – who find that when they do eat anything sweet, it’s a trigger for the wrong thing. So they don’t purposefully use artificial sweeteners. And that’s one of the reasons I chose coffee. This is coffee I’m sipping on throughout the day. This has nothing to do with hydration. This has to do with what I call a mind-cleansing moment, a little emotional restitution, where I’m talking, just like I talk with my hands a lot. So, those are anxiolytics for me that don’t cause harm or very, very little harm. But artificial sweeteners have benefits or liability depending on who you are as a transition. What was the question that you asked me?
Seeing patients
Dr. Eric Westman: How would someone see you in person?
Dr. Rob Cywes: Things have changed dramatically, I think probably in your practice as well, since Covid, when we opened up telehealth. I see patients anywhere from anywhere in the world. And we could do it telephonically, by WhatsApp, or by Zoom. Those are my metrics. And the beauty of my practice is there are enough people out there who are now aware of and trying to do a lower carbohydrate approach, whether it’s diet or addiction or whatever it’s, or gut health issues to resolve. There are so few of us that almost all of my practice, 90% of my practice, is self-referral by people who’ve already decided that they want to do this. I just saw a patient now with horrible Crohn’s and she’d heard about a low-carb approach to Crohn’s disease. Some of the type 2 diabetes. Saw another one this morning with an A1C of 12.6 and a doctor’s telling her to eat a lot of carbohydrates, and she realized, no! They are already motivated to change. They need guidance. They need blood work.
I’m in a luxurious position where very few of my patients that are coming in do I have to convince them they must change. Or I have got a carnivore who’s seeing their A1C going up. Why is my A1C going up when I’m just eating tons of protein? So I’m able to troubleshoot at a higher level. I would struggle with my program to take people off the street and say, you are fat, you are diabetic, come in and see me. I’m going to help you because they are precontemplative to that. I see a few like that, and the ones I struggle the most with are the anorexics and the bulimics because they run instead of trying to fix the problem. That’s an area that we’ve got some expertise with. it’s not just the excessive eaters; it’s the undereaters, who are on the opposite side of the same coin.
I see patients from all over the world. They access us, and then I have got a dietician and a mental health worker. We enroll them in that program, and not everybody has to see the dietician. Some people just need a little tweak. Some people need more blood work done. We individualize therapy, we individualize change, and my job is to arm you with enough information and enough equipment that you become the single best expert on your own life. That you are a better expert on you than I’m on you. I have the knowledge, but you know you, and I help you to see where you are hiding certain things, where you are distorting reality to yourself. So there is a reality check.
I consider our program to be a little bit like AA for fat people, where you are doing great, you’ve been sober for two years, but you still come in for a meeting every now and just to see what’s new, just to reinforce with humility the pathway that you are on. Or you come in to show off. I’m good with that.
Autism spectrum disorder and brain structure
Dr. Eric Westman: You have time to put together scholarly works. Your talks at the meetings I go to are always great, and you contributed to the textbook called Ketogenic – Tim Noakes’ book. Did you have some chapters on autism?
Dr. Rob Cywes: Yes, autism spectrum disorder and brain structure.
I’ve got a three-year-old son, so it’s pertinent. As a pediatric surgeon, and for a long standing I have also seen this massive exponential increase in autism spectrum disorder that defies any of the current reasons why it’s a problem. We’ve debunked completely the vaccine issue that’s been debunked as alive for a long time, but now the narrative is that it’s spontaneous genetic mutations and billions of dollars have been spent on them, and yet there is no consensus. There may be about 5 to 10% that are new mutations, but even if it was a genetic mutation, spontaneous, there is no way that you go from one in 15,000 in 1970 to a low estimate of 1 in 32 by the CDC last year, two years ago. And that rise is just too quick for this to be genetic.
It’s so obvious when my three-year-old son goes to preschool and I sit and watch what they are eating. He opens his lunch box and 90-95% of it is meat. The other kids open their lunchbox and it’s “healthy,” like healthy yogurts, a healthy slice of apple with a little bit of honey to dip it in. Where’s the meat? Where’s the fat? And then the little granola bar because it’s a healthy granola bar or the gummies or the little piece of cheesecake. I looked at a class of, I think it was 14 kids the other day, and I just looked over and peered over their shoulders as they opened their lunch boxes and I would be dead of malnutrition and starvation. I’m a carnivore. If I had to eat what was in their lunch boxes, it’s just quite incredible. These are three-year-old kids.
The human brain continues to develop for the first 5 years of our lives, and the brain is mostly fat. If there is no fat in your diet, now you can convert sugar to fat, but the quality is very poor. So it’s the little three pigs. When we build our house of straw and sticks it doesn’t work so well. When you build your brain of carbohydrates, it doesn’t work so well. If you build it out of bricks, and bricks are your foundation, it’s going to be a much better brain.
Autism spectrum disorder bizarrely is purely by DSM-5 criteria. It’s purely an observational disorder. You can tell on an MRI at 3 to 4 months of age whether a child has structural changes to the white matter that are consistent with a diagnosis of ASD (autism spectrum disorder). But we fail to recognize it’s a structural disorder. If we fail to recognize the structure of the white matter, then we have to wait until the child is seven or 8 years old before we make the diagnosis, and at that age, it’s too late.
Dr. Eric Westman: I know there are some anecdotal stories about people getting better on a low-carb or keto or carnivore. Is there any clinical research or do you know anyone who’s studying autism as an outcome using the diet that we use?
Dr. Rob Cywes: There are people out there who are using a higher-fat keto. The only place in pediatrics where a ketogenic diet is almost universally acceptable is for intractable seizure disorder and epilepsy, and we know spectacular results with that. Everywhere else, it’s questionable.
A lot of the people that work in the epilepsy space will cross over to the ASD space, and what they use – the guy that first described, I think his name was Weinberger, if I remember correctly – but the guy that first described ADD/ADHD said that the disease would not exist if sugar didn’t exist. But we’re medicating everybody instead of putting them in therapy.
The place where you can help an autistic child is, because they have a lot of sensory issues, they prefer to eat a specific consistency with food, which is usually a very smooth consistency, which you get from carbohydrates, you don’t get so much from steak or broccoli. We’re dealing with all those side issues, and it’s a tremendous challenge for the parents of these kids. They often use a low carbohydrate approach to decrease the hyperactivity of these children, but it doesn’t fix the structural damage that gets done in utero and in the first 5 years of structural development of the brain. That’s fixed, that’s permanent, but you can modify some of the behavior by changing the diet.
Eating
Dr. Eric Westman: Do you mind explaining what your family eats? You mentioned carnivore and that your son was eating meat at school.
Dr. Rob Cywes: We live in Florida where DCF, the Department of Children and Families, is very dominant. I don’t want my son taken away from me because I’m killing him with his diet. Everybody knows that gluten is really bad. If you have gluten sensitivity and you are a gastroenterologist you know celiac disease and what is the treatment for celiac disease? No carbohydrates, no grain products at least. My child has celiac disease and therefore, we feed him – and he likes – meat, because he says meat makes muscles, and he’ll show you. He doesn’t like vegetables very much, like so many kids.
Dr. Eric Westman: That’s the parent’s job – to get their children to eat their vegetables.
Dr. Rob Cywes: We try so hard but he throws them on the ground, and he says sour and he throws it out. But you give him a piece of bacon, you give him a piece of steak, he’ll destroy that. So, that’s his preference.
I’ll tell you something very funny. At Easter time, he went to an Easter egg hunt place and he opened his little Easter egg and there was a Tootsie Roll in it. He’s never eaten a Tootsie Roll, so he opened this thing and he said, “Oh, sausage!” We took it away but he actually had a lick of the thing and he said, “Oh, sour,” and he threw it away. He’s conditioned that way. That’s because he doesn’t like vegetables, and he’s not allowed to eat grain products because it’s very inflammatory for his gut. He’s primarily, by default, eating about 95% of his diet as meat.
If you want to know what we eat as a family, if you are on Instagram, my wife has a page called Carb Addiction Mom, and she posts photographs of what we eat. Personally, I’m mostly a carnivore. I’m also about 95% carnivore by choice. I eat vegetables when we go out. We don’t typically eat them at home, primarily because I got sick and tired, not because it’s better or healthier, but because I don’t like throwing out dead vegetables at the end of the week and my dog won’t eat a leftover salad, but he will eat leftover steak or he won’t ever get steak, but he’ll eat leftover animal products.
Dr. Eric Westman: Have you got into the fine art of eating pork rinds?
Dr. Rob Cywes: I don’t. My son does. He loves them. Those are his chips. He loves them. In my own life, because I have a problem with carbohydrates, we’ve talked about, I try not to do the lookalikes. When my wife and my son are together, they’ll have chaffles, they’ll have the pork rinds. They’ll make eggs and cheese into a tortilla. The ingredients are good. What they are eating is not carbohydrates, but I’m not going to eat a chaffle because it’s too triggering for me, and I’m trying to get away from that concept. So again, I’m different than they are. I don’t have that propensity for it. They don’t have the propensity for ingrained behavior like I do, and so I have got to be just a little bit cautious about that.
Where to find Dr. Rob Cywes
Dr. Eric Westman: How do people find you?
Dr. Rob Cywes: We’ve established a single number that people can access us from all over the world, and it’s our back phone. It’s a cell phone that’s got text. It’s got WhatsApp and it’s got email and it’s got phone calls. The number is, no matter where you are in the world, US area code 1-561-517-0642, and that’s the entry into our practice. You don’t need a referral. You don’t need to have a family doctor. A lot of our patients, as you know, are at loggerheads with their family practice. The beauty is you can set up a visit directly with us.
The sad part is that because of the time we spend with our patients, typically an hour for the first visit, and half an hour of follow-ups, I chose at the beginning of this year to radically decrease the insurance I’m taking because to get paid $27 by Medicare for an hour long visit, I try to hold on for as long as possible, but this year Medicare decreased our payments by 2.6% and made it more difficult for us to extract money. So, unfortunately, we’re really not taking a lot of commercial insurance, and that’s a tragedy. The reality is, you’ve got to see 20 patients in an hour at 5 to 10-minute slots. I can’t do that.
Dr. Eric Westman: That’s great that you are doing it. My people are the Adapt Your Life Academy AA membership group. They’ll watch this first, and then it’ll go out onto the Adapt Your Life YouTube channel.
Dr. Rob Cywes: There are not many people in the space that I look up to as mentors. There are about two or three folks in the space that I look up to, and you are one of those. You are way out there in terms of what you do. I have the utmost respect for you, especially with what happened in Ottawa, which I think about often. You have no compunction about calling people out when they fail and I appreciate what you’ve done. You are so solid with your information.
Dr. Eric Westman: Thank you for your kind words. We do have to kind of self-police a little bit.
Dr. Rob Cywes: We do, of course. We’ve got to be inquisitive. I look at oxalates more from the calcium malnutrition perspective than from the problem of oxalates. Even in our space, we’re over-focused on protein and still under-focused on fat. So there are a lot of those little questions that we can continue to ask and that’s what you do. You are inquisitive all the time and you adapt and you move forward, and I love that.
Dr. Eric Westman: I’ll have you on again.
Watch the full video here.
